If cosmetic surgery is asked for, usually the patient wishes to have the correction of defects caused by aging or resulting from developmental disproportions to obtain an aesthetic improvement.

The goal of surgery is to produce a happy postoperative patient with his wishes fulfilled. How can we obtain this goal? There are, as we all know, multiple variables involving the judgement or the interpretation of what the patient wishes to have improved, normalized, or ameliorated. From their point of view, the patients consider themselves normal. It is the physical condition that causes their psychological problems that, in turn, motivates them for surgery. For the patient, surgery offers a cure, as opposed to the outcome of psychiatric treatment that is not certain. Surgery not only requires less disturbance of the patient’s activity, but also may be less costly [1].

One of the first surgeons specializing in cosmetic surgery was Josef [2]. In his monumental text and atlas of 1931, he devotes a chapter to the problems of his patients, according to him. The satisfaction of a patient depends upon the quality of his aesthetic feelings or upon his sensitivity. In this respect and on the basis of his experience, Josef distinguished four types of patients:

  1. 1.

    Hypo-aesthetic patients

  2. 2.

    Normo-aesthetic patients

  3. 3.

    Hyper-aesthetic patients

  4. 4.

    Para-aesthetic patients

The hypo-aesthetic patient tolerates even a severe deformity, e.g., a pronounced nasal hump, and is grateful for any improvement. The normo-aesthetic patient interprets the deformity in a realistic way and accepts any possible shortcomings such as small imperfections in the surgical result that are not worthy of concern. The hyper-aesthetic patients are unhappy with even minor deformities. They are probably responsible for the often-expressed belief that cosmetic surgery patients, as compared to the general population, have exaggerated psychopathological problems. Today, we probably would consider these patients to have “body dysmorphic disorder”: They view themselves as deformed, but in the eye of the observer, they have a normal body [3]. The para-aesthetic patients, and fortunately they are few, cannot be helped by cosmetic surgery. They need psychiatric care.

In his 1931 book, Josef stresses not to promise or even guarantee the patient an ideal or perfect surgical result. The surgeon should always wish and strive for a desirable, successful outcome [4].