The Law Malpractice is defined as “treatment which is contrary to accepted medical standards and which produces injurious results in the patient.” Usually the “failure” of the defendant and/or physician to exercise the reasonable degree of skill, learning, care, and treatment ordinarily possessed by others of the same profession in the community. Dealing with the risky patient Effective Communication All litigation in plastic surgery has poor communication as a common denominator. Often marked by impressions of surgeon's arrogance, hostility, coldness (real or imagined), and, mostly, by the fact that “he or she didn't care.” Only 2 ways exist to avoid such a debacle: (1) ensuring that patients have no reason to feel that way (2) avoiding patients who are going to feel that way no matter what the outcome. Have strategies to defuse patient anger. Recognise that anger is often a defensive reaction to fear. Offer understanding, support, and encouragement. Discussion of risks: Affirmative duty means that the physician is obliged to disclose risks on his or her own, without waiting for the patient to ask. It is the patient's—not the physician's—prerogative to determine what is in his or her best interests. Thus, the physician is legally obligated to discuss with patients therapeutic alternatives and their particular hazards in order to provide a sufficient basis of information for patients to decide what is in their best interest. How much explanation and in what detail they are given are dictated by a balance between the surgeon's feelings about his or her patients and the applicable legal requirements. It is simply impossible to tell patients everything without scaring them out of surgery. Rather, the law states that patients must be told the most probable of known dangers and the percentage of that probability. The rest may be disclosed in general terms while reminding the patient that he or she also has a statistical possibility of falling down and hurting themselves that same day. Accurate Documentation Any discussed information is wasted unless it is documented in the patient's record. For legal purposes, if it is not in the record, it never happened. Patient Selection Unlikely candidates are those with 1) anatomic unsuitability a. degree of deformity b. medical problems – smoking, anticoagulants, steroids, diabetes 2) psychological inadequacy. Those with major deformity and minor concern do best as opposed to those with minor deformity and major concern. Strength of motivation is critical because it has a startlingly close relationship with the patient's postoperative satisfaction level. A strong, motivated patient has less pain, a better postoperative course, and a significantly higher index of satisfaction regardless of result. Realistic Expectations Important that the surgeon provides realistic expectations to the patient. Beware ‘brag books’ – showing off good results only Where computer imagery is used, qualify that this is a simulation only. If possible, also show imagery of complications or present results in good but not stellar results. Indicators of a future malpractice claim 1) High expectations 2) Excessive demands 3) Indecisiveness - The more the decision to undergo surgery is motivated from within and not “sold,” the less likely that recriminations will follow an unfavorable result. 4) Immaturity 5) Secretiveness 6) Familial disapproval 7) Personal dislike 8) Surgiholism Common procedural lawsuits Breast augmentation Unquestionably, the loss leader in any medical liability carrier's plastic surgery loss experience is breast surgery, both augmentation and reduction. Of these 2 categories, augmentation is by far the greater. Approximately 44% of all elective aesthetic surgery claims involve augmentation. Momentarily setting aside the hotly debated issue of gel-filled devices causing autoimmune disease, the main complaints have been as follows: 1) 2) 3) 4) 5) Encapsulation with distortion and firmness Wrong size (whether too large or too small) Infection Repetitive surgeries and attendant costs Nerve damage with sensory loss Breast reduction 1) Unsatisfactory scar 2) Loss of nipple or breast skin cover and consequent need for revision/grafting 3) Asymmetry and/or disfigurement Scarring It is imperative that the plastic surgeon obtains clear evidence that the patient realizes there is no healing without scarring.. Rhytidectomy and blepharoplasty Rhytidectomy (ie, face-lift) and blepharoplasty account for approximately 11% of claims. 1) 2) 3) 4) 5) Excessive skin removal resulting in a “scary” appearance Dry eyes and/or inability to close eyes Nerve damage resulting in distorted expression Skin slough resulting in excessive scarring and the need for revisional surgery Cost of additional revisional surgeries (as in evacuation of an expanding hematoma) Beware outpatients In a survey of blindness after blepharoplasty performed some years ago, researchers discovered that the only trait all patients had in common was that they were discharged shortly after the outpatient procedure. Upon arrival at home, all did something (eg, constipated bowel movement, sudden coughing fit, bending over and reaching down to tie shoes) to generate a sudden rise in blood pressure at the time of maximal reactive hyperemia as the epinephrine in the local anesthetic wore off. All patients undergoing outpatient surgery involving undermining of heavily vascularized tissues must be strictly warned to avoid maneuvers that generate sudden elevations in blood pressure (ie, Valsalva-type maneuvers). Additionally, it is strongly recommended that no patient be discharged from an outpatient surgical facility until at least 3 hours have elapsed and all local anesthetic effects have worn off. Rhinoseptoplasty This category of cases constitutes approximately 8% of claims. 1) 2) 3) 4) 5) Unfulfilled expectations Unsatisfactory result (improper performance) Continued breathing difficulties Asymmetry Cost of revisional surgery Abdominoplasty Abdominoplasty, with or without suction-assisted lipectomy, comprises approximately 3% of claims. 1) 2) 3) 4) Skin loss with poor scars Nerve damage Inappropriate operation Infection with postoperative mismanagement Undoubtedly, the combination of suction-assisted lipoplasty and abdominoplasty has significantly increased morbidity. A much higher percentage of skin sloughs clearly occurs in procedures preceded by suction-assisted lipectomy. Skin resurfacing Chemical peels and laser resurfacing constitute the next category of claims, at approximately 3%. The principal allegations are as follows: 1) Blistering/burns with significant scarring 2) Infection/postoperative mismanagement 3) Permanent postoperative discoloration Because of the unpredictability of individual healing characteristics, it is probably a good idea to try a test patch in an area that can be hidden, such as the back of the neck. The documentation preceding this operation should contain clear warnings that quality of healing is linked to individualized genetic characteristics and cannot be predicted. The operator must make it clear to the patient that final color and texture determinations are not always in the hands of the surgeon and heavy makeup may be needed for an indeterminate period of time High-volume liposuction Any amount above 5000 cc of extracted fat constitutes high volume. More importantly, the extraction of this amount of fat causes profound physiologic changes, which can then lead to severe complications and/or death. The infusion of large amounts of fluid with even a weak solution of lidocaine has also resulted in a number of deaths as a result of anesthetic overdose. To worsen matters, these procedures are often combined with other prolonged operations. The percentage of complications and/or fatal outcomes rises dramatically for patients undergoing multiple procedures who remain under anesthesia for more than 6 hours. The following 2 categories of liability arise from conventional assisted lipectomy procedures: Minor allegations Disfigurement and contour irregularities Numbness Disappointment/dissatisfaction Major allegations Unrecognized abdominal perforations requiring life-saving or disabling secondary surgery, possibly resulting in death Lidocaine overdose resulting in death Pulmonary edema from overhydration Pulmonary embolism and death Miscellaneous allegations Approximately 5% of all complaints against plastic and reconstructive surgeons have to do with miscellaneous allegations. Untoward reaction to medications or anesthesia Improper use of preoperative or postoperative photographs Sexual misconduct (physician or employee)