Plastic Surgery: Answers to Frequently Asked Patient Safety Questions to Reduce Your Risk

Patient selection is the most important decision you will make. Consider a checklist for the patient to complete prior to the initial consultation. This would include medical history, medications, prior plastic surgery, and patient expectations for the procedure and its outcome. Obtain this information prior to agreeing to perform a surgical procedure.

Proceed cautiously with any patient who:

• Voices multiple complaints regarding prior plastic surgery procedures.
• Has undergone repeated surgical procedures by other physicians.
• Sued another practitioner as a result of a plastic surgery outcome.
• Appears to be “doctor shopping” (i.e., visiting multiple physicians to obtain the medical opinion the patient wants to hear).
• Displays exaggerated concerns over a minor or nonexistent problem.
• Exhibits behavior that suggests fixations on particular physical features, imperfections, or surgical results.
• Recently experienced a major life change, such as a failed relationship or a lost job.
• Has a history of mental health issues and is on multiple scheduled drugs. Check state prescription management programs in advance of the first visit to identify any scheduled drugs currently prescribed for the patient.
• Appears to be looking for a quick fix to a long-term problem.

Avoid patients who:

• Are angry, hostile, or abusive to your staff on the phone or in the office.
• Are demanding and have unrealistic expectations.
• Have a history of nonadherence or poor relationships with other physicians.
• Request repeat procedures on the same site without adequate reasons.

Consider patients for plastic surgery who:

• Have realistic expectations about surgery.
• Comply with instructions and keep scheduled appointments.
• Have a spouse or family member who is aware of the planned procedure and agrees with the plan.
• Can afford the financial cost, including recovery time.
• Present with conditions or request procedures that you are experienced with and thoroughly comfortable performing.

We recommend that you:

• Obtain and document a thorough informed consent from the patient. Informed consent is not just the form signed by the patient, but includes the clinician’s informed consent discussion and shared decision-making with the patient.
• Beware of making an implied warranty by using before-and-after images. Make it absolutely clear there is no guarantee the outcome of a surgery or a cosmetic procedure will be the same as in the photos. Document this conversation in the record.
• Have an in-depth discussion with the patient about his or her expectations from the surgery and correct any misperceptions.
• Discuss aftercare requirements and document the patient’s agreement to follow the aftercare instructions. Use quotes around the patient’s response, e.g., “yes, I will follow your postoperative instructions to wear a garment as instructed, moderate activity, refrain from smoking or vaping for (a certain period of time), etc.”
• Solicit input from staff members who may have made observations or heard patient comments that were not shared with the physician.
• Reconsider patients who bring in photographs of celebrities or models and want a specific feature duplicated.
• Document your discussions with the patient carefully. It is critical to include details of the patient’s expectations and the informed consent discussion, including the most common risks, benefits, and alternative treatments for the procedure.
• Consider obtaining medical records from a patient’s prior plastic surgeon before agreeing to a procedure.

Ask yourself the following questions:

• Is this patient a good surgical candidate overall?
• Are the patient’s potential risks increased with longer anesthesia and operative time?
• Do accepted and sound medical practices indicate that the requested procedures can be completed safely in one session?
• Is the patient an appropriate candidate to have surgery at the requested location?
• Are the requested procedures appropriate for an outpatient setting?
• Would you recommend this treatment plan to a member of your family?

If you answer no to any of the questions, decline the request. Patient safety must take precedence over saving the patient time and money. The physician—not the patient—determines the standard of care for where to perform a procedure and the safety of performing multiple procedures during one session. Do not let a patient pressure you into doing what the patient wants if it is not good medical practice.

No. The first concern is postoperative care and whether the patient will remain in the practitioner’s state long enough to ensure optimal recovery and follow-up. This becomes even more critical if the patient develops postoperative complications.

The second issue involves practitioners who provide advice to patients outside the state where they are licensed. All states require clinicians to be licensed in the state where the patient is located. Providing medical consultation or advice to a patient who is physically out of the state could be viewed as practicing in the patient’s state without a license. Practitioners must take care when communicating by phone, email, or other electronic means, including via telehealth, with a patient in a state where the clinician is not licensed. For more information, see our article “Telehealth: Frequently Asked Questions.”

In addition, take care to avoid creating an expectation of a practitioner-patient relationship if you use social media or websites to provide literature or schedule appointments.

Avoid mislabeling the patient and address the tobacco smell during a presurgical consultation. Perhaps she stopped smoking, and the tobacco smell is coming from a smoker in her family. If the patient continues to smoke after receiving extensive education about the risks of smoking and the associated complications, it may be best to decline performing surgery on this patient.

Consider preoperative testing for tobacco use. Follow the American Society of Plastic Surgeons Practice Reference on Managing the Risks of Smoking in Plastic Surgery Patients.

If, in the physician’s best medical judgment, a revision of this type is not sound practice, decline the request. The standard of care to be met is that of a reasonably prudent physician, not what the patient wants. This is elective surgery; you are permitted to refuse the request.

To prevent this situation, conduct a thorough pre-surgical informed consent and educate the patient about what will be done. Avoid vague or subjective terms, such as “to the patient’s satisfaction,” in the consent form. A patient who makes veiled threats of legal action may not be an appropriate candidate for surgery.

As with any surgical candidate, thoroughly assess the patient’s request and expectations. Absent a biohazard exposure risk to the patient or a prior request from a defendant in a pending matter, the implants can be released to the patient by using the following steps:

• Have a pathologist examine the implants and issue a report, similar to when a specimen is removed from a patient. The report will provide additional support to your surgical description of the condition of the implants at the time of removal.
• Photograph the implants to show their condition at the time the patient assumed possession of them and keep the photos in the medical record.
• Have the patient sign a release that documents what was given to the patient, the condition of the released implants, the date of release, and that the patient assumed all responsibility for them.
• Retain a copy of the release in the patient’s medical record, and document what was released and when.

Understand that the husband may feel afraid and angry about his wife’s diagnosis. His behavior may be an expression of loss and fear rather than a reaction to anything the office staff and physician have done. Empathize with them and acknowledge that it is difficult for the patient and for her husband. Remind them you are here to help and that all parties—including the spouse—must cooperate to achieve an optimal outcome. If the abusive behavior cannot be resolved, help the patient establish care with another practitioner before terminating the relationship.

Dismissal of a patient is always a last resort. The physician has an ethical duty to continue care until such care is no longer indicated or until the physician-patient interaction is no longer therapeutic. Attempt to resolve the interaction issues and then decide if care should be transferred to another practitioner.

The office manager should speak with the patient in private and explain that, based on the husband's or guest’s abusive and disruptive behavior, the individual will no longer be welcome in the medical practice office. The conversation should be memorialized in a letter sent to the patient after the conversation.

Develop a Conditions of Treatment Agreement that is provided to and signed by every patient. Include your conditions of treatment as part of the intake process. The agreement outlines your expectations of the patient and may include complying with instructions, keeping all appointments (both pre- and post-procedure), taking all recommended medications, complying with financial arrangements, and requiring the patient and family/significant other to be respectful of the physician and staff at all times. Failure to comply with any of the conditions may be grounds for terminating the relationship. For additional information, see our article “Set Expectations for New Patients With a Conditions of Treatment Agreement.”

Permitting patients to use credit cards to pay for procedures has become common. However, if the patient is unhappy with the result, he or she may dispute the charge and ask the credit card company to deny payment. This situation impedes payment and raises HIPAA and confidentiality concerns if you are required to provide medical records to the credit card company.

Careful consideration should be given when a patient wants to pay a large amount with a credit card. In these situations, we recommend that the patient sign an agreement that he or she will not dispute the credit card charge and execute an authorization to release medical records to the credit card company in the event there is a dispute in the future. Many medical practices limit the amount a patient can charge to a credit card and offer alternative payment options available through third parties. For more information, read our article “Patient Billing Challenges, Frequently Asked Questions.”