A 34-year-old lady, Mrs C, consulted a private plastic surgeon, Mr Q, about her lax abdominal skin. Nine days later, she was admitted under his care for an abdominoplasty (“tummy tuck”). The procedure was uneventful and the patient was discharged after 24 hours.

A fortnight later, at a postoperative nurse-led clinic, Mrs C complained of lower abdominal swelling. This was identified as a seroma and she was briefly admitted for aspiration by Mr Q.

Three months later she was seen again at a nurse-led clinic, on this occasion complaining of peri-umbilical pain. She was reviewed two days later by Mr Q himself, whose examination noted nothing amiss. Her symptoms continued and four months later her GP referred her to the local general hospital, raising the possibility of an incisional hernia. Mr Q was contacted by the hospital and reviewed Mrs C again. He offered to perform a scar revision and to waive his fee.

Three months after this revision surgery was performed, Mrs C had further problems around the scar site, this time manifesting itself as an infection, which developed into an abscess. Initially her GP treated this with antibiotics and dressings. However, despite this intervention, she was seen again by Mr Q, who re-admitted Mrs C for drainage of the abscess and revision surgery to the scarring around the umbilicus.

Mrs C was unhappy with the cosmetic result, and after her discharge from hospital, Mr Q referred her to a colleague, Mr H, for a further opinion. Mr H reviewed Mrs C and replied that in his view the umbilicus and the horizontal scar were placed too high, and he recommended a further revision. Subsequently, Mr Q received a letter of claim from Mrs C’s solicitors alleging that the surgery had been carried out negligently and she had been left with an unsatisfactory cosmetic outcome requiring further surgery. 

Expert opinion

An expert opinion obtained by Medical Protection was critical of a number of aspects of Mr Q’s management, including the positioning of the incision line, consent issues around scarring, and some technical aspects of Mr Q’s wound closure methods. In the light of the expert’s comments the case was settled for a moderate amount.

Learning points

A patient’s decision to make a claim against his or her clinician often reflects more than one point of dissatisfaction or poor performance. Some of the important points in this case include:

• The interval between Mrs C having her first consultation with her surgeon and the subsequent operation was just nine days. When cosmetic surgery is being considered it is good practice to allow a cooling-off period of at least two weeks before the surgery. The patient should be provided with, or directed to, sources of information about the proposed procedure. It is also best practice to offer patients a second consultation, which allows the patient to discuss any doubts or questions which may have arisen. Patients should be under no pressure to proceed with aesthetic surgery.
• Complications can occur after any surgery. In abdominoplasty, issues of scarring and the formation of seromas can occur. It is vital that these possibilities are discussed during the pre-procedure consultations. It is insufficient to simply list them on a consent form, signed in a rush on the morning of operation by a nervous patient.
• It is vital to ensure careful documentation of the pre-procedure consultations. This should outline what has been discussed, including the alternatives, potential outcomes and possible risks associated with any procedure. You should also document any literature that has been supplied to the patient or sources of information that were signposted.
• Aesthetic surgery requires a strong element of psychological understanding of the patient, and patients need to feel supported by their surgeon. Good communication and timely reviews are essential in maintaining a good relationship.
• Being asked to provide a second opinion can be an extremely challenging task, particularly if you may disagree with the original doctor. In this case, Mr H was critical of the repeat surgery carried out by Mr Q. Doctors should always convey their honest opinion to patients. However, you should consider the effect that the manner you express an opinion can have. Excessive or derogatory comments to a patient about a colleague are unlikely to be helpful and may encourage a patient to complain or pursue a claim.