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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;



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

Liposuction Seroma

 Seroma formation after liposuction

Liposuction is a procedure in which your board-certified cosmetic plastic surgeon can remove specific unwanted areas of fat from your body.

Here are is a blog post about liposuction, swelling and seroma:


Arm liposuction photo

Complications of liposuction

As with any cosmetic surgery procedure, there are a number of complications that can occur after liposuction. Some lipo complications include:

  • infection
  • bleeding
  • uneven contour
  • loss of skin
  • liposuction seroma formation


Liposuction Seroma

Seroma is the name given to an accumulation of serum, or lymph, under the skin. Essentially, it is what causes the initial swelling in an area of the skin after an injury. In this case, it’s just that the swelling does not go away and continues to get larger, forming a seroma!


Seroma formation

After skin is injured by any form of trauma, a bump or a cut, blood vessels in the area become more permeable. This allows white blood cells and other blood protein factors necessary for the skin to heal to go out of blood vessels  and lymphatics and surround tissue cells to help in the repair process.

This fluid mixture is called lymph, and its accumulation is called a seroma.

In fact, there is a constant flow of lymph in and out of blood vessels, which is picked up by the lymphatics and taken back into blood circulation through specific points on the left side of the neck for the head and the groin for each side of the body.

Injury merely means there is more fluid going into the tissues than can be absorbed, leading to its accumulation as swelling or seroma.

With time, this fluid is absorbed back into the blood vessels once healing has occurred.

If the fluid cannot be absorbed fast enough after surgery because the vessels carrying lymph (lymphatics) have been cut, a seroma will form.


Seroma after liposuction

A main cause of seroma formation after liposuction is damage to the lymphatics by liposuction cannulas ( this is worse with laser and ultrasound injury) . The normal tissue response to injury also occurs, and more lymph and fluid pours into areas where lipo has been performed, causing swelling.


What to do with seroma

Once a seroma has formed, the fluid needs to be removed so the skin can stick back down. Seroma can either:

  • drain spontaneously
  • be resorbed spontaneously
  • be drained surgically


Spontaneous drainage

Spontaneous drainage is usually messy but is also efficient and typically occurs when a seroma is least expected. The skin over the seroma may not feel like it’s holding the clear yellow to brown liquid. It may just feel firm. Once spontaneous seroma drainage occurs, I tell my plastic surgery patients to encourage the drainage by expressing the fluid out. Keeping the area clean with hydrogen peroxide is also important.

Infection is a rare but possible complication of seroma, and both the patient and the plastic surgeon need to keep an eye out for it and treat it if it becomes apparent.



Spontaneous resorption is a common occurrence for small seromas and probably occurs in all cosmetic plastic surgery procedures without the cosmetic patient or plastic surgeon even knowing about it.  One does not know about it, and so nothing needs to be done!


Surgical drainage of seroma

When the cosmetic plastic surgeon feels an accumulation of fluid under the skin, it is usually drained with a needle and syringe. In rare cases, drainage using a drain that stays in for a week or so may be necessary.


Compression after seroma

Wearing  compression garments for at least two weeks and, later on,  massage, will help move the fluid out of skin areas. The skin needs time to stick down to the underlying muscles and have a chance for the lymphatic vessels to heal together. During this healing phase, it is important to prevent shear forces on the skin, and exercise is not recommended.

So, when a seroma develops, get the fluid out, watch for signs of infection, wear a compression bandage and don’t exercise until the skin has adhered to the underlying tissue.


Morad Tavallali, M.D., FACS

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 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:


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 doesn’t mix with alcohol

Alcohol and surgery

Last night a patient called me at 11.30 (after my bedtime) to ask me if she could have a beer. She was recovering from a breast enlargement surgery, brazilian buttock lift and mini tummy tuck. The cosmetic plastic surgery procedure was ten days ago.
I was initially a bit pisssed off. After all she had called the emergency line after hours; a line reserved for true medical emergencies. I initially thought of telling her NO! NO beer! but then realised that it might have been an emergency beer she needed and so told her to go ahead and swig one back!

See here for links to some articles on postoperative care https://tavmd.com/category/general/pre-and-post-surgery/

Complications of plastic surgery occur at known rates for infection, bleeding etc. It is important though not to increase your chances of having a complication by limiting factors that delay your healing or give post operative recovery problems. Alcohol causes problems in this period!


Alcohol after cosmetic surgery

The timing of when a patient can start to drink alcohol after cosmetic plastic surgery will depend on a number of factors. The basic factor is that alcohol has a number of effects that can alter postoperative results of a cosmetic patient.


Alcohol as vasodilator of skin

Vasodilation means opening of blood vessels. You may know those ruddy cheeks you get when you have had a few too many drinks. You know, red cheeks along with a warm feeling, slurred speech and bad jokes?  Skin vessels will open to allow more blood into them and rob blood volume from vital organs. You are already dehydrated from surgery and with more loss of fluid from areas that need it- brain and heart- you will only feel light headed, get nausea and worse!


Alcohol as a nervous system depressant

Alcohol effects our brains by depressing our central nervous system.

Initially this means decreasing our psychological inhibitions and mellow us out. It also mellows out our breathing rate and brings it down . If you are taking narcotics for pain control, they also decrease your breathing rate. The additive effect can mean you stop breathing! Not good for a cosmetic surgery recovery.

Alcohol increases vomiting

Another effect of alcohol is to increase our brain’s sensitivity to noxious stimuli and make it easier for us to vomit. Not good if you have had any type of cosmetic surgery. The anesthesia will already have lowered your vomiting threshold. With a tummy tuck vomiting will be very painful as stomach muscles contract. With a face lift,  increase in blood pressure occurring with vomiting can lead to bleeding.


Alcohol as a diuretic

Alcohol also has the effect of increasing the rate of urine formation (increases your peeing) and as such can lead to dehydration. That is why when you have a hangover you have a headache. Dehydration causes fluid to leave the area around your brain (cerebrospinal fluid)  which leads to headache. If you are already dehydrated from surgery, the increase in dehydration will only make you feel worse.
You may think that alcohol will allow you to relax after your cosmetic plastic surgery and maybe it will if taken in moderation. However you will be better off taking a Valium to decrease your anxiety and avoid all the other alcohol side effects.Also drink lots of…water!

Swelling after Liposuction

Swelling after Liposuction

Causes of swelling after liposuction


What is liposuction?

Liposuction surgery is a cosmetic plastic surgery procedure in which fat is aspirated (sucked out) from under the skin through small tubes called cannulae. The skin is by necessity lifted off underlying muscle tissues to a certain extent, though it is still attached by connective tissue, blood vessels and nerves (unless laser liposuction is used, where such connections are destroyed). Nevertheless, there is an area under the skin that is “empty” and the body will fill any empty area with fluid, causing swelling after liposuction. The important questions are first how to minimize the post-lipo swelling and second how to remove it (the subject of another post).

Minimizing post-liposuction swelling

What is swelling?

Any time our bodies are “injured” in any way, be it by surgery or a mosquito bite, the area will swell.

Swelling is a combination of two different types of fluid accumulation in our tissues after any trauma and is a necessary part of wound healing.
Intra-cellular swelling
Intra-cellular swelling is swelling or enlargement of the individual cells that form our tissues. With any trauma, cell membranes will become more porous and fluid-bearing nutrients outside cells will go in to swell and plump it up. Fluid that enters cells comes from the fluid outside and in between cells, called interstitial fluid, which is initially derived from the blood.

Extracellular swelling

This is the type of swelling we are more used to seeing. You hit your head on a wall and get a bump almost immediately. That bump is initially due to blood vessels in the area becoming porous (not the cells yet) and allowing fluid from the blood to enter the area between cells, adding to interstitial fluid. Of course, if you hit your head hard enough, you may get some bleeding as well and get a bruise (blood and fluid mixed).
For example, think of it this way. You burn the back of your hand on an oven. Very soon, you get a blister and the area swells up. The blister is dead skin and blister fluid, and that clear/yellow liquid is your lymph or interstitial fluid, the fluid around and outside your cells. Burnt cells send a signal that opens channels in the blood vessels to allow the lymph part of the blood to get into the tissues. The red blood cells are kept out; that is why blister fluid is not red.
Fluid that comes in to bathe injured cells has proteins, antibodies, white blood cells and other factors needed in wound healing. With the continued effects of injury, interstitial fluid then goes into cells also, as described above. So “swelling” is a combination of intracellular and extracellular swelling. In the next post we’ll see what this means to for liposuction treatment and garment use. The suspense is thrilling…

Instructions after Cosmetic Plastic Surgery, Part 2

Instructions after Cosmetic Plastic Surgery, Part 2

Cosmetic surgery instructions

This is the second of three parts on general instructions for care of  post-operative cosmetic plastic surgery patients.

Bandages , Bras and Binders after surgery

Leave your bandages on until your plastic surgeon or plastic surgery staff takes them off. Bandages protect wounds and provide a level of compression, decreasing post-operative swelling. Expect some drainage of pink-colored fluid seeping through bandages or even out onto your skin. This is normal.
If the bandages are too tight you can loosen them somewhat, but do not take the bandages off completely! Bras and binders can be adjusted to be firm but comfortable. If your bandages do fall off, clean the area with hydrogen peroxide and apply antibiotic creams such as Neosporin over wounds.
If you have a bra and /or binder, LEAVE IT IN PLACE!!  Removing the binder or bra will allow even more swelling to creep in to the area of surgery causing tension on the skin and…Pain. Keeping the binder on until your surgeon tells you it is ok to take it off is very important.

Walking after surgery

After any cosmetic plastic surgery it is very important to get up and walk. The very first night, you can be a bit lazy and get up only for the bathroom, but the day after plastic surgery you must walk around for a few minutes every few hours. This is important to allow blood to circulate in your legs and decrease the risk of blood clots developing and leading to embolization toward lungs—a bad thing. As soon as you feel better, go out for a walk. Movement will help decrease swelling and pain.

Exercise post-surgery

You will not be able to exercise for two weeks after cosmetic surgery. Exercise will increase blood pressure, which may lead to bleeding from the wound in the early post-operative period. When you do start exercise, begin slowly and carefully. Brisk and sudden movements will hurt and cause damage to your plastic surgical wound. Start with stretching exercises.

Swelling and surgery

Expect to have swelling in the area of surgery for months! Although swelling decreases rapidly after surgery, it still remains in the area for months. You may look great one day and be swollen the next! This is normal and will go away. There is no need to take water pills to diminish post-operative swelling, and in fact it may be dangerous to take medications for that purpose. Swelling causes pain, and efforts to decrease it will make you more comfy.

Elevation of the affected area is the best way to decrease swelling. For example, keep your head elevated if you have had facial cosmetic surgery. Ice the affected area to get pain relief and decrease swelling. Place ice in a bag or use frozen peas on the skin above and below your bandages. This will cool the blood going toward the surgery area and decrease swelling. Lymphatic drainage, a  type of massage, has been proven to be effective after surgery to decrease swelling. You will need at least ten treatments to get a great result. Other types of massage can also be helpful. This would start only after your first post-operative visit.

and finally here is PART 3         https://www.tavmd.com/2011/02/26/instructions-after-cosmetic-plastic-surgery-part-3/