10 Reasons Your Cosmetic Surgeon Might Say “No”

Announcer (00:02):
You are listening to Alabama the Beautiful with cosmetic surgeon, Dr. James Koehler and Kirstin Jarvis.

Kirstin (00:12):
Hey, Dr. Koehler.

Dr. Koehler (00:13):
Hey, Kirstin.

Kirstin (00:14):
What do you want to talk about today?

Dr. Koehler (00:15):
You know, you get to pick.

Kirstin (00:18):
Yes. I love that you let me pick. Okay. Today we're going to talk about why sometimes you have to tell patients no on procedures that they're asking for.

Dr. Koehler (00:29):
Sometimes it's more often than you think actually. People don't like to hear. No, no. Is not an answer anybody wants to hear, but

Kirstin (00:37):
I don't ever hear No.

Dr. Koehler (00:39):
Yeah, you're a spoiled rotten brat.

Kirstin (00:41):
It's not in my vocabulary. Well it's in my vocabulary, I just don't ever hear it. Okay. Let's talk about some reasons that you might have to tell a patient no to a certain procedure.

Dr. Koehler (00:52):
Maybe just start with simple stuff like these nonsurgical procedures that people will come in for Botox and fillers. You sort of think, well, that means it's nonsurgical. I mean, why would you say no? But I say no to people all the time, and I mean,

Kirstin (01:04):
I'm aware.

Dr. Koehler (01:05):
Yeah, I mean, they may not like it, but I always look at my patients are a reflection of my work and me and I have been in a few situations where it's kind of uncomfortable and people, like I say, they're not sometimes very accepting of No. So I'll give you a good example. There's a patient that came to see me and she had a lot of filler in her face, quite a lot of filler, which I did not do. And she wanted some filler, so I really was not keen on putting some filler in her face. But this first time that I saw her, I was like, well, I mean, you could put a little bit in, but I really wouldn't recommend. I think already you've got a fair bit of volume. And anyhow, I had agreed to putting in a syringe and you're kind of like, oh, well, what's the harm one syringe?

(01:56):
It's not that much. Okay, so I did the one syringe and it was no issues, no problems. And then the patient returns not that long after, let's say a month or two later wanting more filler. And I was like, you know what? I think you've got quite a bit of filler right now. And then the kicker came, and this is when I really was just like, okay. She said, you know what, Dr. Kohler, everybody asks me where I get my filler done. And I always tell 'em, I come to see you. And I was like, oh, please.

(02:31):
I was like, because there's way too much and I've only done it one time. And anyhow, I mean, it was just kind of like if you're the last one to touch it, I guess it's all your work. But anyhow, that was a situation where then I was like, okay, the answer's no, I haven't done. So that was somebody who maybe we could say a little bit body dysmorphic, which is a reason, and we can get into that when we talk about surgery. But somebody that just, well, we can talk about, so body dysmorphic, that's a true clinical psychiatric diagnosis. And really what it entails, and we've talked about it before I think in one of our other podcasts, but it really just sort of entails people that are almost hypercritical of their body appearance and they're critical of things that really appear normal to everybody else.

(03:20):
You'd look at it and go, well, that's kind of normal. Or if it's not normal, it's barely not normal. And there's this hyper fixation on things. These people have a very, they can be very nice people, but they have a very distorted view, distorted self image. And unfortunately for people like that, you're never, ever going to actually make them happy because sometimes the target keeps moving too. If you get 'em a little better, then they want even more. So it's like there's never an end point. And so the classic example would be a Michael Jackson. Look good after one or two operations on his nose, and then it really went downhill. And it has nothing to do with the skill of the surgeon, but actually it's the fact that he'd had multiple operations or scar tissue. There's issues with blood supply. And when you head down that road, that's the road of complications.

(04:08):
And which actually kind of takes me to, I'm going to transition from body dysmorphic briefly to, let's say you end up with a body dysmorphic patient who comes in and they've had multiple operations, and even if you think you could improve the situation, because maybe they did have a complication from something else. And what's really hard for surgeons is if you have a celebrity that comes in, because you want to be, oh, I'm Michael Jackson's doctor, even though you can't tell anybody that, everybody in the office would know, oh, Dr. Koehler, he's really good. He did Michael Jackson surgery. Well, maybe he didn't. But so anyhow, I guess there's an allure to treating people that are perceived as important people. And so I think it's hard for sometimes these doctors and people to say no to these folks because they're perceived as important people, and I want to be treating important people. So that's an issue with the doctor, not the patient. But the body dysmorphia is a issue that we are trained to basically look for these signs, and I'm not going to share them with you because then you're going to fool me when you come in. And I don't want.

Kirstin (05:11):
You don't want people to learn your tricks?

Dr. Koehler (05:11):
I don't want you to have the playbook because I need to know what's up. But anyhow, people will, sometimes, for instance, a good thing when you're wanting a surgery is to maybe show representative examples of what you're hoping to achieve. So if you want your nose done, you say, I kind of like the way this nose looks, or I want my breasts, I like 'em to look like this. And it can be helpful in the discussion because your anatomy may not provide that kind of a result. So sometimes women will say, oh, I want to have really tight cleavage. And you examine them and their ribcage slopes backwards and they have a naturally open cleavage, and you're like, well, there's just no way I can get you to that picture because your anatomy doesn't support it. And so it's good because at least you brought it up, and now we can actually bring that expectation into what's more realistic.

(05:54):
So that's good. So we're both on the same page, and if we both agree that you still want to go ahead and do it, that's okay. But sometimes people will bring in pictures and they're so detailed. They're like, I want the tip of my nose to angle 37 degrees this way, or whatever. Those kinds of things where the precision and what they're actually wanting to achieve is so difficult that it's just a red flag. And we're not miracle workers. We can do some pretty great stuff, provided everything, you know, we've got good tissues to work with a healthy patient and all these things line up, but we're still restricted by a lot of factors that are out of our control. So anyhow, that's one no. Sometimes I have really young patients that come in to see me for Botox, and I'm like, look, you don't have a wrinkle to treat. And I understand the whole preventive Botox thing. And the age is not necessarily the thing because there are young people that have heavy wrinkles that are going to get much worse. Similarly, I see people that are maybe in their late thirties or early forties that have great skin and no issues with wrinkles, and they don't really need Botox. So if I'm telling you no, and I'm going to make money off of the procedure, that should be like, if Dr. Koehler says no,

Kirstin (07:06):
Sign number one.

Dr. Koehler (07:06):
you should be like, well, thank you Dr. Koehler, say thank you for saving me money. I'm going to go buy a purse now or whatever. So I like to think about it as I'm in this for the long-term with my patients. If they come to see me for Botox or fillers or whatever, that's great, but maybe at some point they do want a facelift or something else. So I would like to make sure that we understand that I'm going to shoot it straight to you, and I'd like you to do the same for me. Tell me what you realistically want, what you think, what you expect, and then we're going to be a good team and down the road we can do that. So that's one. Another big no, and this is one also where sometimes patients will do a little doctor shopping until they get the right answer is so for instance, health stuff.

(07:51):
So maybe you have some health things like you're a heavy smoker and you're wanting to get a tummy tuck or a breast lift. And if you come to see me, I'll be like, yeah, I can do your surgery, but not until you've quit for the specified period of time before and after, and we're going to nicotine test you and we're going to make sure that you're clean and all that. And it's not because I have something against smokers, it's that I don't want you to have a complication. That is another example. And the problem is, is sometimes people, if they've gone to one or two doctors and maybe they've been told, oh, I can't do your surgery, you're smoker. Some people unfortunately, they don't truly understand why they're being told no, will then go to the third doctor and be like, are you a smoker? Nope, I don't smoke. And that has happened. People are like, oh, obviously when I tell them about my horrible heart disease, nobody wants to operate on me. This is elective surgery. So we need things to be the right way so that you end up with the right outcome. So that's another no.

Kirstin (08:50):
And sometimes I think especially people with a significant health that come in here and really downplay their health issues, I don't know if they don't think this is real surgery. This is real surgery. You get general anesthesia. This is not just getting a tooth pulled.

Dr. Koehler (09:08):
It is real surgery and it carries all the same real risks, and we take it very seriously. It's different in the sense that because it is elective and we want to have it, and it's exciting because if you get your gallbladder out, you're like, oh, I'm glad I don't have that pain anymore, but you're not excited about it. You're like, I got to get my gallbladder. You're going to go and get a breast augmentation. You're like, oh, summer's coming. I want this done and different. It's a whole different vibe. But that's why I always say, if your doctor's telling you no, you should first of all explore why that is. Like say, well, doctor, why would you tell me no? I don't understand. And they should explain that to you. But there are reasons. And when people say no, at least I would like to think when I tell people no, the only reason is because it's in their best interest to take my advice.

(10:00):
I'll share another example of no is wrong motivation. I actually just experienced this today as a matter of fact. Okay, so when people do procedures to please someone else rather than themselves or so marriage is going bad, and maybe if I get some implants that's going to fix things that'll make it better. If you want them, then that's great, but if you're only doing it because you think that it's going to keep your spouse around, that's the wrong reason. And that's not motivated by you. It's motivated by other people or the influence of other people. Another one, which this is, I find this one to be a little more sad, is that I'll have some older patients and their spouse died recently, maybe within the past couple months. And there's this sort of panic and fear like, I am single now and I've got to get myself back out there at some point, and I need to get all this stuff done because I want to find someone, I want to be with somebody.

(11:07):
All this kind of stuff. And the answer to that one is, yes, we can do your surgery, but maybe just not right this moment because you're going through some stuff and I don't want you to make a decision that's like, you're like, why did that, I let that doctor do that. I was not clear in the head. I had so much going on. So that's a no for me. So I want to share with you what happened today. So I had a patient who a year ago came to get her implants removed because she got them, her husband did not like them at all. She didn't get his sort of stamp of approval before she got them or anyhow, that's how the story goes. And so we removed them a year ago because she felt like it was affecting her marriage and everything else. Fast forward we're one year later, she is not married anymore, and by the way, she would like her implants back because she got 'em for her, not for him, and she took 'em out for him.

(12:09):
So again, the reasons for surgery, whether it's putting something in or taking something out, just the whole motivation, she did that for him. And that was a nice gesture to try to save a marriage. But at the end of the day, it's got to be about you. It's your body and your choice. You've got to figure that out. So anyhow, so that's the example from today that actually happened today. And then another one that this one is probably kind of a little bit, not a pet peeve of mine, but this is one where I've been doing this long enough now that I don't budge. I used to budge a little bit before.

Kirstin (12:43):
You don't get pushed over.

Dr. Koehler (12:45):
Well, I don't know about that, but not by you. So anyhow, a big one is a woman comes in and she needs or she'd like her breast looking better, and the treatment really requires a breast lift and an augmentation. But because of anatomical factors, which is a whole nother discussion, this is a procedure that in my mind, I will not do the two of them together, even though probably 80% of the time I will do the lift and the augmentation together. There's a subset of people that for various reasons, are not good candidates for it. And so I'm not saying no to the surgery, however, I'm saying no to both of them at the same time. It means we're going to do one surgery first. We're going to do the lift, we're going to get things where they're supposed to be, let things heal, and then we're going to come back and do the augmentation.

(13:34):
People don't like that because one, it's two surgeries, it's two recoveries, and the cost can be a little different because I mean, we try to make it as fair for people as possible because it's not their fault that they want to have it and other people can, but it's just what it is. So we try to make it better, but it still costs a little bit more to separate it. But really it might cost less because if you did it at the same time and you end up with a complication and now you need multiple revision surgeries, guess what? It costs you way more in recovery, cost and all those other things. So even though it might seem on the surface to be more expensive, in some cases, in a lot of cases, it actually will save you. And like I said, I've been burned on this before.

(14:17):
I think of a specific example of a patient of mine that I was like, yeah, it was a little different, but she had implants. They were above the muscle, and there was a lot of stuff going on there, but I really recommended it. Sometimes I can switch from above the muscle to under the muscle and do the lift at the same time, and I do that regularly. But this was a case, again, without getting into the details, felt it was best to take the implants out, do a lift, and then we're going to come back and put in plants under the muscle. She came in for two consults and then brought her husband, and I got the story of, I only have much time off work. I totally understand what you're saying. I'm totally willing to accept the increased risk. And everybody says the same stuff until it happens to them.

(15:01):
So we did it all at once. And guess what? As I expected, I shouldn't have let her talk me into it. I don't say, let me talk into it. I'm much better about, I'm sorry, if you want that, I'm just not your guy,. But you want to make people happy and you do want it, you're like, can I, have done it before I mean? But in your heart and in your soul, you're like, yeah, but the possibility of an issue is higher than normal, and do we really want to walk down that road? And we did. And I was able to get her looking good, but it required a couple other operations and we could have really done it in two operations instead of more than two operations. And then I guess my last one, which is a little bit my pet peeve, I don't want to say pet peeve, but patients coming in and specifically telling the doctor how to do the surgery.

(15:52):
Again, this isn't the best example, and I don't want to offend anybody who suffers from breast implant illness, but people come in with very clear ideas of exactly how they want their condition treated. It's fine if some of that stuff is grounded in research and science, but sometimes it can be, I'm willing to definitely, I treat a lot of patients like this, but when they're telling you exactly how they want it done, I'm like, yeah, we're going to do that, but I can't guarantee you that, let's say we get it all out in one complete piece. And if we don't guess what, actually the science says, it's going to be just fine. We're going to get it all out. So anyhow, or a better example might be like somebody's like, oh, my friend said I should get a such and such pain pump or something like that.

(16:33):
And I could be like, you know what? I've used those and I haven't found 'em to be of any benefit. And they're really more of a nuisance than a problem. It's okay that people ask about it, but if the doctor says, yeah, I've tried that, and actually I don't like those and I don't like that particular product or thing and I don't want to use it, you're always welcome to go elsewhere. But people say no for usually good reasons. And then I guess probably the last reason, and this would be again, a doctor reason, and they may or may not divulge this, but sometimes a patient asks about a procedure and the doctor just doesn't do it a lot. I'll tell you a common example for a lot of cosmetic surgery practices that maybe they do a lot of body stuff, but they maybe don't do a lot of face. And so if somebody says, well, can you do my ears or my nose? And they're like, no. And they may say that I don't know that you're a good candidate or whatever, but maybe it's really because they just don't feel comfortable with it. And I'm just being honest. Some people just maybe have a hard time telling somebody, I'm just not, that's not my thing. Those are probably all the reasons of why a Dr. may say no. And I think, oh, there's one more.

Kirstin (17:39):
Bring it on.

Dr. Koehler (17:40):
The last one.

Kirstin (17:41):
The last one, the last, last one.

Dr. Koehler (17:43):
Yeah. And this one is maybe it's hard to really know for, because it's like you only make this sort of a jump to this conclusion based off of comments the patient makes. But if financially a person is really, they tell you multiple times like, oh, I've saved every penny, I just don't. And sometimes you're thinking, well, they're just trying to hope that you can give them a break on the cost or something like that, and they're trying to do that. But really, if you can't afford this, you shouldn't be doing this. And the answer is, I have said to some people before, I'm like, look, I understand that you want this really badly, but it kind of sounds to me like you're really scraping the bottom to get everything you can to have this happen. And I just don't want you to put yourself in a very bad financial position because you did an elective procedure that I know you want, but maybe that's not the time.

(18:38):
And why are people disappointed with surgeries? Well, this is a separate topic, but it can be a lot of different things. And one of them is like, well, maybe they were hoping that if they had this surgery done that it was going to save their marriage, and they did scrape every dime. So now they're disappointed because the marriage isn't saved. And they also just spent a whole bunch of money that they're making payments on, and so they're not happy with the surgery, but really they're just not happy with the outcome. And it's not the surgical outcome, it's the what I expected my life to be outcome after I had the surgery. So that's my pearls of advice on why you should listen to your doctor. The end.

Kirstin (19:15):
The end.

Dr. Koehler (19:16):
I'm off my soapbox.

Kirstin (19:18):
That was actually a really good, you're passionate about that.

Dr. Koehler (19:21):
Well, I'm just passionate about, I think for me personally, when I tell people no, it's out of kindness and it comes from a good place, and it's not anything mean or bad. It's like I truly care and I don't want people to do something that I think could sometimes a no turns into a yes, but not often.

Kirstin (19:39):
Is that all? Do you have any other reasons that you want to talk about?

Dr. Koehler (19:42):
No.

Kirstin (19:43):
Okay.

Dr. Koehler (19:44):
Done.

Kirstin (19:46):
Done. Do you have a burning question for Dr. Koehler or me? You can leave us a voicemail on our podcast website at AlabamatheBeautifulPodcast.com. We'd love to hear from you. Thanks, Dr. Koehler.

Dr. Koehler (19:58):
Thanks, Kirstin.

Kirstin (19:59):
Go back to making Alabama beautiful.

Dr. Koehler (20:01):
I'm trying.

Announcer (20:03):
Got a question for Dr. Koehler? Leave us a voicemail at AlabamatheBeautifulPodcast.com. Dr. James Koehler is a cosmetic surgeon practicing in Fairhope, Alabama. To learn more about Dr. Koehler and Eastern Shore Cosmetic Surgery, go to easternshorecosmeticsurgery.com. The commentary in this podcast represents opinion and does not present medical advice, but general information that does not necessarily relate to the specific conditions of any individual patient. If you enjoyed this episode, please share it and subscribe to Alabama the Beautiful on YouTube, Apple Podcast, Spotify, or wherever you like to listen to podcasts. Follow us on Instagram @EasternShoreCosmeticSurgery. Alabama the Beautiful is a production of The Axis, theaxis.io.