Two months ago, I mentioned on this page that PSP receives numerous e-mail messages and even phone calls from current or would-be plastic surgery patients who request medical advice or physician referrals. In the past 6 months, we received these poignant or unusual requests:

• A woman who had gastric bypass surgery saw an article in which we interviewed two surgeons about postbariatric procedures. She wanted to know how to reach them.
• A woman who had received breast implants complained of a poor result. ("I feel like a freak.") She evidently could not obtain satisfaction from her surgeon and didn't know where to go for help.
• A man requested information on procedures to remove acne scars from his chin, and how much they would cost.
• A woman who believed that her legs were too thin wanted to know whom she should go to for thigh implants. She couldn't find a source for them on the Web.

And finally:

• A man claimed that his wife wanted 2,000-mL breast implants and that none of the implant manufacturers would help her obtain them. They wanted to mimic a woman whose Web site indicated that she had 850-mL implants that were overinflated to 2,000 mL.

These requests span the spectrum from the almost hopelessly pathetic to the sublimely ridiculous, but I'm convinced that all of these people truly believe that their lives would be greatly enhanced if they received the help they were seeking. The best that PSP can do is to direct them to the Web sites of professional associations or commercial directories that can help them locate appropriate physicians in their localities.

But the real question isn't what PSP can do for these patients, but what you can and will do for them. Aesthetic medicine is very unlike other types of medicine in that it's primarily elective, and this country's capitalistic principles would dictate that if a patient is willing and able to pay for a procedure, he or she should be entitled to receive it. On the other hand, "first, do no harm" and other medical ethical standards—not to mention malpractice insurance companies—might require a practitioner to refuse service to a patient, or at the very least talk him or her down from undergoing an extreme procedure.

If you are an experienced surgeon, I suspect that you've encountered this dilemma on several occasions. How do you handle it so that the prospective patient doesn't feel rejected or unserved? You are probably careful about selling patients "up"—trying to get them to buy more than they came in for—but how do you go about convincing them that they don't need the huge breasts or severely overliposuctioned neck that they may show you in magazine photos? How you handle this will determine whether you get the business or—possibly more importantly—whether the individual eventually obtains the outrageous result that you would never provide.

PSP  would like to know how you deal with these awkward cases. Let us hear from you!

Michael J. Block