Oral and maxillofacial surgeons are in a unique position to further develop comprehensive skills for performing facial cosmetic surgery. Our expertise in orthognathics and facial bony structures forms the foundation for being able to provide the full scope of facial cosmetic procedures. The authors firmly adhere to the philosophy that evaluation of facial esthetics is deficient without considering both the hard and soft tissue structures of the face. Similarly, adhering exclusively to soft tissue (facial plastic) procedures while ignoring hard tissue (orthognathic) surgical procedures is most often a lack of understanding in modern facial cosmetic surgery.
The full scope of facial cosmetic surgery encompasses three disciplines: orthognathic surgery, dental implantology/prosthetics, and facial plastic surgery with cosmetic dermatology ( Fig. 102-1 ). When possible, adjunctive dermatologic/skin care procedures are used to enhance the surgical results.
The first step in evaluation of a patient is to determine the chief complaint, which may relate to one of three categories:
An aging face
An acquired deformity of soft or hard tissues
A combination of both
Ethnic, Cultural, and Gender Differences
It is often said that beauty is in the eye of the beholder. However, the perception of beauty is continually evolving. As with fashion, our minds adapt to new trends and our eyes progressively break away from traditional patterns. The public often looks to actors, musicians, sports stars, and politicians to set trends in fashion and beauty.
Not unlike the fashion industry, the trends in cosmetic surgery are continually changing, although the general sentiment of youthful appearance is a common denominator. As cosmetic surgeons, it is extremely important to set aside our personal perceptions of beauty and surgical norms and understand the perspective of the patient. Cosmetic parameters for beauty have regional, ethnic, and cultural differences. The surgeon needs to consider the classic norms that pertain to a patient and must never compromise form for function. A successful cosmetic result with compromise of function is a failure.
When consulting with patients of a specific ethnicity, it is important to determine how much of their ethnicity they wish to preserve. In some cases, a patient may want to make only a minimal change in a particular feature (for example, a large dorsal hump or a wide alar base). A surgeon must quickly understand and be comfortable with the patient’s expectations and desires for cosmetic surgery.
Today, cosmetic surgeons treat all aspects of the population. In the past, cosmetic surgery was considered to be “in vogue” only by wealthy female patients. Current cosmetic surgery encompasses all socioeconomic classes and genders. In fact, younger patients and male patients are increasingly interested in undergoing cosmetic surgery.
In addition to surgical and dermatologic cosmetic procedures, the surgeon should be an advocate of general preventive health care. The cosmetic consultation allows the opportunity to assess overall wellness, and it is our opinion that performing cosmetic surgery on patients who are not involved in an appropriate wellness program or do not make an active effort to improve their overall health may be counterproductive. Nutrition, exercise, and a healthy lifestyle are the foundations to successful cosmetic surgical interventions. Good nutrition and exercise optimize a person’s cardiovascular system and improve cellular turnover. General facial and body appearance often dramatically improves with weight reduction, especially in the younger population. Patients who maintain their body mass index within healthy norms will generally be considered more attractive. In many instances, if overweight patients return to their optimal weight through diet and exercise, their appearance will improve greatly. This will also help the surgeon determine the extent of the cosmetic defect versus excessive weight. It is important for patients to be cautioned that most cosmetic surgical procedures (including body liposuction) are not for weight loss.
Patient selection is one of the most difficult components of facial cosmetic surgery and is especially important for surgeons with less experience. Being able to understand patients and their needs is one of the most important skills that a surgeon can have. Occasionally, during an initial encounter with a patient, surgeons may be so excited to have a patient showing interest in undergoing a particular procedure that they forget to determine whether the patient is truly a candidate for cosmetic surgery. The surgeon must be thorough in the initial evaluation to determine whether the patient is psychologically and physically stable enough for surgery.
Interpretation of patient desires is the most important factor in determining patient satisfaction. A surgeon can perform a perfect operation, but if the results do not meet the patient’s expectations, it will result in an unhappy patient. This is frequently due to inadequate preoperative interpretation of the patient’s desire or unreasonable expectations that were not recognized. The ultimate goal is for the patient to be happy and the surgeon to be proud of the work completed.
It is fundamental that during the initial visit a trusting patient-doctor relationship be established to facilitate the patient’s comfort and willingness to express goals and concerns regarding cosmetic surgery. Patients should be allowed to freely express their chief complaint without interruption. The presence of an assistant is highly encouraged. Asking open-ended questions such as “How can I help you?” or “What brings you to see us today?” allows patients to express their needs and concerns. Specific questions such as “Are you here to discuss the bump on your nose?” should be avoided. The examination and interview process are best done with access to mirrors to allow improved communication regarding facial anatomic regions.
Past Medical History
As with any other surgical procedure, a thorough medical history is imperative. Conditions that have an impact on wound healing (such as diabetes, autoimmune connective tissue disorders, hepatic and renal insufficiency) need to be managed adequately before committing to surgery. The cardiopulmonary status of the patient should be assessed for safe induction of general anesthesia. Uncontrolled hypertension should be managed preoperatively to avoid unstable swings in blood pressure and to aid in homeostasis and prevent hematoma formation.
Psychiatric illnesses should be noted and investigated before any surgical intervention. The following specific conditions and diagnosis should be noted.
Patients with Unrealistic Expectations
Such patients may be grouped into two general categories:
Patients who bring pictures of celebrities and request the surgeon to transform their face similar to the image. They may bring magazine photographs of models with chiseled features or a particular feature that they want the surgeon to mimic.
Patients who request drastic changes such that the face would become disproportionate. These patients often seek the opinions of multiple surgeons.
Perfectionists fall into this category. These patients are usually well dressed and are often overly compulsive when arranging the initial examination. They have usually been treated by other surgeons and have complaints about them. They may have a long list of unrealistic questions. These patients magnify any minor imperfection or asymmetry and demand immediate revision surgery. Perfectionist are, by nature, never happy with themselves and will never be happy with the surgical result.
“I Want to Have the Surgery Immediately” Patients
Such patients wish the surgeon to perform the surgery immediately. They feel no need for a proper evaluation and put tight time limits on the surgeon. They generally have little patience with the surgeon’s efforts to be thorough during the examination and do not want to hear or care about complications or any possibility of a poor surgical outcome. Usually, these patients have had some previous underlying psychological event.
These patients have often had multiple consultations and are unclear about which procedure they want. They are uncertain whether they really want to undergo a procedure and often prefer the surgeon to take a paternalistic rather than an autonomous approach toward decisions, frequently stating “do whatever you think is best.” They are usually seeking cosmetic surgery because of a suggestion of a relative or career advisor. The hallmark of these patients is that they are vague about what would make them happy. Surgery is frequently scheduled, canceled, and rescheduled again.
Such patients are generally pleasant to the surgeon, but when dealing with office assistants and hospital staff, they can be pushy and demeaning and demand preferential treatment. These unpleasant traits generally surface during the initial evaluation as inappropriate, unpleasant behavior.
Overly Flattering Patients
These patients are generally full of compliments and praise the surgeon’s expertise and reputation. With careful probing, the surgeon might determine that the patient has had previous consultations and outcomes that were not satisfactory. They often travel great distances to see the surgeon, with little background knowledge of the doctor or practice. Surgeons should be careful because these patients can quickly turn on them if the surgical outcome has minor imperfections. The compliments may turn to anger.
Patients with a Minimal or Imagined Deformity
At first, most surgeons would agree that a small modification of a minimal deformity might result in a perfect outcome. This may not be the case, though, when dealing with a patient who is overemphasizing a minor deformity. In the mind of this type of patient, a minor deformity can seem as large as a major deformity. These patients are often looking for perfection, and the surgeon must be very careful not to fall into this trap.
During the initial evaluation and history, the surgeon must be aware of any history or present diagnosis of depression. The social history of a patient can determine stability in a patient’s life. Facial cosmetic surgery may only temporarily improve the mood of a depressed patient, but it rids the patient of the underlying cause. Evaluation by a therapist is prudent in these situations.
Patients with Body Dimorphic Disorders
Body dimorphic disorder (BDD) is defined as preoccupation with an imagined or slight defect in appearance that leads to significant impairment in functioning. Any area of the body may be of center of concern. Some studies show that up to 7% women who seek cosmetic surgery meet the criteria for BDD. There is a 2% prevalence in the general public. Reports have shown that the majority of patients with BDD do not benefit from cosmetic surgery, and in some cases, patients have become violent toward themselves or the surgeon. If a surgeon has any suspicions preoperatively that a patient may suffer from BDD, psychological evaluation may be indicated to rule out BDD.
Patients with Eating Disorders
Patients with anorexia and bulimia generally have a poor self-image and are underweight with altered nutritional status. These patients can be at risk during the perioperative period. Extreme caution has to be taken to screen for this type of patient. When dealing with patients with possible eating disorders, an important question is whether they are happy and satisfied with their current weight. Weight fluctuations in some patients can be very noticeable in the face. Significant weight fluctuations can be due to underlying metabolic or psychological disorders. Red flags should be raised if a patient has lost more than 10 lb in the past year or is constantly changing diets. Some cosmetic surgeons will advise their patients that if they plan to lose more than 10% of their body weight, they should defer surgery until their weight has stabilized. It has been shown that patients who exercise regularly bounce back from surgery much quicker than those who have a sedentary lifestyle. In an aging face, both weight gain and weight loss can give a perception of increased age.