Keywords

A number of unhappy factors converge in the care of any disappointed aesthetic surgery patient, including the psychological aspects for the patient and how these concerns additionally burden the care team (see Chaps. 28 and 29). Monetary costs that factor in include the financial costs incurred by the patient, time, pain and suffering, potential litigation with legal and settlement costs, and costs incurred by a care team that may be reluctant to pass the entire financial burden on to the patient.

The famous plastic surgeon, Sam Hamra MD, commented to me some years ago at a plastic surgery meeting in Miami regarding how cosmetic surgery had changed during his time in practice, with a shift from wealthy stay-at-home spouses with few daily obligations to a more egalitarian group of working individuals whose ability to hide away for weeks or months if needed to recover from surgery is problematic. The incorporation of third-party loan arrangements to finance cosmetic surgery has worsened the problem, drawing in people with even less business pursuing cosmetic surgery. People with minimal or no savings or financial credit are undertaking expensive and often complex cosmetic surgery. Dr. Hamra commented that many patients should be asked before undertaking an operation whether they could pay for surgery a second time if needed. This is not a snarky question to the patient, but a reality check as to whether they are in a position to pay for revision surgery if something goes wrong with the initial surgery. This question is unfortunately almost never asked of any patient.

To the extent possible, I have always striven to provide surgical revision of any suboptimal surgical result of my own at no additional charge to the patient. Patients are generally very happy and accepting of this approach, if not pleasantly surprised. Being a perfectionist, I will usually offer modest revisions such as the injection of botulinum toxin into a tonic eyebrow or the excision of a small roll of skin if the tarsal platform show on a cosmetic blepharoplasty is not perfectly symmetric. The total time investment to do this is minimal (20–60 minutes including all follow-up visits), and patient satisfaction is high. The next “step-up” in postoperative management would be the injection of a filler to better volumize the tear trough and periorbital area after lower blepharoplasty. I generally bundle this treatment into the blepharoplasty fee preoperatively, with the filler injected weeks or months postoperatively. This is accepted and favorable for the patients, making the filler treatment an expected accompaniment of the surgery, and lowering the stress and financial anxiety of this treatment. It is also a positive way to continue to connect with a postoperative patient who is generally appreciative and will continue to offer good reviews and refer family and friends. In occasional cases where we have a result that I believe is suboptimal and would benefit from filler, I may perform that treatment as a previously unplanned free service.

Life becomes complicated when the surgeon must refer the patient out to another physician to manage a complication they are unable to treat, or when significant expense is incurred in the medical evaluation and treatment of the patient. Years ago, a patient on postoperative antibiotics developed a high fever and was admitted one day postoperatively to the hospital to rule out sepsis. The patient’s medical insurance company initially ruled this to be purely related to the preceding cosmetic surgery (despite a lack of any surgical wound infection and a possible unrelated urinary tract infection). On appeal, we were able to get the insurance company to cover this admission under the patient’s health insurance plan. Had they refused, the hospital would have billed all charges at “usual and customary” rates, and the total would have easily exceeded $40,000 for a one-day hospitalization. This would have left an awkward and ethically, morally, and financially difficult situation in the relationship between the doctor and the patient. A colleague had a patient suffer a cardiac arrest preceding a facelift. The patient was resuscitated, but potentially any ischemic or arrhythmic condition in his heart and all future consequences could have been determined to be due to the aborted surgery. This patient fortunately had a third-party insurance purchased to cover a rare circumstance such as this, as his ischemic coronary disease had developed during his entire lifetime, but the cardiac arrest event was blamed on this elective procedure.

Finally, there are the challenges encountered in treating the patient who consults you for a suboptimal surgical result in which the original surgeon cannot correct the problem, won’t correct the problem, or the patient has lost faith in the original surgeon and is seeking outside help. These patients carry all of the psychological baggage detailed by the authors in Chaps. 28 and 29, and are often financially “tapped out.” Furthermore, they are typically extremely challenging to the treating physician, monopolizing the surgeon’s time, and requiring very technically difficult and time-consuming surgery and postoperative care. Surgical results are often suboptimal at best, while expectations are high. It is important to distinguish these patients from those who may actually have an excellent result but still believe themselves to look bad, thus suggesting an element of body dysmorphia.

Surgeon fees for the revision of cosmetic surgery should be higher than those for a routine, first time surgical patient presenting to the same surgeon, as the procedure is more complex, requires more time and expertise, and the patient is much more challenging to deal with postoperatively than a “primary” patient treated as a clean slate. It can be expected that a surgeon experienced in patient selection, communication, surgical technique, and postoperative management will have 3–6% of primary cosmetic patients that create some sort of significant “trouble” postoperatively, versus 15–30% “trouble” patients when performing revision of other surgeon’s work. In addition, it is important to realize that once you operate on a patient requiring revision, they become “yours,” making the problems created by the previous surgeons, and the complaints against them, now your complaints and problems. One noted specialist in this arena has related the expectation of 3–5% of patients requesting and being given refunds of surgeon’s fees due to postoperative patient concerns and unsatisfied expectations, which he looks at as a cost of doing business and a maneuver essential to “move on” for both the patient and the surgeon. A 20–100% upcharge for a complex revision procedure from charges for the “normal primary patient” charge is appropriate and routine.

Typical fees for a revision upper or lower blepharoplasty surgery , depending on surgical complexity, locale, reputation, and fees of the surgeon along with the unique characteristics of the patient, can easily top out at over $50,000 when surgical facility fees and other factors are included. The expense and expectations are very regional and practice specific. There is a geographic variability in cost, with the top southern California revision surgery specialists being on the upper end for fees and the more staid “flyover state” practices often being more approachable for many patients. Travel, time off of work, and recovery time can compound this expense. Finally, these more complex procedures are generally necessitated by the severity of the patient’s injured anatomy, and the results after revision surgery may seem lackluster to a patient who may have paid over 10 times more for their revision than for the original surgery that went wrong.

When compounded with the psychological damage the patient with a “botched” surgery has suffered, it is easy to see how threatened or real litigation can enter the picture. This only further drains time, money, and other resources from both the original surgeon and the revising surgeon. The paper by Fante et al. [1] provides important data from the Ophthalmic Mutual Insurance Company for ophthalmologists including most oculofacial surgeons in the USA over the period from 2006 to 1016. Although only 19% of claims in oculofacial plastic surgery derived from a cosmetic surgery case, cosmetic dissatisfaction was the most common reason for a claim. Despite this, only two of 74 (2.7%) claims for cosmetic dissatisfaction closed with an indemnity payment to the litigant. Indemnity payments were low ($10,140 and $17,500), but despite a median defense cost of $1403 on these apparently largely spurious “cosmetic” claims, the range of defense cost was up to $125,408. Also of interest, 100% of “inadequate informed consent” claims and 83% of “unmet standard of care” claims led to an indemnity payment.

In some areas, there is an ethos and arrangement that a patient with a distinctly substandard outcome will receive a refund of their surgical fee from the original surgeon or have their revision paid for by the original surgeon to the revising surgeon. I have always refused to be an intermediary on the receiving end of funds from another surgeon, and have told any patient who mentions this that they must deal with the original surgeon and bring payment over once they have settled with them. Patients suggesting this sort of arrangement have often seen multiple doctors already to discuss revision surgery and are simply hoping to enforce rules on the past and present surgeons that they see as favorable to them.

Revision cosmetic oculofacial surgery presents a morass of disagreeable issues ranging from patient psychology and unhappiness to the technical challenge and emotional drain on the revisionist surgeon. Anyone considering entering this “marketplace” as a specialist who will perform revision surgery on another surgeon’s patients must consider whether they have the skill as a physician and surgeon to undertake these challenges. An appropriate practice setup that allows for the care of such injured patients and appropriate case selection, patient communication, and care is paramount. Ultimately, the quality of life for the patient and the surgeon is an important end-goal in this equation. Caveat emptor! would be the best advice to all in this undertaking.