Just this week I saw a very nice patient whom I had seen in 2006 and again in 2011.  At that time, she had already had multiple nasal surgeries, the previous two by a superb surgeon.  Her nose was straight and worked well.  But she wasn’t happy.  Her descriptions were filled with disaster language: every irregularity was “huge”, every imperfection “awful” or “disgusting.”  I could see some of the problems she tried to show me; others I could not.  Perhaps I could make some small improvements, and I described minor procedures to her that were safe and would not jeopardize the result she had.

I never heard from her until she returned this week having undergone a major rib graft reconstruction of her entire nose last year.  The result was actually pretty good, better than I would have imagined from such a bold plan in a nose that had already undergone many operations.

But she was dismally unhappy and had a list of six or seven “extreme” problems that “I can’t live with” and that needed my immediate attention.

This time I had no ideas.  The problems that she saw were either uncorrectable because nature would not permit them or they were prohibitively risky.  I would have been just as likely to create a brand-new problem as I was to make the corrections she wanted.

In addition, she had just survived cancer surgery.  She had a very good surgical result.  I told her that, and I said it was time to stop having rhinoplasties.

It is rare that I cannot think of something to do for a patient.  However, first I have to be able to see the problem, and see it in the same way as the patient.  Here, I could not.  Second, I have to feel that I can fix it safely with a high likelihood of success for the patient.  I could not.  Finally, every patient must understand that perfection is never a realistic surgical goal; it is the best possible outcome, given the variability of human tissues and healing.  I am not sure she did.

There was something else going on here that I could not explain.  My research indicates that underneath many of these suffering patients are significant self-esteem issues that are not their fault, but that result from childhood trauma.  Surgery cannot create self-esteem.

She is a nice lady and I hope that she takes my advice.