It was a pleasure to meet and talk with Nicole Paraskeva yesterday. She is researching patient rated outcomes in cosmetic surgery with the Centre for Appearance Research as part of her doctoral thesis. I am delighted to be participating in this important work. It is so important to know whether cosmetic surgery is in the patient’s best interest, whether they would be better helped by psychological therapy or by a combined approach. The Michael Jackson scenario is tragic and research in cosmetic surgery practice must strive to understand patients better and to fill the gaps in current knowledge. This is why I am so pleased to contribute to the research. Unfortunately even the most experienced of us do not have all the answers and so may operate on a patient who can not be reliably diagnosed as psychologically unsuitable for surgery. Failing to meet previously undisclosed, unrealistic expectation may lead to a very angry patient despite good surgery. This is made worse if unpredictable healing produces a problem. If research can help better identify patients whose expectations can not be met aesthetically or who cannot accept the unavoidable unpredictability of surgery and if we can identify patients for whom surgery is not the answer then that will be a wonderful advance for patients and their surgeons.