Cosmetic Surgeries Don’t Always End in a Smile

By many accounts, Dr. Michael Tavis was a popular plastic surgeon, committed to his profession and kind enough to provide free reconstructive surgery to needy youths in Petaluma, the Northern California town where he practiced.

“He had a real passion for doing to patients what he did for them--sometimes reconstruction, sometimes improving someone’s image,” says an employee at a Petaluma hospital who knew him.

But in recent years, the 53-year-old doctor had also suffered his share of troubles, including lawsuits filed by patients claiming their surgeries hadn’t given them the results they expected. Then, in April 1997, the Medical Board of California accused Tavis of gross negligence and incompetence in caring for two patients.

But perhaps no patient was as disgruntled as Theresa Mary Ramirez, 46, who reportedly had undergone breast reconstruction by Tavis and later sued him, unhappy with the outcome. Her lawsuit was dismissed, but she was not ready to give up.

On the morning of July 3, 1997, Ramirez allegedly entered Tavis’ office and, according to police reports, shot Tavis several times and his office manager once. The office manager survived; Tavis did not.

Last year, Ramirez pleaded not guilty. In July, Ramirez was judged competent to stand trial, according to the Sonoma County District Attorney’s office. The trial is set to begin Oct. 13.

The case strikes fear in the hearts of the nation’s plastic surgeons. Tavis is the latest in a trio of plastic surgeons during this decade to meet a violent death at the hands of patients--sometimes not even their own.

Dr. Martin Sullivan, a surgeon in Wilmette, Ill., was murdered in 1993 by a man who selected his name at random from a phone book and made an appointment. Posing as a patient, Jonathan Haynes opened fire and shot Sullivan as soon as the doctor introduced himself, according to Wilmette Police Department reports. Haynes was reportedly angry that plastic surgeons create “fake Aryan beauty.” He was found guilty and is on death row in Illinois.

In 1991, Dr. Selwyn Cohen, a surgeon in Bellevue, Wash., was preparing to speak to a local women’s group when Beryl Challis, a disgruntled patient with a revolver, ambushed him in his office and then killed herself.

While most surgeons specializing in cosmetic work have not faced a gun barrel, many can relate incidents of patients so angry they telephoned death threats or smashed office furniture.

Physicians in other specialties--notably emergency medicine and psychiatry--are generally considered at higher risk of being hurt or killed by angry, violent or disturbed patients, experts say, although statistics of the number of physicians murdered by patients are not kept by the American Medical Assn. or by medical specialty organizations. According to the U.S. Department of Labor, Bureau of Labor Statistics, 11 physicians were killed on the job from 1992 to 1996, but no details are available on their area of specialty.

Increased Awareness

Although the actual risk of being killed by a patient is small, the topic is much on the minds of plastic surgeons. In May at the annual meeting of the American Society for Aesthetic Plastic Surgery in Los Angeles, a big draw was a one-hour panel discussion titled “Identifying and Understanding the Psychologically Disturbed Aesthetic Surgery Patient.”

The April issue of the Plastic and Reconstructive Surgery journal featured an article calling for more study on what motivates people to seek plastic surgery and asking whether it may be inappropriate for some.

Meanwhile, practicing surgeons debate whether violence is increasing or people are simply more aware of it. Dr. Brian Kinney, chief of plastic surgery at Century City Hospital, believes there is at least more potential for violence.

“The number of unhappy patients has risen,” he says, blaming the increase in part on what he terms “unreasonable claims--almost hype” from practitioners and advertisements promising too much. Patients can begin to believe anything’s possible, given the right surgeon.

Also, procedures have gotten more sophisticated.

“What we’re trying to do is much more complicated these days, so the more intricate the procedure, the longer the list of potential complications,” says Dr. Mark Constantian, a plastic and reconstructive surgeon in Nashua, N.H., who had experiences with three violent patients in a span of a year and a half.

As the number of people having cosmetic surgery has increased, doctors wonder whether the pool of potentially violent patients, in turn, has increased as well.

More than 2 million Americans underwent cosmetic procedures in 1997, according to the American Society for Aesthetic Plastic Surgery. From 1992 to 1997, the number of cosmetic procedures tracked by the American Society of Plastic and Reconstructive Surgeons increased by at least 50%.

And some of these patients may have severe body-image problems. In a study published earlier this year in the journal Plastic and Reconstructive Surgery, Dr. Linton A. Whitaker, chief of plastic surgery at the University of Pennsylvania Medical Center, and his colleagues found that seven cosmetic surgery patients, from a sample of 100, met the criteria for body dysmorphic disorder, a psychiatric condition defined as a preoccupation with a slight defect in appearance that begins to take over a person’s daily life, interfering with normal functioning. (About 1% to 2% of the general population is believed to have body dysmorphic disorder.)

The stories of violent or near-violent patients are harrowing. At the medical meeting, Constantian recalled a sixtysomething college professor who wanted a nasal revision and seemed to have realistic expectations.

“Her surgery went absolutely smoothly,” he says. “She came back at two weeks and she was furious.” So sure was she that the results looked horrible that she refused to leave her house and went food shopping at night in another town so no one would see her. After delving deeper into her history, he found she had body dysmorphic disorder, obsessive-compulsive disorder and depression.

Another patient went into detail about how he wanted his nose reshaped, and Constantian followed his wishes exactly.

“I took his splint off after the procedure, and he said, ‘You’ve destroyed my face.’ I thought I was in the wrong room.”

The man called Constantian’s office constantly, complaining about the results. About four months later, he was admitted to the emergency department. In utter despair, he had tried to amputate his new nose with a razor.

Hostility and Threats

Other surgeons report terrifying threats from unhappy patients. Whitaker can still recall a note he received years ago. Written in blood-red ink and slipped under his door, it read, “You will be dead by the end of the day.”

Another patient got hostile after her surgery. After Whitaker convinced her to leave his office, he got a call from the woman’s psychiatrist, whom she had visited next.

“Did you know,” the psychiatrist asked Whitaker, “that she had a gun in her purse?”

Overall, Constantian estimates, a low percentage of cosmetic surgery patients have the potential for violence. About a third of patients could probably be classified as difficult.

Still, the threat of violence has motivated many surgeons to emphasize safety. For some, that means locking the doors between waiting rooms and offices.

Says one Westside surgeon: “We have auto-dials, and one is to the guard station outside the building.”

And even after they take these extra precautions, some doctors say, they sometimes enter the operating room wondering: Did I pick the wrong patient?

To ensure they don’t, many surgeons now insist on longer consultation times before surgery, typically half an hour to an hour or more, and require a patient to return twice or even three times for additional consultations, to be sure they are realistic.

“The key is to be selective before operating,” says Dr. Mark L. Labowe, chief of plastic surgery at Santa Monica-UCLA Medical Center.

Dr. Edward Terino, a Thousand Oaks plastic surgeon on the panel at the aesthetic meeting, helped to develop a preoperative psychological screening test more than 20 years ago and still uses it. If a patient scores too high on the “trouble index,” he is declined surgery.

Most doctors rely on their gut feelings--and the input of others.

“I listen closely to the office staff,” says Dr. Lawrence Seifert, a West Los Angeles plastic and reconstructive surgeon and UCLA assistant clinical professor who serves as a spokesman for the American Society for Aesthetic Plastic Surgery. “And I try to be very careful not to oversell myself.”

“A lot of patients expect more than what can realistically be done,” says Sally Dieterle, Seifert’s office manager. She confers with Seifert on patients, to pool their impressions. Prospective patients tend to talk more freely with office staff, doctors say, than with physicians.

Kinney administers a “patient expectation work sheet,” asking patients to write down what they expect from the surgery. Among the red flags: “I want liposuction because I’ll get more modeling jobs.”

Some doctors refer patients to counseling before cosmetic surgery, either to align their expectations with reality or to deal with other issues in their lives. When Seifert told one woman that counseling would be mandatory before he would operate, she never returned.

To identify patients who may have body dysmorphic disorder, Dr. Katharine A. Phillips, an expert on the disorder, advises surgeons to simply ask a prospective patient: How much does this defect bother you? If the answer is less than an hour a day, she says, “I’d be reluctant to make the diagnosis of body dysmorphic disorder.” If they say they spend more than an hour thinking about it, that information should be a red flag.

To reduce the risk of operating on troubled patients, Dr. James H. Wells, a Long Beach plastic and reconstructive surgeon on staff at Long Beach Memorial Medical Center and Hoag Memorial Hospital Presbyterian in Newport Beach, often builds in a one-month interval between the last consultation and the surgery.

“The 30 days is kind of a test of their patience,” he says. “Some handle it very well. Those who didn’t--over the years--turned out to be not very good patients. You need patience for recovery. Wound healing and swelling can be slower than usual.”

Other doctors say they regularly decline patients too, telling them they don’t think they can deliver what the patient wants. But that may be a temporary solution.

“I’ve told patients I don’t think I can achieve what they want,” Labowe says. “The reality is, they’ll find someone to operate. Anyone who has the money can probably find someone to operate on them.”