Reoperation: Rationalization or Good Care?

Sir: In our editorial “Is Reoperation Rate a Valid Statistic in Cosmetic Surgery?”1 we reviewed some subjective features of cosmetic surgery that could prejudice reoperation rate, in both a positive direction and a negative direction, bringing into question the validity of this statistic as a valid benchmarking criterion. In his editorial “Reoperation as a Benchmark: The Rhetoric, the Logic, and the Patient,”2 Dr. Tebbetts refutes this as a rationalization that he believes ultimately works against the patient. He states, “What should matter most to every surgeon is the patient. What matters most to patients is their outcome.” However, while the editorial repeatedly states that the patient’s needs are foremost, its arguments contradict this point. The editorial calls for eliminating subjectivity in favor of science. The logic falls short in its failure to accept that there is a subjective aspect to cosmetic surgery (and often this is the only aspect a patient considers). The justification for cosmetic surgery is to improve the patient’s self-image by improving his or her appearance. How do we make one’s feelings about one’s self-image scientific? The improvement of the patient’s self-image through surgery must include an assessment of the patient’s goals. Similarly, that patient’s opinion in regard to the result is relevant and must also be considered by the surgeon. In aesthetic surgery, there must be a balance between use of good scientific data and a patient’s subjective opinion. Employing strictly objective “processes” that disregard the patient’s satisfaction with his or her outcome is the ultimate rationalization by an aesthetic surgeon. No patient wants to have a secondary procedure, and as surgeons, we would prefer to avoid reoperations as well. But no patient wants his or her surgeon to ignore the patient’s subjective concerns on principle alone. It is the rare case that the surgeon initiates revisional surgery for aesthetic indications; rather, it is the patient’s subjective goals that drive reoperation. The surgeon is simply the gatekeeper to reoperation. And certainly all will agree that excessive risk should be avoided both in primary and secondary procedures. However, if one’s goal is to avoid all risks that are not indicated by strictly objective criteria, one should avoid aesthetic surgery altogether. When patients are considering a revision, they should be counseled just as they were for the first surgery. The patient should be an active participant in the decision to go forward with surgery or not. If a patient’s goal is realistic and the surgeon feels he or she can achieve that goal without unacceptable risk, then a reoperation is not just appropriate but desirable. Reoperations may not be good business nor absolutely scientific, but, in our opinion, appropriate secondary surgery is in the best interest of the patient. Todd A. Pollock, M.D. Harlan Pollock, M.D.