Key points

Facelift surgery is the most comprehensive cosmetic facial procedure, and the most impressive and emotional cosmetic surgery anywhere on the body. Mediocre breast, belly, and buttock surgery can be easily camouflaged by clothing, but the face is always exposed. From an emotional standpoint, any cosmetic surgery procedure can improve self-confidence and provide a more youthful appearance, but it is the face that is seen and focused on in primary visual encounters. Giving an older person a younger face is an impactful experience.

The public is diverse on thoughts of surgical enhancement. Some people believe they have earned their wrinkles, whereas others disdain anything unnatural. Having said that, the average person with excess neck skin and jowls would jump at the chance to reverse them if they knew the outcome was natural and affordable.

This brings up the first tenant of cosmetic surgery diagnosis: “why is someone having cosmetic surgery?” Although this sounds trite and obvious, the answer to this question can have a lot to do with the success or failure of the biopsychosocial part of cosmetic surgery. My practice is limited to cosmetic facial surgery, so 100% of the patients that come to see me are doing so because they perceive defects in their appearance. Most of these patients have obvious defects that are normal signs of aging, such as excess eyelid tissue, facial wrinkles, jowls, and extra neck skin. We are all going to get it, so in that sense, there is no escape. The difference is how these aging changes play into the everyday life of patients. The key word to discern from the first several minutes of a facelift consult is “normal.” Is this patient’s assessment and motivation for having surgery normal? A normal scenario is a 46-year-old woman who presents for consultation and says, “Dr Joe, I exercise daily, I watch what I eat, I live a healthy lifestyle, but when I look in the mirror, these darn eyelid bags, make me look and feel older than I am.” An abnormal scenario is a 33-year-old man who presents with the chief complaint of a minor dorsal hump and states that he cannot maintain a female relationship because of his deformity. He may have lost jobs or done poorly in personal relationships because of his perceived horrendous nasal deformity. He may think that people avoid him socially or stop at traffic lights and make fun of him; that complete strangers continually stare at his deformed nose, or chin, or hair line, or mole or anything else that signals body dysmorphic disorder. If you have never personally experienced this condition, it difficult to sit and listen to someone who for all intent and purpose looks totally normal describe this litany of negative social encounters. Body dysmorphic disorder is a real condition, and if the surgeon is not astute enough to realize this disorder, these patients can become very negative, frequently litigious, and sometimes physically, even deadly violent.

Good surgeons know how and when to say “NO”

Everyone that performs facelift surgery has invested innumerable hours of education and hundreds of thousands of dollars to get to the point where they can offer these procedures. As any young, just into practice surgeon will attest to, it is hard to say no to a patient that has an aging face and a checkbook. We have strived to get to the point where we can perform competent surgery and here sits a patient with facial aging and $15,000. “How or why would I tell them no?” “They will just go to the guy down the street!” “I love surgery and could use the income.” These are all natural responses, but operating on unstable patients can be one of the worst experiences of a surgeon’s professional life. You may gladly pay twice the surgical fee to make them go away; they can and will make your life miserable. Always remember Niamtu’s first law of surgery: If things do not seem right, do not accept that patient. This is frequently a cascade where this type of patient is pushy or rude to the front desk, then they are demanding to the nursing staff, but they may be normal to the surgeon. It is important that all staff evaluate all interactions of patients because sometimes the surgeon gets fooled.

I occasionally encounter a totally normal patient that turns out to be a management nightmare, and conversely start out with a patient that has some warning signs but their surgical experience is an actual delight. You cannot win every time and we all get fooled once in a while. Some good “red flags” on patient behavior that may cause the surgeon to reevaluate taking the case include the following:

• •

  Patients with known body dysmorphic disorder or psychiatric condition

• •

  Any overly narcissistic or immature patient

• •

  Unfriendly or impersonal patients

• •

  Patients that do not smile or make eye contact

• •

  Patients that are too busy or too important for surgery

• •

  Patients that speak negatively about previous surgeons but are complimentary to you

• •

  Patients that will not listen and just talk

• •

  Patients that are having surgery for the wrong reason, such as a failing marriage, promotion, or in the midst of a loss

• •

  Patients that cannot decide on a surgical plan or say “do what you think I need”

• •

  Patients that are overly impulsive and want to book surgery at first evaluation appointment

• •

  Patients with unrealistic expectations

• •

  Patients that “know” more about a procedure than the surgeon

• •

  Patients that tell the surgeon what procedure to do and in extreme detail

• •

  Patients obsessed with online cosmetic surgery bulletin boards or cosmetic surgery sites

• •

  Young patients that have already had numerous surgeries or request surgeries generally performed on older patients

• •

  Patients overreacting to a small flaw

• •

  Patients that complain about financial arrangements or are pushy about discounts or are otherwise “shoppers”

• •

  Patients that insist on absolutely no photographic documentation or are resistant to give important information, such as cell phone numbers, and insist on “secrecy”

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  Patients desiring surgery with intense familial disapproval

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  Patients that you or your staff does not like (rude or pushy)

• •

  Patients that have someone else speak or call for them

• •

  Celebrities or patients that think they are celebrities

Although some surgeons ask these patients to first see a psychiatrist, I never do that. It is embarrassing and many patients are resentful. If I have a patient that I believe will be a management problem (and perhaps a future legal problem), I simply tell them “Mrs Jones, I have analyzed your entire case and I simply don’t think I can make you happy or meet your expectations. I think you are a fine person, but feel you would be better served by another surgeon.”

Good surgeons know how and when to say “NO”

Everyone that performs facelift surgery has invested innumerable hours of education and hundreds of thousands of dollars to get to the point where they can offer these procedures. As any young, just into practice surgeon will attest to, it is hard to say no to a patient that has an aging face and a checkbook. We have strived to get to the point where we can perform competent surgery and here sits a patient with facial aging and $15,000. “How or why would I tell them no?” “They will just go to the guy down the street!” “I love surgery and could use the income.” These are all natural responses, but operating on unstable patients can be one of the worst experiences of a surgeon’s professional life. You may gladly pay twice the surgical fee to make them go away; they can and will make your life miserable. Always remember Niamtu’s first law of surgery: If things do not seem right, do not accept that patient. This is frequently a cascade where this type of patient is pushy or rude to the front desk, then they are demanding to the nursing staff, but they may be normal to the surgeon. It is important that all staff evaluate all interactions of patients because sometimes the surgeon gets fooled.

I occasionally encounter a totally normal patient that turns out to be a management nightmare, and conversely start out with a patient that has some warning signs but their surgical experience is an actual delight. You cannot win every time and we all get fooled once in a while. Some good “red flags” on patient behavior that may cause the surgeon to reevaluate taking the case include the following:

• •

  Patients with known body dysmorphic disorder or psychiatric condition

• •

  Any overly narcissistic or immature patient

• •

  Unfriendly or impersonal patients

• •

  Patients that do not smile or make eye contact

• •

  Patients that are too busy or too important for surgery

• •

  Patients that speak negatively about previous surgeons but are complimentary to you

• •

  Patients that will not listen and just talk

• •

  Patients that are having surgery for the wrong reason, such as a failing marriage, promotion, or in the midst of a loss

• •

  Patients that cannot decide on a surgical plan or say “do what you think I need”

• •

  Patients that are overly impulsive and want to book surgery at first evaluation appointment

• •

  Patients with unrealistic expectations

• •

  Patients that “know” more about a procedure than the surgeon

• •

  Patients that tell the surgeon what procedure to do and in extreme detail

• •

  Patients obsessed with online cosmetic surgery bulletin boards or cosmetic surgery sites

• •

  Young patients that have already had numerous surgeries or request surgeries generally performed on older patients

• •

  Patients overreacting to a small flaw

• •

  Patients that complain about financial arrangements or are pushy about discounts or are otherwise “shoppers”

• •

  Patients that insist on absolutely no photographic documentation or are resistant to give important information, such as cell phone numbers, and insist on “secrecy”

• •

  Patients desiring surgery with intense familial disapproval

• •

  Patients that you or your staff does not like (rude or pushy)

• •

  Patients that have someone else speak or call for them

• •

  Celebrities or patients that think they are celebrities

Although some surgeons ask these patients to first see a psychiatrist, I never do that. It is embarrassing and many patients are resentful. If I have a patient that I believe will be a management problem (and perhaps a future legal problem), I simply tell them “Mrs Jones, I have analyzed your entire case and I simply don’t think I can make you happy or meet your expectations. I think you are a fine person, but feel you would be better served by another surgeon.”

The art of the consultation

The actual physical facelift consultation is an important event in the patient experience because it is the introduction to the surgeon and vice versa. Because this is an oral and maxillofacial surgery text, I am writing under the assumption that most oral and maxillofacial surgeons (OMSs) do not have practices limited to cosmetic facial surgery as I do and therefore must make some adaptations to handling these patients. I began pursuing cosmetic facial surgery in 1997 and it became an increasingly larger part of my practice, until in 2004 I stopped doing any other oral and maxillofacial surgery procedures. This worked well for me but I have many OMS friends that incorporate cosmetic surgery with their traditional procedures. I believe that to do this well, the practice has to address some considerations for maximum efficiency.

It is sometimes difficult to be a master of multiple domains and can be confusing to patients. OMS like dermatology, ophthalmology, otolaryngology, and other specialties does not necessarily have a traditional long-standing reputation for cosmetic surgery. The last 20 years has shown a trend for numerous specialties including oral and maxillofacial surgery to train residents for cosmetic procedures. It can be confusing for some patients (and referral sources) to have wisdom teeth extracted in one room and a facelift in the other room. This can be said about any specialty practice that is not limited to cosmetic surgery. To mitigate this confusion and enhance one’s credibility, some practices only see cosmetic surgery patients on certain days or at certain times as not to have other types of surgical patients in the office. A facelift patient sitting in a waiting room with other patients with bloody gauze in their mouth, a large smelly facial abscess, or a street warrior with facial trauma is not the best introduction to your practice. By having only cosmetic patients in the office on a particular day, these patients are in the company of other similar patients and this can be important. Also, cosmetic surgery is an upper class luxury and one’s competitors probably have very spa-like upscale offices. Although all of our offices should be clean and contemporary, going above and beyond and catering to upper class and fashion-conscious patients is a given. I know some OMSs that actually have two sets of stationary, business cards, and so forth to specifically cater to the cosmetic side of their practice.