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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
e-mail: [email protected]
C. Sereday
Inpatient Department, Burn Hospital, Buenos Aires,
Argentina
e-mail: [email protected]
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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
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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
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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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