Mrs J, a 42-year-old mother of two children aged 14 and 12, attended a private cosmetic surgery clinic for a consultation after seeing the clinic’s advertisement in the back pages of a lifestyle magazine.
Her marriage had not been in great shape for the previous five years and she explained to the surgeon, Mr S, that she needed to make herself look attractive again. Surgery, she indicated, might help rekindle the romance in her marriage.
During the consultation, Mr S elicited a history of depression with previous psychiatric input. Clinical examination indicated a modest excess of abdominal skin, but without the classic “apron” or concomitant intertrigo, which often troubles abdominoplasty candidates. At the end of the interview it was agreed that she could have a date for surgery for an abdominoplasty.
Two weeks later Mrs J was admitted to the clinic where a routine abdominoplasty procedure was carried out by Mr S. She was discharged home within 48 hours but unexpectedly reattended the clinic on the fifth postoperative day with central tenderness, redness and discharge in wound line. She had to have a further procedure under anaesthetic to drain and debride the infected wound.
During the following months the wound settled but remained very prominent and tender at the scar line.
Because of difficulty getting further appointments with the clinic concerned, Mrs J made some 15 visits to her family doctor, who was initially surprised to learn that she had had cosmetic surgery. She was also treated for a recurrence of her depression.
Despite this she became more depressed and claimed that the pain was so bad that she could hardly walk.
She made a claim against Mr S.
Further investigations of Mrs J’s medical records by a cosmetic surgery expert revealed that she could have suffered in the past with a somatisation disorder. This would have made it difficult for her to deal with the anxiety of the operation and produced an abnormal illness behaviour.
Whilst the expert involved could not fault Mr S for his surgery, the clinical complication or its management, he was critical of the clinic’s patient selection, the consent taking and the level of pre-operative advice. Eventually the claim was settled for a moderate sum.
It is unusual for patients seeking cosmetic surgery to declare any psychiatric history even where this exists. The surgeon making the assessment should always consider this and exercise special caution about operating on such patients, especially where there may be a body dysmorphophobic disorder. It may well be useful to communicate with any previously-involved psychiatrist.
Self-referring patients should be regarded with special caution. You should get the patient’s consent to contact their family doctor and provide details of the proposed surgery. If consent is not forthcoming, it would be good practice to explore the reasons why, and document these carefully in the patient’s notes.
Careful patient selection is vital in aesthetic surgery. It is especially important that the patient can identify the specific points of the anatomy that disturb them rather than complaining of generalities. It is also important to assess the patient’s expectations for the outcome, which would generally be modest, and be for “self” rather than the benefit of others or to improve relationships.
A signed consent form is not necessarily evidence of legally valid consent. Preferably, the surgeon should document all relevant points discussed either in the notes or in the letter to the GP. Patients should also be offered literature discussing the operation and the potential complications and the offer of such literature should be recorded. For example, in this case, a quite prominent lower abdominal scar is a not uncommon sequelae, which might shock the uninformed patient.
A second consultation should always be offered to aesthetic surgery patients, and if the surgeon has doubts, insisted upon. This offers a vital “cooling off” period and also the opportunity for the patient to ask more questions.
The use of pictures to illustrate cosmetic outcome can be useful in helping patients to decide if surgery is for them. Dr Yvette Godwin has compiled a CD-ROM of clinical photographs for this purpose. An Atlas of Consent is free for MPS members and can be ordered by emailing firstname.lastname@example.org or telephoning 0113 241 0530.