Improving Outcomes in Aesthetic Surgery

Attend any aesthetic medical conference where the lecture hall is addressing the newest technique for tightening a neckline or lifting a jowl and it will be filled to capacity. As students of science, as well as artisans of anatomy, we are drawn to believe that our healing influences are primarily delivered through our fingertips. Yet, if our measure of success is recalibrated to achieving patient satisfaction rather than just the mathematics of perfection, then the secret to a robust practice and happy patients may have as much to do with the psychic allure as the technique du jour.

It is not uncommon for a patient seeking cosmetic surgery to have experienced pubescent taunting and emotional scarring secondary to physical form falling outside of a standard deviation.  Others may seek cosmetic treatments because they deem beauty as a means toward professional advancement, a romantic interest or an improved social status. Regardless of the motivators, our patients may be particularly vulnerable to critical judgments.  And the likelihood of them achieving their goal is more related to the self-esteem gained, than the physical form obtained. As any practicing aesthetic physician can report a seemingly great outcome, meeting all objective measures of physical perfection may fall short of a patient’s expectations whereas a less than perfect result may be met with utter adoration.  Additionally, at times doing nothing at all akin to placebo can be effective at improving self- esteem. Our success both as individuals as well as a specialty is determined by the satisfaction of our patients regardless of the means to achieve it.

The question is what factors and to what extent does each determine our patients’ post-treatment happiness? How much of our success and the patient’s satisfaction is based on the physical outcome achieved and how much of it is based on other seemingly less direct causes such as the post treatment judgments by peers, family or even the physician’s  communication style, mood and attitude? Clearly all of these impact their mindset, attitude and self –esteem and ultimately calculate into their satisfaction.

Perhaps we shouldn’t limit our attention to only one of the contributing factors? Shouldn’t we study all the influencers on a patient’s mind and mood as well take a critical look at ourselves and how much our communication and practice styles as well as our personalities influence our patients’ satisfaction rates and perceived outcomes?

Two well- studied pathologies highly dependent on patient psyche and perceptions are pain management and major mood disorder. Both conditions are associated with a plethora of published research evaluating the influence of placebo and physician personality on outcomes. If we are honest with ourselves we would have to acknowledge that patients’ psychological dispositions are critically important to perceived outcomes in aesthetics as well. Yet, in aesthetic medicine while there is a dusting of attention to the psychology of the patient, there is little to no study on physician’s personality, communication style or the placebo effect.  When 13 percent of those who get saline injections (1) believe they have improvement in their glabellar wrinkles or 28 percent of those who don’t get injected with filler believe their lips are fuller (2) or 38 percent of those injected with saline believe their submental fat has been reduced. Maybe the placebo effect deserves more than a curious footnote.(3)  There are plenty of examples of the power of placebo in general medicine. (4,5,6)

Before we can honestly study placebo, we have to be willing to admit its proof detracts from the brilliance of our direct intervention and elevates the patients mind as a contributing curative. This is not a new revelation, in fact for the majority of medicines existence and prior to the last century, placebo may have been our best tool in the armamentarium.  Alternative medicine which attracts 38 percent of Americans (7) may achieve its benefits because of the placebo effect, and the more time and “hands on” the alternative medical provider’s intervention, the greater the placebo’s potency. (8).  Many doctors, if pressed, will admit to using placebo on occasion, but in today’s litigious, regulatory, political and ethical environment of full transparency the placebo treatment has less place in our tool box. By the virtue of being completely honest we negate the effect.  And perhaps being too literal or callous in our communication may lead to a bad outcome by virtue of the Nocebo.   The nocebo effect, the evil twin of the placebo, was first described in 1960. (9) It is when a symptom or illness results from expectation or fear of a bad effect occurring. (8) In fact, the verbal and non-verbal communications of the doctors and other staff do contain numerous unintentional negative suggestions that may trigger a nocebo response. (10) Perhaps physicians contribute to a nocebo effect when we sterilely stress all the possible negative outcomes or complications that can occur without putting them into context. If we are ethically or legally bound to disclose all the risk including the very remote risk for death or significant morbidity but place it in context by saying, “As a healthy person you have more risk in your car ride on the way to the surgical center than you do from anesthesia” we then offer the message in a manner that allows the patient to understand the relative risk. Many aesthetic physicians recognize the impact of a nocebo effect from outside our practices. This happens when an easily influenced patient is predestined toward a perceived unsuccessful outcome by an insulting or disapproving mother, husband, friend or an in- law who is quick to criticize the patient post procedure. Attempting to mitigate or quash these offenders’ influence on our patient’s psyche would be prudent.

Unlike most other fields of medicine, it was not until very recent that placebo and nocebo effect could be studied in cosmetic medicine. Prior to the introduction of botulinum toxin cosmetic physical interventions were so clearly recognized that a randomized controlled trial was not possible. The introduction of botulinum toxin as a temporary injectable agent of change has however, opened up our field to level one evidence clinical trials. In the broad landscape of medical fields aesthetics is still very academically immature.  Nonetheless, if placebo and nocebo truly have been proven in medicine then why not recognize and further study it. Perhaps even harness, repackage and use their power in a contemporary acceptable manner to our patient’s benefit?

If we are to truly study the effects of placebo/nocebo as well as the indirect psychosomatic and psycho-social interactions impact on our patient’s perceived outcomes, then all aspects of the treatment need to be taken into consideration. This would include, but not limited to the type and expense of the procedure as well as the specialty/personality of the provider, and the associated pain.

A comprehensive review of randomized controlled trials evaluating physician communication styles and outcomes led the authors to conclude, “Patient health outcomes can be improved with good physician-patient communication. The studies reviewed suggest that effective communication exerts a positive influence not only on the emotional health of the patient but also on symptom resolution, functional and physiologic status and pain control.” (17) While the studies evaluating health outcomes and physician interaction are mostly centered in primary care settings can the same conclusion hold true in aesthetics? As much as we want to believe our hard earned degrees and aesthetic skill set lead to better perceived outcomes one of the few studies to evaluate patient satisfaction and physician interaction in plastic surgery occurred at the University of Michigan.  Chung showed that patient satisfaction was more determined by doctor patient communication and clinic efficiency than physician’s skill level. (18) The manner in which the physician engages and listens to the patient as well as duration of the visit all likely impact perceived outcomes.

Cosmetic seeking patients are likely highly suggestable patients (19) and are easily vulnerable to influence from family and peers.  The more support, time and optimism a provider affords to the patient, the more likely they are to achieve the intended effect from the treatment intervention. (8)  We spend so much time stressing technique in aesthetic medicine and while there is no doubt being a talented technician, and a well -educated scientist is critical to delivering a good outcome, our success in aesthetic medicine necessitates an ability to also understand all the controls that make a patient happy. And this includes not only studying the mind and personalities of our patients but perhaps also critically evaluating our own.

Are we open to that?

-Steve Dayan

1. Carruthers J, Lowe N. et al. Double-Blind, Placebo-Controlled Study of the Safety and Efficacy of Botulinum Toxin Type A for Patients with Glabellar Lines. Plast and Reconstr Surg; Sept 2003;112:1089-98.
2. Dayan S. Randomized, Evaluator-Blinded, No Treatment Controlled Study of the Effectiveness and Safety of Small Particle Hyaluronic Acid Plus Lidocaine in the Augmentation of Soft Tissue Fullness of the Lips. Oral Presentation Cosmetic Surgery Forum; Dec 3, 2014
3. “Outstanding Paper Presentation” Session 2 of the Cosmetic Scientific Paper sessions American Society of Plastic Surgery (ASPS) Annual meeting, October 13, 2014. “A Pooled Analysis of the Safety and Efficacy Results of the Multicenter, Double-Blind, Randomized, Placebo-Controlled Phase 3 Refine-1 and Refine-2 Trials of ATX-101, a Submental Contouring Injectable Drug for the Reduction of Submental Fat”
4. Dimond EG, Kittle CF, Crockett JE. Comparison of internal mammary artery ligation and sham operation for angina pectoris. Am J Cardiol.1960;5:483-486.
5. Dodick DW et al. Onabotulinum toxinA for treatment of chronic migraine pooled results from the double blind randomized placebo controlled phase of the PREEMPT clinical program. Headache 2010;50:921-936.
6. Waber RL, et al Commercial Features of Placeboand Therapeutic Efficacy JAMA, March 5, 2008—Vol 299, No. 9 1016-17
7. https://brainblogger.com/2014/06/09/who-uses-complementary-and-alternative-medicine/
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12. https://www.medscape.com/features/slideshow/compensation/2015/public/overview#page=17
13. Scheepers RA, et al. A Systematic Review of the Impact of Physicians’ OupationalWell-Being on the Quality of Patient CareJ. Behav. Med. DOI 10.1007/s12529-015-9473-3 Sept 2015
14. Fabi, SG, personal communication, February 2015
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18. Chung KC, Hamill JB, Kim HM, Walters MR, Wilkins EG. Predictors of patient satisfaction in an outpatient plastic surgery clinic. Ann Plast Surg. Jan 1999;42(1):56-60.
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