This is an essential question that every plastic surgeon must face during his or her consultation. To assess whether the patient has realistic expectations a very detailed discussion must precede the physical exam. I usually start with past medical history to determine the anatomic and physiologic suitability of this patient. In other words, if there exist multiple pre-existing conditions including and especially behavioral, heart, and lung issues then cosmetic surgery may not be indicated.

Next, once this is complete, we assess the past surgical cosmetic history. Most of the time the percentage of these patients present with a first-time desire. This may cover the face, including the nose, cheeks, and neck or we may assess the breast and body.


Realistic expectations and suitability for surgery go hand in hand. A thorough discussion of the anatomic location will reveal whether the patient has a realistic goal. We emphasize very clearly and repetitively that plastic surgery is medicine. This means that a complete and thorough diagnosis must be achieved before any surgical plan.

Revision surgery presents a slightly more challenging situation. For example, with breast surgery revision may require a two or three step process. This concept may be contrary to what the patient has expected. Nasal revision presents an even a more challenging situation especially if the patient has had multiple previous procedures.

Revision patients for rhinoplasty must understand that they may be missing significant internal supportive structures and possess challenging internal scarring both of which must be discussed and addressed. It’s absolutely a contraindication if someone presents with a desire for someone else’s face or body. This is a red flag  of emotional instability and absence of a clear vision for a realistic outcome. In the 90s there were doctors who promoted procedures looking like celebrities? I was opposed to this concept then and am opposed to it now.

Some patients refuse to accept the doctor’s explanation of situations preoperatively. These are not good candidates. Some patients reject the preoperative clearance process which is designed to maximize safety – this is a red flag. The patient may not be a good candidate. Rudeness to office staff is a red flag, as well as the patient being in the middle of a life crisis.

These are not good candidates. We require a very detailed and extensive preoperative evaluation to determine physiologic suitability. PCP clearance, cardiac clearance if necessary and even psychiatric clearance if needed are essential. Patients must be cooperative with respect to this process. This is an essential component of determining if a patient has realistic expectations.

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