In Lessons Blog

When I first met Mary, already in her forties, she had suffered throughout her life from an arteriovenous malformation of the face. As a result, from early childhood she had endured the discomfort and humiliation that accompanies the stares of strangers. She came to me hoping I could improve her appearance.

The abnormal connection between the arterial and venous halves of her circulatory system caused her cheek, jaw and neck to be constantly swollen and red, pulsing with every beat of her heart. Normally, the pressure of the pulse is dissipated as the arterial vessels narrow and the blood flows through the very small capillaries. By the time the blood enters the venous side, the flow is smooth, more like the surface of a lake, but for Mary, the effect was more akin to the pounding of the surf on a beach during a major storm.

Mary had tried everything in her power to hide the disfiguring facial deformity, from makeup to surgery, but her efforts were to no avail. By the time we met, she had undergone more than two dozen surgeries, yet her deformity remained highly visible.

Operating on this type of blood vessel malformation can trigger massive bleeding, so surgeons need to be careful. They also need to be humble in contemplating surgery after so many other attempts have failed to correct a deformity. If a problem can be easily solved, it usually is on the first or second attempt.

To Operate or Not to Operate?

I knew from long experience that patients commonly feel disappointed after plastic surgery, particularly when their expectations exceed the results. With the outcome so visible, such disappointment can be out of proportion to the objective reality. What others might see as a relatively minor problem – a small, inconspicuous scar or a slight degree of asymmetry – can seem disfiguring to the patient.

In Mary’s case, a great result was simply impossible. I warned her that any improvement would be minimal, at best, and that operating risked further scarring and deformity.

And as difficult as it was to say to her, I made sure that she understood that no matter how successful the procedure was, her facial deformity would remain visible. Strangers would keep staring.

I believed it was essential to be honest with her, not offer false hope. For many patients, I would have refused to do the surgery, but something about her demeanor made me decide to offer her the option of going ahead.

I explained what the procedure would entail, and that she should expect, at best, a 1 percent improvement. She assured me that 1 percent would be worth it.

The operation went without complication. A week later, scheduled to see her in a follow-up visit, I worried about what she would say. But as I entered the exam room, she beamed with a big smile. She handed me a beautiful, handwritten thank-you card, and expressed her deep gratitude for her improved appearance.

Objectively the change was minimal, but to her it was major.

Mary faced the world as she was, dealing stoically with what for most people would be unbearable pain. Her courage inspired me. Over the next decade, I performed several more procedures on her, each bringing small improvement but continued gratitude.

Some of us are bothered by barely discernible imperfections, and 1 percent does not seem like a lot. But through gratitude, Mary was able to accept what she was given, embrace life and move forward.

As physicians, we learn much from our patients.

Dr. Robert Pearl is the bestselling author of “Mistreated: Why We Think We’re Getting Good Health Care–And Why We’re Usually Wrong” and a Stanford University professor. Follow him on Twitter @RobertPearlMD

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