When Transparency Hurts—and Heals: Why Ethical Surgeons Must Be Willing to Revisit Their Work

Every plastic surgeon has stories that humble them. One of mine came recently, when I performed two facelifts in the same week. The first unfolded as every surgeon hopes: smooth tissue planes, balanced tension and a result that matched the patient’s goals. The second was different. I had operated on this patient a year earlier. As she recovered, it became clear that the outcome did not meet my standards—or hers. I told her so. She trusted me enough to let me revise it, and in the second operation, the result aligned beautifully.

It is tempting, in our Instagram‑driven world, to share only the triumphs. But honest conversations about complications and revisions are long overdue. We need them not because we enjoy reliving our missteps, but because transparency builds trust and, ultimately, improves outcomes.

How Common Are Revisions and Dissatisfaction?

Revision surgery and patient dissatisfaction are more common than many imagine. RealSelf’s 2019 Aesthetics Trend Report noted that revision and corrective procedures were among the fastest‑growing categories in cosmetic surgery, suggesting that a significant number of people seek to refine previous work.

And yet, even with meticulous technique and decades of experience, not every result will be ideal. We don’t finish a case until we’re fully satisfied in the operating room, but a few months later, we may encounter unexpected asymmetries or scars that don’t heal as intended. In some cases, we may never have a definitive explanation for why things didn’t turn out as we expected. 

Acknowledging this reality without shame enables us to set honest expectations and support patients when outcomes fall short of the ideal.

Saying 'no' to surgery can be the most ethical decision—because true beauty starts with emotional readiness.Courtesy of thomsond at Adobe StockWhy Surgeons Sometimes Say “No”

Declining to operate can feel like turning away business, yet it is often the most ethical choice. Over the years, I have said “no” or “not yet” for various reasons.

Unrealistic expectations top the list. When a patient hopes that surgery will mend a relationship, transform self-worth or achieve anatomically impossible results, it signals that they may be disappointed regardless of surgical excellence.

Mental-health considerations are another critical factor. Studies indicate that a subset of cosmetic-surgery candidates have underlying conditions such as body dysmorphic disorder, depression or anxiety. In these situations, operating rarely alleviates distress and can even exacerbate it. 

Screening tools like the B.A.T.H.E technique—which helps physicians assess anxiety and depression—are invaluable in deciding when a psychological referral is more appropriate than a scalpel [1]. B.A.T.H.E stands for background, affect, trouble, handling and empathy. Although it can be done in under a minute with practice, the technique is most effective when used with genuine compassion and active listening.

The best plastic surgery outcomes happen when patients are physically and emotionally ready for the journey. Over the past 25 years, I’ve turned away many patients. Some of them later returned—healthier, more prepared and genuinely appreciative that I had been honest with them. 

Managing Expectations and Mitigating Risk

Preventing dissatisfaction begins long before a patient is wheeled into the operating suite. The work starts in consultation, where the surgeon must paint an accurate picture of what surgery can and cannot achieve and explain potential complications.

Healing depends on partnership. A patient’s choices, such as quitting smoking, following post-operative instructions, managing inflammation and prioritizing sleep, are as important as my surgical skill. Empowering patients with that knowledge creates an environment of mutual accountability.

When a result is suboptimal, owning the outcome is crucial. Admitting that something didn’t go as planned and working collaboratively on a revision preserves trust and often produces a better result than ignoring or denying the issue. Some revisions can be performed in-office. Other times, we use lasers, targeted injections or non-surgical therapies to treat scarring or asymmetry. Occasionally, a return to the operating room is warranted. Knowing when and how to intervene requires experience, humility and clinical discernment.

A Call for Transparency and Cultural Change

The aesthetic industry celebrates aspirational outcomes, but we must also normalize discussions about complications, revision rates and the reasons we turn patients away. Revisions and dissatisfaction are not rare flukes, but an intrinsic part of our specialty. Acknowledging this openly and responding with integrity by revising when appropriate, declining when necessary and communicating candidly will make aesthetic medicine safer and more humane.

There is nothing easy about telling a patient that surgery may not be the best option, or that a previous result needs to be revisited. But these conversations are central to ethical practice. Our success, ultimately, is not measured solely by the highlight reel of perfect before-and-after images but by the trust we earn, the honesty we maintain and our willingness to walk alongside our patients through triumphs and setbacks on their journey toward feeling whole.

References:

1- https://healthcareexperience.org/bathe-technique/

Diane Alexander, MD, FACS, is an award-winning Atlanta plastic surgeon with over twenty years of experience.Courtesy of Diane AlexanderAbout the Author: 

Diane Alexander, MD, FACS, is an award-winning Atlanta plastic surgeon with over twenty years of experience. In 2000, Alexander co-founded the first all-woman physician plastic surgery practice in Atlanta, now known as Artisan Plastic Surgery, an Olympus Cosmetic Group partner. As an artist and a surgeon, she has expanded her expertise into skincare and wellness at Artisan Beauté, offering a 360-degree approach to health, beauty and wellness. Artisan Beauté and Plastic Surgery serve over 70,000 patients.

Alexander is board-certified by the American Board of Plastic Surgery and a Fellow of the American College of Surgeons. She is also an American Society of Plastic Surgeons member. Consumers Research Council of America named her one of the top plastic surgeons in America. Alexander has been named a Top Doctor by Atlanta Magazine every year since 2014 and was recognized as the Best Facelift and Body Surgeon in the South 2023 by Cure for Aging.