Template May Help Resolve Rhinoplasty Ethical Problems

Janis C. Kelly

June 20, 2012

June 20, 2012 — Few medical procedures are as fraught with ethical quandaries as aesthetic rhinoplasty. Therefore, Kian Karimi, MD, from the Pacific Eye & Ear Specialists, Los Angeles, California, and colleagues provide a new template to help resolve these ethical problems. The template, published online June 18 in the Archives of Facial Plastic Surgery, may help surgeons sort out some of the more difficult questions.

The authors used 15 clinical vignettes to survey fellowship directors and facial plastic surgery fellows of the American Academy of Facial Plastic and Reconstructive Surgery. Their report was based on responses from 30 of 56 (54%) fellowship directors and 26 of 47 (55%) fellows who agreed to participate in the study. Most fellowship directors had performed more than 100 rhinoplasties, and most fellows had performed from 10 to 50.

"This is an interesting analysis of responses to a survey that poses questions on how to handle case vignettes common to the rhinoplasty surgeon," said Leo R. McCafferty, MD, president of the American' Society for Aesthetic Plastic Surgery, who reviewed the study for Medscape Medical News. "The questions involve ethical issues and medical judgment. The 54% response rate is high for a survey of this type and adds credibility to the study."

The vignettes were based on the nearly 30-year experience and observations of senior author Peter A. Adamson, MD, FRCSC, from the Division of Facial Plastic and Reconstructive Surgery, University of Toronto, Ontario, Canada.

The vignettes included ethical conflicts between practitioners, conflicts about whether to perform rhinoplasty in specific cases, how to deal with mistakes made during surgery, and questions about patient selection. Responses from the fellowship directors differed significantly from those of the fellows for 2 vignettes. Responses differed, but not significantly, for 3 other vignettes.

In one of the vignettes answered differently by fellowship directors and fellows, a disgruntled malpractice attorney returns 1 year after rhinoplasty with what is described as an acceptable result. He asks for a revision rhinoplasty despite having short nasal bones, thin skin, and very friable cartilage in the middle vault that required additional grafting. The patient also wants the fee waived. Sixty-five percent of the directors compared to more than 70% of the fellows would proceed with revision surgery and waive the surgeon's fees; however, 30% of directors, compared with only 15% of fellows, would refuse further surgery. The authors comment, "The fact that fellowship directors were twice as likely to refuse performing additional surgery may reflect how experience teaches surgeons when not to operate in situations in which the probability of a favorable outcome is low."

The second vignette involved an 18-year-old woman who lives with her parents and who requests aesthetic rhinoplasty, to which her parents are strongly opposed. She can pay for the procedure and has a "supportive" boyfriend. The researchers found that 45% of fellowship directors but only 15% of fellows would speak to the parents of the patient and proceed only with their consent. Sixty-five percent of fellows but only 37% of the directors would proceed if the boyfriend seemed supportive and agreed to help with postoperative recovery. Ten percent of fellowship directors but not a single fellow would refuse to do the operation altogether.

The authors comment, "Although 18 years is the legal age of consent for surgery in most jurisdictions, the varied responses in this vignette suggest that fellowship directors are more aware of the negative consequences that an unsupportive environment can have, especially pertaining to rhinoplasty. It is well documented that positive and negative feedback from family members can influence patients' overall satisfaction after aesthetic rhinoplasty. Negative feelings are easily transferred from the family to the surgeon."

The authors propose a template for surgeons to follow to resolve rhinoplasty ethical problems.

Dr. McCafferty said, "Most experienced rhinoplasty surgeons have a similar checklist that they go through when evaluating and treating these patients. The authors have done a nice job summarizing a very useful template that would be beneficial to both the experienced and novice rhinoplasty surgeon."

According to Dr. McCafferty, although there were differences in the answers between the more experienced surgeons and the novices, most of the answers were ethically correct. "The more experienced surgeons, having the benefit of their years in practice, generally made wiser decisions. Indeed it is difficult to teach 'experience,' but utilizing case studies similar to those presented in this paper would prove helpful in our training programs. Interestingly, many similar cases were discussed during my training at our weekly Grand Rounds, and I suspect this is also true for many other programs throughout the country. It is helpful to teach with real cases and real patients."

Dr. Adamson has been a medical consultant for Allergan Canada. The other authors and Dr. McCafferty have disclosed no relevant financial relationships.

Arch Facial Plast Surg. Published online June 18, 2012. Full text

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