4 Preoperative Patient Evaluation
Success in aesthetic surgical rejuvenation of the face and neck is measured in several dimensions. First and foremost is the safe completion of the procedure, minimizing complications and morbidities associated with surgical intervention. Success is also measured by the patient’s final assessment of whether the surgery was successful in meeting the patient’s objectives in pursuing the intervention. In view of this, the most important preoperative information to obtain is probably what the patient hopes to achieve by undergoing the rejuvenation procedure and the point at which the patient will be satisfied with the outcome of the procedure. This information is obtained by the most astute surgeons through a thorough investigation of the patient’s unique personal attributes, done by interviewing the patient and then assimilating the patient’s observations in such a way as to predict the likelihood of being able to meet the patient’s expectations. Ultimately, the surgeon must ask: “Can I make this patient look better, younger, or both, and can I make this patient happy?” Often it is easy to see that the patient looks better or younger after rejuvenation surgery, but making a patient happy can sometimes be an entirely different matter. In determining the likelihood of satisfying a patient’s aesthetic desires, it is necessary for the surgeon to preoperatively examine any unique psychological predispositions, behavioral patterns, and life situations that may lead the patient to be less than satisfied with the outcome of a surgical rejuvenation procedure.
◆ Patient Expectations and Psychosocial Considerations
Patients’ expectations of and motivations for having rejuvenation surgery can be influenced by information easily obtained on their initial intake forms. When considering patient satisfaction with the outcome of a rejuvenation procedure, a relative predictor for success, and often the first thing the surgeon investigates when interviewing the patient, is how the patient heard about the surgeon and the surgeon’s practice. If a new patient was referred by a satisfied and happy prior patient, the new patient already has confidence that the surgeon can make the new patient as happy as the referring patient. Such patients are likely to have a higher likelihood of being satisfied by their surgery than those who respond to external marketing materials or who contact a surgeon after viewing information about the surgeon online. Marital status and financial status are also important factors to consider in regard to patient satisfaction with surgical rejuvenation of the face and neck, for several reasons. Patients experiencing life-changing events such as divorce or the loss of a spouse are often motivated to have rejuvenation surgery for reasons other than a desired improvement in appearance, and the surgeon should assess the motivations and emotions predicating the desire for surgical intervention, particularly touching upon the possibility of depression or anxiety as a factor in the decision to seek such intervention.
Financial status is another important consideration in the preoperative evaluation of a patient, because all other things being equal, patients for whom a rejuvenation procedure is financially stressful may expect that it will contribute positively to their eventual well-being to a sufficient extent as to balance their financial sacrifice in having the surgery. Some patients undergoing plastic surgery may become disappointed despite having good results because they feel that the results do not match their financial sacrifice for the surgery. Higher fees may contribute to the “relative satisfaction” sometimes seen in patients undergoing aesthetic surgery. This may be especially true for patients undergoing procedures expected to produce only subtle results.
Other important considerations in assessing a patient’s demographics include the patient’s home status. Does the patient have a supportive spouse or family member who will participate in the patient’s postoperative care, or will the patient need special arrangements to facilitate a safe recovery? Who will provide the patient with emotional support in the postoperative period, and is that person sufficiently comfortable and mature to help the patient in the period of unattractive bruising and swelling that often follows plastic surgery?
In today’s active society, time for recovery from surgery also becomes important, and employment status and the time available to the patient for recovery are important matters. Giving patients realistic schedules for recovery is important, and if predictions of the time needed for recovery are inaccurate, and recovery takes longer than predicted, the patient’s satisfaction may diminish. In patients not working full time, social engagements or special occasions must be discussed. In estimating recovery time it is clearly better to err on the side of more rather than less time, especially if the time available to the patient for recovery is unlimited.
Aesthetic surgery is a very personal and almost a spiritual surgical specialty. The results achieved are measured in proportion to patient happiness, self-esteem, self-confidence, and other psychological parameters not usually associated with medical procedures. Consequently, because psychological factors may affect the results of such surgery and a patient’s satisfaction with the surgery, the psychological status of the patient becomes important. In the 1940s and 1950s, Jacobsen and colleagues1 suggested that all patients undergoing cosmetic surgery might be viewed as having some sort of psychiatric disorder. As recently as the 1970s and the 1980s many mental-health professionals shared the opinion that patients who sought plastic surgery had psychiatric “issues.” By contrast, Stambaugh,2 in 1998, suggested that there were no poor candidates for cosmetic surgery. As might be expected, the truth probably resides somewhere between these two extremes and depends on existing attitudes and professional opinions about self-improvement via plastic surgery. Previously, any patient taking a psychiatric or mood-altering medication was considered a risky candidate for an aesthetic surgical procedure, whereas probably a third or more of patients who now undergo aesthetic surgery are taking some sort of mood-elevating medication.
Although the operating surgeon should thoroughly consider a patient’s psychological profile before performing surgery, the surgeon should also consider the potential psychological effects of plastic surgery on patients who have no apparent pre-existing psychological problems but will have to deal with a changed and improved appearance after surgery. Another dimension of postoperative change, and one that is often not considered, is the way in which plastic surgery affects both those persons who have the closest relationships with the patient and other persons in the patient’s life.
A further manifestation of the growth in availability of plastic surgery is the development of strong cultural pressures about personal appearance, which may be unrealistic. Surgeons and psychologists need to assess why this is happening and how it affects patient satisfaction with the results of plastic surgery. This chapter explores some specific psychological characteristics that surgeons should seek in patients seeking plastic surgery because they may be absolute or relative contraindications to such surgery.
Psychosis, Mania, and Severe Depression
As noted by Veale,3 a cosmetic surgical procedure is usually contraindicated in three groups of patients. The first group consists of patients with psychosis, mania, or severe depression, whose judgment about the need for a cosmetic surgical procedure may be impaired or who may have systematized delusions or command hallucinations about cosmetic surgery or the surgeon performing it.
Cosmetic surgery may be contraindicated in patients with a diagnosed eating disorder, and a history of bulimia should be evaluated in patients presenting for liposuction or body contouring.
Body Dysmorphic Disorder
Body dysmorphic disorder (BDD) is characterized by a preoccupation with an “imagined” defect in appearance or by a markedly excessive concern with a genuine though slight physical anomaly. Table 4.1 4 lists the diagnostic criteria for BDD in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) of the American Psychiatric Association. Besides the diagnostic criteria listed in DSM-IV, BDD is frequently accompanied by comorbidities, especially depression, social phobia, and obsessive–compulsive disorder (OCD). The most common preoccupations in patients with BDD are concerns with the head and neck, and include concerns about the skin, hair, nose, eyes, eyelids, mouth, lips, jaw, and chin. Other parts of the body may be involved, and the preoccupation may be focused on several body parts simultaneously. Patients with BDD may have multiple complaints about minor facial flaws, disproportionate or asymmetrical body features, thinning hair, acne, wrinkles, scars, spider veins, complexion problems, or simply unattractiveness, as but a few examples. Time-consuming behaviors such as mirror gazing, comparison of features, skin picking, seeking of reassurance, and avoidance of social situations including intimacy characterize BDD, and the disorder is associated with an increased incidence of suicide.
Depression and Anxiety
Although the incidence of depressive and anxiety-producing disorders in patients seeking plastic surgery is unknown, one study found extremely high rates of these disorders in such patients.5 “Active” or untreated clinical depression is usually considered a relative contraindication to plastic surgery. Patients with depression associated with bipolar disorder need to be carefully assessed before a recommendation for surgery is made. Patients with depressive or anxiety-producing disorders who are successfully treated or maintained on psychotropic medications constitute a second and growing group for whom plastic surgery should be recommended only after careful consideration.
Although the plastic surgeon should have appropriate concerns about proper decision-making with regard to patients who have anxiety and depression, some studies suggest that successful plastic surgery can be effective in reducing these patients’ anxiety and depression. Gaboriau6 notes that ~100 scientific studies and surveys have explored the connection between plastic surgery and depression. A landmark study of this issue, using a survey of depressed patients who had breast-reduction surgery, found that 70% had relief of their depression after this surgery. A psychosocial survey at the University of Manchester, England, of 33 patients who had breast-reduction surgery found good overall improvement in their health status and psychological functioning, and the investigators who conducted the study recommended that the taxpayer-supported National Health Service of the United Kingdom provide the surgery to women who needed it. An American study of 362 patients undergoing cosmetic plastic surgery,6 61 of whom were taking antidepressant medications at the time of surgery, found that only 42 of these patients were still taking antidepressants at 6 months postoperatively, representing a 31% decrease in cases of depression in the study cohort. Perhaps unsurprisingly, 98% of the patients in the study said that the surgery had markedly improved their self-esteem. Anecdotal reports of patients with major depression being helped by the injection of Botox® (onabotulinumtoxin A) into frown lines have also been published.6
In the course of patient evaluation, personality assessment is strongly advised to consider whether certain personality traits of the prospective patient are adaptive and helpful in coping with life’s challenges or whether they represent an extreme manifestation of the same coping skills. Patients with certain personality types are not well suited for cosmetic surgery. In addition some of these maladaptive personality traits are also associated with more serious psychiatric disorders, and two in particular have strong associations with BDD. Patients with schizoid, paranoid, histrionic, and depressive personality disorders as listed in the DSM-IV are considered poor candidates for cosmetic surgery.
Schizoid Personality Disorder
Individuals with schizoid personality disorder are described as being socially withdrawn, introverted, eccentric, and uncomfortable with others. Such patients often express vague reasons for wanting aesthetic surgery and are unable to supply precise goals for the procedure even upon detailed questioning. The patient may, for example, request surgery because “it would be better to look that way.” Characteristically, these patients avoid eye contact, show little emotion, and have difficulty relaxing during consultation with the physician. They make few if any spontaneous comments, and they answer questions without elaboration.
Paranoid Personality Disorder
Paranoia refers to a pervasive and unwarranted skepticism of others. The individual with paranoid personality disorder (PPD) is most commonly a young, unmarried male who often keeps to himself and is hypersensitive to perceived criticisms. Individuals with PPD are likely to have an unstable work history, to present themselves as innocent victims of unfairness, and to place blame on others (e.g., prior physicians). Patients with this disorder can appear tense, guarded, and secretive. They are often argumentative or even belligerent, and highly moralistic. During consultation, patients with PPD are likely to be overly concerned with keeping themselves “all together” and tend to be very businesslike. They may anxiously scan the room and have great difficulty relaxing, and are often preoccupied with minor details and with overcoming their suspicions.
Histrionic Personality Disorder
Individuals with histrionic personality disorder (HPD) are often excessively emotional and seek constant attention. They are colorful, with labile and shallow emotional responses that range from laughing easily to bursting into tears. These patients can use their displays of emotion and appearance to control others. For example, a person with HPD may use an inappropriate seductive demeanor to solicit special services from the surgeon. Patients with HPD tend to be noncompliant, disorderly, and nonpunctual. They have an intense need for attention, and they seek it through their external appearance, about which they are excessively worried. During an interview, patients with HPD constantly seek reassurance, approval, or praise. They often have a style of speech that is highly impressionistic. Thus, for example, when asked to describe his or her mother, the patient may not reply more specifically than by saying, “She was a beautiful person.”
Depressive Personality Disorder
Patients who have depressive personality disorder do not necessarily desire cosmetic surgery; rather, they may be prone to seek it on the belief that an enhanced physical appearance will improve their feelings about themselves. They have multiple somatic symptoms, constricted thought processes, and diminished spontaneous behavior. They anxiously repeat questions, demand guarantees, and do not appear optimistic even with assurances. In the evaluation of a patient who may have depressive personality disorder, specific questions about life stressors are important. Loss of a loved one is the most common cause of depression in such patients.
When considering the possible presence of the personality disorders described above in patients being assessed for plastic surgery, it is important to consider that they may have psychiatric comorbidities. Thus, for instance, Phillips and coworkers found that the severity of symptoms of BDD, as assessed with the Yale–Brown Obsessive–Compulsive Score (YBOCS), was significantly related to two factors: the number of diagnostic criteria for schizotypal and for paranoid personality disorders.7
Motivations for Surgery
According to Edgerton and Knorr,8 patients seeking cosmetic surgery are motivated by internal or external pressures. Several examples of external motivational pressures deserve a closer examination. The need to please others (e.g., husband, relatives, lovers, and strangers) often arises from the false belief that a change in outward appearance will produce results such as saving a marriage or improving a relationship. Of course this notion is rarely true, and may indicate a more serious disturbance in the patient’s psyche. Seeking cosmetic surgery as a way to advance one’s career often results in more disappointment than satisfaction after surgery. Despite the generally held notion that more attractive persons are more successful, using plastic surgery as the means to such an end is often ill advised. Conversely, the patient who is aware that successful surgery does not ensure career advancement may effectively use the enhanced appearance resulting from such surgery. Patients citing internal motives for aesthetic surgery are generally considered good candidates for having it. Such internal motives may be described as long-standing feelings about deficiencies in physical appearance and a strong commitment to physical change.
◆ Medical and Preoperative Considerations
The preoperative consultation and evaluation of the patient seeking plastic surgery is a very important and necessary interaction between the patient and the physician. During the process of the preoperative evaluation the surgeon and the surgeon’s staff are charged with carefully assessing the medical condition that requires surgical intervention, evaluating the patient’s overall health status, determining risk factors that suggest more focused testing or consultation, educating the patient, and discussing in detail the surgical procedure proposed for the patient. During this process the patient should gain a realistic understanding of the proposed surgery, become aware of alternative treatment options, and realize the complications that may occur in the perioperative period. The additional time invested in a preoperative evaluation yields an improved patient–physician relationship and reduces the potential risk of surgical complications.
The Medical Evaluation
The preoperative medical evaluation is an important requirement for the patient seeking plastic surgery, and may contribute to answering many questions before surgery is undertaken. The patient’s health status may influence the choice of anesthesia for the procedure and the choice of an ambulatory versus an inpatient facility in which to perform the procedure, as well as whether the surgical procedure would entail excessive risk to the patient. A complete history and physical examination are required for an adequate preoperative appraisal of risk factors in patients being considered for surgery, and are also mandated by most state laws and national accreditation standards. The choice of a facility for performing the procedure is also influenced by state laws and the standards of national professional organizations. Both the American Academy of Facial Plastic & Reconstructive Surgery and the American Society for Plastic Surgery require surgeries involving intravenous (IV) sedation to be performed in nationally accredited surgical facilities. Inpatient facilities are also necessary or preferable to ambulatory surgical facilities in the case of certain other considerations. These would include very lengthy surgical procedures done under general anesthesia, procedures for patients with a history of poor recovery from general anesthesia or those lacking proper home-care support systems, and procedures for patients who may need hospital-based laboratory testing or inpatient consultation to facilitate a safe recovery from anesthesia or surgical intervention. Inpatient procedures may also be necessary if adequate options for ambulatory surgery do not exist. It is estimated that only 15% or less of cosmetic surgeries are performed on an inpatient basis.
Current and Past Medical Conditions
Diabetes mellitus is a common chronic disorder, affecting ~7% of the population of the United States.9 Careful assessment of diabetic patients before surgery is required because of their complexity and high risk for coronary heart disease, which may be relatively asymptomatic as compared with its manifestations in the nondiabetic population. Diabetes mellitus is also associated with an increased risk of peri-operative infection and postoperative cardiovascular morbidity and mortality.10 A key aspect of the perioperative management of patients with diabetes mellitus is glycemic control, because the complex interplay of a surgical procedure, anesthesia, and postoperative factors can lead to lability of blood glucose levels. A rational approach to the management of diabetes mellitus allows the physician to anticipate changes in blood glucose levels and to improve glycemic control perioperatively.
Hypertension and Cardiovascular Disease
Hypertension and cardiovascular disease (CVD) are related disorders and will be discussed together. Hypertension is an important cause of perioperative bleeding and hematoma, especially in men. Hematoma is the most common postoperative complication of rhytidectomy, with a higher risk of occurring in men (7 to 9%) than in women (1 to 3%).11 Factors predisposing11 to hematoma in face and neck surgery include male gender, poorly controlled hypertension, and unreported use of aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs). It is often postulated anecdotally that hematomas are more common in men than in women undergoing plastic surgery because of the greater vascularity of surgical flaps in men in relation to hair follicles of the beard and their associated adnexal glands. Intraoperative factors in the formation of hematomas include extensive undermining of skin, the use of general inhalational anesthesia, and failure to obtain adequate hemostasis. Postoperative factors in the formation of hematomas include poor control of nausea/vomiting accompanied by excessive retching or coughing, and excessive activity.
Hypertension can be a significant cause of a poor outcome of flap or graft surgery, including rhytidectomy on the face and neck. Adequate control of pain and anxiety is essential in hypertensive patients, as is the optimal management of blood pressures preoperatively. Patients with hypertension also have a high incidence of concurrent CVD. Concerns about heart disease in patients undergoing cosmetic surgery include the factors involved in the surgery itself as well as potential issues in postoperative recovery. Patients with histories of ischemic coronary artery disease (CAD) or angina may need sublingual nitroglycerin, which should be readily available. The use of epinephrine in agents for local anesthesia may be detrimental because of its vasoconstrictive and cardiostimulatory effects. Patients with valvular heart disease or prosthetic valves have a greater than average risk of developing endocarditis. However, the risk of bacteremia with routine face and neck surgery is very low and may obviate the need for prophylactic antibiotics. Patients with cardiac pacemakers or defibrillators should be identified when their histories are recorded. Potential interference with a pacemaker, and particularly with a demand-type pacemaker, is a consideration if electrocautery is used in a surgical procedure. Bipolar cautery obviates the risk of disabling a pacemaker or initiating an arrhythmia. The evaluation of cardiac risk in candidates for plastic surgery is discussed in detail later in this chapter.
Some underlying diseases, inherited disorders, and medications can interfere with the normal blood-coagulation process. In general, bleeding disorders are caused by abnormalities of platelets, the intrinsic coagulation system, the extrinsic coagulation system, or a combination of these factors. It is clearly important to detect any bleeding disorder in a patient scheduled for plastic surgery and to reverse it before surgery. Severe liver disease is associated with decreased protein synthesis, which can appear in the form of a coagulative disorder and impaired wound healing. End-stage liver disease caused by hepatitis B or C may create blood dyscrasias.