Saying "No"

In aesthetic medicine, the customer—or patient—is not always right, and practitioners need to be prepared to deny unreasonable requests.
MedEsthetics September 2019

Cosmetic procedures are elective. Patients come in with expectations, not medical concerns, which can make some situations challenging. Aesthetic practitioners often need to guide patients away from procedures not in their best interests. When safety is an issue, physicians readily say “no,” and patients are usually grateful. Conflicts can arise, however, when patients present with preconceived notions of how best to achieve a certain look. Following are some of the situations in which practitioners need to carefully consider whether to move forward with treatment, as well as tips on how to decline unreasonable requests clearly and compassionately.

Some key signs that a patient will not be happy with their outcomes include a lack of specificity in their goals or a lack of concern with the recovery process. “Early in my career, there were some rhinoplasty patients whom I performed surgery on which I regretted later,” says Newport Beach, California-based plastic surgeon Kevin Sadati, MD. “All of them were physically great candidates for the surgery, but showed either a vague understanding of what they wanted or were overly ambitious or misdirected when considering the outcomes they hoped to achieve.”

Through these patients, Dr. Sadati identified common red flags: patients who bring in portfolios of celebrity pictures showing what they want and are resistant to attempts to bring some reality into the conversation; and patients who show little concern for the recovery time needed and anticipate instant results that will fix relationship problems or work situations.

Unrealistic Expectations

Unrealistic expectations have always been the biggest barrier to patient satisfaction. The growth of social media has only heightened this problem. “Social media drives our profession in good and bad ways,” says Gregory Buford, MD, founder of Beauty by Buford Plastic Surgery Center in Englewood, Colorado. “Snapchat and other apps offer images with totally smooth, flawless skin. Patients, especially teens, bring in these images and say, ‘This is how I want to look.’ Our first job must be to establish what is possible. That often means being willing to tell the truth even if that truth might upset the patient.”

The second downside to social media is its tendency to disseminate less than accurate information or impressions. “Photos are not presented in context. No one is pointing out the poor lighting or soft focus. There is a slew of information out there; some is true, some is not. Patients often do not recognize the difference,” says Dr. Buford.

Another concern often fueled by social media and celebrity culture is a desire for unnatural-looking enhancements. Robyn Siperstein, MD, of Siperstein Dermatology Group in Boca Raton and Boynton Beach, Florida, recently treated a 19-year-old patient seeking lip augmentation. “I did a slight augmentation that still looked natural. She came back and told me she wanted more because no one noticed she had had her lips done,” says Dr. Siperstein. “I explained that she should not want to look ‘done’ but rather naturally beautiful. She looked at me in disbelief and said, ‘Why would I get it done if no one noticed? I want to be like the Kardashians!’ At that point, I realized the patient was getting the filler for the wrong reason and told her I didn’t think I was the correct injector for her.”

Fillers are the nonsurgical service to which Dr. Buford most often says “no.” “It’s common for patients who have injections in their cheeks or lips to tell me how pleased they are with the procedure the next day, but when the swelling goes down they are disappointed,” he says. “They liked the more exaggerated look. It is my job to guide them, to impress upon them the importance of proportional features. In reality all cosmetic surgeons are artists. Saying ‘no’ is part of that artistry.”

Dr. Siperstein agrees, pointing out that overfilled lips are the current fad. “Unnaturally large breasts were a fad 20 years ago, large buttocks became popular 10 years ago, and now it is large lips. My mantra is: The best injectable is undetectable,” she explains.

Treating Minors

Cosmetic enhancement has become more and more commonplace in our society and, as a result, practices are seeing younger and younger patients walk through their doors. How young is too young for cosmetic procedures? “As a general rule I will only inject teens under age 18 if their appearance is part of what they do for a living (i.e., a model or actor) or if they want me to fix something that is causing them emotional pain (a patient who is being made fun of for having tiny lips, for example) or for medical reasons (injecting a neuromodulator for someone who is asymmetric due to Bell’s palsy). And the patient and her guardian must be in total agreement,” says Dr. Siperstein.

Cosmetic surgery requires further restrictions. “First of all, patients have to reach certain ages to be eligible for cosmetic surgery,” says Dr. Sadati. “For example, females need to be 14 or older to be good candidates for rhinoplasty, and males should be 17 or older. The desired changes must be initiated by the teenager, not the parents, and whenever possible, both parents need to be onboard with the surgery. The teenage patient needs to show signs of maturity and understanding of pre- and post-operative instructions, since compliance is crucial at any age.”

Michael K. Newman, MD, of South Bay Plastic Surgeons in Torrance and Beverly Hills, California, doesn’t have specific guidelines for operating on teenagers. “Every case is unique,” he says. “Typically, I recommend avoiding most cosmetic procedures until at least age 16 so that the face and body have time to develop. However, there are cases where surgery earlier may be warranted, such as in patients with prominent ears, severe breast asymmetry or an obviously deformed nose. Earlier surgery in these cases can save the patient from years of harassment and embarrassment. For milder deformities, such as small breasts or a small bump on the nose, waiting until age 18 when development is more complete and patients can legally make their own decisions is best,” he says.

Questionable Motivation

The patient consult is where practitioners are likely to uncover underlying psychological problems, hidden motivations and, perhaps, Internet-driven misinformation. This is where noninvasive treatments can be challenging. When a patient comes in for a surgical consult, the process tends to be quite thorough. There are underlying health concerns to be discussed, along with surgical risks and recovery. But, in some cases, physicians don’t spend as much time with patients seeking quick treatments, such as neuromodulator or filler injections. This can be a mistake.

In order to identify patients with underlying psychological concerns or unrealistic requests and/or expectations, Lorrie Klein, MD, medical director of OC Dermatology in Laguna Niguel, California, starts by making sure patients understand that aesthetic treatments are a partnership. “I listen closely to what the patient wants, what bothers them and what they want fixed,” she says. “Based on that, I tell them what I think will help them and show them with my hands approximately what their results could look like. I will treat most patients but I am very clear about the probable results so they have realistic expectations.” Despite these efforts, some patients are still disappointed when they don’t get the facelift-like results they envisioned.

Dr. Buford begins his consults with a general question: “What can I do for you?” “The answer will often be something like: ‘I want bigger breasts,’ but asking additional questions might elicit that she has had a couple of kids and has kind of lost her self-confidence when it comes to being nude in front of her husband,” he says. “Ascertaining her motivation for wanting bigger breasts can really improve your ability to provide the best service for the patient.”

Dr. Sadati agrees. “I try to get to know my patients on a personal level,” he says. “I ask them how long they have been thinking about rejuvenation or other cosmetic changes. What is their motivation? Are they making changes for themselves or are they considering surgery based on some other individual’s suggestions? Are they under any stress or going through life-changing experiences such as divorce or death of a family member? It’s very important to understand what is driving the patient to seek self-improvement and to verify that they are truly self-motivated. The patient also needs to be in a place in life that allows him or her to make a sound decision.”

Being aware of signs of body dysmorphic disorder (BDD) is also important. “BDD patients typically see a deformity that is dramatically beyond reality,” says Dr. Newman. “I ask questions about the functional aspects of life, such as school or work and relationship with friends and family. Patients with severe BDD can be dysfunctional to the point where they miss work or school and become disassociated from their friends and family.”

How To Say “No”

When your reason for denying a patient request is the result of an underlying medical condition that poses a safety hazard, patients are typically very understanding of that concern. When the issue is a potential underlying psychological issue, unreasonable demand, questionable motivation or simply a gut feeling on the part of the physician, it is more challenging to say “no.”

Dr. Buford credits his mentor, Scott Spear, MD, at Georgetown University with preparing him for situations in which he may need to decline patient requests. “He told me that the most important and least uttered word for plastic surgeons is ‘no,’” says Dr. Buford. “As a young surgeon, I didn’t really appreciate how incredibly important that gift was. I was just starting a business and was excited about working with all kinds of patients. The temptation to let my guard down was substantial.”

Dr. Newman acknowledges the difficulty of disappointing patients or turning them away when they’re being unrealistic. “And since these discussions often lead to angry patients, many of us naturally try to avoid them,” he says.
The key to refusing treatment without creating anger is to explain your reasons clearly and gently, but don’t argue. “On rare occasions when I refuse to treat a patient, I tell them I think they look great as they are and they don’t need my help,” says

Dr. Klein. “If what the patient really needs is surgery, I tell them that the services I can offer won’t make them happy. If a patient just wants something I think is wrong for them, I tell them I don’t think I am a good fit for their needs.”

When Dr. Siperstein feels a patient is a poor candidate for fillers or neuromodulators, she explains her reasoning and says, “I would never want to take someone’s money unless I absolutely know I can give them the desired result, as I only want happy, satisfied patients.” She goes on to explain that “the procedure they want won’t be worth the money due to the limited outcome and they will ultimately be unhappy. Most of the time, patients really appreciate my candor and that my desire is not to make money but instead to make patients happy.”

The wide array of cosmetic treatments available today can make it easier to move patients away from desired procedures that are not the right fit. “Patients often ask for procedures that can be risky or they seek unrealistic results. It is our job as physicians to guide them into options that are less risky and more realistic,” says Dr. Newman. “Oftentimes, there is a slightly more conservative option that may balance the risk with the reward. Most patients appreciate that guidance and education, which allows them to make an informed decision about their treatment.”

Dr. Buford follows his mission to always treat the patient with dignity and respect. “We listen carefully to what they want. If I think I can provide services that will make the patient happy, we proceed. If I don’t, I say ‘no,’” he says. “Taking on a patient just for the money is like selling your reputation, if not your soul. Most patients recognize respectful candor and understand that it’s coming from a good place. We have longtime patients whom I have said ‘no’ to many times, and their response is most often appreciation. If you treat patients with respect, you usually get respect in return.”

Linda W. Lewis is the contributing editor of MedEsthetics.

Image copyright iStock.com/Evilwata