Category Archives: PRE & POST SURGERY INFO

Bruising and Bleeding After Plastic Surgery

 

Most of my cosmetic plastic surgery related blogs are rather technical and concern how plastic surgery procedures like

breast augmentation: https://tavmd.com/2010/12/12/breast-enlargement-surgery-with-implants/

breast lifts:  https://tavmd.com/2011/01/28/cosmetic-breast-lift-surgery/

tummy tuck: https://tavmd.com/2013/02/17/full-or-mini-abdominoplasty/

facelift: https://tavmd.com/2012/10/05/face-lift-surgery-a-modern-approach/

and so on are performed.

I sometimes forget that as a forum for providing plastic surgery information I should discuss the basic issues and questions that cosmetic patients have before and after surgery. Here I am going to talk about the differences and similarities between normal bruising and bleeding after plastic surgery and hematomas—abnormal bleeding—after surgery.

 bruising

Bruising after plastic surgery is normal

All surgery will result in blood vessels in the skin being cut and  a small amount of bleeding. Of course, deeper structures may also have to be cut, and they will also produce their own bleeding. The bleeding typically stops or is stopped at the time of surgery. Bruising is due to the blood left over.

Blood that is outside of the blood vessels will start to undergo a process of coagulation, where the liquid blood transforms into a clot, which is a jelly-like accumulation.

Under the skin the clot remains in this “jelly-like” form for up to 10 days while it slowly transforms back into:

  •  a yellow-colored liquid (serum) that is absorbed by the body
  • rust-colored remnants of blood cells—the bruise; this is caused by the iron in the blood, which changes color to red, blue and yellow as it oxidizes and is removed by our white blood cells from the skin; in rare cases, the iron deposits stay in the skin for six months to a year

 

Normal bleeding under the skin is usually not apparent for a few days unless the skin is very thin, like it is around the eyes. The bruise typically develops over 2-3 days and rises up to the surface of the skin before disappearing.

One of the main jobs of a cosmetic plastic surgeon is to minimize bleeding by tying off blood vessels with sutures or cauterizing blood vessels with electricity. Despite these efforts, a basic principle of surgery, abnormal bleeding can and does occur; this is called a hematoma.

 

Hematoma, abnormal bleeding, after plastic surgery

Hematoma occurs when there is a large amount of bleeding under the skin or in the body after surgery or due to some other trauma. Hematomas can also occur within body cavities like the abdomen, lungs, muscles, brain, etc. The bleeding typically continues after the surgery and does not stop. If the hematoma is under the skin it initially looks like a large bruise and can be easily diagnosed. If the hematoma occurs deeper in the body, such as under the chest muscle after a breast augmentation, it may be difficult to diagnose without a CT scan.

 

In cases of hematoma, the normal process of removing blood that occurs with normal bleeding and bruising is overwhelmed. There is just too much blood for the body to handle, and the larger amount of bleeding causes:

  • stretching of skin and pain
  • decreased blood supply to skin with possibility of skin dying
  • sometimes even more bleeding due to biochemical processes that start up!

This can lead to death!

 

When a large hematoma occurs, it usually cannot be left alone to be reabsorbed by the body and requires a second surgery to  remove blood and stop the source of  bleeding if it is continuing.

 

In summary:

 

Signs of bruising or hematoma

  • less blood loss or more blood loss
  • color changes on skin; color changes may not be visible on skin
  • smaller amount of swelling or greater amount of swelling
  • less pain or more pain
  • self-limiting; may need surgical evacuation

 

Morad Tavallali, M.D., FACS

Lymphatic Drainage after Cosmetic Surgery

Swelling after surgery

 

All cosmetic plastic surgeries will produce swelling as a normal healing reaction. Some cosmetic surgeries, such as tummy tucks and liposuction, will disrupt the natural body conduits more by the sheer area that undergoes surgery. Other body areas, such as the nose, have different types of swelling that persist for up to a year, such as after a rhinoplasty. Some procedures, such as face lifts, will have swelling persist for up to six months. I have discussed in the past some of the ways to reduce swelling after surgery:

https://tavmd.com/2012/11/13/how-to-decrease-swelling-after-cosmetic-plastic-surgery/

Today I want to specifically discuss the use of lymphatic drainage massage as a way to reduce swelling after cosmetic surgery such as liposuction and abdominoplasty.

lymphatic drainage

What is lymph and what are lymphatics?                         

 

Most people know that our bodies have a series of vessels that carry blood from the heart to tissues (arteries and arterioles) and others that carry blood back from tissues to the heart (veins and venules). What most people do not know is that there is a whole other system of vessels running parallel to arteries and veins that transport lymph throughout the body. These are lymphatics, and they carry around lymph! You have all seen lymph when you have burnt yourself and your skin has formed a blister. Lymph is essentially blister fluid!

Lymph is a yellow liquid that can be thought of as the fluid in which blood cells travel. The combination of blood cells and lymph (plasma) is blood.  When blood arrives at our tissues, oxygen is released from red blood cells and dissolved in lymph, which, because of pressure differentials between arteries and veins, is distributed into tissues.   While most of this fluid goes back into the  blood vessels, a small portion, about three liters a day, stays around the tissues and is then collected in lymphatic vessels and taken back to be re-introduced into the bloodstream in three main areas after going through a series of collection areas called lymph nodes. Each side of the body, thigh and leg empties into the femoral vein on each side of the groin, and the lymphatics of the head and neck drain into the subclavian vein on the left side of the neck.

 

Injury and lymphatics

When a part of the body is injured, there is an increase in the permeability of blood vessels in that area, and more lymph spills out into tissues. We see this as swelling. The more “injury” to an area, such as after a tummy tuck with liposuction, the more swelling and lymph in tissues. In some surgeries, such as abdominoplasty, where skin is elevated from underlying abdominal muscles, lymphatics must be cut and must re-establish continuity and grow together before they can remove the fluid from the area. If this does not happen fast enough and lymph hangs around, you have what is known as a seroma.

When there is an injury or infection, the increased amount of lymph and increase in white blood cells that get recruited to the area of injury will lead to enlargement of the lymph nodes. This is why you feel lymph nodes when you have a cold!

In surgeries where lymph nodes are removed for disease, as occurs after breast cancer mastectomy, injury to lymph nodes and lymphatics can lead to accumulation of fluid within the limb or area of injury, a condition known as lymphedema (swelling due to lymph).

While providing a series of channels for white blood cells and body defenses to get to areas of injury or trauma, the lymphatics also provide for a way for infection to spread through the body. Red streaks up an arm after an injury to a finger are a sign of infection in the lymphatics!

 

Lymphatic drainage

Most swelling a cosmetic plastic surgeon sees after surgery such as tummy tucks or liposuction is expected. There are a number of techniques to decrease swelling, such as garments, elevation of the affected body part and icing of the area to decrease the amount of blood coming and hence the amount of swelling. Once swelling is present, though, massage can help greatly. Lymphatic drainage is a type of massage to help empty lymphatics in the area of surgery that has retained lymph. It is a very superficial massage and is more like a firm stroke rather than a deep tissue muscle massage. Lymph is pushed through the lymphatics, and swelling decreases.

Lymphatic drainage is a useful and beneficial ancillary procedure to cosmetic surgery procedures such as tummy tucks and liposuction where there are large areas of  damage to lymphatics. For smaller areas of cosmetic surgery, such as the nose after rhinoplasty or face after a facelift, patients can massage themselves, but for larger areas, help from a massage therapist trained in lymphatic drainage is well worth any cost.

Morad Tavallali, M.D., FACS

Preventing Infections with Cleanliness, Part 1

What are infections and what can we do about them?

 

Admit it. You’ve been there. Once you are finished, you go to wash your hands. Do you turn on the faucet, which has been touched by the dirty hands of god knows who? What about the paper dispenser? Now, how do you get out of the bathroom? Do you dare pull the handle, which those who did not wash their hands may have touched as they left? Let’s face it—taking a pee in a public bathroom is a stressful experience.

I have previously written on this subject as it relates to a hospital environment and preventing infections: https://tavmd.com/2011/07/30/alcohol-kills-germs/

We live in a pretty dirty world, but a little prevention can help keep you healthy. For example, a recent study showed that the handles of two thirds of grocery carts are contaminated with fecal material. Also, 70% of the lemon wedges in your drink at a restaurant were found to be contaminated with bacteria—E. coli or fecal bacteria! As a cosmetic patient or plastic surgeon, minimizing the risk of infection is important for recovery.

How bacteria cause infection

Our bodies are teaming with bacteria. There are billions of them in different parts of our bodies—even our left and right hands have different types of bacteria on them. Even though we think of the anus as the dirtiest part of the body, there are actually more types of bacteria in our mouth than in any other body part (our mouths are, in that sense, dirtier than a dogs’ mouths, which have less bacterial load and variety!).

Infection as a disease occurs when either:

  1. Pathogens (bacteria or viruses) break through our natural defenses against infection, such as through a break in the skin, or
  2. There is an imbalance in the normal bacterial flora where the different types keep each other in check 

Some particularly virulent bacteria, like some strains of E. coli, streptococcus and salmonella, don’t need much of a break in our natural body defenses to enter and cause infection. A small scratch in the skin, some inflammation of the gut. Others, like Clostridium difficile, lurk in the intestines, and if you are on antibiotics and kill off your normal gut flora, the C. diff. goes wild, takes over and makes you sick.

 

Natural defenses against infection

Once the bacteria is inside our bodies, we have a number of defenses:

  1. Antibodies – small proteins circulating in our blood that attach themselves to and destroy pathogens
  2. White blood cells – a number of different types of white blood cell are present in the blood and will accumulate and kill invading organisms.

 

What antibiotics do

If you go to the doctor, he or she will give you antibiotics, which are medicines that either:

  • directly kill bacteria, or
  • prevent their replication

If you have a viral illness, there is usually not much to do but keep yourself comfortable, hydrated and rested until the disease hopefully runs its course. Only a few viral illnesses, such as herpes and HIV, have medicines available that can slow the rate of replication and keep you somewhat healthy. Some viral illnesses can now be immunized against, such as:

  • HPV (human papiloma virus, which has been linked to cervical cancer)
  •  Herpes zoster (which gives you shingles)
  •  Hepatitis C

 

Cleanliness as a way of fighting the risk of infection

All of this is important because to remain healthy, we need to limit our exposure to bacteria and viruses. One of the best ways to do this is to clean our hands and bodies regularly to decrease the amount of bacteria on our bodies. We don’t want to take a bath in alcohol every day—that would kill almost all the bacteria and leave us open to attack by the one strain or another that was not killed, like the C. diff. example above. We just need to limit our exposure to pathogens.

 

Where are pathogens located?

Pathogens are located everywhere. Most commonly, though, bacteria and other pathogens are associated with dirtiness—dirt on our bodies or dirt on the food we eat and water we drink. Purifying water and properly cooking and washing food takes care of many pathogens. Dirt on our bodies should be washed away with soap and water. Alcohol sanitizers will also kill many pathogens on our hands—use them!

In a recent issue of the Wall Street Journal, there was a small article about some studies that have been done on the subject of public bathrooms and the public’s preferences and habits regarding them. I became re-interested  in the question of handwashing a few weeks ago myself.  I was watching the movie Contagion, in which a worldwide killer disease is passed from one person to another through the air (by sneezing and coughing) or from fomites (transmission from one person directly to another by touch or via rough physical objects like door handles and glasses). You soon realize that we are essentially constantly touching each other. Another interesting fact I learned from the movie: we touch our faces between 2000 and 3000 times a day!  And our noses are where most of the pathogens hide. Also, average adults touch up to 30 objects a minute!

In the next post, I’ll amaze you with some facts about using public restrooms.

Morad Tavallali, M.D., FACS

Cosmetic Plastic Surgery Complications, Part 2

More risks of plastic surgery

 

This is the second part of a post on cosmetic plastic surgery complications and risks. I have written on this topic in the past:

https://tavmd.com/2011/11/26/complications-with-tummy-tucks/

https://tavmd.com/2011/10/08/bad-scars-in-cosmetic-surgery/

https://tavmd.com/2011/09/19/ruptured-silicone-breast-implants/

https://tavmd.com/2010/11/17/complications-of-breast-enlargement-with-implants/

complications2

 

Damage to deeper structures in plastic surgery

Most cosmetic plastic surgery takes place on the skin and muscles. Damage to deeper structures rarely occurs but can include damage to the nerves or structures inside body cavities. In medical literature, there are reports of entry into the lungs or abdominal cavities during liposuction—obviously not a good thing. Thankfully, these occurrences are rare.

Nerves are commonly bruised and will return to normal within a few days to weeks. The cutting of nerves, causing permanent areas of numbness, is common and expected on areas of the skin where incisions have been made, such as the abdomen after a tummy tuck. It is much more common in cases where the nerves are in a different plane of the body, such as under the facial muscles in a facelift.

 

Scars

Though scarring is a normal response to any injury and part of the way our bodies heal, it can cause complications when normal scarring processes do not occur.

For example, capsular contracture is an abnormal type of scarring that occurs around breast implants, causing deformation of the breasts. Keloid or hypertrophic scars are thickened, painful scars that heal in an abnormal manner and require further treatment. Problems with the healing of wounds can also occur due to decreased blood supply, too much tension on wounds, sutures spitting out or allergies to tapes/sutures.

 

Clots and emboli

Any surgery and many medical conditions can cause a slowing down of blood circulation. If you add in a lack of activity in days after surgery, the risk for blood clots forming and then breaking off to become emboli that lodge themselves in lungs or other organs becomes greater. Most surgery is performed with the patient’s legs in massage socks and machines to keep circulation going during surgery. Having patients start to walk early on will significantly reduce the risks. In cases at a high risk for these problems, injections of heparin may be necessary before surgery.

Each type of cosmetic plastic surgery will have its own set of complications in addition to the ones above. It is important for patients to understand that complications do occur and that no surgeon can give you a guarantee of the results you will have; a surgeon can only do their best to minimize risks. If a cosmetic plastic surgeon gives you a guarantee of specific results and a lack of complications… run, run away, and never go back!

Morad Tavallali, M.D., FACS

Cosmetic Plastic Surgery Complications, Part 1

Making sense of surgery risks

 

I have written on cosmetic plastic surgery complications in the past:

https://tavmd.com/2011/11/26/complications-with-tummy-tucks/

https://tavmd.com/2011/10/08/bad-scars-in-cosmetic-surgery/

https://tavmd.com/2011/09/19/ruptured-silicone-breast-implants/

https://tavmd.com/2010/11/17/complications-of-breast-enlargement-with-implants/

Cosmetic Plastic surgery complications are a fact of life. As much as you and your cosmetic plastic surgeon want nothing to do with complications, they can and do occur. The challenge for both plastic surgery patients and cosmetic plastic surgeons is to minimize the risks.

complications photo

Risk of complications common to cosmetic plastic surgery

 

Anesthesia risk

The risk of dying under general anesthesia, if you are reasonably healthy, is the same as the risk of dying in a car crash driving for five minutes in an urban area! There—that’s what everyone is worried about, isn’t it?
The risks of local anesthesia are very low and mainly involve getting too much anesthesia and getting a toxic dose. This is why large-volume liposuction are rarely performed these days.
Other complications can, of course, occur, but they are typically rare. These include:

  • soreness of muscles from being positioned in an uncomfortable manner
  • soreness of the throat from the placement of the breathing tube (50% risk)
  • damage to teeth (less than 2% risk), dentures or caps
  • scratching of the cornea (less than 2% risk)

 

Bleeding

The risk of bleeding is about 2% for most cosmetic surgeries. Bleeding is an important complication that most surgeons will do a great deal to avoid, as the results of surgery can be very adversely affected by hematomas, which are collections of blood. Most bleeding will occur within the first 48 hours. After that, the risk is decreased significantly. The risk of hematoma can rise, however, if patients take any blood-thinning medicines like aspirin, Motrin or other non steroidal anti-inflammatory medications.

Infection

The risk of most infections after cosmetic surgery is about 2%.  Despite the fact that surgery is performed in a sterile manner, there is a minimal and finite risk for infection in all surgery based on the bacteria on the skin and the ability of the body to deal with an influx of bacteria. Surgeries in areas with a high amount of bacteria, such as the mouth or gut, will have higher rates of infection. In some very rare cases, there are virulent “flesh-eating bacteria” on the skin, and the moment they get a chance to invade the body through a cut, they can cause severe and life-threatening infections!

 

Morad Tavallali, M.D., FACS

How to Decrease Bruising after Plastic Surgery

How to reduce bruising after plastic surgery 

 

This post is about how to reduce bruising, but it’s important to read a previous post about how to decrease swelling after plastic surgery before reading on:

https://tavmd.com/2012/11/13/how-to-decrease-swelling-after-cosmetic-plastic-surgery/

Causes of bruising after cosmetic plastic surgery

Let’s see how bruises form. When blood vessels are injured in surgery through cutting, they will bleed into the tissues around them. This bleeding shows up as bruising (in a red, blue and black color) under the skin. Any action or medication that interferes with or delays the normal healing process and stops blood clotting will cause bruising. With time, leaked red blood cells start to break down into bilirubin and iron components, creating a yellow color as the bruises heal. White blood cells then come into the injured skin area and start to remove the remnants of red blood cells.

Some areas of the body are not covered with skin, such as the eyes. When bruising occurs around the eyes, such as after a cosmetic eyelid surgery, blood actually shows red in the white part of the eye!

Here are some other posts about swelling and bruising and the use of ice and heat after plastic surgery:

https://tavmd.com/2011/08/30/swelling-after-liposuction/

https://tavmd.com/2011/02/05/should-i-apply-heat-or-cold-after-plastic-surgery/

 

How to stop bruising after plastic surgery

Stopping bruising involves not only the removal of blood that has seeped into tissues, but also mechanisms to heal vessels and encourage clotting along injured vessel walls so that no more blood seeps out.

  • Elevation of injured area

Decreasing blood flow will decrease swelling and the amount of blood that seeps into the skin through injured vessels.

  • Ice

Cold contracts blood vessels, resulting in fewer cells going out into the tissues. Likewise, avoiding heat (heating pads or warm towels) will be beneficial in the initial 72 hours after surgery because it increases flow and bleeding before the blood vessels have had time to heal.

  • Avoidance of NSAIDs

NSAIDs (see above) decrease blood clotting. Specifically, they decrease the production of prostaglandins, which are essential for forming a clot. No clot and you keep on bleeding. Swelling might be decreased, but you keep on bleeding!

 

  • Foods to increase vitamin K

Food high in vitamin K levels, such as green leafy veggies (or even vitamin K pills), can also help clotting.

 

  • Pressure on injured area

Applying pressure to bleeding areas will help clotting, decrease swelling and decrease the amount of blood that escapes. Once bleeding has stopped, pressure does not do any more good other than to decrease swelling.

 

  • Application of heat after 48 hours

The initial application of ice to an injury site will decrease bruising. After 48 to 72 hours, though, once the blood vessel has clotted, applying gentle heat with something like a moist warm towel will encourage blood flow through normal vessels, which aids in the removal of remnants of dead red blood cells in tissues. Some of my Far Eastern patients roll freshly hard boiled eggs (shell on) over the areas of bruising for heat and massage at the same time!

Of course, you should call your plastic surgeon immediately if you have an area of bruising under the skin that is getting large. This may be a hematoma, a large collection of blood under the skin that may need to be surgically removed.

 

Morad Tavallali, M.D., FACS

How to Decrease Swelling after Cosmetic Plastic Surgery

Ways to decrease swelling after plastic surgery

Swelling is a normal part of healing after cosmetic plastic surgery.

Here are some posts on the science of healing:

https://tavmd.com/2011/08/30/swelling-after-liposuction/

https://tavmd.com/2011/02/05/should-i-apply-heat-or-cold-after-plastic-surgery/

Causes of swelling

After any “injury,” cells release chemicals that affect the permeability of blood vessels in the area of trauma (surgery is trauma as far as the body is concerned). This permeability (porousness) increase allows fluid-containing proteins, white blood cells and other chemicals to reach injured areas to begin healing. This causes swelling in those areas. The process is also known as inflammation.

 

How to reduce swelling

Sometimes an area can become swollen without having a bruise present; no blood vessels are injured. For example, when you have a cold or an allergy, areas around the eyes can swell without blood vessel damage.

Techniques to stop swelling are aimed at decreasing the permeability of blood vessels so that fluid (lymph) does not pass through them to the tissues. Some of these include:

 

  • Elevation of the injured area

One way to drain lymph from injured areas is to elevate injured body parts so the lymph can drain back toward non-injured body areas to be absorbed. This is why elevating your injured foot feels good. It decreases swelling and thus pain.

  • Ice

The application of ice will contract blood vessels and decrease the amount of blood and lymph going through them. Ice should be applied to injured areas as soon as possible in a 15 minutes on/15 minutes off cycle to prevent frostbite on already injured skin. It can be applied for up to 72 hours, though after the initial 24 hours its effectiveness decreases. This is not as bad as it seems, since permeability of the injured blood vessels returns to normal around the same time period. Thereafter, applying ice can feel good but does not really reduce swelling.

 

  • Anti-Histamines

Medications such as antihistamines (Benadryl) can also decrease swelling by decreasing the effects of histamine. Histamine is released from cells when they are injured or irritated (e.g., with pollen).

  • NSAIDs

Non-steroidal anti-inflammatory drugs (NSAIDs) such as Aspirin, Motrin, Naprosyn, Aleve, etc.—but not Tylenol/acetaminophen—will decrease swelling in injured areas. They will decrease inflammation. They will increase bruising, so beware—see below. They will also help reduce pain, which often accompanies injury and swelling. A pinch of the skin, for example, hurts since the skin is being stretched; swelling does the same thing in stretching skin.

  • Steroids

Steroid creams, pills and injections help decrease or rather prevent swelling by stabilizing the cells of blood vessels and decreasing their porousness. There is a limit to their use, as they also have less favorable effects on healing, so they must be used judiciously.

  • Anti-inflammatory foods/herbs

A number of anti-inflammatory/anti-swelling foods and homeopathic drugs have been touted as helping to reduce inflammation. There is no proof other than the fact that some swear by them. They include:

  1. Arnica Montana
  2. Bromelain—a compound found in pineapples
  3. Ginger
  4. Chili peppers
  5. Herbs such as parsley

 

  • Massage

Gentle massage of injured areas or even of other areas of the body will encourage healing of  the lymphatics and re-establish normal lymphatic flow.

Decreasing swelling after any cosmetic plastic surgery will help decrease pain and speed up your recovery.

 

Morad Tavallali, M.D., FACS