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Improving Outcomes in Aesthetic Surgery: Get Your Head in the Game

Could placebo and even nocebo play a role in managing expectations and outcomes? Maybe more than you think.
By: Steven Dayan, MD, FACS


Attend any aesthetic medical conference and you’ll find the lecture halls addressing the newest technique for tightening a neckline or lifting a jowl filled to capacity. As students of science as well as artisans of anatomy, we are drawn to believe that our healing influences are primarily delivered through our fingertips. Yet, if our measure of success is recalibrated to achieving patient satisfaction rather than just the mathematics of perfection, then the secret to a robust practice and happy patients may have as much to do with psychic allure as the technique du jour.

When assessing patients, it’s important to understand the underlying motivating factor causing them to seek treatment in order to provide the best possible outcomes. It is not uncommon for a patient seeking out cosmetic surgery to have experienced pubescent taunting and emotional scarring secondary to their physical form falling outside a standard deviation. Other would-be cosmetic seekers may desire beauty as a means toward professional advancement, a romantic interest, or an improved social status. Regardless of the motivators, our patients may be particularly vulnerable to critical judgments. And the likelihood of them achieving their goal is more related to the self-esteem gained than the physical form obtained. As any practicing aesthetic physician can report a seemingly great outcome, meeting all objective measures of physical perfection may fall short of a patient’s expectations, whereas a less than perfect result may be met with utter adoration. Additionally, at times doing nothing at all, akin to placebo, can be effective at improving self-esteem. Our success both as individuals as well as a specialty is determined by the satisfaction of our patients regardless of the means to achieve it.

What factors and to what extent determine our patients’ post-treatment happiness? How much of our success and the patient’s satisfaction is based on the physical outcome achieved and how much of it is based on other seemingly less direct causes, such as the post-treatment judgments by peers and family, or even the physician’s communication style, mood, and attitude? Clearly all of these impact the patient’s mindset, attitude and self–esteem and ultimately calculate into their satisfaction.

Perhaps we shouldn’t limit our attention to only one of the contributing factors? Shouldn’t we study all the influencers on a patient’s mind and mood as well take a critical look at ourselves and how much our communication and practice styles as well as our personalities influence our patients’ satisfaction rates and perceived outcomes?

Two well-studied pathologies highly dependent on patient psyche and perceptions are pain management and major mood disorder. For both conditions a plethora of published research evaluates the influence of placebo and physician personality on outcomes. If we are honest with ourselves we would have to acknowledge that patients’ psychological dispositions are critically important to perceived outcomes in aesthetics, as well. Yet in aesthetic medicine, while there is a dusting of attention to the psychology of the patient, there is little to no study of physician’s personality, communication style, or the placebo effect. When 13 percent of those who get saline injections1 believe they have improvement in their glabellar wrinkles, 28 percent of those who don’t get injected with filler believe their lips are fuller,2 or 38 percent of those injected with saline believe their submental fat has been reduced, maybe the placebo effect deserves more than a curious footnote.3 There are plenty of examples of the power of placebo in general medicine.4,5,6

Before we can honestly study placebo we have to be willing to admit that its proof detracts from the brilliance of our direct intervention and elevates the patient’s mind as a contributing curative. This is not a new revelation, in fact for the majority of medicine’s existence and prior to the last century, placebo may have been our best tool in the armamentarium. Alternative medicine, which attracts 38 percent of Americans7 may achieve its benefits because of the placebo effect, and the more time and “hands on” the alternative medical provider’s intervention the greater the placebo’s potency.8

Many doctors, if pressed, will admit to using placebo on occasion, but in today’s litigious, regulatory, political, and ethical environment of full transparency, the placebo treatment has less place in our tool box. By the virtue of being completely honest we negate the effect. And perhaps being too literal or callous in our communication may lead to a bad outcome by virtue of the Nocebo. The nocebo effect, the evil twin of the placebo, was first described in 1960.9 It is when a symptom or illness results from expectation or fear of a bad effect occurring.8 In fact, the verbal and non-verbal communications of the doctors and other staff do contain numerous unintentional negative suggestions that may trigger a nocebo response.10

Perhaps physicians contribute to a nocebo effect when we sterilely stress all the possible negative outcomes or complications that can occur without putting them into context. If we are ethically or legally bound to disclose all the risks, including the very remote risk for death or significant morbidity, but place these in context by saying, “As a healthy person you have more risk in your car ride on the way to the surgi-center then you do from anesthesia,” we then offer the message in a manner that allows the patient to understand the relative risk. Many aesthetic physicians recognize the impact of a nocebo effect from outside our practices when an easily influenced patient is predestined toward a perceived unsuccessful outcome by an insulting or disapproving mother, husband, friend or an in-law who is quick to criticize the patient post-procedure. Attempting to mitigate or quash the influence of these offenders on our patient’s psyche would be prudent.

Unlike most other fields of medicine, in cosmetic medicine the placebo and nocebo effects could not be studied until very recently. Prior to the introduction of botulinum toxin, cosmetic physical interventions were so clearly recognized that a randomized controlled trial was not possible. The introduction of botulinum toxin as a temporary injectable agent of change has, however, opened up our field to Level One evidence clinical trials. In the broad landscape of medical fields, aesthetics is still very academically immature. Nonetheless, if placebo and nocebo truly have been proven in medicine, then why not recognize and further study it? Perhaps we can even harness, repackage, and use their power in a contemporary acceptable manner to our patient’s benefit.

If we are to truly study the effects of placebo/nocebo as well as the indirect psychosomatic and psychosocial impact on our patient’s perceived outcomes, then all aspects of the treatment need to be taken into consideration. This would include but not be limited to the type and expense of the procedure as well as the specialty/personality of the provider and associated pain.

A manageable modicum of discomfort seems important to the patient believing something beneficial was done, whereas too much pain can lead to the patient being less satisfied.11 Price likely impacts the perceived outcomes, as well. When it comes to non-ablative skin tightening devices, it seems patients expect a more expensive treatment to be more effective. Additionally, patient expectations may vary based on the provider. They may be satisfied with a less dramatic result if a nurse or a laser technician delivers the treatment at a lower price versus if they are treated by a surgeon who charges a higher price. Many researchers also know that non-ablative skin tightening devices curiously seem to achieve higher satisfaction rates in dermatologists’ offices. Do dermatologist workplace satisfaction rates, which differ from a plastic surgeon, have an impact on patient satisfaction rates? A 2015 Medscape survey of over 19,500 physicians from 26 specialties found dermatologists as the physicians with the highest career satisfaction rate.12

A systematic review evaluating studies of workplace happiness revealed that doctors with better workplace happiness are more likely to be better communicators, offer a contagious optimism, and achieve better outcomes in their patients.13 If doctors have better moods, this may manifest in a more positive and upbeat attitude that leads to optimum results perceived by patients.8,14 If a positive doctor and work place environment can lead to better outcomes, can the converse also be true? Can a negative stressed out doctor with a chaotic office lead to bad outcomes? An interesting study revealed that lay observers can correlate a surgeon’s malpractice history to his or her communication style within 40 seconds of listening to the surgeons speak to their patients.15 Additionally the average doctor interrupts their patient within 18 seconds of taking a history.16 A dominating tone of voice and speaking style is more likely to lead to adversarial relationship and perhaps negatively perceived outcomes.

A comprehensive review of randomized controlled trials evaluating physician communication styles and outcomes led the authors to conclude, “Patient health outcomes can be improved with good physician-patient communication. The studies reviewed suggest that effective communication exerts a positive influence not only on the emotional health of the patient but also on symptom resolution, functional and physiologic status and pain control.”17 While the studies evaluating health outcomes and physician interaction are mostly centered in primary care settings, can the same conclusion hold true in aesthetics? As much as we want to believe our hard earned degrees and aesthetic skill set lead to better perceived outcomes, one of the few studies to evaluate patient satisfaction and physician interaction in plastic surgery occurred at the University of Michigan. Chung showed that patient satisfaction was more determined by doctor/patient communication and clinic efficiency than physician’s skill level.18 The manner in which the physician engages and listens to the patient as well as duration of the visit all likely impact perceived outcomes.

Open Minds

Cosmetic-seeking patients are likely highly suggestable patients19 and are easily vulnerable to influence from family and peers. The more support, time and optimism a provider affords to the patient, the more likely they are to achieve the intended effect from the treatment intervention.8 We spend so much time stressing technique in aesthetic medicine, and while there is no doubt being a talented technician and a well-educated scientist is critical to delivering a good outcome, our success in aesthetic medicine necessitates an ability to also understand all the controls that make a patient happy. And this includes not only studying the mind and personalities of our patients but perhaps also critically evaluating our own. Are we open to that? n

1. Carruthers J, Lowe N. et al. Double-Blind, Placebo-Controlled Study of the Safety and Efficacy of Botulinum Toxin Type A for Patients with Glabellar Lines. Plast and Reconstr Surg; Sept 2003;112:1089-98.

2. Dayan S. Randomized, Evaluator-Blinded, No Treatment Controlled Study of the Effectiveness and Safety of Small Particle Hyaluronic Acid Plus Lidocaine in the Augmentation of Soft Tissue Fullness of the Lips. Oral Presentation Cosmetic Surgery Forum; Dec 3, 2014

3. “Outstanding Paper Presentation” Session 2 of the Cosmetic Scientific Paper sessions American Society of Plastic Surgery (ASPS) Annual meeting, October 13, 2014. “A Pooled Analysis of the Safety and Efficacy Results of the Multicenter, Double-Blind, Randomized, Placebo-Controlled Phase 3 Refine-1 and Refine-2 Trials of ATX-101, a Submental Contouring Injectable Drug for the Reduction of Submental Fat”

4. Dimond EG, Kittle CF, Crockett JE. Comparison of internal mammary artery ligation and sham operation for angina pectoris. Am J Cardiol.1960;5:483-486.

5. Dodick DW et al. Onabotulinum toxinA for treatment of chronic migraine pooled results from the double blind randomized placebo controlled phase of the PREEMPT clinical program. Headache 2010;50:921-936.

6. Waber RL, et al Commercial Features of Placeboand Therapeutic Efficacy JAMA, March 5, 2008—Vol 299, No. 9 1016-17

7. http://brainblogger.com/2014/06/09/who-uses-complementary-and-alternative-medicine/

8. Tavel ME.The Placebo Effect: the Good, the Bad and the Ugly. The American Journal of Medicine (2014) 127, 484-488.

9. Kennedy WP. The nocebo reaction. Med World 1961; 95: 203–5.

10. Ashraf B, Saaiq M, Zaman KU. Qualitative study of Nocebo Phenomenon (NP) involved in doctor-patient communication. Int J Health Policy Manag 2014; 3: 23–27

11. Dayan SH. The pain truth: recognizing the influence of pain on cosmetic outcomes. Facial Plast Surg. 2014 Apr;30(2):152-6. doi: 10.1055/s-0034-1371897. Epub 2014 May 8. PubMed PMID: 24810126

12. http://www.medscape.com/features/slideshow/compensation/2015/public/overview#page=17

13. Scheepers RA, et al. A Systematic Review of the Impact of Physicians’ OupationalWell-Being on the Quality of Patient CareInt.J. Behav. Med. DOI 10.1007/s12529-015-9473-3 Sept 2015

14. Fabi, SG, personal communication, February 2015

15. Ambady N. et al. Surgeons’ tone of voice: A clue to malpractice history Surgery 2002;132:5-9.

16. Frankel R, Beckman H: Evaluating the patient’s primary problem(s). In Stewart M, Roter D (eds): Communicating with Medical Patients, Sage Publications, Newbury Park, Calif,1989: 86-98

17. Stewart MA.) Effective physician-patient communication and health outcomes: A review Can Med Assoc J. May 1995; 152 (9) 1423-33.

18. Chung KC, Hamill JB, Kim HM, Walters MR, Wilkins EG. Predictors of patient satisfaction in an outpatient plastic surgery clinic. Ann Plast Surg. Jan 1999;42(1):56-60.

19. Koblenzer C. Psychologic aspects of againg and the skin. Clinic in Derm 1996;14:171-177.