Plastic Surgery Consultations Where the Right Answer Was No

Case 1: The Patch I Could Barely See

A patient came in asking for surgical excision and skin grafting for a patch of facial pigmentation. On examination, the pigmentation was barely visible. I had to look closely to even find what he was referring to, and if I were to be honest, he probably had better skin than I did. To him, though, it was the dominant feature of his face.

He had already gone through five to seven sessions of PICO laser elsewhere with no perceived improvement, and said topical retinoids only irritated his skin. What he wanted now was something faster and more permanent - excision and skin grafting.

I said no, and explained that grafting for pigmentation this faint would leave a patchy, visibly grafted result. This would be much more noticeable, not less, than what he was presenting with. I drew it out on paper so he could see and understand what I meant.

He repeated the request. I explained again. He repeated it a third time, and I told him plainly: "I am a plastic surgeon. Cutting is my favourite thing to do. If I say no to surgery, there is a very good reason for it."

We agreed instead on a stepwise approach, Triluma, followed by microneedling with topical hydroquinone, reassess, and escalate further only if there was no meaningful improvement. He asked if microneedling with topical hydroquinone could be done on the day, then almost immediately, changed his mind to try the Triluma cream first.

At four weeks, he told me the pigment had considerably lightened with Triluma. I asked if he'd like to come back for reassessment to plan next steps. I haven't seen him since.

Case 2: Nine Months Out, and Still Not the Time

This patient came to see me after facial surgery performed elsewhere, having developed ectropion. She had already consulted multiple surgeons, both locally and abroad, for revision surgery, before coming to me. She was understandably distraught as she was young, in a people-facing job, and had actually been referred to me originally before choosing to go with another surgeon, which is its own quiet weight to carry into a consultation.

She described her original concern as a festoon, and looking back at her older photos, I agreed. She had, by her account, been told by more than one of the surgeons she'd already seen that there was nothing wrong, and that her distress was out of proportion to her result.

On assessment, eight to nine months following her surgery, I found otherwise. There was no evidence of exposure keratopathy, and she confirmed her partner could see her eyes close fully while she slept, so there was no functional issue. There was a slight rounding at the corner of the eye. This was real, not imagined, even if it was not something a layperson would immediately register. Most importantly, she was pregnant.

I told her so, in that order. The functional finding is the one that matters most, and it was reassuring as otherwise there is a risk of blindness. I understood why the rounding bothered her, and what she was seeing was real. However, even if we operated as soon as possible, she entering the later stages of pregnancy could/would bring water retention and facial swelling, which would land her squarely in the middle of recovery following revision surgery. That alone, takes months to settle under the best of circumstances. How would she cope then, mid-recovery from revision eyelid surgery, while also nearing delivery, or newly postpartum?

I told her to have the baby and come back at least six to twelve months later, with her kid. At that point, she may still want the surgery, or she may not.

Case 3: The Request for Surgery within 72 Hours

A patient came in for a consultation having previously undergone breast implant removal followed by fat grafting. She was now looking for a second round of fat grafting specifically targeted to the upper poles. This was an entirely fair and reasonable request - her prior fat graft had either not taken fully or simply lacked the volume she desired.

Up to that point, everything seemed straightforward. Then came the unexpected - she asked if we could schedule the surgery for the coming Monday, less than 72 hours after our Friday consultation. I said no, and explained why based on three clear boundaries:

1. Cooling-Off Period & Second Opinions: In Singapore, Ministry of Health (MOH) guidelines recommend a cooling-off period of up to 10 days for any elective procedure performed under general anaesthesia, during which patients are encouraged to seek a second opinion. When I mentioned this, she said she didn't want to get undressed to be examined by another surgeon as she had already made up her mind. Sounds fair, until what transpired next.

   
   

2. Logistics, Safety, and Post-Op Care: I explained that organising surgery requires time, not just to secure an available anaesthetist and operating theatre space, but to coordinate with vendors for a custom, measured-to-size post-operative compression garment. She brushed it off, claiming that she had undergone cosmetic surgery before, found the recovery a non-issue, and asked if we could skip the post-operative garments altogether. This was a major red flag. Proper post-operative care and compression are just as critical, if not more so, than the surgery itself. In fact, cutting corners on recovery might well have been a contributing factor as to why her previous fat graft might not have survived as well the first time.
   

3. Travel Schedule: She mentioned that she was flying in and out of the country due to demanding work commitments. While a busy travel schedule is not uncommon for many patients, it is fundamentally incompatible with safe immediate post-operative care. Even for a procedure as seemingly minor as fat grafting, I explained that I would like her to remain local, in the country, to recover for at least a week. This is so that in the event of unexpected issues such as bleeding or infection, they can be addressed promptly.

What These Consultations Were Really About

Three patients, three requests, and three entirely different reasons to say no.

While the first two cases dealt with psychological nuances which may suggest body dysmorphic disorder (which has a higher tendency in cosmetic surgery patients), timeline realities, and the fine line between distress and anatomy, the third case was about safety, compliance, and respect for the surgical process. Cosmetic surgery is NOT a same-day tailoring appointment; it is a medical intervention that requires physiological stability, meticulous planning, and disciplined recovery.

Rushing into the operating room to accommodate an unrealistic timeline, while ignoring safety guidelines, specialised garments, and necessary post-op downtime, serves neither the patient nor the surgeon well. Sometimes, saying no is not about the anatomy at all. It is about protecting the patient from their own haste, to avoid harm.

Written by Dr Ng Zhi Yang, UK & Singapore accredited Plastic Surgeon.

References

• Kaleeny JD, Janis JE. Body Dysmorphic Disorder in Aesthetic and Reconstructive Plastic Surgery-A Systematic Review and Meta-Analysis. Healthcare (Basel). 2024 Jul 4;12(13):1333. doi: 10.3390/healthcare12131333. PMID: 38998867; PMCID: PMC11241264.

• Salari N, Kazeminia M, Heydari M, Darvishi N, Ghasemi H, Shohaimi S, Mohammadi M. Body dysmorphic disorder in individuals requesting cosmetic surgery: A systematic review and meta-analysis. J Plast Reconstr Aesthet Surg. 2022 Jul;75(7):2325-2336. doi: 10.1016/j.bjps.2022.04.098. Epub 2022 May 2. PMID: 35715310.