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A bad nose day

01 May 2009

Mrs Y, a 32-year-old fashion magazine editor, had been dissatisfied with the appearance of her nose for a long time. She was promoted at work and was finally able to afford the cost of a cosmetic surgical procedure.

She went to see Mr G, a private consultant ENT surgeon, and requested a procedure to make her nose shorter, less broad and with a less bulbous tip. Mr G noted that Mrs Y had suffered an episode of depression two years earlier, but established that this was not connected in any way with her facial appearance.

Mr G recommended an open rhinoplasty technique, having recently attended a seminar on its use, feeling that the cosmetic appearance Mrs Y wanted was most likely to be achieved in this way. However, Mr G’s experience of rhinoplasty up to this point in his career had been largely in the endonasal rhinoplasty technique.

Mr G’s documentation of the consenting process was brief, with no explicit note that he had warned Mrs Y of possible adverse outcomes from the surgery. Mrs Y recollected that there had been a brief discussion of potential side effects and that she had been encouraged by seeing photographs of the results of the procedure on other patients.

Mrs Y was not satisfied with the postoperative appearance of her nose. She felt that it appeared asymmetrical and hook-shaped. Mr G commented in his notes that he had perhaps removed slightly too much cartilage from the nose tip, but advised against any revision procedure. Mrs Y was adamant that she wanted further surgery and Mr G acquiesced.

Unfortunately, the revision procedure did not satisfy Mrs Y. Mr G eventually carried out a total of four procedures, but the final outcome was cosmetically poor. Mrs Y launched a legal claim against Mr G alleging that he had conducted the surgery improperly leaving her with a deformed facial appearance, and had not warned her sufficiently of potential adverse outcomes.

Expert opinion

ENT and cosmetic surgical experts concurred that Mr G’s understanding and execution of the techniques used in the initial operation were poor. It was also felt that the first revision procedure was carried out far too quickly.

They were surprised that Mr G had not sought the opinion of a colleague on how best to proceed, given the poor initial outcome. They were unhappy with the documentation of the consenting process. The claim was settled for a moderate amount.

Learning points

  • When attempting to integrate new techniques into your clinical repertoire, ensure that you have sufficient knowledge, supervision and experience to do so. If not, then it will be very difficult to defend your actions in the event of an adverse outcome.
  • Where the outcome of an intervention is significantly poorer than anticipated, particularly for cosmetic surgical procedures, it is good practice to seek the advice of a colleague on how best to proceed and remedy the situation.
  • The consenting process for cosmetic surgical procedures needs to be particularly rigorous, with documentation of the fact that the patient is aware that there exists a risk that the outcome may leave them less satisfied than they were with their original appearance. Dedicated consent leaflets, which doctor and patient complete and sign together, can be helpful in this area.
  • Revision procedures in cosmetic surgery are fraught with difficulty and should be embarked upon with extreme caution, and preferably with the advice of a colleague, or someone more specialised in this area.
  • See the following paper, which explores the complexity of psychological factors in revision rhinoplasty: Ambro BT and Wright RJ, Psychological Considerations in Revision Rhinoplasty, Facial Plast Surg Aug;24(3):288–92 (2008). Epub 24 Oct 2008.
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