Category Archives: PRE & POST SURGERY INFO

Hypertrophic scars

Thick scars after plastic surgery- hypertrophic scars

 

One of the topics that I am constantly trying to explain to my cosmetic plastic surgery patients is the occurrence of hypertrophic scars.   A recent study showed that 50% of scars will become hypertrophic after surgery and that the majority will decrease with time. Making patients understand that hypertrophic scars are a condition due to their skin type and reactivity and not due to what their cosmetic plastic surgeon can control is challenging.

Hypertrophic scar Good normal scar

 

 

Causes for Hypertrophic scars

There are many theories as to why Hypertrophic scars occur. The short answer is that no body knows why some patients develop hypertrophic scars or even Keloid scars. Hypertrophic scars are scars that produce extra collagen and become thicker and inflamed.  Keloid scars are the same process but occurring on skin on the outside of the area of trauma and also having even greater collagen deposition.Patients also have itchiness and sometime pain in the scars. The scars occur commonly at injury sites to the skin dermis layer such as occurs with burns or trauma, but also occur along surgical incisions.

Hypertrophic scars are known to be more prevalent in patients with darker skin color. Why? Again no body knows but that fact has allowed people to study the differences between darker and lighter skin and to look for other differences which may also be involved.

It turns out that darker skin individuals have more sebaceous oil glands in their skin than light individuals. That may be one of the causes.

More importantly, it  appears that hypertrophic scars occur more commonly in areas of the body that have higher concentrations of sebaceous glands; the arm pits, around the areola and under the breast, around the umbilicus and the pubic areas. Unfortunately all of these are areas where we plastic surgeons have to put our scars for cosmetic surgery!

Sebaceous glands

If sebaceous gland are in fact a contributor for hypertrophic scars then what are they?

Sebaceous glands are a type of oil gland in our skin that produces sebum- an oily discharge that lubricates the skin and hair .  Each hair follicle has a sebaceous gland attached to it which lubricates the hair. Those of you who have greasy skin have a lot of sebum production. These glands are also the ones involved in causing acne and other skin conditions.

Typically they will get larger and grow with puberty. The sebum also has a bit of an odor which like any oil can become rancid and cause you to become smelly . The sebaceous glands are found in all areas of the body except the soles and palms; these areas do not have hairs.

Demodex mite

… and one other thing, sebum produced by the sebaceous glands is the food source for the Demodex skin mite that lives in the shafts of hair follicles. That’s right we all have millions of insects living off our skin oils and dead cells. These mites normally do not cause much bother but can at times grow in population to cause itching ,irritation,  and redness of skin. All of these are what is seen with hypertrophic scars. They have also been associated with various forms of acne.

Treatment of hypertrophic scars

The treatments available for hypertrophic and keloid scars have had poor results. When we don’t know why something occurs its obviously difficult to find a treatment.

  1. Steroid injections ; Steroids injected into the scars can decrease the swelling, redness and itchiness in some patients. injections are given three times with six week intervals. In many patients it does not work.
  2. 5-Flurouracil ; An old cancer drug that reduces the rate of collagen production. I usually mix this with steroids.
  3. Excision; Cutting out the scar and re-closing  with steroid injections at the same seems to work in some patients- and not in others!
  4. Silicone cream; has been shown to help flatten the scars. I tell patients to use it on all scars.
  5. Pressure; has been shown to help in some cases.
  6. Radiation therapy: an old treatment rarely used today

Treatments and causes for hypertrophic scars are plainly a shot in the dark. Plastic surgery patients need to be aware that scars may become hypertrophic and though in most the hypertrophy will disappear with time, some patients may need other treatments that may or may not help. Its not the surgeon’s fault but it might be the fault of the skin bugs.

 

Plastic surgery pain management

New ways  of cosmetic Plastic surgery pain management

Some “discomfort” is an normal and expected part of any plastic surgery procedure.  Plastic surgery pain management is an important part of the recovery from cosmetic surgery procedures. Pain after surgery will change in terms of type of pain and intensity and cosmetic plastic surgeons are trained to hep you get relief from the pain in various ways. here are some previous blogs on pain  found in the pre- and post operative section.

https://www.tavmd.com/2011/03/04/pain-control-after-cosmetic-surgery/

 https://www.tavmd.com/2011/03/08/pain-control-in-plastic-surgery-part-2/

pain

Traditionally, pain management has involved use of  a number of techniques.

  • Medications that control pain;  Drugs for pain control are either

  1. Narcotic medications ( Codeine, Percocet, Vicodin)
  2. Non-narcotic meds like Acetaminophen (Tylenol)
  3. Anti-inflammatory medications that also have pain control (Ibuprofen, Advil).
  • Local treatments for post operative pain

  1. Massage of the area of surgery will improve circulation, decrease swelling and therefore pain.
  2. Hot and Cold therapy will increase circulation and decrease swelling also decreasing pain
  • New findings in plastic surgery pain management

  1.  Music therapy is one of the newer methods to help decrease pain after plastic surgery. It turns out that listening to music which you like can help to decrease pain perception. There is a large body of evidence in control of pain in cancer patients by listening to different types of music or even nature sounds ( like the ones in the spas). The type of music does not seem to matter. If you prefer classical that is fine and if you relax to hard rock that seems to be as efficacious.
  2. Caffeine has recently been found to be useful in pain control. A recent study shows that patients taking Non-narcotic medications like Tylenol or Motrin achieved 5-10% more pain relief by taking 100mg caffeine. That is the amount of caffeine in a cup of coffee. Tea also has caffeine and can achieve the same. So can Coke/Pepsi colas etc. etc. How caffeine works to increase the [pain perception threshold is not fully understood but its stimulation effect on the brain  seems to be part of it.
  3. Under medication has recently been found to be a major cause of lack of pain relief after surgery. A new study has shown that doctors, whether male or female, will tend to under medicate their female patients. Men complaining of pain get medications but women do not! Women complaining of pain are often thought to have a greater psychological component to their pain- which it turns out is not true! So, asking your board certified plastic surgeon for more pain medication is a normal and necessary course if you have been under medicated. Of course too much medication has its own serious and negative consequences, so if the surgeon says no more narcotics, its for your own good!

Using these new findings to help decrease pain after surgery will help you have a smoother post-operative course. Always discuss with your plastic surgeon when and what to take. Even though each technique may only work for 10% reduction of pain, adding them together can give you significant relief!

How to stop smoking before plastic surgery

Smoking no good before or after cosmetic surgery

 

Everybody knows that smoking tobacco products of any type is not good for you.  Rates of smoking in the US have come down but still 30% of the population smokes.

It is important for patients to stop smoking before and after any cosmetic plastic surgery. https://www.tavmd.com/2011/10/26/preparing-for-cosmetic-plastic-surgery/

Most Board certified plastic surgeons will not even perform some surgeries like face lift if patients smoke; we know the disaster that could happen with smokers and facial surgery.

I require my patients to stop smoking for at least 7 days before and 7 days after any cosmetic surgery. The longer the better.

stop smoking

 

 

 

 

 

 

 

Bad effects of smoking cosmetic surgery

Lung cancer is an obvious cause of smoking. Smoking also damages your skin making you look old. For plastic surgeons though, effects of smoking are much more immediate and important for the results you want.

1. Tar

All tobacco products create tar when burned. That is a dark, gooey material you can squeeze out of filters. It is also what lines your lungs. With cosmetic surgery needing general anesthesia, tar build up makes it more difficult for your lungs to clear normal secretions caused by anesthesia. You end up coughing more, and creating even more secretions. Coughing after plastic surgery increases your blood pressure and the risk of bleeding. It also hurts!

2. Nicotine

The main drug effect of tobacco is due to Nicotine. The high from smoking is due to nicotine. All types of tobacco products including electronic cigarettes have nicotine. Of course chewing tobacco does not give you tar.

This drug causes a number of effects; both a stimulant and a relaxant.

It will increase glucose  and adrenalin in the blood and cause stimulation. It increases brain concentration and memory and decreases appetite and pain. It also increases Dopamine ( a brain neurotransmitter) which is involved in enhancing our brain’s perception of pleasure and relaxation. It make you feel good.  Sounds like the perfect drug to give to patients after surgery! However it also acts a an arterial vasoconstrictor. It cuts down on the blood supply to the skin. In fact, each cigarette will decrease the blood supply to the skin 50% for 10 minutes. Imagine having an elastic band tied around your finger for 10 minutes. Your finger would not be happy! If you have 3 cigarettes that is 30 min etc. … Wounds that do not get blood will not heal and will fall apart with dead skin and tissues. Not good.

 

How to stop smoking before plastic surgery

Stopping smoking before and after surgery is important . But, how to stop smoking before plastic surgery is a not so easy. Get past the first three days and the rest is a breeze.

The trick to stopping smoking is to substitute the rewards that your brain has come to associate with nicotine. Every time you think of a cigarette, you will need do something else to substitute for the pleasure you had previously from nicotine.

It’s a question of breaking the habit with respect to time of day.
For example smoking  after meals, every time you enter a car, or  when you feel stress.
Substitute nicotine effects. For example, drink a glass of water, go for a walk around the block, eat something sweet like dried fruit, raisins, or chocolate . All of these will increase Dopamine in the brain and make you feel good the way nicotine did. One of the best methods to increase Dopamine is to have more sex.
You will have to do something to get tension release.
Going told turkey without support usually leads to failure.
By the way, if your partner or other people in the house smoke it makes it more difficult for you to quit. Maybe they can quit along with you!

Decreased swelling after tummy tuck

How to decrease swelling after Tummy tuck

Tummy tuck or abdominoplasty is a common cosmetic surgery procedure. The cosmetic plastic surgeon tightens muscles of the abdomen, remove extra tummy skin,  and liposuction of the flank for fat removal.

Here are a few previous blogs on the topic.

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

https://www.tavmd.com/2011/03/13/abdominoplasty-after-care-part-1/

https://www.tavmd.com/2011/03/17/abdominoplasty-after-care-2/

Healing after an abdominoplasty or tummy tuck is dependent on a number of factors

1. Amount of fat and thickness of skin

2. Patient genetics and lymphatic tree

3. Movement of the body

 

Skin and fat

The more skin and fat a patient has the greater the amount of “water” (swelling)  that is trapped within the abdomen . This will prolong the time for the swelling to decrease. Thinner patients will have a faster recovery from swelling after a tummy tuck. There is not much a patient can do about that after the surgery, but it’s important  for you to know.

 Lymphatic vessels

The lymphatic vessels are responsible for removal of the swelling from the tissues and taking it back to the blood circulation. The lymphatics mirror the blood vessels throughout the body. Any damage to the lymphatics,( surgery can be considered an injury), will decrease lymphatic flow.  Decreased lymphatic flow causes more swelling. With time lymphatic vessels reform and start their function again. Until this time, massage of skin by lymphatic massage, will help to decrease swelling in skin.

https://www.tavmd.com/2013/03/17/lymphatic-drainage-after-cosmetic-surgery/

 Movement

Another way to decrease swelling after a tummy tuck is for the cosmetic plastic surgery patient to move. Walking or even standing are better than sitting. Sitting will increase swelling in the lower abdomen which needs even more time for healing.  Even movement of the limbs will help decrease swelling in the abdomen also as the lymphatic system is a closed system.

 https://www.tavmd.com/2010/10/22/blood-clots-and-tummy-tucks/

Morad Tavallali, M.D., FACS

Unable to urinate after surgery

Urinary retention after surgery

Every surgery has risks and complications and I have written about these in the past.

https://www.tavmd.com/2012/12/13/cosmetic-plastic-surgery-complications-1/

https://www.tavmd.com/2012/12/18/cosmetic-plastic-surgery-complications-2/

Being unable to urinate after surgery is a common cause for apprehension and problems in the first days after surgery. There are a number of causes for patients being unable to urinate after surgery.

1. Anesthesia effects

General anesthesia drugs will have side effects that decrease  or totally block bladder muscle contractions. Effects of these drugs will decrease within a few hours or days depending on each patient’s sensitivity to anesthesia. If your bladder is unable to contract with enough force you may need a urinary catheter to be placed for a few days to get relief!  Catheter is pulled out later by your surgeon. If you are still unable to pee you may need to have a catheter re-inserted.

2. Anatomical reasons

Sometimes bladder muscles have enough strength to initiate a bladder emptying but patients are still unable to pee due to an anatomical barrier in the urethra. For men this typically is an enlarged prostate. Many men suffer form prostate hypertrophy which narrows the urethra. Under normal circumstances the bladder may have enough force to empty through the constriction but with decreased force due to anesthesia it is unable to empty. Women may have a similar anatomy problem due to previous surgery such as bladder suspension surgeries.

3. Medications

A common cause of urinary retention is interaction of pain medication given after surgery with drugs that you may already be taking. Interaction of narcotics and anti-depression medications can be particularly potent in causing urinary retention.

Treatment of Urinary retention                                            urinary catheter

1. Wait and see

If there is no physical pain from the bladder being full, I usually encourage patients to

– get up and walk around the help metabolism of the anesthesia medications

– Try urination while sitting in a warm bath tub. Sometimes that is enough to stimulate bladder emptying.

– Physical pressure can also help to empty the bladder in some cases.

The caveat with this approach is that it is only to be used in the early post operative period. The bladder in some patients will continue to stretch and expand without causing any pain and in the extreme could lead to other serious complications. If there has been no urination after surgery for 4 hours or so its time to go to the ER.

2. Urinary Catheter placement

If there is still inability to urinate after a few hours or if there is pain, a urinary catheter needs to placed. Commonly known as a Foley catheter it is best inserted by a nurse or doctor in the emergency room or office. A rubber catheter with attached bag is placed into the urethra and urine is allowed to drain for a couple of days till the bladder has regained its strength. An antibiotic is usually necessary during the time the catheter is in place to prevent infection.

Although a simple condition to take care of, urinary retention – being unable to pee after surgery is painful and anxiety causing. Not the typical complication one thinks of after surgery but one that both surgeon and patient should be prepared to treat.

Cosmetic Surgery Scheduled at 7 am?

Early morning cosmetic surgery

 

It’s 7 a.m. and I am waiting for my cosmetic plastic surgery patient to arrive at the surgery center for a gynecomastia surgery and a tummy tuck procedure. a cosmetic surgery scheduled weeks ago.  He may still be sleeping, but hopefully he is just late because of traffic.

I have written about pre-operative preparation for cosmetic plastic surgery in the past;

https://tavmd.com/2013/07/19/eatingdrinking-dangerous-before-cosmetic-surgery/

https://tavmd.com/2011/10/30/preparing-for-plastic-surgery-the-day-before/

Why surgery starts early

There are several reasons why surgery of all types, including cosmetic surgery, traditionally starts early in the morning. These include medical reasons and non-medical ones.

 

Medical reasons for early morning cosmetic surgery

1. Hormonal cycle

Perhaps the most important medical reason for starting surgery early in the morning is the body’s normal cycle of contra-stress hormones.

Cortisol is the major anti-stress hormone in our bodies. It has a “diurnal” rhythm of its levels. It is at its lowest level at around midnight and rises sharply to its maximum between 6 a.m. and 9 a.m. It falls during the afternoon.

High cortisol levels protect the body against stress, psychological or physical. In the early morning, the associated high cortisol levels provide a little extra protection against surgery stress. Other hormones also play a similar role in stress reduction, but cortisol is the most important.

 

2. Blood sugar levels

Before any surgery requiring general anesthesia, cosmetic plastic surgery patients are required to fast for eight hours. This is important in preventing having any food in the stomach and decreases the risk of aspiration of stomach contents into the lungs—a condition that can be fatal!

The fast makes sure that your blood sugar levels are low in the morning. If surgery takes place later in the day, it’s like not eating breakfast. The low and decreasing blood sugar levels cause fainting, weakness and headaches, in addition to adding extra physical stress to the body.

3. Hydration

Having an early surgery means there is less chance for your body to become dehydrated. Not drinking water is part of the fasting process. Dehydration has obvious physical consequences and sets off its own series of stress responses that are not good for cosmetic surgery patients.

 

Non-medical reasons

 

1. Cosmetic plastic surgeons

Starting early in the day with cosmetic surgery allows the cosmetic plastic surgeon to have some time to see post-operative and pre-operative patients in the afternoon. Some plastic surgeons will operate all day long on certain days, but in general I like to break my days up and not operate for more than five hours a day.

Also, surgery is unpredictable in terms of timing. Though most plastic surgeons know how long their surgery takes, unforeseen circumstances like extra bleeding can occur and cause delays. This can have a domino effect and cause a string of delays extending into the evening.

 

2. Hospital staff

The workday at hospitals also starts early for nurses and staff. Hospitals are busy places, and the full day is needed to get all the work done; much medical care continues straight into the night! However, as in any workplace, hospitals are not fully staffed at night. The minimum number of staff required to take care of emergencies is usually what’s available. Most of the staff is at home, sleeping like normal humans! At 7:30 a.m., most hospital staff and nurses are at work.

 

3. Surgery complications

As with any other form of surgery, sometimes a complication arises after cosmetic plastic surgery. The complication of the surgery may require the patient to be taken back to the operating room.  Starting early in the morning means there is more time to deal with this possibility with the full complement of hospital nursing and support staff. It’s safer!

These are some of the reasons why cosmetic plastic surgery is started early in the morning. It’s  better for the cosmetic patient, better for the plastic surgeon and better for all the nurses and hospital staff.

 

 

Morad Tavallali, M.D., FACS

Eating Drinking Danger before Cosmetic Surgery

The other day I had a surgery cancelled.

I have written in the past about preoperative instructions, and all patients are told of the eating drinking danger before cosmetic surgery at the surgery set-up appointments, but still some cosmetic patients seem to forget.  See here:

https://tavmd.com/2011/10/30/preparing-for-plastic-surgery-the-day-before/

No solid food after midnight the night before surgery.

Only a cup of water is allowed up to four hours before surgery.

Nothing at all four hours before surgery—no water, no food, no nothing!

 food photo

I arrived at the usual 7 a.m. at the surgery center. My patient was late, and though she should have been at the cosmetic surgery center at 6 a.m., she got lost and arrived at 7:15 a.m. for a 7:30 surgery. That is going to delay surgery.

 

When she did finally get changed, the standard preoperative questions regarding health were asked. One question is always, “When was the last time you ate or drank anything?”

The right answer is  “Before midnight last night.”

The wrong answer is “This morning I had a little fruit and water.”

That answer cancels surgery.

 

Dangers of food or liquid in the stomach before cosmetic surgery

The reason for the danger in having food or water in your stomach before having a cosmetic surgery procedure under general anesthesia is related to the effects of anesthesia.

General anesthesia, as opposed to local anesthesia, will relax the sphincter, which is between the stomach and the esophagus (the tube that brings food from the mouth to the stomach).

We have all felt malfunction of the sphincter at some time. Food and stomach acid go up the tube, and we feel a sensation of “heartburn” or acid reflux.

There are many over-the-counter medications that help with this condition by decreasing stomach acidity, etc., and all work well for daily cases of reflux.

General anesthesia, though, will totally relax the sphincter and allow for easy passage of stomach contents into the esophagus. Also, cosmetic plastic surgery patients usually lie down horizontally, and the risk for stomach contents going up the esophagus toward the mouth is even greater in this position.

 

Aspiration to lungs

A little heartburn would be all that would happen if that was the end of it. But that is unfortunately just the beginning!

With the acidic stomach contents going up toward the mouth, another sphincter that usually closes off our lungs from the throat is approached. This sphincter is also relaxed by anesthesia, and stomach food and liquids mixed with stomach acid enter the lungs.

Hydrochloric acid is one of the most potent acids that exists, and though our stomachs are protected from its effects, no other part of the body is. The acid will start to eat away at lung tissue, and this causes inflammation and then infection.

 

ARDS

Acute respiratory distress syndrome (ARDS) is what happens as a result of aspiration of stomach contents into the lungs. The condition can be deadly, with a 70% or so mortality rate, and it requires extended stays in intensive care units of hospitals and a long recovery.

Usually the syndrome is not diagnosed until after surgery when the patient is having difficulty breathing.

Having an empty stomach before having general anesthesia is a vitally important part of your preparation for cosmetic surgery. Not following this simple preoperative instruction can cause death!

Morad Tavallali, M.D., FACS