Newleaf Plastic & Reconstructive Surgery

This patient came in to my office for a consultation about two issues one being fat herniation/excess skin under her eyes, and the other the tear trough deformity/nasojugal groove.  I had a 1 hour conversation in the presence of my scribe.  At which point, I never told her that she didn't...

need surgery.  I told her that she has two factors contributing to her issues.  One was atrophy of her cheek with ptosis contributing to the tear trough/nasojugal groove and fat herniation.  She also had a little excess skin.  She never told me at that time that she also had swelling everyday.  She didn't tell me that till later.  I told her that surgery on her eyelids will not fix her cheek issues that she needs to replace the volume in her cheeks  by lifting/filling them.  I told her that surgery on the lower lids will only fix part of the problem.  I discussed the option of Voluma (among other things) with her because it is minimally invasive.  I told her that in my experience that we can put this in her cheeks, and it helps to fill the volume loss which improves (not resolves) the tear trough and nasojugal groove issues.  This in turn helps camoflage some of the fat herniation.  I told her that it won't fix the excess skin issue, and she may still need surgery to address that, but some people are happy enough with the improvement from fillers that it buys them some time before they do the eyelid surgery.  I also told her that she may get the fillers and still want the surgery because like I told her she has 2 big issues to fix, and it is better to fix the cheeks first on the off chance that she is happy enough with that, and doesn't want surgery immediately on her lids as there are more risks with surgery on the lids.  I also never promise someone that fillers will eliminate bags. They add volume and can make tear trough/nasojugal grooves better, but don't get rid of excess fat/skin.  I also told her that she would have swelling and bruising for at least 2 weeks, at which point the majority of the swelling, but not all would go down.  In someone who has daily swelling, it is normal to have swelling last longer.  I told her this when I found out that she had daily swelling.  I also told her that it would take at least 2 months to see her final result, which is why we made her a 2 month follow up initially after her procedure.  She called me 1 week out very concerned about what she said was very abnormal swelling, so I told her to come in to be seen.  When I saw her 1 week post procedure, a majority of the swelling was gone on the right and only a little residual swelling on the left.  She looked like a typical patient should.  She also looked much better than the picture that she attached here.  She called again at the 2 week mark and said that she still had terrible swelling.  When I asked her to come back to the office at the 2 or 4 week mark, she refused because she said that she can't take off of work.  I offered to see her after hours to accomidate her work schedule, and she refused and said that she just wanted her money back.  Like I told her all hyaluronic acid fillers are hydrophillic, so they pull water in.  Therefore, swelling is a completely normal part of this procedure and resolves with time.  Therefore, I can't be responsible for her outcome if she refuses to be seen.   Sincerely,[redacted], MD, FACS