Principles of patient selection

The twin adages of “maintaining an open attitude” and “listening to the patient” are certainly appropriate in this setting. During the initial consultation, the surgeon should allow the patient to express his or her concerns and desires for change with respect to the face. A finely honed sense of facial esthetics is usually fully deployed during these interactions. Nevertheless, a feature that may be glaringly unesthetic to the surgeon sometimes may bother the patient little, if at all. Allowing the patient to first state his or her concerns can help the surgeon establish a framework around which subsequent surgical recommendations can be made more easily.

The patient’s general health status, past medical history, medications, allergies, previous surgeries, and social habits need to be elicited to ascertain his or her fitness to withstand, and recover from, the rigors of anesthesia and surgery. Of particular importance is any recent history of tobacco use. Its deleterious effects on healing following face-lift surgery are well documented. These effects are always explained to patients currently using tobacco. Our practice requires patients to discontinue all tobacco and nicotine use at least 1 month before and following face-lift surgery. Patient refusal to comply in this regard jeopardizes the surgical outcome and is a basis for disqualification from surgery.

A thorough evaluation of the patient’s face is performed next. This evaluation involves inspection and palpation of facial structures. Facial esthetic ideals and the changes associated with aging are well elucidated in the article by Friedman elsewhere in this issue. Particular attention is paid to the patient’s Fitzpatrick skin type, overall facial fat content, and facial asymmetry. Patients with higher Fitzpatrick skin types may have a tendency for hypertrophic scar formation and pigmentation changes along incision lines. Patients with thinner faces tend to demonstrate better postoperative contour improvement when compared with patients with fuller faces. Most patients have some degree of facial asymmetry, often originating at the level of the bony skeleton. In addition, personal behavior habits, such as the preference for sleeping on one side of the face, and involuntary repetitive facial expressions can result in superficial asymmetries. All of these issues can affect the final surgical result and should be brought to the patient’s attention.

At the completion of the facial evaluation, a diagnosis is formulated, and the findings are discussed openly with the patient. This discussion takes into consideration the patient’s initial expressed concerns and any additional findings noted by the surgeon. By this time, the surgeon will have a better sense of the patient’s perception of his or her facial features and the desires for rejuvenation. This sense can help the surgeon tailor the surgical recommendations on an individual basis. Although many patients may want all signs of facial aging removed or ameliorated and are comfortable with the extent of surgery required, this is certainly not true for all patients. Patients will usually express their own comfort level as to the extent of surgical correction they feel they can undergo. We, as surgeons, need to be aware of, and sensitive to, this comfort level.

Adjunctive procedures that will clearly enhance the final outcome but may fall outside of patients’ specific expressed concerns, such as brow-lift surgery in conjunction with upper eyelid blepharoplasty, are brought to the their attention and the rationale explained. In this area, the surgeon’s sensitivity needs to be heightened. Usually, gentle guidance from the surgeon can help patients recognize the added benefit. Most patients appreciate their surgeon’s judgment and expertise and are receptive in this regard; however, caution should be exercised in patients who are unreasonably resistant to the additional recommendations. In addition to a possible compromised surgical outcome, this resistance may foreshadow patient noncompliance postoperatively. Preoperative and postoperative photographs can be helpful in demonstrating the intended benefits of proposed treatments and may be provided routinely as part of the consultation.

All potential risks and complications must be discussed openly and honestly. Rather than reciting a laundry list of possible untoward events, they should always be placed into proper perspective for the patient. This approach allows for a more realistic understanding of the nature of these operations and can help emphasize their overall safety when performed in skilled settings.

All financial costs and payment policies related to the proposed procedures should be explained to patients and presented to them in written format. Although the surgeon may conduct this portion of the discussion, many practices delegate this responsibility to a designated financial manager. An occasional patient may demand a discount or a reduction of surgical fees. In our practice, these patients are politely informed that the surgical fees are nonnegotiable, but that our fellow’s surgical services are available at a reduced rate.

Some patients may request to speak to, or meet with, other patients who have undergone similar surgeries. Although this is not routinely offered in our practice, we do accommodate all such requests.

The final surgical recommendation is forged from a combination of the surgeon’s judgment and experience and the patient’s preferences. Both parties must be comfortable with the operations proposed. It is generally better to decline to operate on a patient than to proceed only to achieve an unsatisfactory result.

The final decision to have surgery must be initiated by the patient. Effective presentation of surgical options can help patients reach their decision; however, one should refrain from selling surgeries or pushing patients into having procedures beyond their comfort zone. Contrary to talking patients into procedures, patients should convince the surgeon to perform the surgery for them. This arrangement allows the patient to demonstrate a level of desire and motivation that can help engender a more favorable preoperative attitude and postoperative compliance.

We have found these guidelines to be helpful in promoting patient satisfaction following aging face surgery. When exercised with appropriate surgical skills, these guidelines can facilitate achievement of the desired successful outcome.