Good surgery does not always mean a happy patient — Mohan Rangaswamy

Good surgery does not always mean a happy patient

Submitted by Dr. Mohan on 08 December, 2011

Two cases that taught me a lot about the effects of psychological scarring. 1. The first relates to a Srilankan expatriate working in the middle east. He came to me with long hair and reluctantly parted them to reveal a loss of the outer helix of his right ear. He went on to say that it was bitten off in a fight and that he wants it repaired. He already had a failed attempt and some scars in his neck to show for it. He also claimed that he was of limited means. Correcting this would not be difficult so I planned the treatment as usual and in fact went over it with patient in good detail. The expected scars were explained to him as was the need to harvest some cartilage from the inner ear. He signed an informed consent that clearly stated the expected minor scars.

The surgery went well and after a month of after care, I thought, as the nursing staff, that this was indeed a job to be proud of. The patient however was quite upset and left me a note in tamil stating that I do not know my trade and that I should not operate if I did not know how! This was a rude shock. What went wrong? I talked to him at length and it emerged that he had lost face in the fight and had wowed not to return to his village unless he got back his ear. Although he had a good ear now he lamented about the scars. He claimed that he cannot go back to his village as it still bore the marks of his shame. I learnt the hard way that people carry well hidden emotional baggages and associate any injury, mark or loss with the event that caused it. Any little flaw can get magnified in the immature patient’s mind as it will still remind him of the event that he wants to wish away. Such hidden agendas may completely negate any good that comes out of even excellent corrections. One can learn plastic surgery but it seems it is impossible to read the human mind.

2. Quite another event happened several years later. I had a 52 year old woman coming in for a rhinoplasty. She had a rather fleshy and big tip. The corrections went well and after two months there she was sitting outside my room. I came down the corridor and from the distance I did not recongnize her, but I remember thinking to myself – “there is a woman with a good nose, I wonder what she has come for”. Getting closer, I recongnized her. Once she was in my room, I told her that I was pleased with the outcome but I did not see the smile of happiness on her face. She said she saw no change at all! Now this was a complete shock to me. I did not understand how anyone in her right mind could make that statement. So I took her fresh photographs and put them side-by-side with her preoperative photos. There was total disbelief on her face; she refused to believe that she had looked like that before surgery! What is happening here? A woman in her fifties cannot agree that she has had that nose for over 40 years? After the initial shock and mixed emotions, she revealed that in her mind’s eye she had always pictured herself with a good nose and had completely blocked out her ‘ugly’ nose to the extent that her present operated nose looked no different to her imagined nose. She had apparently endured a lot of teasing about her bulbous nose. I learnt that people can completely block out an ugly feature on their face and may in face see something quite different to what the doctor sees. Human mind is complex indeed.

I decided to bring out these two stories to emphasize that happiness after cosmetic surgery can sometimes be elusive even after apparently good surgery. I am sure that every plastic surgeon will empathise with me and remember similar situations in their practice. But it is very important for potential patients to know the complex adjustment periods required particularly after facial plastic surgeries and the importance of psychological fitness. We all talk about this topic without really being able to understand it. Routinely sending all potential patients to a psychiatrist does not work and can be considered an insult [in many cultures]; I am sure a good percentage of patients will be lost. Many psychiatrists also do not understand the nuances of how patients perceive and react to plastic surgery. I still do not have a perfect way to identify such patients but would be more inclined to suggest a psychiatric consult if there is more than expected distress with a physical defect. I certainly tell them that I cannot be sure if they will be happy after their surgery, I can only assure a good quality of surgery. I further tell them that happiness is a state of mind one chooses to be in and it has nothing much to do with the surgery. This remark usually puzzles them and makes them think.