Notions of individual beauty are inherently personal, bound up as they are with our own self-image and with the outer face that we portray to our fellow beings. At the same time, such notions of what is the “ideal” are profoundly affected not only by the ephemera of fashion but also by the impact of different cultures, races, and generational shifts that attempt to define a human aesthetic. Also, there is no doubt the significant role played by our media, especially television and Hollywood. However well grounded we may be in the details of anatomy and the subtleties of surgical technique, and regardless of our confidence in our own aesthetic judgment, simply by being in the business of human appearance we are positioned on a terrain that is constantly shifting and infinitely malleable by individual desires and myriad social forces.

Consider the varying standards for defining the aesthetically pleasing female breast. Unlikely as it may seem to a generation brought up on Baywatch, these have shifted more than once in relatively recent memory. Even local differences may come into play; currently a breast augmentation may or may not seem “overdone” or “underdone,” depending on whether one is on the East Coast or West Coast. The gluteal area is now gaining increased importance (if not to say prominence) in US culture as a result of the impact of Latin standards—and a certain singer/actress’ well-publicized endowment. Changes such as these continue to make aesthetic surgery both creative and challenging.

The hard part is explaining these dynamics to a prospective patient with all the wrong anatomy but a desperate desire for the most favored attributes of an idolized celebrity. Prospective patients are often disbelieving when we must inform them that their desires are impossible to achieve.

Even more difficult are those cases in which a particular procedure is clinically approachable but in our judgment is not aesthetically appropriate for the patient in question: For example, the patient whose concept of the perfect nose is one that is clearly disharmonious with his other facial features. Or the patient whose desire for the largest possible breasts discounts entirely the notion of proportion. Or the young patient who has heard about buccal fat pad removal and wants to achieve a more high-fashion look with a thinner face and prominent cheekbones; in your judgment, her cheekbones are fine and her face is thin enough, not to mention the prospective skeletonizing effect of too little facial fat 20 or 30 years down the road.

There are times when our own aesthetic judgment, combined with our greater understanding of the long-term consequences of surgical changes, clearly overrides what patients want. For responsible aesthetic surgeons, it is not unusual to “just say no.” In such instances, patients may leave our offices disappointed and ultimately find someone else who is willing to perform the requested surgery. Perhaps less often, they may go home, think about it some more and ultimately decide to trust our judgment. What is far more disturbing is that unrealistic expectations among our patient population seem to be more and more common.

Communication is the key. Visual aids, particularly a photo gallery of typical results from cosmetic surgery, can help demonstrate what is possible or not possible. Viewing photographs of “real” people who have undergone plastic surgery can help bring patients back down to earth. It can also help inspire greater confidence in your abilities — not only your surgical expertise but also your ability to understand what your patient wants. Even if you can’t or won’t deliver the look that she originally requested, you may be able to use photographic examples to better explain your recommendations.

By finding effective ways to convey our experience and our aesthetic judgment to prospective patients, we can help shape their expectations to fit what is clinically possible and aesthetically pleasing. Such “mental contouring” may well be among the most subtle and most satisfying procedures we perform.