Tag Archives: anesthesia

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.

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

Cost of Plastic Surgery: Nickel and Diming Cosmetic Patients

Cost of tummy tuck surgery increases with technology

 

We live in an age of exponential growth in information and technology and in the cost of surgery. Even in the past few years, advances in cosmetic plastic surgery techniques have been enormous—and so has the cost of surgery! Some cosmetic plastic surgeons still cling to old methods. That is sad.

Here are a few other posts on these topics:

https://tavmd.com/2012/02/24/plastic-surgery-without-pain/

https://tavmd.com/2011/07/02/new-technique-for-tummy-tuck/

dollar sign

New surgery techniques  come with  a higher cost. How to deal with an increase in the cost of surgery in an era when we are all trying to keep surgery costs down is problematic.

As a cosmetic plastic surgeon, I have a certain cost for my surgeries. Regularly, costs of implants and garments are added to  costs for surgery in addition to hospital/anesthesia fees. Think of it as the cost of performing surgery + materials.

 

Exparel

I have previously written about Exparel.  This slow-release formulation of a common local anesthetic (Bupivacaine) that many plastic surgeons use is set to explode on the market and change the way we practice medicine. The drug  provides for a three-day area of numbness when injected into the surgical field. That means three days of reduced need for narcotics (with all of its problems), not suffering pain and getting back to normal faster!

It adds $285 to the cost of surgery (breast augmentation or tummy tuck).

The hospital doesn’t provide it to plastic surgeons; they do provide regular bupivacaine as part of a global surgery cost. What do they care if you have less pain once you are out the door?  They don’t save any money.

This leaves cosmetic plastic surgeons with the sad choice of telling cosmetic patients that a drug exists that will reduce their pain but add to the cost of surgery. Patients can then choose whether to buy it or not. First-class ticket or economy? I find it hard to practice medicine knowing that a better alternative exists for my patient but that it will not be offered due to cost. That just seems wrong. Reduce my fee and eat the cost? OK; but by the same token why not increase my fee and include Exparel?

Prineo

This is a new wound closure system from  the Ethibond suture company. The combination of Dermabond (tissue glue) and tape makes for a far superior dressing after surgery that stays on patients for about one month. Scars are rare because it decreases incision and tension on the skin for most patients.

My surgery center used to provide it as part of the hospital fee. Not anymore.  I have to either abandon what I know to be a far better closure system and go back to the old, lesser techniques… or have patients pay an extra $250.

Liposuction

For my abdominoplasty/tummy tuck patients, I regularly include abdominal and hip liposuction. It turns out that many plastic surgeons do not include  liposuction, and if they do, they charge patients extra for it… like I used to!

I used to offer patients the option of liposuction at the same time as abdominoplasty because I knew that the cosmetic results were better.  Most would say “no thanks”—the cost was another 20% on top of  tummy tuck fees and that turned out to be too much for most patients. Those who had the liposuction at the same time were happy, and the ones who did not returned later to have it or left unsatisfied despite my best efforts to forewarn them.

I have decided to include the liposuction in all my abdominoplasty operations as standard. I had to cut my fee down for the lipo, but I now get better results. I was able to do this because it was my work and time, not a fixed cost of materials from another company.

Medical economics

The above gives you an example of how the cost of plastic surgery continually rises advances in technology.  New medical advances cost money, which is usually transferred to the patient’s insurance company, which may or may not pay for particular therapies.

In cosmetic surgery patients who pay out of pocket, a new/better treatment modality will cost more. As a cosmetic plastic surgeon, I want the best possible results for my patients, but now I have to offer them a choice between the “best” techniques and simply “good” ones.  If I keep on eating the cost, eventually I will be performing the surgery for free, as my costs will be greater than my income. After all, this is how I make my living.

I can’t decide what to do! I fear that increasing the cost of plastic surgery without telling patients the reasons will frighten away patients who may not understand the nuances of surgery and differences in results.

Or should I be offering a two-tier surgical result—a basic economy tummy tuck and a first-class tummy tuck with all the extras ? Advice is welcome—only first-class advice at no extra cost please!

Morad Tavallali, M.D., FACS

Face lift with local anesthesia

 Local anesthesia and face lift surgery

 

A couple of years ago, I wrote  this post about performing facelift surgery under local anesthesia: https://tavmd.com/2011/02/14/face-lift-surgery-under-local/

The other day, I saw that the technique is now being offered as a  training course for cosmetic plastic surgeons.  A nice holiday in Portugal, and any plastic surgeon can learn to do face lift surgery under local anesthesia. That is a good thing.

Like most other cosmetic plastic surgeons, I learned how to do a facelift with the patient under general anesthesia. Training plastic surgeons has to occur, and some patients are always going to be learned on, especially those who go to teaching hospitals with residents. Facelift surgery is particularly sensitive, since any error can be easily seen by all. That is why few training programs afford that particular luxury to their residents and fellows. I  was lucky enough to go to such a training program in Houston and saw and was trained in many different types of facelifts, including:

  • deep plane face lift
  • skin only face lift
  • Smas face lift
  •  S-lift
  • Fat injection face lift

I was not trained in face lift under local anesthesia. I had to start my own practice to do that.

I don’t really remember when or why I started to perform all my facial surgery under local anesthesia, but it was at least 15 years ago. These days, I perform my face lift surgery, blepharoplasty surgery (eyelid surgery), chin enlargement surgery (mentoplasty) and tip rhinoplasty (nose tip surgery) under local anesthesia.

Many cosmetic plastic surgeons simply do not want to interact with the patient during surgery and prefer to have a silent body to work on. Perhaps they find it too stressful to cut and sew a person who is actively chatting! On the other hand, I enjoy talking with the patients during facelift with local anesthesia, though at some point most patients fall asleep!

Advantages for face lift with local anesthesia

  1. Less physiologic trauma to patient; blood pressure remains more stable
  2. Less anesthesia concerns post-surgery
  3. More natural look after surgery due to inherent muscle tone
  4. Lower cost for patient
  5. Faster recovery

 

Disadvantages of face lift with local anesthesia

  1. Need for patient to interact with surgeon—say when it hurts!
  2. Need for surgeon to interact with patient
  3. Time limitation of about four hours, the amount of time before patient usually becomes fidgety
  4. Limitation on amount of anesthesia given, though I have never found the need to use high levels

As I have said many times before, there is no right or wrong way to do surgery if you go to a properly trained, board-certified cosmetic plastic surgeon. Each plastic surgeon will have their own techniques and preferences that give them the best possible results.  Don’t ask your plastic surgeon to deviate from the technique they feel most comfortable with; if they are happy, so will you be!

I should have given a course years ago, but Lisbon sounds more fun than D.C.

Morad Tavallali, M.D., FACS

Facelift Surgery: A Modern Approach

Modern facelift surgery

Facelift Surgery (rhytidectomy) is a cosmetic plastic surgery that is increasingly being performed to rejuvenate the facial structures that sag with age.

If you want to see some photos of facelift surgery patients, look here: https://www.tavmd.com/Facelift_photos.html

For more information about the surgery, look here: https://www.tavmd.com/facelift.html

What happens to the face as we age?

The aging process has specific effects on the skin of the face:

  • The skin color changes and blemishes occur
  • Skin elasticity decreases because the elastin and collagen proteins disintegrate
  • Skin thins out as structures such as dermis and hair follicles undergo involution
  • Fat deposits of the face move down as the ligaments and facial structures holding them up stretch and break
  • Muscles loosen and stretch down with gravity
  • The bone structures of the face resorb and cause regression of the maxilla and mandible

What a plastic surgeon does in a facelift

Facelift surgery is designed to address each of these different situations using different surgical techniques:

  • The muscles and fat are lifted up in a rotational manner and sutured into place.
  • Skin is elevated  and excess removed from behind and in front of the ears.

The surgery typically takes about 3-4 hours and  is often accompanied by eyelid lift (blepharoplasty) and/or forehead lift surgery.

Facelift techniques

Although multiple techniques have come and gone over the years, these basic principles have stayed the same:

  • Remove skin only,
  • Lift the skin and muscle/fat, or
  • Lift all of the facial structures clear off the facial skeleton.

In my opinion, a skin-only facelift is a waste of time, a deep plane facelift is horrendous and a skin and muscle/fat elevation facelift is… just right.

A modern facelift

What has not stayed the same is the difference in philosophy with respect to the surgery. Twenty years ago, plastic surgeons would wait until the patient needed a full facelift and often a brow lift, too—a full overhaul. Indeed, cosmetic patients would only come in when everything had drooped!

A more modern approach is to view each cosmetic facelift patient individually and address only the areas of the face that have sagged and need to be lifted. For example, a patient may need to have their neck and jowl lifted but not their cheeks, or they may need a brow lift but not an eyelid lift (blepharoplasty).

Facelift under local anesthesia

Another modern innovation has been performing facelift surgery on cosmetic patients under local anesthesia. The patients are given a mild sedative by mouth such as Valium and some pain medication. The areas for surgery are then injected with local anesthetic to numb the skin.

The advantages of facelift with local anesthesia are:

  • No general anesthesia and its side effects
  • No changes in blood pressure as with general anesthesia
  • Less complicated recovery
  • Less “frightening” surgery
  • Reduced cost

The modern facelift has developed into a safe, reliable and uniquely tailored cosmetic surgery procedure in the hands of board-certified plastic surgeons—of course! A small procedure under local anesthesia and a fortnight of healing can make a huge difference in your face.

Here is another post about facelift surgery: https://tavmd.com/?s=face+lift

Liposuction of the Arms

Liposuction of the Arms

Some people are born with fat arms, some get them with time and almost everyone ends up with some arm laxity and a little wobble sooner or later. The distribution of fat in the arms is, like all other fat distribution, determined by genetics. We are programmed from birth to store fat at different times in our lives and in different areas. Typically, the primary storage areas are the thighs and the abdomen. Fat storage in the arms is usually a secondary storage area but one that has much more cosmetic visibility than other areas. Requests from patients for cosmetic plastic surgeons to reduce the fat are quite common.

Where is the fat in the arms?

Arm fat is distributed around the whole circumference of the arms but usually is more pronounced in the triceps area (the back of the arms). The area over the deltoids (back of the shoulder) also seems able to hold a good amount of fat. In contrast, even though there may be a little fat below the elbow, that is not an area I have ever liposuctioned.

How is the fat removed?

Liposuction is the best method to remove fat from the arms. I usually perform the lipo in the office under local anesthesia. One 5 mm incision is made at the elbow and another in the armpit to allow placement of local tumescent anesthesia. Liposuction is then performed using small cannulae of 2mm and 3mm diameter, taking out fat in little “cylinders.” The skin becomes loose by the end of the surgery as fat is removed.
After surgery, arms are wrapped for a day or two, and I tell my cosmetic patients to sleep with their hands elevated to reduce swelling. All bracelets and rings must be taken off  prior to surgery and not put back on for several days until the swelling is gone.

Healing after liposuction

I allow my patients to remove their dressings and place themselves in a T-shirt with long sleeves. The idea is to have just a little support to lower the discomfort from swelling. Exercise can be started in two weeks, and patients are encouraged to stretch the arms and massage them regularly until they feel fine again—sometimes after about 2-3 months after the surgery! Liposuction provides a relatively quick, efficient and effective treatment for fat arms. Patients can once again enjoy wearing short-sleeved shirts and dresses and not have to worry about hiding their arms.

My Last Surgery

My Last Surgery

Continuing in my self-absorbed mode while I recuperate, this is what happened during my last surgery. Not the last one I performed, but rather the last one that was performed on me.
Those of you who read the previous post, “My First Surgery”, will know that that surgery ended in failure. Failure to remove my kidney stones from their impacted position in my kidney. So there I was in a full and very real deja vu from signing in at the reception desk of the hospital, being escorted to the surgery center, getting dressed in the paper gown and smiling as the nurses went through their routine of information seeding and harvest all over again. This time around, the novelty had worn off, and I was approaching the whole event with more trepidation (knowing what was in store for me) and in a more analytical way since I had already lost my naivete.

The surgeons

As I walked into the holding area accompanied by my wife, I saw my surgeon standing in the middle of the hallway five feet away chatting with two residents (surgeons in training). He must not have seen me—the thought of his ignoring me, his patient and colleague, is just too horrid for my ego to bear. I always say hello to my patients from afar, even if it’s only a quick wave before I go into the cubicle to see them properly, explain the surgery again, tell them the instructions, draw on them and answer last minute questions—they are the reason I am there, after all. Why would I ignore them?

In contrast to my surgeon, the resident surgeon in training was polite, friendly, informative and kind.

LESSON: BE A HUMAN BEING TO YOUR PATIENTS

 

Anesthesia

The anesthesia resident, a young girl, walked up while the nurse was talking to me and began to prepare to insert an IV while the blood pressure monitor was doing its thing—clearly annoying the nurse. No “Hello,” no “I am the resident,” just an introduction with a steel needle that she pushed in too far.  A blood bath ensued, resulting in the sheets having to be changed. The last time, the nurse had done it, and the nurse was much better at it. The resident obviously needed the practice; I just wished it hadn’t been on me.

LESSON: INTRODUCE YOURSELF TO YOUR PATIENTS

The anesthesiologist was young, arrogant, curt and dismissive of my request for a type of breathing tube that is gentler on patient’s throats. The type I had only a few weeks ago. He gave me some rubbish about muscle relaxation being necessary. No room for discussion, just for his attitude. Some surgeries and some patients definitely do need intubation with an endotracheal tube for medical reasons. I had just had the same procedure attempted three weeks ago with a laryngeal mask tube by another anesthesiologist, and let me tell, you the difference is enormous. For three days after the second procedure I could not swallow without thinking ill of the anesthesiologist.

I moved from the stretcher to the bed, lay down, had a mask placed on my head and off I went. Unfortunately, no nice words to fall asleep to.

LESSON: LISTEN TO THE PATIENT, BE FLEXIBLE IN YOUR APPROACH AND LEAVE YOUR ATTITUDE ELSEWHERE

 

Nurses

My wife noticed this, but I guess I have always known it. There are two types of nurses: the kind ones who hold your hand and are honey-sweet but ineffectual, and the no-nonsense, “I’m going to take care of you,” kind-but-serious types. I guess you need both, but in the operating room I was glad the no-nonsense type was taking care of me. Recovery room nurses are a different type all together and a combination of the two. Kind but with a job to do (getting you home), and efficient.

I woke up in that fog one wakes up in after a surgery; I drank the sweet apple juice, and after a while I tried to pee. No luck. Tried again, and again later, and then I was worried, because if you can’t pee you can’t go home, and I knew what the nurse would say after speaking to my doctor, and then he said it and… I went home with a Foley catheter in my bladder. A long tube up the urethra and into the bladder so the urine can come out. The most painful thing I have ever suffered. Yet the relief of having an over-stretched bladder relax is an equally extreme pleasure. That nurse was my hero!

During the early hours of recovery, your brain is in a time warp. A minute seems like an hour, and your next glance at the clock proves you right! You are chatting away with the nurse, making decisions about your healthcare, answering questions—do I want pain medication? am I thirsty? do I want to try to pee?—and you are full of rubbish. You cannot possibly be making real sense. I suppose the questions are not that life-threatening, but it’s the brain I have seen when dealing with patients who are under mental stress or have had head trauma of some sort. The ego takes over to protect the brain and the body. You are charming, verbal, manipulative, seemingly all there while being full of rubbish. It is delightful to experience it firsthand.

 

The way home

My darling wife suffered abuse on the way home. I constantly told her how and where to drive, got pissed off at sitting in the car while my prescriptions were filled and accused her of driving over potholes on purpose. I was in a bad mood. Those closest to you are the recipients of your worst venom just when you need them the most—I have never understood that part of our brain.

LESSON: ALWAYS GIVE PATIENTS THEIR PRESCRIPTIONS BEFORE SURGERY SO THEY CAN BE FILLED THE DAY PRIOR

LESSON: BE NICE TO CAREGIVERS

 

The recovery from surgery

The first night after any surgery is awful. Your family gathers around you with looks that are a mixture of pity and caring that somehow create in you only a sense of doom. Eventually they get it off their faces and make you comfy—as comfy as you can be—and a few pain meds allow you to drift into that place that is not quite sleep. The visitors late at night are anxiety and trepidation. My arm hurts—I’m having a heart attack. I can’t breath, I can’t move, I…

Narcotic pain medications, which I took for the first time in my life during these experiences, do not take the pain away! They take your brain away from the pain, leaving you warm, slightly dizzy and with a stupid grin that explains why they are the number one most abused drug in the US. I took Tylenol and Celebrex for the pain; remember, you cannot take anti-inflammatory drugs like Aspirin, Motrin or Advil because of the risk of bleeding after surgery.

Other medications

For someone who takes at most one pill a day, the deluge of pills I was supposed to take was overwhelming. No wonder the elderly have such problems with our multi-pharmacopoeia-based medicine. Take two of these a day, three of those, four of the others, etc. It ends up with you taking some and forgetting others. Your brain is not equipped to keep it all straight during this phase of recovery—and an elderly brain is similar in many ways to one recovering from general anesthesia.

 

The day after surgery

I woke up, though I never really slept, and looked for the truck that must have run me over in the bedroom. Why does it hurt where I had no surgery? My arms, neck, shoulders and upper abdomen hurt more than my kidney or bladder tube! I am stiff all over. I know what happened this time that did not during the first surgery. In the first surgery, I had laid my arms on the boards and had them strapped down. In the second, Dr. Attitude must have stretched my arms and neck out beyond their norm after putting me to sleep. I should have known.

LESSON: PLACE YOURSELF IN A COMFY POSITION BEFORE FALLING ASLEEP UNDER ANESTHESIA

Slowly, normalcy returns. One pain is hierarchically replaced by another, one awareness of an ill by another, and with each passing you feel a little better. If you can take a shower as soon as you are allowed, it will catapult your recovery forward. The bad memories of the ordeal fade away with time, and hopefully you will be better. Still, I felt I had to write all this down so my cosmetic plastic surgery patients would know that I know how they feel.

 

Morad Tavallali, M.D., FACS

Cosmetic Plastic Surgeon