# Patient Evaluation and Psychology in Aesthetic Surgery

## Introduction
Aesthetic surgery differs from reconstructive surgery in that the patient, not disease or injury, defines the problem. Patient selection is the single most important factor in achieving satisfactory outcomes in aesthetic surgery. Understanding patient psychology, motivations, and expectations is essential for identifying appropriate candidates and avoiding dissatisfied patients. The aesthetic surgeon must be both a technical expert and a skilled communicator; the consultation is itself a therapeutic intervention.

## Patient Motivation and Expectations

### Appropriate Motivations
Desire to correct a specific feature that has been a long-standing source of self-consciousness. Desire to look as good as they feel or to match their appearance to their self-image. Internal motivation (patient-driven) rather than external motivation (partner, employer, social pressure). Realistic expectations: understanding that surgery improves but does not perfect; scars are permanent; aging continues. Emotional stability: patient is in a stable life situation, not undergoing acute crisis.

### Red Flag Motivations
**Vague or unrealistic expectations**: "I want to look perfect" or "I want to look like a celebrity". **External motivation**: surgery to please a partner, save a relationship, or gain a promotion. **Acute life crisis**: recent divorce, bereavement, job loss; patient may be using surgery as a coping mechanism. **Minimal deformity with maximal distress**: disproportionate concern about a feature that is objectively normal or trivially different.

**Surgeon shopping**: patient has seen multiple surgeons, been turned down, and is seeking someone who will agree to operate. **History of multiple aesthetic procedures with dissatisfaction**: pattern of repeated surgery seeking an unattainable ideal. **Hostile or demanding demeanor**: patient who is aggressive, litigious, or threatens from the outset.

## Psychological Screening

### Body Dysmorphic Disorder (BDD)
Psychiatric condition characterized by obsessive preoccupation with perceived defects in appearance that are not observable or appear slight to others. **Prevalence**: 7-15% of aesthetic surgery patients (compared to 1-2% in the general population). **Diagnostic criteria** (DSM-5): preoccupation with perceived defects, repetitive behaviors (mirror checking, skin picking, reassurance seeking), clinically significant distress or functional impairment, not better explained by an eating disorder. **Common areas of concern**: skin (acne, scars, wrinkles), nose, hair, chin, overall body symmetry.

**BDD patients do NOT benefit from aesthetic surgery**: surgery does not resolve the underlying psychiatric disorder; patients remain dissatisfied, shift focus to a new body part, or develop worsened symptoms. **Outcomes of surgery in BDD patients**: 91% report no change or worsened symptoms; high rates of complaints, litigation, and threats of violence against surgeons. **Screening**: BDD Questionnaire (BDDQ) — validated screening tool; positive screening should prompt psychiatric referral before any surgical intervention. **Management**: refer to psychiatry; treatment is CBT (cognitive behavioral therapy) and SSRIs; surgery is contraindicated.

### Other Psychiatric Conditions
**Depression**: may impair wound healing, compliance, and satisfaction; stabilize before elective surgery. **Eating disorders**: common in body contouring and breast surgery patients; screen actively. **Narcissistic personality disorder**: unrealistic expectations, entitlement, difficulty accepting imperfection; high dissatisfaction risk. **Obsessive-compulsive personality**: perfectionism; may fixate on minor asymmetries or scars.

**Gender dysphoria**: requires multidisciplinary evaluation and mental health clearance before gender-affirming surgery per WPATH guidelines.

## The Aesthetic Consultation

### Communication Framework
**Active listening**: allow the patient to describe their concerns in their own words; do not interrupt or reinterpret prematurely. **Open-ended questions**: "What would you like to change?" "How does this bother you?" "What are you hoping to achieve?". **Mirror or photograph analysis**: have the patient point to the specific area of concern; this avoids miscommunication. **Reflective statements**: repeat the patient's concerns back to confirm understanding.

**Manage expectations explicitly**: discuss what surgery can and cannot achieve; show before-and-after photographs of typical (not best) results. **Informed consent**: must include realistic discussion of risks, complications, scars, recovery, need for revision, and the possibility of an unsatisfactory result.

### SIMON and SUSAN Framework
**SIMON** (Single, Immature, Male, Overexpectant, Narcissistic): mnemonic for patients at highest risk for dissatisfaction in aesthetic surgery. **SUSAN** (Stable, Unified expectations, Sensible, Appropriate, Non-smoker): mnemonic for ideal aesthetic surgery candidates.

### Documentation
Standardized preoperative photographs: multiple angles, consistent lighting, no makeup or jewelry. Written informed consent with specific discussion of risks, alternative treatments, and expected outcomes. Document patient's stated goals and the surgeon's assessment of achievability. Psychological screening tool results if administered.

<image>Flowchart for patient evaluation in aesthetic surgery consultation. The flowchart begins with the initial consultation at the top, where the patient presents with a cosmetic concern. The first assessment box evaluates the patient's motivation: internal motivation and specific realistic goals proceed down the left pathway marked as appropriate candidate. External motivation, vague goals, or acute life crisis proceed down the right pathway marked as proceed with caution. The appropriate candidate pathway leads to a psychological screening box that checks for BDD using the BDDQ screening questionnaire. If positive for BDD, the patient is directed to psychiatric referral and surgery is contraindicated. If negative for BDD, the pathway continues to physical examination and assessment of surgical feasibility. A decision diamond asks whether the patient's expectations match what surgery can realistically achieve. If yes, the pathway leads to informed consent, preoperative planning, and proceeding with surgery. If no, the pathway leads to additional counseling, alternative treatments, or declining to operate. The proceed with caution pathway leads to additional psychological assessment, and based on findings either redirects to appropriate candidate pathway or to decline surgery. Red flag indicators are listed in a sidebar: minimal deformity with maximal distress, surgeon shopping, multiple prior procedures with dissatisfaction, hostile demeanor, and BDD symptoms.</image>

## Physical Examination and Surgical Planning

### Standardized Assessment
Systematic evaluation of the area of concern with objective measurements. Compare patient's perception with objective findings; significant discrepancy suggests BDD. Assess skin quality, tissue laxity, fat distribution, skeletal framework, and asymmetries. Document baseline asymmetries and point them out to the patient preoperatively (every face and body has natural asymmetries; patients may notice them for the first time after surgery and attribute them to the procedure).

### Photographic Documentation
Essential for preoperative planning, intraoperative reference, and medicolegal protection. Standardized views for each procedure (e.g., frontal, lateral, three-quarter, and basal views for rhinoplasty). Consistent lighting, background, positioning, and distance. No retouching or filters.

**Computer imaging/morphing**: can be helpful for communication but must be presented as a simulation, not a guarantee; overuse can create unrealistic expectations.

### Risk Factor Assessment
**Smoking**: vasoconstriction impairs wound healing; increases complication rates for facelifts (skin necrosis), abdominoplasty, and breast surgery; mandate cessation 4-6 weeks before and after surgery. **Medications and supplements**: aspirin, NSAIDs, vitamin E, fish oil, herbal supplements (ginkgo, garlic, ginseng) increase bleeding risk; discontinue 2 weeks preoperatively. **BMI**: BMI >30 increases wound complications, VTE risk, and anesthetic risk; optimize weight before elective aesthetic surgery. **Medical comorbidities**: diabetes (HbA1c <7%), hypertension (controlled), bleeding disorders, autoimmune conditions.

**DVT risk assessment**: Caprini score; appropriate prophylaxis for abdominoplasty and body contouring (highest VTE risk among aesthetic procedures).

## Medicolegal Considerations
Aesthetic surgery has one of the highest rates of malpractice claims in plastic surgery. Most claims are based on dissatisfaction with results, not negligence. **Protective measures**: thorough informed consent, realistic expectation setting, standardized photography, detailed documentation, and appropriate patient selection. **Refusal to operate**: the surgeon has the right and obligation to decline surgery for inappropriate candidates; this is both ethical and protective.

Financial policies: clear discussion of revision policies and costs; no guaranteed outcomes. Cooling-off period: consider mandating a waiting period between consultation and surgery, especially for younger patients or those seeking significant changes.

<image>Illustration showing standardized photographic views required for aesthetic surgery documentation. The figure shows a patient model in six standard positions. View 1 is a frontal view with the patient facing directly toward the camera, eyes at camera level, neutral facial expression, ears visible. View 2 is a right lateral view at exact 90 degrees showing the full profile from hairline to clavicles. View 3 is a left lateral view at 90 degrees showing the opposite profile. View 4 is a right three-quarter (oblique) view at 45 degrees. View 5 is a left three-quarter view at 45 degrees. View 6 is a basal view looking upward at the base of the nose. All views show consistent blue background, even lighting without shadows, hair pulled back, no makeup or jewelry, and the camera at the same distance and height. Measurement reference points are indicated on each view.</image>

## Informed Consent in Aesthetic Surgery
Must be more comprehensive than for reconstructive procedures due to the elective nature. **Elements**: diagnosis (cosmetic concern, not disease), proposed procedure, alternatives (including no treatment), risks and complications (general and procedure-specific), expected recovery, expected outcome and limitations, financial responsibilities, revision policy. Discuss common risks: bleeding, infection, scarring, asymmetry, numbness, need for revision, unsatisfactory result. Procedure-specific risks: e.g., rhinoplasty (nasal obstruction, saddle nose), blepharoplasty (dry eyes, ectropion), facelift (facial nerve injury, hematoma).

**Written consent with patient signature**: document that the patient has had opportunity to ask questions. Preoperative photographs reviewed with the patient as part of the consent process.

## Key Clinical Pearls
Body dysmorphic disorder is present in 7-15% of aesthetic surgery patients and is the single most important contraindication to cosmetic surgery; these patients do not improve with surgery and frequently become hostile, litigious, or self-harming; screening with the BDDQ should be routine. The surgeon's greatest protection against dissatisfaction and litigation is proper patient selection, realistic expectation setting, thorough informed consent, and standardized photographic documentation; these are more important than surgical technique in determining patient satisfaction. Always document preexisting asymmetries and point them out to the patient before surgery; patients often become hyperaware of their appearance postoperatively and may attribute longstanding asymmetries to the surgical procedure. Declining to operate on an inappropriate candidate is not only the surgeon's right but an ethical obligation; patients with red flag motivations (external pressure, acute crisis, surgeon shopping, BDD) will not be satisfied regardless of how well the surgery is performed. Smoking is the most significant modifiable risk factor for wound complications in aesthetic surgery; mandate nicotine cessation for a minimum of 4-6 weeks before and after surgery, and verify compliance with urine cotinine testing.

## References
- Sarwer DB, Crerand CE. Body dysmorphic disorder and appearance enhancing medical treatments. Body Image. 2008;5(1):50-58.
- Crerand CE, Franklin ME, Sarwer DB. Body dysmorphic disorder and cosmetic surgery. Plast Reconstr Surg. 2006;118(7):167e-180e.
- Honigman RJ, Phillips KA, Castle DJ. A review of psychosocial outcomes for patients seeking cosmetic surgery. Plast Reconstr Surg. 2004;113(4):1229-1237.
- Rohrich RJ, Cho MJ. Patient safety in aesthetic surgery: an analysis of 30,964 cases. Plast Reconstr Surg. 2022;149(6):1397-1405.