The use of complimentary or alternative medicines such as those found in herbal or homeopathic preparations has increased from 20% of our patient population to more than 60% of our patients. The fascination of herbals, teas, and homeopathic products exists because people believe these medicines to be “natural” and therefore perceived to be “safe.” Only recently have these products been scrutinized carefully by the medical community to determine how safe they actually are. In preparing for plastic surgery, safety issues are being addressed due to the fact that there are an increasing number of reports describing bleeding
complications due to herbal remedies. We now know the chemistry of most herbals so we can now identify the substances within each herbal preparation that are likely to cause bleeding problems. To date, the only documented sequelae of herbals that effects plastic surgery is the increased risk of peri-operative and post-operative bleeding which usually manifests as more swelling and bruising than one would normally see. In more severe cases, these homeopathic medications may even cause significant bleeding and hematomas.
A partial list of common herbal supplements that are known to cause bleeding problems is provided:
Oil of Wintergreen
Red Chili Pepper
Other dietary supplements known to effect healing or cause bleeding:
Chondroitin & Glucosamine
As a general rule of thumb, any herbal supplement which is known to cause or have any pharmaceutical activity should be discontinued 2 weeks prior to a general anesthetic or outpatient surgery under local or sedation. Since many herbal or homeopathic formulations contain numerous plant extracts, it is best to stop all homeopathic remedies including herbal teas a full 2 weeks before surgery. Patients may renew taking their supplements once uncomplicated healing has progressed for at least one week post-operatively. It is probably in the patient’s best interest to assume all homeopathic supplements have the potential to effect healing and should be discontinued 2 weeks prior to surgery.
Patients who smoke are a problem for plastic surgeons for multiple reasons. It is a well-documented fact that smokers are much more likely to have wound complications especially with procedures that require undermining the skin such asface liftsandtummy tucks. Smoking also affects the healing of all incisions whether undermining or not, and I think smoking is one of the causative factors for capsular contracture of breast implants (hardening of the breast implants). Even those incisions that appear to heal initially are more likely to open after the sutures are removed and usually produce poor scars both in quality and appearance. In scars that technically heal without “complication,” the period of time it takes for effective healing of incisions is longer than for non-smokers. Once incisions have failed to heal, primarily the problems escalate. In addition to poor quality scars, these incisions act as though they have an inadequate blood supply similar to scar healing after radiation therapy. Open incisions are prone to bacterial infection and require a great deal of time and effort for local wound care.
Inhaled cigarette smoke also causes damage to living tissue causing bronchitis, wheezing, and eventually emphysema. Intrinsic lung damage complicates the administration of general endotracheal anesthesia and blood oxygenation. These pulmonary problems with smoking are not exclusive to plastic surgery patients, but nonetheless should be counted in our complication list for smokers.
There are several things that plastic surgeons can recommend to the smoker to mitigate some of the problems caused by smoking thereby reducing but not eliminating complications. The most important thing a smoker can do is stop smoking. There is data that suggests stopping smoking for two weeks before surgeries decreases smoking related complications. A good pre-operative evaluation may uncover some pulmonary related problems such as congestion associated with bronchitis or bronchospasm. Early recognition and treatment of those problems may reduce the pulmonary related complications. Personally, I believe that staying away from general anesthesia if possible decreases smoking related risks. Full monitoring with local anesthesia plus sedation decreases complications for smoking and stabilizes swings in blood pressure for both non-hypertensive and patients with hypertension.
Only those patients who refuse pre-operative instructions and cannot or will not stop smoking should not be accepted as a candidate for elective cosmetic surgery. It is not clear if the wound problems are secondary to nicotine alone or a combination of nicotine and other toxic substances associated with cigarette smoke. The data is unclear if using nicotine containing products to stop smoking causes the same level of wound problems associated with smoking. Chantix® is a good alternative to stop smoking without using replacement nicotine (Nicorette®, etc.)
Patients should be careful to create a healthy non-stressful environment. Recovery in a smoke-free environment is extremely important as second-hand smoke has been shown to be as harmful as first-hand smoke to wound healing.