abc preoperative triage system in breast augmentation

8/17/2019 ABC Preoperative Triage System in Breast Augmentation

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O R I G I N A L A R T I C L E BREAST

ABC Preoperative Triage System in Breast Augmentation

Jorge Manuel Albertal •

Gabriel Davalos •

Angelica Maydana • Carlos Sereday

Received: 14 November 2011 / Accepted: 29 May 2012 / Published online: 6 October 2012

Springer Science+Business Media, LLC and International Society of Aesthetic Plastic Surgery 2012

Abstract

Background A successful outcome of elective aestheticsurgery should be preceded by clear criteria for patient

selection. A solid patient–doctor bond and, ideally, a

relationship where ‘‘empathy’’ is the key should be the goal

before proceeding. We describe the usefulness of a new

practical psychological triage system: the 5 Preoperative

Key Points.

Methods Six hundred fifty-five consultations for primary

breast enlargement performed by the same doctor that

culminated in surgical procedures were included. A graphic

was used to classify patients, taking personal adaptation

into consideration.

Results The system’s scores were organized into three

groups: group A (32 %, n = 210), B (55 %, n = 360), and

C (13 %, n = 85). Of a total of 655 nonconsecutive con-

sultations, 646 (98.6 %) proceeded to the second consul-

tation and its respective procedure. Only nine group C

cases (1.3 % of total consultations and 10.5 % C group

patients) were discouraged from undergoing the procedure.

Conclusion These 5 Preoperative Key Points proved to be

simple, practical, and applicable to our daily practice. Apply-

ing a simple and practical psychological triage system shall

prove beneficial not only for surgeons but for patients as well.

Level of Evidence V This journal requires that authors

assign a level of evidence to each article. For a fulldescription of these Evidence-Based Medicine ratings,

please refer to the Table of Contents or the online

Instructions to Authors www.springer.com/00266.

Keywords Breast augmentation Psychology

Preoperative evaluation Patient selection

A successful outcome of elective aesthetic surgery should

be preceded by clear criteria for patient selection. A poor

choice at this point may lead to inevitable patient dissat-

isfaction and potential litigation [1]. Many authors have

made great contributions by tailoring and defining

informed consent processes along with morphological

factors for preoperative systematic evaluation [2–5]. Other

authors, like Gorney [1], have outlined the importance of a

psychological approach in preoperative evaluations. Proper

detection of social and psychological issues is a time-

consuming task for surgeons, especially when dealing with

a patient who is asking for improvement of her physical

appearance.

A solid patient–doctor bond and, ideally, a relationship

where ‘‘empathy’’ is the key should be the goal before

proceeding. Practical and applicable evaluation protocols

are not easily found in the medical literature. Here we

describe the usefulness of a new practical psychological

triage system.

Materials and Methods

Six hundred fifty-five consultations for primary breast

enlargement performed by the same doctor that culminated

J. M. Albertal (&) G. Davalos A. Maydana

Tornú Hospital, Armenia 1929, Buenos Aires,

CP 1414, Argentina

e-mail: [email protected]

G. Davalos


C. Sereday

Inpatient Department, Burn Hospital, Buenos Aires,

Argentina


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Aesth Plast Surg (2012) 36:1334–1339

DOI 10.1007/s00266-012-9982-2

http://www.springer.com/00266http://www.springer.com/00266


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in a surgical procedure between February 2003 and

December 2009 were selected and included in this study.

To categorize the patients into the ABC classification, first

the known graphic, with our adaptation (Fig. 1), is used to

analyze a combination of expectation level (1–5) and

physical complaint scale (1–5). The resulting scores wereorganized into three groups of gut feelings: group A (more

ideal cases), group B (intermediate cases), and group C

(complex cases) (Fig. 2). Then the five key points mor-

phological and empathy list is applied by the author

(Fig. 3).

Results

The patients were classified in three groups according to

their psychological profile: group A (32 %, n = 210), B

(55 %, n = 360), and C (13 %, n = 85) (Fig. 2). Of a totalof 655 nonconsecutive consultations, 646 (98.6 %) pro-

ceeded to the second consultation and its respective pro-

cedure. Of the total, 533 (81 %) were aesthetic HMO cases

(cases in which no fees were charged to the patient). Only

group nine C cases (1.3 % of the total consultations and

10.5 % of group C patients) were discouraged from

undergoing the procedure. Only one legal problem has

arisen and that was from group C.

Discussion

The psychological aspect of the preoperative evaluation is

a delicate matter. It is difficult to analyze new ways to

address this aspect without the risk of being labeled non-

scientific. Common sense, some experience, genetic skills,

and literature review help to study the interpersonal con-

nection between the patient and the doctor. The Preoper-

ative Key Points need to be a mixture of psychological and

morphological factors, which will enable us to conduct a

complete evaluation. This list (Fig. 3) proved to be simple,

practical, and, what is most important, applicable to our

practice on a daily basis.

Letting the patient open up to us is a time- and energy-

consuming process. However, it is imperative that we

should do so in answer to our medical calling as doctorstreating human beings, not just bodies. Once these psy-

chological points have been addressed during consultation,

the artistic/surgeon side of our practice can get involved.

Studies are focused mostly on the morphological preoper-

ative aspects and not so much on the psychological view. It

is believed that is because it is more difficult to standardize.

Studies carried out by Tebbetts [6] and Adams et al. [7]

are brilliant examples of how to deal with the informed

consent process [8] and the morphological aspects of a

procedure. The present work can synergistically comple-

ment those analyses in a practical and applicable way,

which is especially useful for young doctors.

Unquestionably, competence is the ultimate criterion

of success in our craft, but I have seen any number of

situations where the surgical result was frankly poor,

yet no claim was filed. In contrast, all of us have also

seen great results in unhappy patients. Often when

you probe enough, you find out that the problem is

not rooted in the physical results but rather in the

interplay of personalities or the chemistry between

surgeon and patient … [9].

In ‘‘successful’’ practices, the surgeon struggles against

the pressures that separate him from the patient. These forcesworking against the ideal doctor–patient bond are, among

others, devoting less time to each case interview, more time

spent in the operating room, and less time in the office. Also,

we might list fatigue and fame, among other factors.

First Consultation

A bilateral and accurate analysis between the doctor and

the patient is carried out. The women we consulted stated

Fig. 1 Graphic with author’s adaptation

1

2

3

3

4

5

0 1 2 3 4 5

28

56

15

30

31

28

33

33

27

71

72

99

85

9

20

18

E x p e c t a t i o n s

Physical complain

Fig. 2 ABC group distribution population, all 655 cases of the study

Aesth Plast Surg (2012) 36:1334–1339 1335

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that they are mostly focused on choosing one particulardoctor over another. They are involved in an internal dialog

in which they are judging if the doctor sitting across from

them will be the one to accompany them in the transcen-

dental process, which is not an easy decision to make. In

making this decision there are many factors involved such

as the surgeon’s attitude, the way he looks, his posture, his

hands, his clothes, the furniture, and the paintings on the

walls in the office; they are all carefully and unconsciously

analyzed.

Motivation is one of the highlighted factors to be con-

sidered. It is reported that highly motivated patients

experience less pain, better postsurgery conditions, and a

higher rate of satisfaction. Women were motivated to have

breast augmentation primarily to feel better about their

physical appearance and to improve the way they feel

about themselves, not to please their partner, improve their

sex life, or increase their chances of meeting a partner,

unlike what men might think [10].

What we do in our practice is pose a question such as:

What do you think plastic surgery can do for you? This

always works as an icebreaker and enables the patient to

break the uncomfortable silence. One minute of carefullylistening to a patient might render many physical and

psychological details. We surgeons find it more difficult to

listen than to talk. Nonverbal communication is vital:

keeping a relaxed posture and looking directly into the

patient’s eyes convey that the patient is the sole focus of

our attention. Thus, we enhance THE doctor–patient con-

nection. Relevant questions such as Did you like that

school? or What type of horse do you breed? can show and

strengthen the patient’s impression that we are interested in

getting to know her even more. By evoking answers and

taking some notes, we are winning the trust battle. The

message that ‘‘We really care’’ or, even better, ‘‘This is

the doctor that will take care of me’’ has clearly been

delivered.

The patient should not be rushed into making a decision.

If you rush the patient, she will walk away. It is also

important to know who referred the patient. If she has been

referred by a former patient, we are one step ahead in this

conversational tango that will ideally lead to both the

surgeon’s and the patient’s expectations being met. It is

most likely that the decision has already been made as

Fig. 3 Five Preoperative Key

Points list

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regards choosing the surgeon. These efforts to communi-

cate better will eventually result in a better consultation/

surgery success rate (Fig. 4).

Empathy

Despite doctor’s personality, we will inevitably come

across people with whom we find difficult to relate with.The experienced surgeon will immediately realize if the

patient is a candidate or not. Questions such as: Would I

choose this person as a patient? Are we going to relate

easily? Would we be able to undergo together unpredicted

postsurgical complications? The female members of the

team frequently contribute greatly thanks to what it is

called woman’s intuition. Having doubts and going ahead

with the surgery is a misstep that may be regretted in the

future. In the end, we might define empathy as a good or

bad ‘‘vibe,’’ a feeling that we all experience but is difficult

to define.

Reed [11] stated that it is important for a surgeon tomaximize the time he or she spends with the patient. An

expression of concern or a short chat regarding the

patient’s expectations will help build a rapport between the

surgeon and patient.

ABC Factors

Implementation of the ABC factors with the known adapted

graphic (Fig. 1) has been a cornerstone in classifying the

patients psychologically in a practical and fast way. On the

one hand, we consider the patient’s level of expectations

and concerns expressed at the actual interview (value

range = 1–5). On the other hand, we evaluate the objectivemorphological situation (value range = 1–5) that brought

the patient to the interview. Being an A, B, or C group

member is a subjective interpretation that facilitates and

helps the whole team clarify what we might expect. There are

different stages of patient care for each group (Fig. 5).

Group A patients (32 %) show a clear physical condi-

tion (such as severe hypomastia or tuberous breast). They

have low or reasonable expectations and have established

an empathic rapport with the surgeon. These patients

constitute foreseeable cases of happy and satisfied patients

after the procedure.

Group B patients (55 %) have a less evident physicalcondition (moderated hypomastia), bear reasonable

expectations, and have also established an empathic rela-

tionship. This group is likely to be satisfied but have less

tolerance for complications than group A because their

morphological condition was not so evident before the

procedure. We should take more time to explain the risks,

complications, and resulting scars. The cost/benefit balance

is not so obvious. These are cases were the motivation

should be explored and dissected.

Group C patients (13 %) are more complex cases. Their

aesthetic needs are not so evident and/or they are seeking

‘‘perfection.’’ This does not contribute to a good relation-

ship between the patient and the doctor. We spend even

more time explaining our limitations and, frequently, we

ask far more questions and even suggest getting a second

opinion in order to slow down the process and hopefully

Initial call

FirstConsultation

Blood Tests

Surgery days

Next Consultation

SecondConsultation

Secretary

Secretary

Call consultationrate

Procedure Q & A

Meet family

Surgery

Consultation/Surgeryrate

Try implants

Fig. 4 Author’s office flowchart

- Complications

- Scar pictures

- Limitations

- Risks

Group B

Group A

- Consultation

- Consultation

- Sizers session

- Signed informed

consent

Group C

- Extra consultations

- Family consultation

- Team decision

- Rejection

Fig. 5 Different stages of patient care. Guidelines for preventing

communication failures. Aspects to emphasize in each level. All three

categories share the Preoperative Key Points

Aesth Plast Surg (2012) 36:1334–1339 1337

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encourage deep reflection. We frequently show the graphic

(Fig. 1) to the patient and invite her to categorize herself

using it to insure a better understanding of her condition

and the potential outcome. This strategy forces the patient

to rethink and lowers her expectations, frequently resulting

in an upgrade from C to B. The easy cases (group A and

some group B cases) represent more than 85 % of the cases

in our study.After we have met with the patient once and have gone

over the first hurdle, we engage in a second interview,

which has four intentions:

1. To maintain a good patient–doctor relationship. We

have realized that remembering contextual details such

as family members, boyfriends, etc., recorded in the

first consultation contributes in a positive way and

shows a genuine interest and makes the patient feel

special.

2. To verify if the patient is still truly motivated.

3. To evaluate the outcome of preoperative blood tests.4. Although it can demand lots of patience on behalf of

the surgeon, to try out different sample implants with

the proper clothes and brassiere at the office. It is a

moment enjoyed by the patient and further strengthens

the relationship. It is not suggested that patients try

sample implants in other places since it often leads to

confusion and desertion.

There are some papers stating that results often satisfy

doctors but not patients [12]. Hsia et al. [13] demonstrated

that patients are more involved in the size matters and

doctors are more concerned about natural appearance and

balance of the breast. Dialog should be clear on these topics.

Handling Group C Patients

We all have had to deal with a delicate situation such as the

following: We are facing a patient who is seeking surgery

but who clearly has no indication for it, and by indication

we do not refer only to the physical condition. The decision

that a specific case will not be ending in a procedure is

generally a team decision. Once this decision has been

reached, some doctors might resort to using a letter in order

to explain the determination. However, in our practice we

have seen that this is not viable when dealing with Latin

patients. Also, the ‘‘very high fee strategy’’ to discourage

the patient might not be effective or sincere. If you decide

that the patient is not a fit candidate at the time, do not go

ahead with the procedure.

Nine cases (1.3 % of total consultations and 10.5 % of

group C patients) in this study were dismissed. However,

we suggest that the matter be addressed face to face and

that we always try to ‘‘leave a big back door open’’ so as to

not make the anxious patient to feel increasingly rejected.

Flaherty shared with us in private communication that an

elegant way of addressing the matter could be to refer to the

‘‘limitations of our hands’’ rather than focus on the patient’s

instability, unrealistic expectations, and/or the absence of

empathy in the professional relationship. With phrases like

‘‘My hands will not be able to obtain the goal you are looking

for,’’ the final objective is to make the patient understand that

this specific doctor is not the one for her. This is the strategywe use to handle these cases. Gorney said, ‘‘The most suc-

cessful professionals among competence have in common an

odd combination of charm, sensitivity, and warmth often

referred to as ‘bedside manner’ by the public.’’

The case that resulted in a legal issue was clearly a

group C case. The surgeon accepted it due to the pressure

exerted by a friend. She was an unstable patient with

marital and economic problems who was seeking perfec-

tion without scars. After the procedure and some compli-

cations that ensued, it was clear that the relationship had

deteriorated and the professional was unable to breach such

barriers. When the situation does not feel right, do not goforward; you will most likely regret the decision. If to say

no should prove too complex or too difficult, at least pause

the process and restart it a couple of weeks later.

Conclusion

A balanced assessment that includes a psychological and

morphological mix proves to be simple, useful, and secure.

The input of female assistants and nurses has been found to

be vital in the psychological perception. They facilitate and

hopefully ensure that the doctor and the team flow togetheras a unit inspired by the same spirit of care. Applying a

simple and practical psychological triage system shall

prove beneficial not only for the surgeon but for the patient

as well. Focusing not only on the morphological but also on

the psychological aspects will help understand and get to

know our patients and their desires better, further

improving the complex doctor–patient relationship.

Conflict of interest The authors have no conflicts of interest to

disclose.

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abc preoperative triage system in breast augmentation

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