FROM the moment you sit down for an hourlong consultation, any facial plastic surgeons worth their salt are trying to determine whether you are the kind of patient who is best turned away.

Ron Barrett

Are you the “great expectations” patient who covets the camera-ready nose of a certain red-carpet walker? Or do you consider yourself an expert who knows precisely how your brows should be lifted and how far?
Or, perhaps, you have a few facial rejuvenations behind you and a BlackBerry full of coming consultations, because you are still looking for a Dr. Perfect to wind back the clock?
“There have always been problem patients,” said Dr. Peter Adamson, a facial plastic surgeon in the department of head and neck surgery at the University of Toronto. “It’s just that now with such a growing interest and availability of procedures, we’re seeing more of them and perhaps more varied types.”
Dr. Adamson, who has written and lectured extensively about patient selection, has identified no fewer than a dozen archetypal problem patients that he warns fellow facial plastic surgeons to be wary of. He calls them the “Dangerous Dozen.”
“The point is, it’s best to identify these potential problem patients early on to determine if the risks of operating on them outweigh the chances of them achieving satisfaction,” he said.
Despite the financial incentive to take on any patient, facial plastic surgeons, who only do cosmetic enhancements from the neck up, say that operating on someone who has unreasonable expectations can have stark consequences for their livelihood and reputation: Doctors may have to do revision surgery. Postoperative follow-up is very time consuming — not to mention the potential damage a single disgruntled patient can do over the Internet.
Videos of the kinds of patients surgeons should avoid were shown for the first time at the 2007 annual meeting of the American Academy of Facial Plastic and Reconstructive Surgery. A standing-room-only panel discussion followed.

Facial Plastic Surgery Clinics of North America, a medical journal, devoted its May issue to difficult patients. Some doctors wrung their hands over their vulnerability; others shared practical solutions such as beware of the cloying patient who butters you up with compliments. It can be their way of convincing themselves that you can do no wrong.
“Doctors are paying more attention to this issue,” said Dr. Donn Chatham, a facial plastic surgeon based in Louisville, Ky. “A problem patient can be very destructive to a practice. They can be disruptive in the waiting room and take up inordinate amounts of a staff and surgeon’s time. They can also use extreme measures.”
Malpractice can be hard to prove when it comes to elective cosmetic procedures, especially if there is no postsurgical medical problem. Whether or not a nose job looks smashing or horrible is subjective.
Facial plastic surgeons say some of their most taxing cases involve former patients who do not sue but instead vent their frustration online in the comments section of plastic surgery Web sites like or
The most disgruntled and Internet-savvy may go further to create complaint sites in the hopes that patients see these sites when they search for a doctor online.
One such site, which was created by a former patient in 2005 who was suing a facial plastic surgeon in California for malpractice, detailed how she thought her brow lift and cheek implants left her looking permanently surprised. The doctor filed a cross complaint to have the Web site dismantled, but a California court ruled in favor of the patient, citing freedom of speech.

PATIENT selection is not a perfect science, nor is it a skill taught in medical schools. Rather, a facial plastic surgeon learns which patients to turn away as a fellow in another surgeon’s practice, then hones this skill on the job.
“I have been training fellows for years,” said Dr. Vito Quatela, a facial plastic surgeon in Rochester and the president of the American Academy of Facial Plastic and Reconstructive Surgery. “The No. 1 call I get once they leave is about this very topic, the difficult patient, and how to handle him or her.”

Facial plastic surgeons estimate that roughly 10 to 15 percent of the potential patients in consultations harbor outright hostility toward past surgeons or have unrealistic expectations about how radically surgery can transform the chin they hate.
“Many times the motivating factor of someone wanting a change in their appearance has more to do with an emotional issue than the actual physical issue,” Dr. Chatham said. “They may want to get a marriage proposal, save a marriage or hold on to a job, and no amount of surgery no matter how well done can guarantee that’s going to happen.
“When it doesn’t, that’s when the patient can come back to blame the doctor and if we’ve allowed that patient into our practice, then we are going to suffer.”
Patients are most likely to cause trouble when they have heightened or unfeasible expectations, said Wendy Lewis, a consultant to candidates of aesthetic enhancement surgery.
“A lot of people do not take into account that, yes, if you get a nose job, your nose may look different, maybe very different, and maybe not like the nose you’ve imagined,” said Ms. Lewis, the author of “Plastic Makes Perfect.” “Unless there’s been very clear communication about expectations between a doctor and patient, a lot can go awry in the post-op phase.”
Ms. Lewis says television makeover programs are partly to blame.
“I used to tell my staff, ‘Be careful on Tuesday morning,’ because we’d get the calls from the viewers of ‘The Swan,’ who watched on Monday nights, and would want come in, having a lot of the wrong ideas about what was possible,” she said, referring to a 2004 show in which contestants would undergo extensive plastic surgery.
Increasingly, facial plastic surgeons also employ a staff member or two to vet their potential patient pool before they sit down with prospective patients.

“Just five years ago about 40 percent of the practices I consulted with had a patient-care coordinator or coordinators on staff to help assess potential patients,” said Robin Bogner, the founder of RMB Virtual, which consults with dozens of facial plastic surgery practices nationwide. “Now 90 percent do.”
A STAFF member concerned about a patient’s unrealistic expectations may leave a Post-it on the patient’s chart or take the doctor aside. But ultimately, it is the surgeon’s call.
Once a note of caution is raised, “the hope is that they’ll turn someone down,” Ms. Bogner said. “But it’s not always the case.”
A patient-doctor consultation is, in essence, a two-way assessment, said Dr. Jonathan Sykes, a professor of facial plastic and reconstructive surgery at University of California, Davis.
“The patient is selecting the doctor and vice versa. But, whereas preoperatively it is the patient who is most vulnerable, now, postoperatively it is the surgeon.”
That vulnerability is something Dr. Richard Goode, a facial plastic surgeon in Palo Alto, Calif., has come to accept.
“We do all we can,” said Dr. Goode, who is also an otolaryngology professor at the Stanford University School of Medicine, “but no matter how beautiful the results may look to us, to our staff, to the patient’s friends and family, if the patient is not satisfied, it can be very painful for us, too.”
One patient, dissatisfied with a rhinoplasty, went over Dr. Goode’s head to his superior, the dean of Stanford’s medical school, to complain about how awful she thought her new nose looked.
The patient worked her way through his various colleagues at the university, who found nothing wrong with her new nose, Dr. Goode said.
She eventually dropped her argument months later.
But, Dr. Goode said, it was grueling.
“I’ve been in practice for many years and sure I remember some of my successes, the good relationships I’ve built with patients,” he said. “But it’s the ones who turned, the ones who became difficult patients that haunted the practice and could not be satisfied, those
are the ones I’ll never forget.”