When facelifts go wrong: Stanford expert counsels plastic surgeons on dealing with unhappy patients

Watch for the red flags: the patient who pulls out a photo of Tom Cruise and says he wants to look just like that, or the perfectionist who comes to the initial interview with each hair in place, makeup just so.

There's the price haggler, and the multiple-surgeon shopper and then the paranoid personality.

For plastic surgeons hoping to avoid the potential wrath of a disgruntled patient, the best defense is a good offense, said Richard Goode, MD, professor of otolaryngology at the Stanford University School of Medicine and chief of otolaryngology at the Veterans Affairs Palo Alto Health Care System. Goode is the author of the article, "The unhappy patient following facial plastic surgery: What to do?" which appears in the May issue of the journal Facial Plastic Surgery Clinics of North America.

The best way to deal with unhappy patients following facial plastic surgery, Goode advised his colleagues, is to have never operated on them in the first place.

"There are some patients you just want to avoid," said Goode, who has garnered a certain amount of expertise on the topic through 40 years of occasionally painful experience with patients. "If you can pick them out before surgery, that's the best."

Goode was approached by the journal to write on the topic, along with several other nationally recognized experts in the area of facial plastic surgery, for this month's edition of the online magazine, which focuses entirely on the topic of the unhappy patient. The issue was also published by Elsevier as a book titled The Difficult Patient, guest-edited by Donn Chatham, available online at http://www.facialplastic.theclinics.com.

While the articles are written sometimes in light-hearted, tongue-in-cheek fashion, the topic remains a serious issue, one that repeatedly comes up among plastic surgeons and their professional organizations. Doctors take seriously the research that shows a small percentage of plastic surgery patients are at risk of experiencing psychological problems after undergoing elective plastic surgery. For some, it leads to depression and occasionally even murder.

"There is a death rate of plastic surgeons killed by unhappy patients," Goode said. "Patients can get very, very angry. They call you repeatedly, write you harassing letters, leave notes in your mailbox. They talk about you (not in a good way) at every bridge party, every social event. They may sue you. They go see other doctors and say how terrible you are."

Goode said he hadn't received any death threats from plastic surgery patients, but he has dealt with patients extremely angry after surgery even when he was quite happy with the postoperative results.

One woman was so furious after Goode operated on her nose that she visited five other doctors looking for confirmation that his work was shoddy before she would leave him alone. All five told her the nose work looked fine.

"She was angry, angry, angry," Goode said. "She kept saying, 'People stop me in the street. People are laughing at me. My friends all asked me what happened to my nose.' I tried to get her to see a psychiatrist. That made her more angry." He added, "She made my life very unhappy. In retrospect I could see she was obsessive with unrealistic expectations, and I probably wouldn't operate on her today."

The key to avoiding the patient with unrealistic expectations, or those with obsessions with imagined physical defects, is to use the initial interview as an effective screening process, Goode said.

"We teach facial plastic surgeons in great detail how to evaluate a nose, the eyes and other facial features, but we need to provide more training on how to predict who will not be a 'good' postoperative patient."

Take your time, listen carefully and, if necessary, schedule a second appointment, Goode advised in the article.

"It is easy to identify and send elsewhere the 60-year-old woman who ... expects after surgery to look like Paris Hilton," Goode wrote. He added, "The paranoid schizophrenic, the patient who has already sued four surgeons, and the patient who has no discernible deformity are relatively quick to identify and dismiss."

Other patients who "may produce postoperative pain - to the surgeon" are not so easy to identify. Doctors need to rely on their gut instincts, listen to staff recommendations and consider hiring someone who has the necessary skills and time to interview prospective surgical patients.

"In my experience, this is usually an older woman who is good at sizing up people and has had cosmetic surgery herself," he said. He added, "A background in human psychology helps but is not required."

Goode also provided doctors a list of patient types to interview carefully before making the final decision on whether to operate:

• Perfectionists: Those seeking a flawless face cannot accept minor asymmetries or slight imperfections after surgery. Their hair is perfectly coifed, their attire and jewelry just right, nails and makeup flawless. They have the potential to be unrealistic patients.
• Dissatisfied patients: Some of these were dissatisfied with previous facial plastic surgery by another surgeon. She or he wants you to "fix" it. Watch out, Goode said. "Do they really need correction? Are customers always right as long as they can pay for it? I don't think so." (A conversation that starts out, "That doctor, what a butcher," is not a good sign.)
• Patients whom you or your staff don't like for some reason: Your first instincts may be correct. Be careful.
• VIPs: Someone highly visible to the public, such as actors, TV personalities and politicians, have bigger stakes. An unhappy VIP after surgery is definitely worse than an unhappy non-VIP.

Goode also recommended using electronic computer imaging during the interview process to help judge the prospective patient's expectations. And it's important for every surgeon to have a policy on who pays for revisions when necessary and to make sure this is clear preoperatively, Goode said.

"Listen carefully to what they say," Goode wrote. "If you think they are unrealistic, tell them so.

"None of us wants to turn away patients, but I can give testimony that it is far better for your peace of mind to do so than to operate on someone you can never satisfy.