Tag Archives: complications

Surgical checklists

Checklists do not work for surgery


A few years ago a a book came out that made a big splash called ” The checklist manifesto” by Dr. Atul Gawande.

The premise of the book was that having checklist will decrease errors in surgery. The prime example given was that of airline pilots who run a checklist before every flight.

Everyone started to make checklists for everything- and to a great extent they do work. The work for airline pilots, fr inventory and distribution of products etc. They do not work for surgery, as a recent study in the New England Journal of Medicine has shown.

“There may be value in the use of surgical safety checklists, such as enhanced communication and teamwork, and the promotion of a hospital culture in which safety is a high priority; however, these potential benefits did not translate into meaningful improvements in the outcomes we analyzed,” they reported.

… and all this despite the fact that this study, was conducted in over 90 hospitals in Canada with over 91% compliance, and covering 200,000 surgical procedures. No difference in mortality or complications occurred as a result of use of checklists.

Surgical checklists

One of the themes of “The checklist manifesto” was that checklists would prevent complications and standardize protocols. Other research has shown that in a hierarchical grouping of people, such as with airline pilots where the captain is all knowing, members of the group will rarely question decisions of the group “leader”.

In many hospitals, the  group”leader” (surgeon) in the operating room still cuts the wrong leg off or operates on the wrong side of the brain because other group members ( anesthesiologists, nurses and techs) do not question the decision and authority of the surgeon.

Still, why do checklists not work in the operating room or in medicine? I don’t know! They should!


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!

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

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:


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.



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

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.

Cosmetic Plastic Surgery and Being Human

Errors in plastic surgery

As much as you as a patient would like to think otherwise, errors in medicine do occur at rates that are frightening for any patient. I am not talking here about the risk of complications in surgery or medical errors of judgement or application of known protocols. That is a whole topic on its own. For example, look at this old post about the potential complications of abdominoplasty:

Instead, I want to talk about all the other snafus that occur when plastic surgeons attempt to provide care to cosmetic patients.

Plastic surgery error today

It is now 6:45 a.m. and I arrived a few minutes ago at the surgery center, just to be asked why I was here! My patient is here, I am here, my staff told to me to be here; in fact, I have another surgery after this one! Both surgeries were scheduled weeks ago—faxes were sent to the surgery center, photos of patients were taken, payments were made to the hospital and for anesthesia, etc. Yet no one at the surgery center knows what happened.

How could this be?


Plastic surgery error yesterday

Yesterday morning, I arrived at the office 20 minutes late. It usually takes me about 30 minutes to get to the office from my home. Yesterday it took an hour. Lots of traffic: no accidents, no presidential motorcades—just traffic.

When I arrived at the office, two patients were waiting for me. A third, new patient had already left, having been pissed off for being kept waiting. My staff was not there. One texted me that her normal 40-minute commute had taken over 2 hours and was still in progress (there was an accident on the road), and the other made no sound (it later turned out that she had overslept!).

How could this be?

Plastic surgery error last month

Last month I was in the middle of a breast augmentation procedure when I asked for the breast implants to be given to me. They were the wrong size. In over 25 years of surgery, I have never seen or even heard of the wrong implant being shipped. My confidence in the delivery and ordering system was such that the thought of actually opening the box to verify the contents had never even crossed my mind. I had to place the implants in and at a later time exchange them. It was a great inconvenience for my patient and a great embarrassment for me. Now I always check the contents, but still…

How could this be?

In any field of human endeavor, and cosmetic plastic surgery is but one, the important word is “human.” No matter how hard we try, we cannot escape the shackles of humanity, and we remain restrained by our innate inefficiencies, frailties and unpredictable behavior. Traffic jams will occur, and plastic surgeons and their staff will get caught in them and be late. Surgical procedures are scheduled and confirmed and still somehow get deleted from the schedule as if they had never existed. The wrong sizes of breast implants are delivered despite email confirmations of the correct size having been sent!

As a cosmetic plastic surgery patient, you should worry about the errors of technique or surgical and medical judgement that can occur in any surgery. Those medical situations can be controlled only to a certain degree by your plastic surgeon. Risks and complications will occur in the best of patients under the care of the best of surgeons.
There are other errors that can also occur as a result of non-medical situations. Be patient with the humans caring for you in the office, in the factory, in shipping department, and others who may have failed to get everything needed for your cosmetic surgery in order. You will feel less frustrated.
We all try our best, but sometimes we fail. We are only human.  Do you ever fail in your endeavors?