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:

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

Cosmetic Surgery by Plastic Surgeons?

Non-plastic-surgeons doing more cosmetic surgery


For a multitude of reasons, more and more untrained doctors are performing cosmetic surgery and making themselves out to be plastic surgeons. There are even reputable “board-certified” doctors doing cosmetic plastic surgery. The only problem is that they are not board-certified in plastic surgery. They are “certified” in any one of 30 other medical specialties but not qualified to do any plastic surgery at all. A surgeon is only qualified to perform plastic surgery if they have been certified by the American Board of Plastic Surgery, which means they have taken multiple exams after a minimum of six years of training after medical school. (Many plastic surgeons, like myself, have eight years of post-medical-school training.)

It’s like having your “certified” electrician do the work of your “certified” accountant! There is even a TV ad like that going around these days!

For the past three years I have written about the problem of unqualified doctors (or even non-doctors) performing cosmetic plastic surgery. Here are two of those posts:


I recently heard that the radiologists (those are the doctors trained to look at X-rays) at Inova Fairfax Hospital outside of Washington, DC, where I perform some of my cosmetic plastic surgery, have started to perform laser liposuction. They feel that since they can put in IVs to inject patients with dye or tubes to drain fluid, they are now trained to do liposuction! They are even advertising themselves as “board-certified surgical specialists” in a wanton attempt to confuse and trick cosmetic surgery patients into thinking they are being treated by a plastic surgeon. They take a two-day course in laser liposuction and then let themselves loose on the uninformed public.

Katie Couric had a show last week on her TV program “Katie” in which she interviewed a number of patients who had sought cosmetic surgery by untrained doctors and suffered horrific consequences. Surgery always has risks, and even board-certified plastic surgeons will have complications, but you can at least mitigate the chances by going to someone who has trained for years. Watch this:

It’s high time for the government to intervene to protect the public from the “wild west” mentality that exists in cosmetic surgery today.


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:

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

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:

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:


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

The End of Laser Liposuction

Laser liposuction complications

Laser liposuction is apparently nothing more than a short-lived fad. In fact, it appears that this technique may actually be causing irreparable harm to many patients, irrespective of whether a board-certified plastic surgeon is performing the procedure or not!

It’s like they say: “All good things must come to an end,” and in this case all bad things are coming to an end, too! Here is some more information on this topic:

And here is a link to another post about liposuction:


How laser liposuction works

The concept of fat removal by laser liposuction is to melt the fat under the skin using laser energy and then suck the molten fat out. Laser energy is essentially heat energy that dissipates under the skin to cause the fat to burn, and unfortunately also the skin. This burning of the skin is touted by the companies selling the machines for $100,000+ as the cause of skin tightening in excess of that obtained by gentler methods of liposuction. Touted… as there is no proof! What there is proof of, unfortunately, is the sequels of scarring, unevenness and skin irregularity, as well as burnt skin.

Complications of laser liposuction include:

  • scarring
  • seroma (fluid) collection
  • skin irregularity
  • color changes

These complications are in addition to and more pronounced than the usual complications of liposuction, which include:

  • infection
  • bleeding
  • numbness

The way our bodies react to burns that occur under our skin after laser liposuction is similar to the skin’s reaction to an outside burn:

  • There is a zone of cell death centrally where tissues are vaporized and melted
  • An outer zone is one of cell damage where a variable number of cells will die depending on many factors
  • A large amount of “blister fluid” is drawn into the area of damage
  • White blood cells and other cells and chemicals involved in the inflammatory response come to the area of injury
  • Months of healing are necessary, including changes that occur to skin color and texture

At a recent meeting on “complications in plastic surgery” in Washington, DC, that was organized by the American Society of Aesthetic Surgery, several surgeons showed the results of patients following laser liposuction who now needed corrective surgery with fat grafting and other procedures. The final results, though improved, were not great. The damage done by laser liposuction seems to be permanent! The End of Laser Liposuction.

Psychology of Weight Loss Changed by our Environment

Where you sit affects your weight loss for diets


Readers of this blog are familiar with my particular and specific interest of the boundaries of psychology and cosmetic plastic surgery. Here is a new nugget to put on your table when trying to lose weight. See my previous post about weight loss diets:

In my post above, I describe experiments affecting weight loss. Size of plates (obviously), color of food  (!), contrast between plate and place mat (!!)—these things all affect our eating behaviors. How we arrange our physical world changes our intake of food. Your intake can be lessened or increased, depending on where you want to be on a weight scale. Being told that we are eating a large portion will make us eat less and leave food on the plate, while being told it is a small portion will invariably lead to all  food being eaten—in the experiment, the amount of food on the plates was equal in each case!

The latest research shows that our eating habits can further be influenced by our immediate physical surroundings and by not-so-subliminal references to our weight. Weight loss is affected by where we sit!  Psychology of Weight Loss Changed by our Environment.


Eating habits affected by photos


In a study conducted in Switzerland, researchers placed test subjects in a room with chocolates and asked them to fill out some evaluation forms about the taste. After all, these were Swiss chocolates! Subjects were free to eat as many as they wanted. Half of them were in a room with a computer screen showing a photo of Giacometti sculptures—tall, narrow, anorexic human figures the Swiss sculptor is famous for. The other half was in a room with an abstract  photo of a painting by Mark Rothko on the screen. Which group ate more chocolates?  That’s right (pretend, even if you got this wrong): the group with the Rothko painting in the room ate more. Subjects in the Rothko painting room ate an average of 6.4 pieces of chocolate, while those in the Giacometti thin human form room averaged 4.7.

Rothko watchers eat more











Giacometti watchers eat less












Most importantly, a majority of  participants did not even notice the photos on the screens—on a conscious level. They did notice them on a subconscious level, however, in their peripheral vision, and it seems that this was enough to make them eat less. Why?

It could be that the thin Giacometti figures remind us of being thin, and eating chocolate is associated with getting fat. Or is it guilt that tells us not to eat too much when there are hungry-looking people around? Any ideas about this weight loss method?


Eating affected by recording weight


In another Swiss research study also involving chocolates, two groups were given questionnaires to fill out that included information about age, sex and weight. One group filled out the questionnaires before tasting the chocolates, the other after tasting. My paragraph title already gives you a clue as to what happened. Those who wrote their weight down before the tasting ate less than those who ate chocolates and then wrote down their weight and other vital statistics at the end. Except for men, that is! Women ate less when indicating their weight, but not men. I  don’t know why. Maybe it has to do with the particular sensitivity women in Western societies have regarding their weight—something men as a group do not have. There are far fewer men on diets than there are women concerned with their weight and on weight loss programs.

To be fair, it has to be noted that these experiments used Swiss chocolate, which is particularly tempting. Nevertheless…

Morad Tavallali, M.D., FACS

The Thin-Fat Patient

Distribution of body fat is determined by our genetic makeup. Fat is stored in our bodies, either in the skin or inside body cavities as visceral fat. The types of surgery needed to reduce fat depends on where the fat is. Below is a photo of a patient who came to me for an abdominoplasty. It was difficult to tell where her fat was. Examination showed a thin layer of fat in her abdomen and very loose muscles.


Every so often, I get to see this illustrated beautifully in my patient’s anatomy when I am performing a tummy tuck (abdominoplasty).

The patient I was operating on the other week appeared torose (a fancy word I love which essentially means fat). When I pinched her skin, though, there was not much to her. Barely an inch of fat; yet she looked big!

before tummy tcuk








Her appearing to be fat was caused by two main factors:

  • Visceral fat – the fat around her internal organs, intestines, etc.
  • Loose muscles of the abdomen – during pregnancy, the muscles had been stretched out so much that they could not hold her abdominal contents in; it was a huge hernia, if you will

After tummy tuck surgery










In these types of patients, the plan for the abdominoplasty surgery is different from the plan for those patients who carry their weight in their skin fat. With internal (visceral) fat and loose muscles, the muscles must be tightened to push the abdominal contents back into the body.  The amount of liposuction is minimal, and most of the surgery involves tightening the muscles and excising skin. That is the thin patient who looks fat.
With patients who have fat in their skin, there is more liposuction and fat removal and less tightening of the muscles required. That is the thin patient who looks fat.

The end result after the two types of abdominoplasty is the same: a flat abdomen. The road to get there is just a little different!