Later in this article, I will give you suggestions on how to overcome this situation, but first I would like to relate a real world case study. Recently I had a conversation with a cosmetic surgeon who reported an experience that many others have probably had. He reported that he performed surgery on a woman who was excessively concerned about her appearance. After the surgery she was extremely dissatisfied, insisted on a "redo", was not satisfied with that and then began harassing the physician and his family. She took out ads in all of the local papers, created a negative blog about him and threatened his wife and his office staff. This went on for about 6 months and then she committed suicide.

Those who are cosmetic surgeons are well aware of people's concerns over their appearance. Presumably, individuals who seek cosmetic enhancement for some aspect of their physical appearance are seeking to improve their self-esteem and self-confidence, and a good surgical outcome should improve these domains, as well as result in increased confidence in social situations. However, as exemplified in the incident cited above, this is not always the case. Some individuals will never be satisfied with the surgical outcome. These "insatiable" patients return for repeated procedures seeking relief from extreme body image dissatisfaction. These individuals have a disorder known as body dysmorphic disorder (BDD) which is exemplified by a preoccupation with an imagined defect when the perceived appearance flaw is actually nonexistent or slight, and they have unrealistic expectations about the outcome of surgery. Patients with BDD perceive imagined physical defects and seek cosmetic procedures to correct them. Since these procedures will not improve the underlying psychological condition, the patient will not be satisfied with even the most successful surgery.

In some cases, concern with physical appearance reaches an intensity where it causes subjective distress to the individual and leads to impairment of functioning in social and other domains (Honigman, et al., 2004). Research has shown that those with BDD do not improve with cosmetic surgery but their symptoms tend to worsen. These findings have led to the argument that BDD is contraindicated for cosmetic surgery (Phillipa, et al., 2004).

In addition, patients may exhibit other psychological disorders that may cause undo stress to the physician including those with borderline personality disorder, paranoia, and narcissism. Individuals with these disorders do not have the ability to self-regulate and often need the attention or adulation of others, especially those in authority. While depression and anxiety are not contraindicated for surgery, these disorders will not necessarily be improved upon by cosmetic surgery. According to Dr. Grossbart of Harvard medical School, cosmetic surgery patients often look for more than changes in their physical appearance. If these procedures do not lead to improvements in body satisfaction, self-esteem, or quality of life, then the patient perceives them as a negative surgical outcome. Patients with BDD as well as those with other psychological problems may request repeat procedures or experience depression and adjustment problems, social isolation, family problems, self-destructive behaviors, and anger toward the surgeon and his or her staff, which can lead to malpractice claims and negative referrals.

Research has also shown that external factors such as expectations for bettering career, relationships, and life in general and dissatisfaction with previous surgery are indicative of poor surgical outcomes. If patients regard cosmetic surgery as a life changing event, they are likely to be upset when physical changes do not lead to the desired social outcome (Phillipa, et al., 2001).

Research indicates that one of the major mistakes made by doctors that lead to legal issues is the doctor's failure to create a rapport with the patient.

"A survey of 115 experienced cosmetic surgeons found that nearly one-half had been sued for malpractice. Of this group, 51.6% attributed the suit to lack of rapport (v 17% for the next highest cause: unrealistic expectations), and only 14.5% attributed the suit to poor surgical results... Thorough screening of patients is critical to insure that postoperative expectations are met, and can also be vital to identifying the patient who becomes a management problem" (Hodgkinson, 2005). Acquiring more knowledge about the patient as well as time spent with them builds a solid rapport which lessens the frequency of legal action.

The challenge for the cosmetic surgeon is having enough time to properly assess the patient, and a 30- to 45-minute consultation is just not enough time to learn about an individual's psychosocial status. In addition, prospective patients will be on their best behavior during the preoperative consultation and will often expend a great deal of effort to present as "appropriate" for surgery. Grossbert and Sarwer contend that an assessment by a well-qualified mental health consultant with a good understanding of body image dissatisfaction and BDD can be a valuable asset to a cosmetic surgery practice.

So, after the assessment process, how should you handle the problematic patient? Here are a few suggestions that you can implement as part of your office protocol.

• Take extra time to listen and build rapport
• Follow up on phone calls within 24 hours to make sure the patient understands the procedure and if there are any concerns
• These patients can be annoying because they take up an inordinate amount of the staff and physician's time. Be patient. They tend to feel abandoned easily and will misconstrue impatience as a lack of caring.
• Be careful not to advise the patient, but rather to ask questions about what they would like to have happen.
• Document, document, document!
• Implement a special release form documenting that the patient has been informed about a specific mental disorder and have chosen to go ahead with the surgery even though it may be contraindicated.
• Don't argue with the patient or discount their perceived defect. Their thought processes are often unrealistic and they won't agree with you. Instead, talk to them about their dissatisfaction with life in general and refer them to a counselor.
• Talk about unrealistic expectations, and about how the surgery is not a panacea for life's problems.
• Express empathy and build rapport.
• Set rules and boundaries at the beginning of treatment about office protocol. Include extra consulting fees if needed with problematic patients. If the patient knows what to expect, they are less likely to cause a scene or feel abandoned.

References:

1. Honigman, R., Phillips, K., Castle, D. J. (2004). A review of psychosocial outcomes for patients seeking cosmetic surgery. Plastic and Reconstructive Surgery, 113, 1229-1237.
2. Phillipa, K., Grant, J. E., Sinischalchi, J., Albertini, R. S. (2001). Surgical and non-psychiatric medical treatment of patients with body dysmorphic disorder. Psychosomatics, 42(6), 504-510.
3. Hodgkinson, D. J. (2005). Identifying the body-dysmorphic patient in aesthetic surgery. Aesthetic Plastic Surgery, 29, 503-509.