Buyer's Remorse In Plastic Surgery

"OMG!! what did I do?! ...

I must be crazy to do this!" said my patient only hours after her tummy tuck. She was in some pain and distress, as the anesthesia was wearing off, and began a tirade of self-disparaging statements reflecting all her worst fears and anxieties about the surgery.

I stopped what I was doing, and sat down with her on the recovery room bed to calm her down. It's amazing how comfortable those recovery room beds are...and the patients seem to really like it when I take my time to explain and review things with them. She did fine after some pain meds and a little small talk, and on her 1 week postop visit, was happy as a clam with her new flat tummy. And that's when I realized just how common "buyer's remorse" is in plastic surgery.

Plastic surgery, especially cosmetic surgery, is elective. That means that it isn't surgery that you need, but surgery that you want. Oftentimes, people overlook the pain and discomfort that is inherent to any surgery. Although, most people who have had plastic surgery, and, gladly, the vast majority of my patients, will say that they are happy with the decisions that they made, a certain segment of the patient population will always have difficulties in adjusting to the postoperative demands, no matter how carefully they were selected by the surgeon or how well surgery was performed.

Every plastic surgeon hones his/her patient selection skills over years of education, training, and practice. The goal of every plastic surgery practice is to only have happy patients. As this is an ideal that will probably never be reached, we surgeons must realize that some of our patients will be unhappy, at various stages of the postoperative period. Those patients need special attention, understanding, and a compassionate review of clinical details. They must be empowered, and be actively involved in the procedures of postoperative recovery. It's also important to give your patients options as to colleagues who may serve as second opinions.

As a patient, if you find yourself unhappy with the results of a cosmetic procedure, take a deep breath and fret not, as it depends on the timing. Most early remorse cases are due to the unexpected, and probably poorly managed, pain and discomfort. Moreover, remorse is clearly correlated with incidence of complications of surgery. In the case of the former, simple and more precise pain control and behavior modification is all that is needed. In the latter, both preoperative and postoperative miscommunication between patient and surgeon is the usual contributing factor. As difficult as it is to do, as a patient you must communicate with your surgeon, even if you believe that he/she is responsible for a poor outcome.

We must realize that we can all end up being the patient who regrets having plastic surgery. It can happen if you're the best patient, or if you have the best doctor. What's important for both of you is to keep the lines of communication open so that proper, just, and adequate resolution is reached. No patient should abandon his/her doctor, and the opposite is just as true.

Medical Spa MD: Burned out & depressed plastic surgeons more likely to commit medical errors?

Surgeons who are burned out or depressed are more likely to say they had recently committed a major error on the job, according to the largest study to date on physician burnout.

The new findings suggest that the mental well-being of the plastic surgeon is associated with a higher rate of self-reported medical errors, something that may undermine patient safety more than the fatigue that is often blamed for many of the medical mistakes.

Although surgeons do not appear more likely to make mistakes than physicians in other disciplines, surgery errors may have more severe consequences for patients due to the interventional nature of the work. Some estimate that as many as 10 percent of hospitalized patients are impacted by medical errors.

"People have talked about fatigue and long working hours, but our results indicate that the dominant contributors to self-reported medical errors are burnout and depression," said Charles M. Balch, M.D., a professor of surgery at the Johns Hopkins University School of Medicine and one of the study's leaders. "All of us need to take this into account to a greater degree than in the past. Frankly, burnout and depression hadn't been on everybody's radar screen."

Nine percent of the 7,905 surgeons who responded to a June 2008 survey commissioned by the American College of Surgeons for a study led by researchers from Johns Hopkins University School of Medicine and the Mayo Clinic reported having made a major medical mistake in the previous three months. Overall, 40 percent of the surgeons who responded to the survey said they were burned out.

Researchers asked a variety of questions, including queries that rated three elements of burnout -- emotional exhaustion, depersonalization and personal accomplishment -- and others that screened for depression.

Each one-point increase on a scale that measured depersonalization -- a feeling of withdrawal or of treating patients as objects rather than as human beings -- was associated with an 11 percent increase in the likelihood of reporting an error. Each one-point increase on a scale measuring emotional exhaustion was associated with a 5 percent increase.

Mistakes also varied by specialty.  

Surgeons practicing obstetrics/gynecology and plastic surgery were much less likely to report errors than general surgeons.

Researchers acknowledged the limitations of self-reporting surveys, saying they couldn't tell from their research whether burnout and depression led to more medical errors or whether medical errors triggered burnout and depression among the surgeons who made the mistakes.

The results are being published online on November 23 in the Annals of Surgery and will be published in the printed journal in an upcoming issue.

Notably, the research shows that the number of nights on call per week and the number of hours worked were not associated with reported errors after controlling for other factors.

"The most important thing for those of us who work with other surgeons who do not appear well is to address it with them so that they can get the help they need," says Julie A. Freischlag, M.D., chair of the Department of Surgery at the Johns Hopkins University School of Medicine and another of the study's authors.

via sciencedaily.com

Perhaps the most relevant items here are the decreased reporting of problems by plastic surgeons and the fact that 'depersonalization' has entered the discussion.

I'm really curious about what plastic surgeons think of this study.

Botax: Taxes on Botox and plastic surgery?

The medical spa and plastic surgery community is in an uproar over some proposed legislation that could make a trip to the plastic surgeon or a Botox injection at the medical spa more expensive.

People are calling it the Botax. It's a 5 percent tax on elective procedures such as Botox, Juvederm, Restylane, laser hair removal, facelifts, breast augmentation and other nips and tucks that lawmakers are hoping will help fund the nearly $1 trillion health care plan.

The bill says the tax would not apply to surgeries to fix a deformity either from birth, accident, or disease. It would apply to procedures like face lifts, liposuction, cosmetic implants and teeth whitening.

But as Dr. Paula Hicks points out sometimes cosmetic surgeries have very medical purposes.

"Certainly breast reduction surgery is a very good surgery for a lot of women and a lot of them will get denied by the insurance company as cosmetic surgery," said Dr. Hicks of the Ave Medical Laser Spa and Laser Clinic.

Under the proposal, Dr. Hicks says an eyelid tuck, which can help with vision, would cost an extra $100 in taxes on top of the $2,000 price tag for the procedure.

She says that could be a big hit to her business since most of her clients are not wealthy.

"Most of these procedures are not done on people that are rich and have endless amounts of money, it's middle class working women that would be targeted with this tax and it's really not fair."

According to the American Society of Plastic Surgeons 86 percent of cosmetic surgery patients are women. Sixty percent of them have annual incomes between $30,000 and $90,000.

The tax, if approved, would raise $6 billion over 10 years.

Allergan, which sells Botox, took a civil rights angle: The tax “discriminates against women,” the company said in a statement. Some 86% of cosmetic surgery patients are working women ages 35-50, with an average annual income of $55,000 per year, according to Allergan.

“What’s next? Are we going to tax people who color their hair?” the CEO of Medicis, a drug company that sells fillers, told Dow Jones Newswires.

The American Academy of Cosmetic Surgery, which is fighting the provision, says “a large portion of those being taxed would be the baby-boomer generation. And as this age group continues to age, the more interest will be generated in cosmetic procedures.”

A spokesman for the 2,500-member group said they were surprised to see the provision in the Senate bill this week, because it had already surfaced and sank in July. The tax is not in the House bill.

The tax is on elective procedures, and would not apply to any procedure to correct birth defects or issues arising from disease, accidents or trauma. The CBO says it would raise about $5 billion over the next decade.

Follow Medical Spa MD on Twitter.

Plastic Surgery Product Placement

Be Born Again

To promote Dr. Kim's plastic surgery office, this life scale poster was placed at the entrance of his office and by the elevator in the main lobby of the hospital building.

via dfckr.com

A slick little promo for a plastic surgery practice. You have to love well done attention-getting advertising and medical spas and plastic surgery clinics are certainly rife with products that lend themselves to great advertising and marketing. I've got perhaps hundreds of these types of ads that I keep as something of a library.

Do it yourself Botox? ABC News wants to talk to you.

Have you tried do-it yourself plastic surgery or home Botox injections?

In tough economic times, many try to cut costs, including in their beauty regimen. Despite the risks, some people have decided to skip the doctor -- and obtain and self-administer cosmetic treatments.

If you have self-injected products like Botox, Restylane, Juvederm, silicone, and other substances, 20/20 would like to hear your story.

Please fill out the form below, including information about your experience, and a producer may be in contact with you.

You can tell ABC all about it here.

Plastic Surgery & Beauty

Plastic surgeons and even med spa physicians offering Restylane and Juvederm would be well intentioned to make sure that they understand the cannons of what beauty actually is. In many ways it's the elimination of asemmetry or extra 'noise' like wrinkles or pigment.

Via CNN: It's hard to pinpoint what distinguishes a gorgeous face from an average one, but some researchers are getting pretty close. Psychologist Lisa DeBruine, Ph.D., of the University of Aberdeen in Scotland says she's found that women's faces get more attractive to men when they are ovulating. "We're not entirely clear why there's this difference, but we think that the women might look healthier, have a bit of a healthier glow when they are ovulating."

Symmetry is another factor that determines a face's attractiveness. Kendra Schmid, an assistant professor of biostatistics at the University of Nebraska Medical Center, says there is a formula for the "perfect" face. She uses 29 different measurements to determine someone's appeal on a scale of 1 to 10.

To start, Schmid says the ratio of the length of the face to the width of the face should be 1.6, also known as the golden ratio."The face should also be divided into three equal pieces vertically," she says. "The forehead, then [the bottom of the forehead to] the nose and then from the nose to the chin."

Who's face is the most "perfect," according to Schmid's measurements? No big surprise here! "Brad Pitt's is the highest that I've ever used the [formula] on," she says. "He was a 9.3 [out of 10]."

Brad's partner, Angelina Jolie, didn't fare too badly either. "Angelina was a 7.67, and that's pretty high," Schmid says. "Most people rate about 4 to 6. ... The thing that is probably lowering her score is the thing that she's most famous for -- her full lips." Schmid says that ideally the width of a mouth should be twice the height of the lips.

Other celebrities Schmid tested were Halle Berry, who scored a 7.36, and Hugh Jackman, a 6.45. "There's never been anyone who was a perfect 10," Schmid says. "If you're out there, we're looking for you!"

Plastic Surgery & Plastic Surgeon

Very interesting discussion on the RealSelf.com has kicked out all non-core doctors thread.

TF and Botoxdoc have, er... differing postions on who is able to provide the best plastic surgery care. (Perhaps 'best plastic surgery care' is not the most appropirate term and I should use 'appropriately safe level of plastic surgery care'.)

Anyway, there's been a lively exchange of which the following comments are only a fraction.

Link to the RealSelf.com kicks out all non-core docs thread:

TF:

I have never claimed that plastic surgeons are the only ones who can do aesthetics, which includes laser work, botox and injectables, as well as surgery. I am very supportive of non-plastic surgeons who do botox, injectables and lasers. I have only made the point that plastic surgery training is currently the best method for training surgeons who want to do total body aesthetic surgery. It may not be perfect, but it's still the standard.

There are no shortcuts in learning how to be a master surgeon. Only those, like yourself, who seem to think that there are shortcuts.

Good luck to you - and your patients....

Botoxdoc:

While you say, I am wrapping my self in the cloak of the "free market" flag and have forgotten the fundsamentals of being a physician "doing no harm", nothing could be further from the truth. I only take cases in which I am proficient. I would never put a patient in harms way, nor perform a case which is not appropriate. I have refered many pts to a plastic surgeon when I felt they needed something more than I could provide them. (At the loss of significant revenue, I might add.) On the contrary, I beleive you are wrapping yourself in the cloak of "patient safety" . It is hubris to beleive I would not have the same concerns as you about patient safety. But because I am not a board certified PS or Derm, I must be, in your mind, a sub-par physician with no regard to my pts well-being, or safety. In fact there is absolutely no hard evidence that supports the argument that having Botox, or any other cosmetic treatment performed by a non-core physician results in more complications. Instead of me showing you my before and afters, why don't you show me a paper (randomized, case controlled, or even a retrospective study) that supports the commonly held belief that non-cores are dangerous. In fact, the complication rate in my clinic is better than what has been documented in the literature. While several months ago at a local hospital, a board certified plastic surgeon performing lipo under general aneasthesia penetraed the viscera and killed his pt. For that he received a reprimand. If I did that, I would probably loose my license or worse. Now I ask you, how fair is that?

In my opinion there needs to be a fundamental change in the system which will allow the acceptance and acknowledges "non-core" physicians performing aesthetics. Until that day arrives, those that judge my work will be my pts. and their families.

TF:

You want science - OK, here's some for you.

Subglandular breast augmentation has a higher rate of capsular contracture. Proven in multiple studies.

Subglandular breast augmentation has a higher degree of interference with mammograms. Proven.

Subglandular breast augmentation has a higher rate of unsatisfactory ripples and wrinkles, especially with saline implants. Proven.

Do you offer this procedure because it's the only one you can technically perform?
Do you even offer your patients a choice of sub-pectoral or dual plane techniques?
Do you give a truly informed consent about the other options....Or do you slant it your way, so you can get the patient to book with you?

You claim you are all about patient care - and then you say it's fine to take a weekend course, and then practice unsupervised on the first 100 or so paying customers, so you can master it. Wow. That's messed up!!

RealSelf.com's blogged about how that site is only the 'dispenser of information' (my name not theirs) and has removed more than 3000 physician accounts because they were not boarded in plastic surgery or dermatology. I wonder what the majority of realself.com questions are about? Liposuction? Breast augmentation?  Or, Botox? I don't think that there's any real disagreement that if you're looking for real plastic surgery you want a plastic surgeon (or cosmetic surgeon). The arguement arises over what is 'real' plastic surgery.

The inclusion of technology starts to blur the lines beween what a plastic surgeone does with a scalpel, and what a non-core doc can do using a laser, IPL, or RF technology. The boundries will only be blurred more as more IPLs and lasers are introducted.

Plastic surgery secrets revealed: Vanity goes undercover.

Melanie Berliet, a Vanity Fair writer, went undercover to test her hypothesis that plastic surgeons try to sell additional procedures to patients that they don’t “need.” The 5’9”, 120-pound 27-year-old, who wears a size 34B bra, went into the consultations under the guise of wanting breast augmentation.

Some of the plastic surgeons did not come out looking very good. The three surgeons had different reactions to her physique, but all of them recommended procedures she hadn’t originally asked for.

The one plastic surgeon who did fair pretty well had this exchange with the author:

He goes through the standard health questions, then asks, “How can I help you today?”

“I was just hoping to get a professional opinion about my options in terms of plastic surgery.”

The doctor squints and replies, rather emphatically, “The way it works is: you tell me if something specifically bothers you, and I’ll tell you if I can address it. But I’m not here to sell you services or goods, because there may be something that you don’t see that I see.”

“And you won’t share?,” I ask, somewhat startled.

Dr. Racanelli explains that he has an ethical problem with pointing things out, because he’s heard of cases in which patients felt they were talked into a procedure. He continues, “If there’s a specific area of concern, then you and I can discuss it at length ... I’m not here to, like, pitch you.”

“Is it a legal problem?,” I ask.

“No. Not a legal problem. It’s just the way I like to do things.”

In that case, I tell him, I’d like to talk about my nose and boobs.

Satisfied, the doctor proceeds. Most of what he says is familiar. He says I’m tall enough to carry a full C-cup, and observes that my nose has a “dorsal hump” and a “bulbous tip.”

“Is there a way to image what it might look like?”

“There’s a way to image, and it’s a very successful marketing tool,” he replies. “I do not do it, and the reason is: the only person who knows what your nose is going to look like after surgery is God.” Despite my general discomfort with superfluous references to a higher power, I feel the urge to jump out of my seat and give Dr. Racanelli a standing ovation.