As plastic surgeons, we are trained to value precision, technique, and measurable outcomes. Over the years, I have learned that while technical excellence is indispensable, it is not always sufficient to ensure a successful aesthetic surgery. This realization did not come from complications or poor surgical results, but rather from encounters with patients who, despite objectively good outcomes, remained dissatisfied.
This article was born from that tension.
A recurring clinical paradox
In daily practice, most surgeons eventually face a paradox: patients with technically sound results who continue to express discomfort, disappointment, or emotional distress. Initially, these cases are often interpreted as communication failures or unrealistic expectations. However, with time, patterns begin to emerge. Some patients present subtle psychological and emotional traits that are not captured by traditional preoperative evaluations, yet significantly influence postoperative satisfaction.
These encounters prompted a fundamental question: Are we truly evaluating surgical candidates in a comprehensive way, or are we overly focused on anatomy and technique?
Beyond anatomy and technique
The existing literature in aesthetic plastic surgery offers robust guidance on surgical planning, technical execution, and complication management. What is less structured, however, is the decision-making process that precedes the operation—particularly when it comes to identifying patients who may not benefit emotionally from surgery, regardless of technical success.
This gap became increasingly evident in my practice. I began to realize that the decision not to operate can sometimes be the most ethical and professionally responsible choice a surgeon can make. Yet, making that decision requires more than intuition; it requires a structured framework.
The motivation behind the study
The article published in Aesthetic Plastic Surgery emerged from the need to formalize this aspect of clinical judgment. Rather than proposing a psychological diagnosis or replacing mental health professionals, the goal was to provide surgeons with a practical, ethical, and clinically applicable framework to guide preoperative decision-making.
The work integrates subjective clinical impressions, patient behavior during consultation, and structured evaluation tools to support a more comprehensive assessment. The intention was not to create barriers to surgery, but to protect both patients and surgeons from avoidable dissatisfaction and conflict.
Challenges along the way
One of the main challenges in developing this work was translating clinical intuition into an academically acceptable structure. Much of what experienced surgeons perceive during consultations is difficult to quantify. Nevertheless, ignoring these signals can lead to significant postoperative challenges, including emotional distress, conflict, and medicolegal risk.
Writing this paper required careful balance: acknowledging the importance of psychological factors without stigmatizing patients, and emphasizing ethical responsibility without adopting a paternalistic tone.
What I hope colleagues take from this work
My hope is that this article encourages surgeons to pause and reflect before committing to surgery. Technical mastery will always remain central to our profession, but true excellence also requires discernment, empathy, and the courage to say no when surgery is unlikely to serve the patient’s overall well-being.
If this work helps even a small number of surgeons feel more confident in making thoughtful, ethically grounded decisions, then it has fulfilled its purpose.
A broader reflection
Aesthetic surgery exists at the intersection of anatomy, perception, and emotion. Understanding this intersection is not a weakness—it is a sign of professional maturity. As our field continues to evolve, I believe that integrating structured ethical and psychological considerations into everyday practice is not optional, but essential.