Mrs A was initially happy with the results, emailing after a week to say she was "fascinated observing the changes".
About two weeks later she emailed photos and noted her right eyebrow was slightly drooped and there was more hooding of that eyelid when compared to the left.
"[I]s this aspect likely to become more even as time progresses. This is something I would have asked if I had been attending for my post op visits. Don't want to sound anxious - just asking the question as I don't actually know what to expect," she said.
Dr B called her and left a "discreet" message to call back if she needed to discuss anything but she emailed later in the day to say she was "absolutely fine" with the information he had given her.
"... with no further concerns am happy to let time do its work," she said.
However, by January she was concerned about the skin on her cheekbones sagging and asking whether it was likely to tighten with time. She was advised the final result would not be evident for at least 9-12 months.
Mrs A attended her follow-up appointment a year after the surgery and said she found Dr B "intimidating" when she said she was not happy with the results.
"... the consultation, which was conducted in a treatment room, made her feel inadequate, humiliated and insignificant," Mr Hill said in his report, released today.
"He was vague about the causes of the poor outcome and told her it was not a 'biggie', that he would 'sort it out' and would 'see her right'."
However, he then sent her a quote for $19,000 to carry out another surgery, when she had expected he would do it for little or no cost. She asked for a full refund of the initial $31,000.
"Dr B responded in writing advising Mrs A that he was 'saddened' that she felt she could not return to see him to discuss her concerns," the report said.
"He responded to her comment that he made her feel 'inadequate, humiliated and insignificant' at the September 2009 consultation.
"He said he would never want any of his patients to leave any interaction with him feeling that way, and that he had tried to think what he might have said that would have made her feel like that."
He agreed the result was disappointing but did not believe a refund was justified.
Mrs A said in her complaint to the Health and Disability Commission she felt like a "financial commodity".
"[Dr B] knows very little about me as a person, an aspect, which I suspect, makes it easier for him to disregard me," she said.
"The unexpected results of this surgery have had a huge impact on my confidence and well being. [Dr B] has failed to realise this and continues to respond without genuine consideration of what impact this has had on me.
"I cannot adequately express the distress that this experience has had on myself, or my family. It has been a devastating time. I have felt devalued, disregarded and disrespected by [Dr B]."
Mrs A had further surgery performed by a different surgeon.
Dr B told the commission he did not believe a technical error was made, or that his technique or patient care was inappropriate.
Mr Hill found Dr B did not give Mrs A an adequate explanation of the options available regarding facial rejuvenation surgery, including an assessment of the expected risks, side effects, benefits and costs of each option.
She was therefore not in a position to make an informed choice and give informed consent, meaning Dr B breached her rights.
Mr Hill recommended Dr B apologise to Mrs A.
