KeywordsBody dysmorphic disorderBDDPsychological issuesAesthetic expectationsPsychologic referralUnexpected outcomesRealistic expectations
4.1 Unexpected Patient Responses
Reputations can be elevated from beautiful aesthetic procedure results, or harmed from poor outcomes. Patient perception and subsequent satisfaction have the greatest impact on the success of the outcome. Although rare, an unexpected patient response to aesthetic treatment can occur. Aesthetic practice is highly subjective for both the patient and practitioner and an unexpected response due to unrealized expectations can be particularly emotional. Although comprehensive and detailed consultations are provided, and the patient is initially agreeable, there can be an unexpected patient response. For example, disappointment, anger, or hostility may occur, to the surprise of the practitioner.
The most effective way to avoid medical-legal issues is through prevention (Raveesh et al. 2016). The prudent practitioner provides a thorough and direct consultation by the actual treatment provider rather than through an assistant or technician. Providing the opportunity for the patient to ask questions and relay expectations directly to the practitioner who will perform the treatment will avoid potential miscommunication (Huycke and Huycke 1994).
The reasons patients may pursue legal recourse include (1) feeling like not enough information was provided regarding the condition or options available, (2) the practitioner not being available, (3) poor relationship with the practitioner, and (4) not being referred appropriately (Raveesh et al. 2016; Huycke and Huycke 1994). Practitioners should supply realistic and understandable information about appropriate procedures and thoroughly explain side effects, risks, and benefits to every patient. The patient’s level of understanding and expectations of treatment must be established by asking direct questions and allowing time for discussion (Raveesh et al. 2016; Huycke and Huycke 1994). In the case of any adverse event, prompt follow-up is essential to ensure the patient is evaluated and appropriately treated, or referred to a qualified provider (Huycke and Huycke 1994).
Pictures, diagrams, drawings, and other teaching materials are tools that can be used to illustrate outcomes to the patient and provide realistic visual information. Discussion using teaching tools allows for potential inconsistencies to be realized and misconceptions clarified. As an example, many patients confuse the muscle weakening actions of botulinumtoxin type A (BoNT/A) with the volume replacement action of dermal filler. While the actions and outcomes of these treatment modalities are understood by practitioners, oftentimes a comprehensive consultation and assessment reveal misunderstandings by the patient. Detailed explanation and direct communication of available aesthetic options appropriate for the individual patient result in an excellent outcome.
Unexpected patient responses can include exaggerated euphoria. Unusually euphoric patients are infrequent and, although can be initially pleasant, extreme euphoria is not expected and may be indicative of psychological disturbance. Repeat visits to the practitioner for multiple, additional treatments or fixes have been reported (Scharschmidt et al. 2018; Phillips et al. 2019a). Unfortunately, patients with psychological disturbances respond poorly to cosmetic treatments and the attempt by the practitioner to modify the result may worsen the situation (Rankin and Borah 1997; Phillips et al. 2019b).
Multiple, repeat visits for a previously resolved issue can lead to loss of revenue for the practice because of decreased availability to care for additional patients due to scheduling issues. The extremely euphoric patient who continuously invades the practice under the guise of delight but routinely requests touch-ups or re-treatments is a challenge for the practitioner.
This is not to say patients are not invited to be thrilled with their treatment, but careful consideration of a patient with extreme euphoria is advised. Direct communication and thorough documentation of the consultation at each visit are essential; however, in some cases referral to a psychologist may be warranted.
Hostility is an unexpected and unpleasant patient response in any clinical practice. A compassionate and direct consultation that outlines realistic expectations and limitations of treatment or medication prior to initiation of the procedure can help alleviate the potential for an angry patient. Detailed review of the consent form should include realistic outcomes and possible side effects to help ensure the patient has clear understanding of the limitations of treatment. In addition, the practitioner should have a selection of referral options to offer the patient in the event either the patient or the practitioner is compelled to seek outside assistance.
Many patients have some level of anxiety before or during aesthetic treatments. Some patients may not divulge true expectations and this makes it difficult to identify patients who are at increased risk of hostility (Rankin and Borah 1997). However, some aesthetic patients may not only bring the normal anxious component into the situation but some may have escalating or intense anxiety. Coupled with unrealistic expectations, this can predispose the patient to the unfavorable response of hostility (Scharschmidt et al. 2018; Rankin and Borah 1997).
Nevertheless, if a patient becomes hostile after treatment, whether it is immediate or weeks or months after treatment, a conversation in a sympathetic and calm demeanor along with reiteration of options should be reviewed with the patient (Raveesh et al. 2016; Huycke and Huycke 1994). Understanding the reason for hostility through conversation can shed light on this atypical response and calm the patient. When patients believe the practitioner has their best interest in mind, they are more receptive to options and may ultimately become satisfied (Huycke and Huycke 1994). However, in some cases, referral to psychiatry or to a psychologist may be justified (Rankin and Borah 1997).
4.4 Body Dysmorphic Disorder
Body dysmorphic disorder (BDD) is a psychological condition that is diagnosed according to Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria (American Psychiatric Association 2013). This condition is characterized by an intense preoccupation of hardly noticeable or non-existent defects in the person’s appearance that is upsetting to them in ways where they believe they are ugly or deformed when in reality, they appear normal (Phillips et al. 2019a). This obsessive preoccupation can lead to repetitive behaviors such as continually checking their image in mirrors, windows, or other reflective objects (Phillips et al. 2019b). Interestingly, this behavior is not easily controlled by the patient and they do not enjoy having to constantly confirm their appearance. BDD is more common than practitioners may realize and is associated with suicidal ideation and behavior. According to research, most patients seek help with their perceived defects through plastic surgery or cosmetic dermatology (Phillips et al. 2019b). This is risky for the practitioner because the patient who suffers with BDD will not likely be satisfied with the outcome of the procedure and might focus on the result or discover another defect.
Preoccupation with one or more non-existent or extremely slight defect, thinking about it for at least 1 h per day
Concerns about appearance that lead to repetitive actions such as mirror checking or skin picking or mental acts such as comparing their appearance to others
Clinically significant distress or interruption of social behaviors that result from appearance concerns
The patient preoccupation is not better explained by concerns of body fat/weight in an individual who meets diagnostic criteria for an eating disorder