Tag Archives: general 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

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

Gimmicks in Liposuction

Gimmicks in Liposuction

Liposuction lies

The other day, an ex-employee of mine who now works for a dermatologist who performs liposuction (!) called me to say that the doctor was using a new type of liposuction called “cool lipo” that she said caused no pain. Great!

There are a number new liposuction techniques available and aggressively promoted by medical technology companies to board-certified plastic surgeons. They can be classified into laser liposuction machines and ultrasound liposuction machines.

Laser liposuction

The idea behind a laser liposuction machine is to melt the fat under the skin before it is removed by liposuction. Yes, you still need “regular” liposuction to clear the area of remnant melted fat! Two such machines are the slim lipo and cool lipo machines.

Is laser lipo worth skin tightening?

Burning of the skin from which the fat is removed will lead to skin tightening. However, all plastic surgeons know that any irritation, scraping or fat removal from under the skin will also have the same result. That there is more skin tightening has not been proven.

Less pain with lasers?

A second common claim is that there is less pain associated with laser use. I personally have not seen any difference, since pain perception is such a subjective process. I have had patients in the office reading magazines while having surgery on their thighs under local anesthesia and others who writhe in pain and wish they had had surgery under general anesthesia.

Area of laser treatment

What none of these laser companies or the surgeons using their technology tell you is that laser lipo is useful only for small areas of the body such as the fat under the neck and have been FDA approved only for limited use. For larger areas, such as the abdomen, the heat energy it dissipates is so great that you would end up like a burn victim in need of major IV fluids.

Ultrasound liposuction

This technology has been around for ten years but has been refined by some companies and re-marketed for a new generation of patients who have never heard of it. One of the ultrasound machines is the Vaser system (funny how it sounds like “laser,” isn’t it?).

Skin tightening with ultrasound

Like laser machines, heat energy, this time in the form of ultrasonic energy, melts the fat, which is then suctioned out. There’s no difference in skin tightening in my opinion.
 

Less pain with ultrasound?

This is rubbish. The answer is no.

Area of ultrasound treatment

You can use ultrasonic energy for larger areas but are still limited by the amount of heat energy given off, and though a larger area can be treated than with a laser system, you cannot use it for more than 20 minutes. That’s not enough time to do several areas of liposuction. I use ultrasound liposuction to break up scarred secondary areas of liposuction or on the male breast in gynecomastia surgery, and I revert to regular liposuction once the time is up.

New technologies will keep on coming up, and some may actually be beneficial and deliver on the promises they make. For now, you should beware of plastic surgery centers touting their new machines. You’ll see the ad, think their technology better, go to their office, be told you are not a candidate for the laser since you need a larger area done, etc., but by then you have had a consultation and—fallen for the gimmick.

Nose Surgery Explained

Nose Surgery Explained
Rhinoplasty, or nose surgery, is one of the more common cosmetic plastic surgery procedures. The surgery became popular as a cosmetic surgery only around 1920, when a German surgeon popularized it. Dr. Joseph (aka Noseph) is also remembered for charging exorbitant fees to surgeons who came to see him work his magic and learn his plastic surgery tricks!Anatomy of the nose
The nose consists of two bones and five cartilages.

  • two nasal bones – one on either side at the top
  • two upper lateral cartilages – one on either side
  • two Lower lateral cartilages – at the tip
  • one septum – in the middle

Likewise, rhinoplasty is divided into full rhinoplasty, dealing with the nasal bone and cartilage, and tip rhinoplasty, which deals only with the  cartilage.

Tip Rhinoplasty
In tip rhinoplasty, only the end cartilages of the nose are operated on. The cartilages are usually trimmed and made narrower to pinch in the nose and/or sewn together to narrow or elevate the tip. Nose tip surgery can be performed under local anesthesia as an outpatient procedure. Recovery takes one week, though the nose can be swollen for months.

Full rhinoplasty
A full rhinoplasty involves breaking the nasal bones at their juncture with the cheek in order to bring them together and narrow the nose. This is necessary every time a hump is removed from the nose, as this causes a flattening of the top of the nose, as in a boxer’s nose, which then needs narrowing. Tip cartilage is also operated upon to get a narrower shape that matches the narrower bone. Full rhinoplasty is done under general anesthesia as an outpatient surgery. Recovery takes one week and requires a cast to keep the bones in place. Patients need up to one year for full healing.

The art of rhinoplasty
Even though many plastic surgeons are proficient at the technique of rhinoplasty, few actually perform them, as they seem to lack the art required for this cosmetic surgery.

As opposed to some other cosmetic procedures, the plastic surgeon really needs to have an artistic appreciation of the relationships between the nose and other parts of the face such as the chin to perform a successful rhinoplasty. Rhinoplasty involves changes in millimeters of bone and cartilage, causing changes of great amplitude in the face. There are a number of ratios and relationships the plastic surgeon learns during training, but in the end it comes down to having an eye for the result the cosmetic patient wants, not what the plastic surgeon wants!

It is imperative that the cosmetic surgeon spends the time to really understand what it is the patient wants and expects to avoid disappointment. Using medical imaging can sometimes help the patient understand their options better.

Washington DC, Northern Virginia, Maryland

Health


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