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Preoperative Evaluation of

the Aesthetic Patient

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Historical Aspects

1940s to 1960s:

all cosmetic surgical patientshave underlying psychiatricdisorders

Jacobsen, et al

1998:

There are no poor candidatesfor facial aesthetic surgery

Stambaugh

2004:

Extreme Makeover

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The Surgeons Role

Physician

Psychiatrist

TherapistArtist

Scientist

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Patient Selection

Surgeons responsibility

selection

good technique

Begin with interview

History (family, social)

hidden conditions

desired outcome determined preop (mutual decision)family members?

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The Surgeon, continued

Obstacles in understanding motivation:

projection of values upon patient

manipulative personalities: histrionic disordersobtaining inadequate history

include social and family histories

not allowing patient to talkgoals of patient and surgeon may be different

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The Surgeon, continued

Successful patient selection:

recognizing surgeons role no longer sacrosanct

approach problems affirmatively and assertivelyunderstand patient motivations (MOST IMPORTANT)

what does the patient want

Listen

Restate

self-image

what is not said...

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Psychological Conditions

The Neurotic Patient

defense mechanisms:

worry, anxiety, somatic complaintsrepetitive, detailed questions

DO:

be patient, upbeatDO NOT:

be flippant - (will become defensive)

be impatient

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The psychotic patient

meticulous, detailed postoperative care

Schizophreniadisorganized thoughts, flight of ideas, selfish,

delusions of grandeur, paranoid

can be violent when paranoid

Needs preoperative psychiatric evaluation

may benefit from cosmetic surgery (Edgerton)

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Personality Disorders

masters of manipulation

behavior problems, not psychotic/neurotic

Narcissistic personality:

grandeur, elegant, refined -name droppers

Borderline (histrionic) personality

splitter- idealize, denigratedress inappropriately

Preoperative Psychiatric evaluation may be helpful

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Depressionanhedonia

sleep disorders

poor motivation

50% of all postop surgical patients - transient

treated - excellent patients

Mania/bipolar disorderpressured speech, flight of ideas

infrequent candidates

remember association with depression

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Body Dissatisfaction Disorder43%/56% of Americans

Body Dysmorphic Disorder

Obsession with either slight or imagined defects in appearancePreoccupation causes significant distress and/or impairment in

functioning

Most common focus is skin, face, nose

0.2% incidence in normal population. 2-7% of patients

presenting for cosmetic surgeryPoor surgical candidatessurgery may exacerbate symptoms,

low satisfaction rate

Eating disorders

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The Malingerer

findings not consistent with complaints

monetary motivemalpractice

injury insurance fraud

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Patient Selection Criteria

PatientConcern

Deformity

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Red flag patient type (M. Gorney)

Single

Immature

Male

Overly Expectant

Narcissistic

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Green flag patient type (M. Gorney)

Secure

Young

Listen

Verbal

Intelligent

Attractive

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Dr. Goldwyns admonitions

Dont operate if:You dont like the patientThe patient asks you to do something you cant deliverThe patient asks you to do something outside your aesthetic

sense of what the result should beThe patient is critical of previous surgeons or praises you

excessivelyThe patient is rude to you or your staffThe lies to you or gives you a false history or information

The patient refuses to be examined or photographedThe patient is a perfectionist and wants a guarantee of resultsThe patient is paranoid, delusional, or depressedThe patient fails to communicate or is unable to understand

what informed consent entails

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Patient Rejection

Elective Procedures

Do not reject

outright:reschedule for

additional consultation

allows for reevaluationof patient

refer

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The Dissatisfied Patient

Listen

Often therapeutic

Do not be defensivept will feel abandoned,

unappreciated

Understand patients concerns

listening does not mean agreeingExpress your concerns

Reschedule

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Facial Analysis

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Facial Beauty

[You] cant define it, but you know it whenit walks into the room--Aaron Spelling

Greek Polycleitus 450-420 B.C. first toquantify symmetries and proportions theCanon

Leonardo Da Vinci (1452-1519) Durer (1471-1528) Joseph (1865-1934) father of rhinoplasty

Broadbent (1894-1977) radiographiccephalometrics Ricketts -the golden proportion (1:1.618) Farkas -revised the classic cannon with

hundreds of measurements on living subjects

Doryphorus

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Facial Beauty

Few people, whether Caucasion or ethnic, fit theNeoclassical canon of fixed proportions and ratios(Farkas, Porter, Teck, Milgrim)

Attractiveness consistent across cultural groups.(Cunningham, Thakerar, Buss, Perrett)

Symmetry, averageness associated with beauty

Extreme beauty seems to be associated withmagnification or diminution of at least one feature(Perrett, Rhodes)there is no excellent beauty that hath not some

strangeness in the proportion Francis Bacon
http://www.imdb.com/name/nm0000210/photogallery

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Beauty

Life is easier when youre beautiful

higher grades (score equally on standardized tests)

more often judged kind, decent and honest

given more personal spacemore likely to marry

more likely to be promoted at work (rank in the armed forces)

wait shorter amount of time for services

bad behavior more likely to be forgivenless likely to be reported, caught, or punished for major or

minor crime

easier to procure help in times of need

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Facial Analysis -- Terms

Trichion- frontal hairline

Glabella- most prominent point of

midsagittal forehead

Radix- root of nose

Nasion- depression at root of nose

Rhinion- junction of bony and cartilaginous

nasal dorsum

Tip-defining point- anteriormost projection

of nasal tip

Alar crease- lateral aspect of nasal ala

Subnasale- junction of columella and upper

lip at base of noseStomion- where lips meet

Pogonion- most anterior aspect of chin

Menton- lower border of contour of chin

Gnathion- point at junction of tangents to

menton and pogonion

Cervical point- point at junction of

tangents to menton and anterior border of

neck

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Facial Analysis

Face: General

Divided in 1/3s

trichion to NFA

NFA to subnasale

subnasale to menton

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Facial Analysis

Vertical divisions

1/5s

each equal to one eyewidth

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Facial Analysis

Lips

oral commissure at mediallimbus

smaller mouth preferred inAsia (Chinese)

Nasal ala

lateral aspect at medialcanthus

may be wider in Asian andAfrican-American patients

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Facial Analysis-The Nose

Nose

nasofrontal angle

approximately 120

degrees

nasolabial angle

90-105 in men

100-120 in women

columnellar show2-4mm

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Tip height

Goodes Ratio:

(alar groove to tip)

divided by (nasion totip) = 0.55 - 0.60

Baums Ratio:

(nasion to tip) divided

by (subnasale to tip) =2.8

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Submental vertexview:

equilateral triangle

lateral ala at medialcanthus

may be wider in asian,african noses

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Facial Analysis

Chin projection

Burstones Angle

SN to pogonion to

cervicomental angle isapproximately 100degrees

Vertical line from

subnasale:3 mm for males5 mm for females

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Facial Analysis - The Neck

Neck

Dedo classification

hyoid position

skin position

fat accumulation

muscular position

cervicomental angle

90 to 110 degrees

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Facial Analysis-Forehead

Hairline

Brow position

males: at rim

females slightly aboverim, maximum arch atlateral limbus

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Facial Analysis--Eyes

Brow Position

Dermatochalasia

Lid Fullness/Fatherniation

Lid creaseposition/symmetry

Lid laxity

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Formal Analysis

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Preoperative Evaluation of

the Aesthetic Patient

Glen T. Porter, MDUniversity of Texas Medical Branch at

Galveston

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Bibliography

Alam, M. On Beauty: Evolution, psychosocial considerations, and surgical enhancement Archives ofDermatology 137(6):795-807, 2001

Bailey, B.J., et al. Head and Neck SurgeryOtolaryngology, 3rd Ed. Philadelphia: Lippincott, 2001

Buss, D.M. International preferences in selecting mates: a study of 37 cultures J Cross Cult Psychol.21:5-47, 1990

Cunningham M.R. Their ideals of beauty are, on the whole, the same as ours: consistency andvairability in the cross-cultural perception of female physical attractiveness J Pers Soc Psychol.68:261-279, 1995

Farkas, L.G. Vertical and horizontal prportion of the face in young adult North American Caucasians:Revisions of neo-classical canons. Plast Reconst. Surg. 75:328-338, 1985

Goldwyn, R.M. The patient and the Plastic Surgeon, 2nd Ed. Boston: Little, Brown, 1991.

Gorney, M. Patient selection criteria. Medico-legal issues in plastic surgery. Clin. Plast. Surg. 26:37,1999

Perrett, D.I. Faical shape and judgments of female attractiveness Nature 368:239-242, 1994

Rohrich, R. Streamlining cosmetic surgery patient selectionjust say No! Plastic and ReconstructiveSurgery 104(1):220-221, 1999

Thakerar, J.N. Cross-cultural comparisons in interpersonal attraction of females toward males J SocPsychol. 108:121-122, 1979

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