S05E105 - Navigating Patient Consultations for Cosmetic Surgery - Do's and Don'ts

Plastic surgery demands as much psychological finesse as it does technical skill. In this candid conversation, four board-certified plastic surgeons Dr. Sam Jejurikar @samjejurikar, Dr. Salvatore Pacella @sandiegoplasticsurgeon, Dr. Lawrence Tong @yorkvilleplasticsurgery, and Dr. Sam Rhee @bergencosmetic —pull back the curtain on the complex art of patient consultation and selection.

The surgeons begin by sharing their approaches to the initial consultation, where they must quickly assess not just anatomical concerns but psychological readiness. They describe the delicate balance of listening to what patients want versus identifying what they actually need. As they note, patients often request "mini" procedures when more extensive work is required, or they misunderstand what certain surgeries can accomplish.

Listen as these experienced surgeons identify the red flags they've learned to recognize: patients fixated on imperceptible asymmetries, those bringing extensively edited photos of themselves, individuals undergoing surgery primarily to please partners, and those who've consulted with many previous surgeons. The conversation takes a fascinating turn when they discuss the "six-month flip"—patients who transition from excessive gratitude immediately post-surgery to hypercritical dissatisfaction around the half-year mark.

The doctors share stories of difficult decisions to decline operating on certain patients, despite the awkwardness these situations create. They agree that recognizing psychological warning signs early saves both patient disappointment and surgeon stress, though hindsight often reveals missed signals they wished they'd heeded.

Whether you're considering plastic surgery or simply fascinated by the psychology behind aesthetic medicine, this episode offers rare insight into how surgeons evaluate not just physical characteristics but psychological readiness for transformative procedures. Their collective wisdom reminds us that sometimes the most skilled surgical decision is knowing when not to operate at all.

@3plasticsurgerypodcast #podcast #plasticsurgery #cosmeticsurgery #plasticsurgeon #beauty #boardcertified #aesthetic #3plasticsurgeonsandamicrophone ⁠#bergencosmetic ⁠#bestplasticsurgeon #beforeafter #aesthetics #realpatientrealresult #boardcertifiedplasticsurgeon #njplasticsurgeon #njplasticsurgery #nyplasticsurgeon #nyplasticsurgery

S05E105 - Navigating Patient Consultations for Cosmetic Surgery - Do's and Don'ts

TRANSCRIPT

[00:00:00]

Salvatore Pacella: Hello everyone. Dr. Sal Pacella here from San Diego, California. I'm joined by Dr. Sam Re from Paramus, New Jersey. Dr. Larry Tong from Toronto, and of course, Dr. Sam Jejurikar from Everything's bigger in Dallas, Texas. That's right. So today we are going to talk about a very interesting topic, um, nightmare consults, patient selection and managing expectations.

Before we get into that. We're gonna do a quick disclaimer.

Lawrence Tong: Alright. Uh, this show is for information informational purposes only. Treatment and results may vary based upon the circumstances, situation, and medical judgment. After appropriate discussion, always seek the advice of your surgeon or other qualified healthcare provider with any questions you may have regarding medical care.

Never disregard professional medical advice or delay seeking advice 'cause of something on this show. [00:01:00]

Salvatore Pacella: Excellent guys. Well, um, so this is a very interesting topic that, um, I'm sure we're all kind of well versed on. Um, you know, the thing I I I like about plastic surgery is that it is almost a. Exclusively psychiatry as well.

And so part of what we, um, in psychiatry to me is clearly the most invasive specialty. So part of what we do as a, um, as a plastic surgeon is making sure that we're doing the right things for patients to o obviously do no harm. And sometimes that harm comes from self-harm for patients and, you know, deciding on the wrong surgery or doing it for the wrong reasons.

Um. So I just wanna first start by asking you guys, you know, what is your general approach to the, the, the patient consultation? How do you open it up? How do you sort of start talking? You know, gimme a, gimme an idea of how things start for you.[00:02:00]

Sam Jejurikar: Um, I can start with this. So I think, um, it's an, if you look at it, I don't think patients necessarily think about how we approach a consult. So this is a great question. Um, in a given day, we are seeing a lot of new patients, um, and we are trying to sort of balance, we. Making sure we spend adequate amounts of time with every patient, um, who spent a lot of time thinking about what it is that they want.

So you come into the room and in a relatively quick amount of time, you want to figure out, okay, why is this person here? I. And what is it specifically that they're looking for? Yeah. My schedule may say that this patient wants a breast augmentation, but that can be a lot of different things. They may wanna look fake and round, they may wanna look small, um, and natural.

And so what, what you try to do is very sort of quickly try to hone down with a patient what it is that they're looking for from, um, from anesthetic standpoint. Two, is this person actually a good candidate for what they want? And three, do they have realistic expectations? Because [00:03:00] everyone's done their own research before they've come in.

And sometimes what they think they need is gonna be perfect. And sometimes what they think they they're gonna need is gonna lead to invariable disappointment. So you try to do all that in a relatively condensed period of time, um, which sometimes goes great and sometimes is a, is very much a challenge.

Sam Rhee: I usually take about four to five minutes to go through their medical history, even though we've already taken it, just so that I can talk to them a little bit.

Um, I like hearing what they're saying about something like, you know, just what their medical history was very quickly, and then I. It's so funny. I remember Nip Tuck was a show that I watched a long time ago and they always opened with, so what is it you don't like about yourself? Which is, like you said, a very psychiatric type of question.

Uh, I usually open with a variation of like, so what would you like to talk about today? And then let them sort of get into it. Uh, you're right with the crunch of time, I really wish I could keep it really open, but I usually end up [00:04:00] directing it pretty quickly into what it is that we, I think. They are really looking forward to prioritize because they'll often come in with a laundry list.

I don't like my breasts, I don't like my belly, I don't like my face. I want, and I'm kind of like, alright, let's kind of get down to the nitty gritty about what it is that you really need to focus on that would really do you the most for yourself. And so as I've gotten along in years, I think I've gotten better at sort of doing that without.

Looking so obvious that I'm doing that when I'm talking to them.

Lawrence Tong: Yeah. And, and honing down on, on what the patient wants versus what the patient actually should have is sometimes different. So a lot of times a patient will come in thinking that they need a certain procedure, but then you end up. Having to suggest something that's different.

For example, patients will often come in and they'll say, oh, I need a brow lift. And I'll talk to them, okay, why do you think that is? And they'll say, because there's too much skin [00:05:00] on my lids. Because when they lift it up, they see the, the, the, uh, the skin in the lids elevates a little bit in, in reality, they might need a blepharoplasty or they'll come in, they say, um, I need a breast augmentation.

And they take a look at them and they're very droopy and they have this impression that. A breast implant is gonna lift the breast. So it is very important to, um, listen to the patient, but not exactly what surgery they're wanting because they may have a misconception of what the surgery can do, but actually what their issue is and, and honing in on that.

Salvatore Pacella: Those are, that, that's great insight, Larry. Um, you know, I, I think what I, what I commonly hear from, uh, you know, I, I find the, the patient population that's looking for facelifts, not so much the middle aged patients, but some of the older patients, 70 and 80, that come in and, you know, by that time it's like, you know, it's a lot, it's a lot easier to take a 60-year-old and make 'em look 40 than it is an 80-year-old and make 'em look 60.

Right. And so, um. [00:06:00] Almost every single facelift patient that comes in says, yeah, I'm, I'm interested in the mini lift. The mini facelift. And, and, and they put the, the phrase mini in front of everything. Right. And so, but it's like their neck is down here and everything has dropped. They haven't had any procedures throughout their entire lifetime.

And you know, I used to try to. Try to correct them and say, well, you know, a mini facelift is this, but I, I'm realizing everybody has a different definition of it, so I just try to take that word mini and break it down slightly. You know, Samir, I know you have a, you have a thought about mini tummy tucks, right?

Sam Jejurikar: Mini tummy tucks are my favorite. They're a full tummy tuck on a mini patient. What? No, and I'm joking, but there are some patients that are appropriate candidates for, for, uh, for many, many procedures. But you're right, you sort of just break down each individual component. What I will say is I think patients, when they come in.

Wanting a mini [00:07:00] procedure. It's just important for them to know that you're listening to what they're saying, and then you break down, well, this is what's going on with your neck, and this is what I need to do to break this down. This is what's going on with your midface. This is what I need to do for this.

This is where you're dealing with from a volume standpoint. Here's what's going on with your eyes. So I think it's great. I think we should do a mini facelift on you. And I'd also like to do these additional procedures on you as well, and they're like, oh, great. He heard me. Um, yeah, like

Salvatore Pacella: that's, uh, uh, absolutely, absolutely.

Um, you, you know, so, so getting back to this kind of psychiatry component of things, you know, I, I, I always find it fascinating. To understand exactly why patients want the procedures they want, and why are they they're choosing that at that particular time in their life. And, you know, if that hasn't come out through my consultation, I'll usually ask it at the very end.

And, and I'm oftentimes very surprised that the answers I have and, and again, going back to that facelift population. Um, you know, the classic example is [00:08:00] 70, 80-year-old patients that had nothing in their entire lifetime, and then all of a sudden they want everything from the brow, the eyes, the lips, the the face.

And I, I ask them, what, you know, what, what's going on? Why do you want this done? You haven't had anything done in your lifetime. And that's. I lost my spouse, you know, I'm moving into a new place. Um, I just woke up one day and looked in the mirror and I don't like what I see after ignoring the mirror for 70 years, you know, and it's, it's, it's fascinating why people choose the, the procedures they, they choose.

And it's, you know, it's a small amount of'em that are not candidates, you know, and it's, and I, you know, it's just absolutely fascinating to me.

Sam Rhee: What do you think are some of the red flags when someone comes in that gives you concern when you're, when you're doing a consultation with a patient?

Lawrence Tong: I'm gonna say something about that.

The biggest red flag that I see is when a patient comes in and they tell you that. [00:09:00] There's some asymmetry or something very, very minor to the point where you have to ask them to point it out to you and you can't really see it, even if they're pointing it out to you, or they'll tell you it has to be in some certain lighting or they have to move their face in a certain way.

So that's red flag number one. And then in addition to that, if they have a laptop with them or an iPad with them and they have like mockups of um, photos of themselves, I think those are red flags because. You're dealing with a patient who has a very, very extreme sense of what can be achieved with surgery.

And I find that if you end up operating on a patient like that, you have to be very, very, very clear on what can and can't be

achieved with surgery or else they're gonna be disappointed. And a lot of times I will actually try to maybe. Reassure them that you know, what they are perceiving as some big [00:10:00] red flag or, um, something that they think is disfiguring is probably something that 99.9% of people will never notice.

You're on. Are you on mute, Pacella? Yeah. He just

Sam Rhee: muted him.

I can barely hear you, Sal.

Sam Jejurikar: Yeah.

While he's sorting that out. Maybe I'll talk. That's all right with you, Sal. So, um, so, um, you know, for me a big red flag sometimes is more of a relationship aspect where someone is coming in and they're having surgery about something that may not even. Bother them all that much, but they're doing it to please a significant other.

Maybe during the consultation, a significant other will spend more time talking about the problem than the actual patient will. You know, you'll see this, um, sometimes when a female patient has a male spouse or boyfriend who sort of pushing the dialogue in terms of size of breast implants or. Starts pointing things out about fixing this on this person and the, and the patient is just relatively quiet because it almost seemed like in that [00:11:00] situation, um, the patient is doing things to salvage a relationship that may or may not be that healthy.

You can do the surgical procedure, but you can't fix those underlying relationship issues. Testing, testing, testing. Usually, even though I can get a result that, you know, might achieve the objective or look good, it's still doesn't necessarily lead to a happy patient. And to me that's a huge red flag when I see that preoperatively.

Lawrence Tong: Yeah. A, a classic thing that you'll see is like the boyfriend will be like, oh honey, you're, you're getting this breast implants. You might as well get a size that's, you know, that it's gonna be worthwhile. And then that's how they push them to a larger size.

Salvatore Pacella: Can you guys hear me now?

Yeah. It's like, it's like, yeah.

Sam Jejurikar: It's like a, it is going to Larry's point. It's like Patella's house. It's like, uh, just going, going for the, the, the biggest house gets you, you know, gets you more value for it. So the same with the breast documentation, you know, just, uh,

yeah. I, I, uh. Let me, uh, [00:12:00] let me say this too. Um, he goes for the big

Lawrence Tong: news, but the worst internet.

Sam Jejurikar: Yeah. Yes. Yeah, that's what I, yeah. Patella's Internet connection is so bad because it's basically like he's in the middle of the ocean in this giant manner in which he's living. I'm,

Salvatore Pacella: I'm, uh, I have non-board certified internet. Okay.

You know, I hate, I hate to continue to harp on, on face on the facelift evaluation, but I'm going to continue to do so. Um, you know, so, uh, there's this other psychology I see not infrequently where patients are very reasonable going into their procedure. At least that's what their impression is based on my assessment.

And then for the first few months after surgery, they are. They are just overly thankful, like to the point of giving you a hug every time or telling you how awesome you are as a surgeon and you know, to, to the extreme. And, and I always take that [00:13:00] with a grain of salt because I think those are the patients that are gonna start focusing on some minutia.

Are gonna come back and tell me how I'm the worst surgeon ever. Okay. And you know that that usually happens right around six months for some reason. It's a, it's a fascinating psychological change. And invariably it's some spouse who pointed out something or some partner that pointed out something. The spouse has spent a bunch of money on this and the wife or partner is still unhappy.

You know, and that happiness is not really related to the surgery. It's related to everything inside.

Thoughts, gentlemen.

Sam Marie?

Sam Rhee: Uh, yes. I mean, I missed the last part of your thought, but I agree with that. Uh, you're right. Uh, you, I, how do you, I was gonna ask you, so how do you identify these people before you operate? 'cause once you operate on 'em, you're, you're, you're kind of stuck at that point. Like what, what's your tip to sort of identify these?

Sam Jejurikar: You [00:14:00] asking Pacella? Are you asking him? Yeah,

Sam Rhee: I was asking Pacella, but Well, he might

Sam Jejurikar: be talking right now. He could be talking possible. He is talking right now. Uh,

Salvatore Pacella: it's this, I'm sorry guys. This is the worst my internet has ever been. Hands down. No,

Sam Jejurikar: I don't actually think that's true. No, I think it's fairly pretty typical, like, but, uh, Hey, why don't I answer Patella's question for him.

Um,

Salvatore Pacella: what was the question? Unless he wants to. That was out. I was out. Oh.

Sam Rhee: How do you identify these patients before surgery? Because, yeah, because how do you identify them beforehand? Because after surgery it's too late, you already operated on it. How do you figure this out before you operate on? That's a

Salvatore Pacella: fascinating question and, and I will say that, you know, I am not a drive-by surgeon whatsoever.

You know, I see patients at least twice before surgery. An initial consultation and a [00:15:00] very extended history and physical where we spend at least 45 minutes going over things. And sometimes it's multiple consultations ahead of time because a patient may not have, may have additional questions. So many times, probably about 60% of the times it's at least three times I've seen them beforehand.

Um, you know, I dive into their medical record, I dive into their history and physical from their primary, but you, you know. Patients wanna show you what they wanna show you, uh, psychologically, and it's, uh, it's very hard to tease this out. I think, you know, what I've learned over the last 16 years of practice is the revisional patient is somebody that you really have to look at.

Even in a greater microscope, if you, a massive red flag is somebody that's had, oh, I saw Dr. Smith for this. I saw Dr. Uh re for this, and I saw Dr. Tang or Tong for this. And you know that that kind of multiple surgery phenomenon is something we always want to take with a grain of salt. So I, [00:16:00] I oftentimes dive into each of those surgeries and say, what exactly did you have?

What did you like about it? Why aren't you go back, going back to that doctor for this particular reason?

Sam Rhee: Yeah. All good points. Excellent. Um, one of the things that always makes me worry is if a patient seems like they're really trying to take a lot of control before the procedure, um, maybe, uh, like for example, they'll, they'll, uh, say, you know what?

I need to have the surgery like right now. Can you do it Tuesday? Uh, and I'm like, no. Well, I really want it, like on Tuesday, and they're completely inflexible. Or they'll say, um, you know, I really, you know, can I still take my Ambien? And I'm like, no, you really need to start tapering that off and stop, you know, before the surgery.

Like, no, but I really need it. I, I, I want it. Right? I I'm gonna keep taking it. Or, you know, anything where, and I understand patients are often worried or about giving up control for a procedure or, [00:17:00] or following directions and stuff for sometimes like they're used to being in, uh, getting what they want.

And if you tell them things that are in opposition to what it is that they would want or prefer, and they have a lot and they give you a lot of pushback on that before the procedure, um, you know, uh. Then it's, it's a, it's going, it's a red flag for me. Uh, uh, you know, if I set a post-op for you and you're like, well, no, I, I, I wanted, I can't, I, I gotta do this first, so I'll see you on this day instead.

Like, those are the kind of things that really get, like, I. There are a lot of things that I set up that I just want patients to follow beforehand, because I know if they don't do these things, they're not gonna do anything for me after the procedure. So I have pretty strict rules about what medications you can and cannot take.

Um, what I want from your primary, what tests I want, when I want them by, you know, our, um, payment [00:18:00] schedule. Like if they, if they don't really follow any of that, like I'm more than happy. I. Not because it's somehow detrimental to the procedure itself, but if you can't really follow, you know, a lot of these.

Uh, steps up until the procedure happens, you're probably not gonna follow anything that is really important Afterwards.

Salvatore Pacella: I, I had a very interesting patient interaction a couple years ago. I, I was evaluating a older gentleman for a facelift and, you know, we saw him a couple times. You seemed very reasonable.

And then with weeks leading up to the surgery, he was calling several times for various questions. And became very upset that his, that my coordinator wasn't immediately available within three minutes to, to talk to him, or my nurse wasn't immediately available in two seconds to talk to him or I wasn't immediately available.

And, and so he, he just kept le [00:19:00] leaving sort of more aggressive messages. And I finally spoke to him and I asked him, you know, how long have you been waiting online or on, on the phone? And he said, 20 minutes. It's great. I went back and I looked at our, I'm like left hanging.

Sam Rhee: Yeah, I know.

Salvatore Pacella: What, what, what did you say to

Sam Rhee: him?

I wanna know.

Salvatore Pacella: So I went back and I looked at our call logs and he, he never waited longer than four minutes on the phone. And so finally this was somebody that I just said, look, I, I. I, I just can't provide you the service that you, you need. Um, it's just not a good idea. And, and, and that was, that was the best decision.

I think I've.

Sam Jejurikar: Yeah, I think you can tell a lot by how people greet your staff ahead of time if they are very, very sweet to you, but verbally abusive to your staff. Those are gonna be patients that usually turn into, uh, unhappy patients [00:20:00] postoperatively. Um. You know, and earlier Patella had mentioned, uh, patients that see sort of multiple physicians as well.

I, I think it's always really normal when, when patients see me and they've seen three, four other plastic surgeons, you know, to try to get an idea, see if everyone's plans matching who they mesh with. But when I see patients, and I'm the 10th, 12th, 15th. 21st, which happened not that long ago. Patient Wow.

Looking, you know, getting, getting a relatively straightforward operation. Um, you wonder like, what exactly is this patient not finding in their previous consults? How is it that they saw 20 other board certified plastic surgeons and none of them could tell 'em exactly what they were looking for in that situation.

I, I don't really feel like I need to be the, that person to, uh. I don't need to be the one that they choose. Like I just need to do my best. They wanna win the lottery. Yeah, exactly. Because there something is lacking in, in that they're that they're just not finding.

Lawrence Tong: What [00:21:00] I, what I find is, um, actually letting go of patients is sometimes difficult because what I've typically seen is that they are not happy when you tell them, um, that you, you don't say you don't wanna operate on them, but even if you say in a way where you don't, you say you can't meet their expectations, a lot of times they get pretty upset.

Especially if you've gone pretty far down the road, just like, uh, with Sal's patient where, you know, they're scheduled for surgery and it, and it's upcoming. It's a, I find that usually quite difficult. But, um, I will also say that in those patients who Sal has described where they, you know, sort of turn, um.

A little while after, uh, having had the surgery, I can always look back and say, yeah, those signs were there and, you know, I probably should have thought twice or thought harder about doing the surgery. But I find sometimes because of inertia, it makes it more difficult to, um, to [00:22:00] not operate on patients sometimes.

And because you, at the time you don't know. For sure that that's gonna happen. You're just, you just have a, a hunch, you have a feeling. Um, so I guess hindsight is 2020 sometimes, but I find it hard to, to cancel patients, um, after a certain point.

Sam Jejurikar: I, I got, one of my most scathing negative reviews was from a patient who was exactly like that.

Who, uh. Seeing for a rhinoplasty consult. And, um, there was another doctor whose pictures she kept going to to achieve certain results. And then she would pull up, uh, filtered pictures of herself to sort of show how she wanted to look. And I genuinely didn't think that I could achieve what it was that she was going for.

And the other surgeon that she would kept referring to is someone that I know who is a phenomenal rhinoplasty surgeon. And so I made the comment. I don't think I can achieve what, and I wasn't trying to even get rid of this patient. I, I, I said, I made the comment, [00:23:00] um, I don't think I can achieve what it is you want.

Perhaps you should see so and so. And, um, and I never operated on her, but I got comments that I was rude and condescending and unfriendly and, and unwilling to help. And, and sometimes we're not trying to get rid of the patients. Sometimes we genuinely don't feel as though we can accomplish what it is they want.

And people do not like hearing that sometimes.

Sam Rhee: So true.

Salvatore Pacella: Well, well, gents, that's a, that's a good place to stop and I don't wish to torture you anymore with my internet connection. So, um, appreciate, uh, you guys joining in and, uh, take care.