14th June 2012

Thoughts from Las Vegas – rhinoplasty complications and unhappy patients

I was on the “complications can and do occur” panel with a very notable line up including Norman Pastorek, Phil Miller, Paul Nassif, Bahman Guyuron and Dan Becker. It seems that infection is more of a problem now than in the past and that it can have devastating consequences. Some of the panellists with long, distinguished careers are seeing problems that have never been an issue before. We have all individually seen similar problems and have come to change our practices to encompass more vigorous anti-infective regimes. Jay Calvert was moderating and did draw attention to the fact that these new regimes could risk encouraging bacterial resistance to measures that have been reserved for MRSA. Complications unfortunately can never be eradicated as we will never understand every facet of the individual patient’s healing process and immune system. We all do everything we can but still communicate very clearly to our patients that outcomes of surgery will forever be associated with unpredictability and so we cannot guarantee the hoped for results.
I also was a member of a panel discussing how to help angry, disaffected patients. On the panel with me was Paul Nassif and Jonathan Sykes. This area had been drawn attention to as a complication by Bahman and all of us in the previous panel too. The goal for all of us is to help make all our patients happier with surgery. Key to this is good patient selection. Patient selection involves careful assessment of expectations. These expectations relate not just to whether they are realistic regarding what is possible but also whether they are realistic with regard to accepting risk. Risk acceptance in rhinoplasty means fully appreciating that despite good surgery a nose could look worse – again because as surgeons we do not have full control over how tissues change with accepted, contemporary surgical techniques and with healing. It is hugely disappointing for patients and surgeons when complications occur. As surgeons deeply committed to rhinoplasty we all affirmed that we would do everything we could for our patients to correct unwanted results – our experience in secondary, revision cases in such situations is invaluable. Very occasionally patients who sadly suffer a complication or who even have a good result will demonstrate considerable anger. This may unfortunately mean they were never a good candidate for surgery as their expectations aesthetically or psychosocially or their acceptance of risk could never be realistic. Despite our best intentions as surgeons, as a panel we agreed this scenario means as surgeons we got our patient selection wrong even if we got the surgery right. Patients may have had unrecognised body dysmorphic disorder, social anxiety or a personality disorder. The difficulty is that we don’t have criteria to diagnose these conditions with complete reliability or that will give us and our patients 100% certainty that surgery is right for them. I have reflected at length on patient assessment for surgery and am lucky to have been able to discuss these difficult areas with Alex Clarke, Clinical Psychologist at The Royal Free Hospital and School of Life Sciences, University of West England. She has considerable experience in the field of body image on which she has written extensively – see my likes on our facebook page. Working with Alex we have instituted the Centre for Appearance Research (CAR) cosmetic surgery psychology screening tool in The Nose Clinic. This tool has been produced following on from earlier questionnaires www.iop.kcl.ac.uk/cadatquestionnaire and is being used now in a pilot study with other cosmetic surgery centres to help select patients for surgery and additional psychological care if needed or when surgery is inappropriate. We want to provide a gold standard of care which extends to ensuring that we do everything we can to make sure patients are suitable for cosmetic nasal surgery and that it is right for them. We always put our patients’ best interests first and to set gold standards in our practice.