Starting a practice in cosmetic facial surgery is daunting. Every new facial plastic surgeon is eager to make his or her mark and to put into practice his or her numerous years of training, although, in truth, the real education is only just beginning. The true value in having completed a fellowship is in acquiring a lifetime of lessons in what really matters to a cosmetic practice. Of course, what interests the young surgeon is to be technically excellent and to master the latest in techniques. Few surgeons, especially neophytes, jump to the topic of this chapter with enthusiasm, yet psychology is as germane to a successful rhinoplasty practice as is any other topic in this book, if not more so. Aesthetic surgery, more than almost any other branch of medicine short of psychiatry, is really a study of human relations. A patient’s happiness has to do with so much more than just the technical proficiency and the surgical result. Recognition of this fact is a critical component underpinning all that we do. This chapter will attempt to encapsulate some of the most useful aphorisms a cosmetic facial plastic surgeon would do well to keep in his or her breast pocket at all times. It will also elucidate the warning signs that herald the potential for a maladaptive response to surgery and an unsatisfying situation for both the patient and surgeon.
Patients choose our services based on so many real and intangible factors. They do not really “need” us but they simultaneously hope we have something to offer them that will satisfy one of their most basic desires—to feel valued by themselves and by others. Most rational, healthy people do not actually want to have surgery. They understand, though, that surgery is the step that must be taken to reach their desired level of self-fulfillment. While they may not have decided on the surgeon or on an exact procedure, most patients have already taken the leap and decided to have surgery before they visit us. The objective of the consultation in their eyes is to determine if we are the right surgeons for them. Likewise, many young surgeons believe they must “sell” their abilities. Instead, the surgeon should concentrate on determining patients’ suitability to his or her practice based on his or her skills, personality, and comfort level while interacting with the patient. That critical assessment is the focus of this chapter.
A great deal has been written about the psychology of patients seeking aesthetic surgery, but this subject has never been more topical than in the past few years. Now that aesthetic surgery has entered the mainstream, prospective patients are treating it much like any other luxury purchase. The “retail-ification” of cosmetic surgery has advantages and disadvantages for both patients and surgeons. On the positive end, aesthetic improvements have become more accessible to a host of people who would not otherwise have had the chance to benefit from these procedures. On the negative end, the decision to undergo aesthetic surgery may be less deliberate than it had been in years past. The selection of a surgeon may be more impulsive and the preoperative rapport developed between patient and surgeon may be less than ideal. In addition, the number and types of practitioners who are providing these services have expanded immeasurably, and not all share the same level of training and proficiency. Market conditions have led to the commoditization of even invasive procedures such as rhytidectomy, where franchises are owned and operated by business people and surgeons are being used as technicians. Intensive marketing, competition, and mass media coverage of cosmetic surgery have trivialized operations and overidealized outcomes. Patients are also now led to believe that they can obtain a surgical rhinoplasty result with the use of injectable fillers alone. These factors increase the possibility that a rhinoplasty patient may encounter a poor outcome and, what may be worse, be ill-equipped to assimilate it.
Against this backdrop, it is ever more important that surgeons understand and embrace a rhinoplasty patient’s psychology. Psychology is arguably more relevant to rhinoplasty than it is to other facial plastic surgical procedures, because patients seeking aging face procedures are not in search of a change so much as they are in pursuit of a return to a previously favorable self-image. Rhinoplasty patients, on the other hand, have often been living since puberty with the insecurity attached to their nose. This uneasiness has usually been a formative part of their body image. They are more apprehensive about the changes proposed since they often possess a clear vision of their preferred self-image, although they may have a hard time articulating that ideal. The failure of a rhinoplasty procedure to harmonize with this desired self-image can meet with profound anxiety. This is especially true for revision rhinoplasty patients who carry the added burden of already having experienced an overwhelming disappointment.
The gravity of this reality should not be underestimated. Physical violence against surgeons is rare but real. In the decade from 1995 to 2005, five plastic surgeons in the United States were killed by former patients. We all possess a dominant personality type and we tend to use it as a filter in response to our surroundings. In times of stress, this response mechanism becomes exaggerated. Some of us weather the storms of our lives with little fanfare. Some withdraw and retreat into ourselves. Others strike out with aggression. A patient’s personality type can be of prime importance in determining how he or she will interact when faced with an unexpected surgical result.
What Makes Patients Unhappy
Treatises on the subject of patient unhappiness usually focus on patient factors that may contribute to this unfortunate situation and tend to deemphasize the discussion on surgeon-related factors as a possible cause. Since surgeon factors are the only ones we can really influence, it makes sense to explore these more in depth. You may find it hard to admit that, more often than not, patients are justifiably unhappy because you failed to meet their expectations. With any luck, this happens very infrequently but, as the saying goes, if you do not have any surgical problems, you are probably not operating enough. Even the most meticulous and accomplished among us has a measurable revision rate. Having a very low revision rate, however, does not by itself declare you a great surgeon. Your unhappy patients may simply be taking your revisions elsewhere.
Patient expectations may have been unfulfilled for several reasons that may or may not fall within your control. The surgical outcome may have been truly subpar. The patient may be the inauspicious recipient of a complication despite your best efforts at avoiding one. You may have unwittingly misled the patient as to what you could accomplish with the proposed procedure. You may not have given the patient the time and attention he or she deserved. You may have talked the patient into having a chin implant because you thought it would improve her rhinoplasty result, even though she expressed no interest in this procedure. You may have been insensitive when she was airing her postoperative concerns. You may have accepted a patient who was a decidedly poor candidate for rhinoplasty. Most of these factors are avoidable. A patient’s happiness with the procedure is arguably as much dependent on your attitude and conduct toward the patient as it is on the technical result itself and on the patient’s personality features.
To be sure, many patient factors play a role in this interaction, and these will be examined. Yet, a survey by the American Academy of Facial Plastic and Reconstructive Surgery showed that the most common reason for patient unhappiness, more than all others combined, was a breakdown of rapport (51% of cases). The rapport developed preoperatively is most indicative of the direction of the postoperative dynamic. A strong preoperative bond will usually be reinforced under difficult circumstances when both the surgeon and patient are working toward a common goal of improvement. Likewise, a deficient relationship will usually decay under duress, sometimes beyond recovery. To fully understand and prevent problems pertaining to the surgeon–patient relationship, the microscope must be turned inward.
Avoiding and Preventing Unhappy Patients
There is a kernel of truth in the old adage that the secret to a successful practice is first Affability, followed by Availability and, finally, by Ability. Yet, there is no getting around an undeniably flawed technical result. No amount of kindness on the part of the surgeon can fully compensate for this failure. Jack Anderson, M.D., was known to teach that it is not essential that you operate brilliantly; rather, you should strive to never operate badly. The best defense against unhappiness, then, is to consistently do good work. But, what of the majority of patients who encounter an “adequate” result, one that most people would describe as at least good, if not perfect? This result has the potential to produce an overjoyed patient, a mostly satisfied albeit mildly disappointed patient, or a hopelessly discontent one. This difference has mostly to do with perception. A patient who was given realistic expectations and who is treated with true caring will be inclined to overlook the minor imperfections associated with this outcome. A similar patient with the identical result will be given to chronic unhappiness if she was led to anticipate a far superior outcome or if she or he was treated unjustly. The following section takes a practical, rather than theoretical, approach to the discussion of what a surgeon may do to increase the chances for having patients fall into the former category. These truisms are not meant to be patronizing but, rather, to act as a gentle reminder that the surgeon very often controls the direction of the physician–patient dynamic. The fact that they are generally simplistic and even patently obvious does not diminish their value as good principles of patient management.
If you do not like the patient, do not operate. This seems self-evident, but you should follow the principle of performing surgery on happy patients that you like. This is probably the single most important tenet of patient selection. A small percentage of people have a negative outlook on virtually every aspect of their lives and there is no reason to expect that your surgery will be any different. These are pessimists who exaggerate the negative impact of a majority of their life circumstances. Many harbor a general mistrust of physicians. As a result, they are unlikely to be fully satisfied with even an excellent outcome. Thankfully, these patients are relatively easy to identify during the preoperative consultation. Happy people, in general, are more likely to remain happy with their results, to accept imperfection, and to refer their like-minded friends and colleagues. This way, you will continue to attract happy people to your practice.
Take yourself out of the equation. Understand, first and foremost, that you do not matter as much as you might think. We call what we do preoperatively “patient selection” when, in fact, the truth is that you do not choose the patient; the patient chooses you. You are the gatekeeper of your practice. At best, you can refuse a patient. It matters not what you think of your surgical results. It matters only what your patients think; theirs is the measure of your success.
Work at keeping your patients happy. When patients agree to have you perform surgery, they are excited and optimistic. They want to enjoy a fulfilling and productive relationship with you. Contrary to popular belief, most cosmetic surgery patients are usually happy, well-adjusted, and committed people who are interested in self-improvement. Testing has repeatedly shown that cosmetic surgery patients are in the normal range for self-esteem, although most have a low self-image for the particular feature of concern. They are not typically unreasonable, discontent, disordered, experiencing chronic health concerns, or seeking secondary gain. Furthermore, most do not expect perfection. When they cease to be happy, it is usually because we have contributed to their displeasure by the way in which we have responded to them. A cosmetic practice is a little like a marriage in that happiness does not appear out of thin air. With that in mind, you should undertake every interaction with the philosophy that your foremost purpose is in helping your patients to achieve happiness.
Explore patients’ motivations. If you have concerns that a patient may have a generalized low self-image or is undertaking the procedure for some reason other than his or her personal satisfaction, you should consider not doing the surgery. A patient responding to external motivators is far more likely to be discontent even with an outstanding result. Unhealthy motivation and poor self-image often combine to increase the chances of psychological instability and dissatisfaction after surgery. By the time you agree to schedule surgery, you should be absolutely sure of the patient’s sincere motives for self-betterment. Occasionally, surgery is not the answer and patients deserve to know that at the outset. Otherwise, you will discover a patient who continues to be dissatisfied despite obtaining a good technical result.
Listen more. It can be tempting during your consultation to launch into a discourse on what patients need and how fortunate they will be to benefit from your formidable talents. Spend more time listening than speaking during the consultation. A patient’s questions can be as revealing as can their omissions. If the consultation becomes more about you than about the patient, you will have missed your chance to truly evaluate his or her suitability.
Be honest about your own motivations. External motivators play a complicating role when deciding on whether to operate on a potentially problematic patient. Experienced surgeons have the benefit of a more finely tuned “sixth sense” coupled with a motivation to avoid accepting patients who are at higher risk for being dissatisfied. A younger surgeon is more driven to accept every patient early in his career because he or she can ill-afford to lose a case. He or she wants every potential patient to choose him or her and will often ignore the little voice of unease that says this patient may not be right for him or her. Good judgment can easily be obscured by needs pertaining to the ego or to the pocketbook. An unselfish commitment to the patient’s best interests in every situation may necessitate some short-term sacrifice, in the form of refusing surgery where appropriate, but will undoubtedly have the long-term rewarding effect of growing your practice.
Recognize and respect your limitations. It is more important to tell the patient what you cannot do rather than what you can. Check your ego at the door. You cannot be an expert at everything. The most respected giants in our field often do no more than four or five operations most of the time. They accumulate mastery of a technique. That is not to say that all learning should cease after training; quite the opposite is true. But, be cognizant of your place on the learning curve. If you are incorporating an emerging technology that you just discovered at a recent meeting, tell the patient that the potential benefits are not entirely clear. Ask yourself if this new technology is really likely to make your patient happier with the result. If a patient would most benefit from a rib graft, which you perform once a year, consider referring him or her to a trusted colleague who has more experience if you believe that to be the best procedure for that particular patient. A fourth time revision is perhaps not one you wish to include among your first 50 rhinoplasties. In general, a spirit of conservatism and prudence should prevail if you wish to minimize the number of unhappy patients you inherit. This is especially true early in your career where a single unhappy patient can wreak havoc on your budding practice.
Undersell the benefits. When you give your patients an expectation of the result preoperatively, whether by computer imaging or by other means, underpromise so that you can overdeliver, exceeding patient expectations. The authors make a habit of imaging a less than ideal result. We tell our patients that surgery is imperfect but we know that if they can be happy with the imaged “average” result, then we can almost assuredly do better for them. Be cautious of the rhinoplasty patient who also needs a chin implant. Do not push the patient to have a procedure that you think would be more beneficial. The level of unhappiness with a less than perfect result is far greater when the procedure was suggested by you rather than by the patient. Instead, be honest in your appraisal and dissuade patients from pursuing a procedure if they would not benefit optimally. Your integrity will be most welcome and will often result in a successful relationship in the future.
Do not let your head overrule your gut. Your gut instincts are not always right, but they often are. Your impression of the patient in the first 5 minutes of your interaction is usually an accurate preview of how this interaction will play out postoperatively. In the book Blink , the author Malcolm Gladwell describes that subcognitive perception enables us to make rapid assessments that have greater precision than those judgments that result from extensive analysis. The patient you initially think might present a problem after surgery often does live up to those expectations. Most physicians are often influenced by their urge to “do good.” The hope that your technically good procedure will engender a joyful disposition in a patient who is psychologically unsuitable for surgery is rarely realized. If you are unsure about a patient’s suitability, spend more time with him or her. If your doubts are reinforced, you will have made better use of your time in deciding not to proceed with surgery than in spending countless hours with an unsatisfied patient after surgery. Remember, though, that the more time spent with some personality types, the more psychologically healthy they may appear.
Inform your patients properly. There is a saying among experienced surgeons, “What you tell patients before surgery is an explanation … what you tell them afterwards is an excuse.” It is true that patients hear only a small fraction of what you tell them during the consultation. So, make a habit of eliciting questions, speaking slowly, repeating often, and imparting information in more than one format. The authors routinely see patients for a second visit prior to surgery, partly to further gauge their fitness for our practice but also to convey information at a time when they are more relaxed and more likely to be receptive. The authors ask patients to sign a document stating that they have received, read, understood, and agreed to abide by all of the preoperative and postoperative instructions. By doing so, patients grasp that they are partners in this endeavor.
Tell a patient about the possibility of a revision. It is easy to gloss over possible complications because this discussion is uncomfortable and many patients do not even wish to have it. This temptation should be avoided. Patients should be given information along with an explanation of the surgical consent both verbally and in writing. The authors send patients home with a sheaf of literature that is more inclusive rather than exclusive of instructions on preoperative and postoperative care in addition to potential risks of the proposed procedures. Patients should be given time to review this information so they have a chance to digest it quietly at home within their comfort zone. That way, you are not springing something new on them in the follow-up period at a time when they will view new information with suspicion.
Respect your patients . Be likable and courteous. Do not keep patients waiting and apologize when you do. Schedule enough time to answer their questions. Patients are more inclined to be happy with you if you show them you actually care about them personally. Although you cannot forge a successful practice just by being nice, a cordial nature can produce inestimable dividends. If you come off as distant, dismissive, or arrogant, your patient is likely to form the impression that you treat every aspect of his care or her with the same lack of concern, inclusive of the surgery. You are more likely to end up with a practice full of patients who point out your minor failings rather than be accepting of the minor imperfections they encounter.
Save your patients added expense, time commitment, and inconvenience. Do not put them through unnecessary tests. If there will be added expense in the event of a revision, spell these out for them ahead of time. Sometimes a patient is justified in being unhappy with the result. Consider what you are willing to do for them in that event.
Warning Signs of Potential Patient Dissatisfaction
The patients described earlier in this chapter are those we seek for our practices. These are patients who have clear and sensible motivations and reasonable expectations. They understand the risks entailed by surgery and accept that there is no guarantee of a perfect result or of absolute satisfaction. They have divergent features of real concern but they are not excessively preoccupied with them. Their goals are reachable in our hands. They are courteous, pleasant, earnest, and dependable. They accept their share of the responsibility for their actions and decisions. They are not looking for nor expecting a radical, life-altering change. They desire an outstanding result but would be pleased with a good one. In short, these are generous, happy, and well-balanced people who constitute the majority of cosmetic surgery candidates.
We would all like to believe that every patient fits this description, but not all prospective patients do. These are not terrible people but they possess personality and psychodynamic traits and coping mechanisms that place them at an unhealthy risk for dysfunction following aesthetic surgery. They are more likely to be unhappy with any result. We owe it to our patients to remember our oaths and to make recommendations that will most benefit them. For some of these patients, surgery is not the appropriate recommendation and we should make every effort to save them and us the hardship of dealing with an unhappy outcome. Unfortunately, poor candidates for cosmetic surgery do not wear warning signs on their chests. Some of these maladaptive traits take time to become apparent and still others masquerade as wolves in sheep’s clothing, only to surface after the procedure. What follows is an accounting of the common warning signs to which surgeons should be attuned in the preoperative period that will allow them to appropriately counsel patients not to proceed with surgery. These have been previously published in detail by the senior author (P.A.A.) under the moniker “The Dangerous Dozen” and can be further subcategorized as extrinsic or intrinsic factors.
Extrinsic Factors
Patients Experiencing A Life Crisis
Sometimes patients request cosmetic surgery after a divorce, job loss, bereavement, accident, or illness. Alternatively, some patients wish to have surgery before a wedding or graduation. Be careful of operating on patients in the midst of a major life event, whether positive or negative, as these may be significant stressors. It is ever more important in these situations to analyze a candidate’s rationale. It is true that someone who possesses improved self-esteem and confidence, as can be achieved through cosmetic surgery, may in turn have greater success finding a new mate or a new job. However, a decision made under pressured circumstances or situational stress may have unwanted consequences. Patients who thought surgery was the answer to their problems may perceive otherwise after these life stressors have settled. Patients should ideally possess a state of mind that will permit them to focus their energies on recovery. A more considered decision could often be made when life conditions have been stable for some time. Evidence points to the likelihood that patients who are motivated intrinsically to undergo surgery, rather than by expectations relating to external factors, are more likely to view their surgical results as successes. So, while cosmetic surgery may sometimes bring about secondary gains in the way of positive life changes, these desired gains should not be the sole motivation for surgery.
Patients with Culturally Rooted Concerns
Some patients face possible disapproval from family members for their desire to alter the “family nose.” For patients of specific ethnic backgrounds, their desire to even consider undergoing rhinoplasty may be met with condemnation by others sharing their ethnicity. Those close to them may perceive patients as rejecting their racial heritage. However, in our experience most ethnic rhinoplasty patients wish to achieve a more balanced nasal aesthetic while maintaining a strong ethnic identity. If possible, the family should be made aware of this motivation, as they will be more likely to be supportive of the patient’s decision. Nevertheless, the negative influences of family members and friends may unduly taint a patient’s postoperative perspective. Therefore, it is important to counsel patients with delicacy when they face such a situation if you wish to avoid having the patient’s frustration with this scenario transferred to you. In addition, patients who have some ethnic-specific features must accept the inherent limitations presented, in that they may achieve a result that is shy of what they wish. Thicker skin may restrict the amount of definition and refinement achieved. Very low nasal height may permit less than desired augmentation. Darker skin may likewise render scars that are more visible. On the positive side, patients should also be apprised of the advantages inherent to some ethnic characteristics, such as superior graft concealment.
Intrinsic Factors
The following descriptions relate general psychological states and behavior patterns that put patients at risk for postoperative dissatisfaction. These are not meant to be unkind to patients nor should they substitute for a referral for definitive diagnosis and treatment of a categorical mood, anxiety, or personality disorder. While a surgeon cannot take the place of a psychiatrist, he or she should be attuned to detection of these traits, regardless of whether they meet criteria sufficient for diagnosis, as they can impact the patient’s postoperative temperament.
Mood Disorders
Depression. In any given year, 9.5% of the U.S. population, suffer from a depressive illness, with women being affected twice as often as men. Preoperative depressive symptoms are the best predictors of postoperative depression, more so than other psychological aspects of surgery. Rarely, this postoperative decompensation can be severe, even manifesting with psychotic symptoms. Postoperative depressive illness appears to occur more frequently after rhinoplasty. So, it is incumbent upon the surgeon to address this issue in the preoperative period. Patients with a history of depression should be informed of the increased risk for impaired coping in the postoperative period. The patient’s counselor should be involved during the preoperative assessment to ensure that management of this illness is optimized prior to undertaking surgery. Extra care should be taken to ensure that these patients have the support they need to endure the stresses associated with postoperative healing.
Anxiety Disorders
Generalized anxiety disorder. Anxiety affects up to 18% of the U.S. population and often occurs coincidentally with depression. People suffering from generalized anxiety have chronic, nonspecific worry that is difficult to control. Although they may be good surgical candidates, these patients usually need extra attention and care. They are pessimistic by nature and may tend to fret over even normal postoperative healing. Stressful events such as surgery may cause an exacerbation of symptoms. Nevertheless, reassurance and care will often allow these patients to appropriately frame their results and to obtain postoperative satisfaction.
Body Dysmorphic Disorder
Body dysmorphic disorder (BDD) is an uncommon but severe psychiatric disorder in which the affected person is excessively preoccupied with a minor or even imagined physical defect. People suffering from BDD are generally of normal or even highly attractive appearance, yet believe themselves to be so hideous as to inhibit normal social interaction. It is estimated that between 1% and 2% of the general population is affected, although the incidence of a milder phenotype may be as high as 5% to 15% among cosmetic surgery patients. The nose is the third most frequently associated body area after the skin and hair. Thus, facial plastic surgeons must maintain a high index of suspicion for this disorder with all patients seeking rhinoplasty.
BDD is linked to the obsessive-compulsive spectrum of disorders and affects men and women equally. Personality types that are more susceptible to this disorder include introverted, perfectionist, dependent, and avoidant personalities who are highly sensitive to criticism. They tend to be secretive, even reclusive, and reluctant to admit to the severity of the disorder or to seek help for fear of rejection. Psychological comorbidity is prevalent, including social anxiety, obsessive-compulsive disorder, and depression. Suicidal ideation is present in about 80% of sufferers, and the completed suicide rate is more than double that of those with clinical depression and 45 times the rate of the general population. These patients should be identified preoperatively and dissuaded from undergoing surgery since it is destined to failure in that it will not diminish appearance-related concerns. The disorder is likely to persist or worsen despite surgical alteration. Thankfully, effective treatment is usually possible in the form of selective serotonin reuptake inhibitors and cognitive-behavioral therapy.
Personality Disorders
Personality disorders are the psychological disturbance most commonly encountered in patients seeking cosmetic surgery. The following descriptions summarize those specific personality types who are best deterred from considering cosmetic surgery.
Psychologically estranged personalities. If you encounter a patient who displays slightly odd thought or behavior patterns and with whom you have difficulty establishing a meaningful connection, you should consider this personality type. In the initial consultation, it is not uncommon to feel like “there is something missing” in the interaction. It just “does not feel right.” Pay attention to these instinctive reactions, as persons having this personality type may appear more “normal” as you spend more time with them. These are patients who may exhibit some paranoid, schizoid, or schizotypical traits. They tend to have suspicious thoughts and are guarded about their histories and motivations. They may be eccentric in their mannerisms. They may also appear to be emotionally withdrawn and excessively serious and may react inappropriately to conversation. Patients who fit this category have trouble giving you their trust and fall into the generally unhappy group of patients. Plastic surgeons should avoid operating electively on patients with this personality type. In the postoperative period, psychologically estranged patients are more likely to be unforgiving and prone to anger and even aggression. Since surgeons can never truly be able to develop a rapport with patients of this personality type, it will be nearly impossible to deal with them effectively after surgery. Thankfully, these high-risk patients are rare.
Borderline personalities: The Goldilocks syndrome. Borderline personalities are unstable in many areas of their lives, including interpersonal relationships, thoughts, mood, behavior, and self-image. More often female, they are often very bright, manipulative, and beguiling and, for that reason, may escape detection in the initial consultation. Be wary of patients who appeal to your vanity with premature and excessive familiarity or praise. Frequently heard expressions include, “I just knew a surgeon with your talents could help me” and “You’re the first one to understand me perfectly.” This personality type’s tendency to impulsive extremes and absolutes results in the phenomenon known as “splitting.” While you may be idealized preoperatively, you may be vilified postoperatively with comparable ease.
The Goldilocks syndrome is a manifestation of the borderline personality with histrionic characteristics. These patients function at a high level but tend to use their ample social skills in the service of manipulating others in their quest to become the center of attention. Like the protagonist of the children’s story after which this patient is named, they will never be fully satisfied unless everything is “just right.” She often fails to see her personal situation realistically and tends to overly dramatize her problems while shifting the blame for her disappointments to you. All of these factors, along with instability of self-image, predispose this patient to greater risk for development of dissociative tendencies, crisis involving loss of identity, and depressive states after rhinoplasty.
Patients with loss of identity will complain that their rhinoplasty changes, no matter how subtle, have caused them to no longer “look like themselves.” When probed for details, they are vague, evasive, unfocused, and unable to give any more specific descriptions. This frustrates both patient and surgeon and may lead to inappropriate outbursts of anger by the patient. Somatic complaints are frequently associated with the nose, including airway obstruction, pain, and tenderness, especially at the rhinion. Borderline personalities typically become more apparent as the extent of the interaction increases, so ample time should be invested during the preoperative period. If in doubt, one should not operate on patients showing this personality type. Their unstable behavior and fluctuating self-image make these patients prone to isolation, unhappiness, and unpredictable and self-destructive behavior.
Narcissistic personalities: The exceptionalism syndrome. This personality type is excessively preoccupied with issues of personal adequacy, power, and prestige. Often, these patients are successful in their chosen industry and exhibit a pervasive pattern of grandiosity combined with a lack of empathy. These patients are easy to recognize and often will frustrate your front office staff by their blatant egocentrism starting as early as through the first telephone contact. The overriding message projected by this personality type is that his time is valuable while yours is expendable. He is often late, cancels appointments frequently, takes telephone calls in the office, and demands to see the physician immediately upon arrival because he has an important meeting afterward. These patients’ overinflated sense of self-importance extends to their interactions as well. They hold the belief that no one but persons of high status are deserving of their attention and, very often, they will attempt to bypass any dealings with nurses, associates, or other staff members. While a patient with exceptionalism syndrome may treat the surgeon with deference, at least initially, difficulties often arise later. He is usually inconsiderate of the viewpoint of others and does not listen during the preoperative consultation. If the patient will not make time for the consultation or cancels for trivial reasons without the courtesy of notice or apology, you can be sure he will not have much patience for you after surgery nor is he likely to follow your postoperative directions. Since he is unwilling to accept a share of the responsibility for his decision, he is also unlikely to be forgiving of an imperfect result. You should try to identify and avoid this personality type early in the consultative process.
Antisocial personalities: The “my theory” syndrome. While the extreme antisocial personality can be characterized as a true psychopath, a milder phenotype is occasionally seen among aesthetic surgery candidates. These are patients having a superficial charm that masks an inflated self-appraisal and lack of empathy. They may be deceitful, withhold information, and fail to conform to office standards. They may have a history of drug seeking and substance abuse. There may also be a component of antagonistic behavior, including a disregard for financial obligations and a history of lawsuits against previous surgeons. Conduct is characterized by agitation, bouts of aggression, and impulsivity. The “My theory” syndrome patients display a variant of this personality type that blends obsessive and antisocial traits. These patients have little respect for the surgeon’s viewpoint and have little interest in listening to what the surgeon has to say. Instead, they are only interested in advancing their own theories of what is wrong with their noses and what must be done to fix them. They are usually extensively well read and often present with scientific articles and detailed drawings or alterations of their own images. They believe they know exactly what surgical maneuvers are needed to achieve the improvements they seek. “My theory” patients frequently interrupt the consultative process, dominate the interaction, solicit information already provided, and react with veiled hostility when presented with an explanation or recommendation that does not support their own conclusions. Extra care must be taken to ensure that these patients are adequately informed of the risks and realities of surgery. If it appears that a “my theory” patient is unwilling to surrender his beliefs and to entrust his care to his surgeon, it would be wise to advise against surgery. Any patient who demonstrates hostility in the preoperative period or who breaks the “sacred trust” should be avoided altogether.
A more radical version of this personality is the well-described SIMON syndrome ( s ingle, i mmature, m ale, o bsessive, and n arcissistic). This syndrome has received singular attention in the literature because of the dangers involved. Patients falling into this category possess a multiplicity of maladaptive traits that dispose them to both dissatisfaction and potentially threatening behavior. As a result, surgeons should proceed with extreme caution when considering rhinoplasty in such patients.
Obsessive-compulsive personalities: The “package of pictures” syndrome. Compulsive personalities are high-achievers but they are rarely fully satisfied with their achievements and may have a deflated self-image. They are often orderly, punctual, and dependable. You can rely on these patients to follow instructions to the letter. Yet, while they can be reliable patients, they also tend to be excessively cautious and detail-oriented, making it difficult for them to make a decision. They may need to see you numerous times to review the imaging or surgical plan before agreeing to surgery. The “package of pictures” syndrome may be a specific manifestation of the obsessive personality type. Patients presenting with a package of pictures often have unrealistic expectations. They may present preinjury or presurgical photographs of themselves or photographs of models demonstrating the very clear and specific improvements they desire. Very often, these desired changes are unattainable for that patient. This does not mean that every patient in this category is at high risk for postoperative disappointment.
To stratify patients’ risk in this scenario, it is necessary to ascertain to what degree they cling to their expectations. The trouble with obsessive patients lies in their inflexibility. You will be able to differentiate the obsessive personalities by their inability to “let go” of their excessively optimistic demands. If a patient is simply uninformed, he or she will be able to alter his or her expectations after careful explanation of the limitations and realities of cosmetic surgery. These are favorable surgical candidates who understand that the goal of surgery is improvement. If, however, a patient is unable or unwilling to reframe his or her too-lofty expectations and continues to demand unrealistic assurances of any kind, the surgeon should decline to operate. These patients manifest attributes of BDD and obsessive-compulsive personalities and are at very high risk for postoperative unhappiness. They are not dangerous per se, but they will often be troubled with the operative result. Postoperatively, they will perseverate over minor or barely perceptible defects and will find themselves unable to acknowledge the overall improvement or to derive enjoyment from their good surgical result.
Avoidant personalities: The unfocused syndrome. Avoidant personalities are socially inhibited and are preoccupied by feelings of inadequacy. They consider themselves to be personally unappealing and, rather than facing possible rejection, they choose to preempt this risk by consigning themselves to self-imposed isolation. This personality is associated with perceived or actual rejection by parents or close peers during the formative years and, thus, they have an intense desire for intimacy in relationships. This intense need can often be inappropriately displaced onto unrealistic hopes for the surgical outcome. The avoidant personality’s interactions are distinguished by intense monitoring of their own internal reactions along with those of others. This constant monitoring produces in them extreme tension that manifests as hesitant speech and taciturn behavior. Surgeons should look for symptoms of self-loathing, extreme shyness, mistrust, emotional distancing, and loss of identity. They are often unfocused and may show a reluctance or incapacity for identifying a specific complaint about their noses. Instead, they may shift the burden of decision and action to you. This indecision may be expressed by such phrases as, “I’ve never liked my nose but I cannot say why.” Surgical planning is compromised in that surgeons bear the sole responsibility for an undesirable outcome. Patients in this situation are at risk for postoperative dissatisfaction. These will usually manifest as vague complaints, such as, “I do not know what it is, but I just do not like how the surgery turned out.” Preoperative counseling should focus on gaining the patient’s trust, encouraging him or her to identify specific concerns and to challenge his or her exaggerated negative beliefs. If that is successfully accomplished, then a satisfying operative experience is made possible.
Dependent personalities: The “exhausted surgeon” syndrome. As the name suggests, patients exhibiting this personality characteristic have exhausted themselves and every surgeon they have seen. They are the quintessential “doctor shoppers,” spending inordinate amounts of time researching and visiting surgeons. This behavior pattern has arisen from a general lack of confidence in their own judgment, abilities, and capacity to make good decisions. Dependent personalities often require disproportionate amounts of advice and reassurance from spouses, friends, relatives, and even strangers, such as visitors to online rhinoplasty forums.
Like the avoidant personality, dependent patients would prefer for you to direct the consultation. When asked about her nose, this patient may demonstrate her need for you to assume responsibility with statements such as, “You’re the expert. What do you think I should do to my nose?” They may have difficulty expressing open disagreement with your suggestions. When they are finally able to commit to surgery, these characteristics continue to guide the postoperative dynamic. This patient may go to excessive lengths to ensure your unwavering support and nurturance such as through elaborate gift-giving and excessive praise. Yet, they will probably not voice their disappointments and instead will eventually seek another surgeon when events do not go exactly as planned. Frequently, this syndrome is accompanied by anxiety, insomnia, and depression, as a result of the stress associated with perceived powerlessness and indecision. Not infrequently, it may affect aesthetic surgery patients who work in the medical or paramedical field. These patients meet the description of “maximizers” put forth by Barry Schwartz, author of The Paradox of Choice . Unlike “satisficers,” who make quick and confident purchasing decisions and are satisfied by “good enough,” “maximizers” are preoccupied by hypothetical “what if’s.” They are unable to commit to a decision without first exploring every avenue and making comparisons. They suffer from “paralysis of analysis,” holding out for the absolute best conditions and surgeon, taking years to reach a decision. Because of the expectations heaped on this choice, patients with “exhausted surgeon” syndrome often suffer from buyer’s remorse. They cannot help but compare their results to those of others, think of the alternatives, and wonder whether that other surgeon would have done any better. According to The Paradox of Choice , these patients could be happier if they gained insight into their struggles, enacted voluntary constraints on their freedom of choice, lowered their expectations, accepted good enough rather than perfect, and they stopped comparing their experiences to others. This advice is reminiscent of the surgeon’s adage, “Perfect is the enemy of good.” Comparably to the “maximize,” we need to bear in mind that although perfection is our relentless pursuit, it is unattainable.
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