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.
In our current healthy and image conscious environment many people choose to maintain fitness by running, jogging, or high impact aerobics. While these exercises are great for cardiovascular fitness they are extremely bad for facial aging. First and foremost facial aging is primarily a result of loss of skin elastic tissue due to sun damage, environmental factors and smoking. Pounding the pavement has an adverse effect on facial aging in the face of poor skin elasticity. Compression garments can be worn to hold firm abdominal, thigh, and buttock tissues as protection against the effects of running on these tissues. No such garment can protect the face from the deleterious effects of extreme exercise. Runners are usually thinner than others of the same age. It is a well-known fact that while healthy, thin faces age quicker than faces with some fat content. The opposite is true for necks – little fat in the neck is good whereas a fat neck is difficult to contour. Many people who exercise heavily do not maintain adequate hydration. Drinking large amounts of water help keeps skin hydrated and less likely to manifest dryness, fine wrinkles, and laxity of aging. There are plenty of aerobic exercises and machines that provide a serious workout without the up and down pounding that can exacerbate the facial aging process.
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.
Men pay for approximately 80% of the cosmetic surgery performed while becoming a patient only 20% of the time. It is hard to know if this is indicative of the social taboo regarding men and cosmetic surgery or is it a result of the idea that men are much less stoic than women and are basically averse to the minimal discomfort involved. Regardless of the cause, men are more frequently having plastic surgery and generally have the same reasons for having cosmetic improvement as our women patients: improved self esteem, being competitive with younger people in the work place, and to appear more youthful and attractive to the opposite sex.
Men age somewhat differently than women and require surgeries that are tailored for their specific facial aging issues. For instance, men are more likely to complain about their necks while women focus on the midface/cheek area. Both men and women have upper and lower blepharoplasty but men rarely want the browlift procedure so as to not look like “Kenny Rogers.” Kenny Rogers is a well known celebrity, singer, actor and country music star who was the unfortunate victim of an overdone browlift – forehead too tight, too smooth, too high, thus totally changing his appearance for the worse. In addition to eyelid and neck rejuvenation men are likely to inquire about liposuction of the waist and abdomen area. Men desire a nice tight, jaw line and neck with a youthful profile, a sculpted waist and bright, open, uncluttered, youthful eyes. Post-operatively, men tend to go back to work too quickly, tend to bruise worse than women, and are less likely to follow post-operative instructions. Men and women both require a full dose of positive reinforcement throughout the healing process. Early and often post-operative photos to document healing and cosmetic improvement are helpful during the early stages of healing where bruising and some swelling is to be anticipated. Men are less likely to keep all of their post-operative appointments and tend to be more secretive regarding their surgery than women. Men are uniformly less patient while healing but more appreciative of the good results and more youthful appearance over time. Men are less likely to have researched the procedures they want and tend to be referred mostly by other patients and thus are less affected by marketing schemes than women. Terminology is also important to men who shy away from the term “facelift” but respond well to being offered a “necklift.” Even with their idiosyncrasies, men are generally some of our most appreciative patients.
The development of liposuction about 30 years ago was driven by our patients who asked for a method to reduce body fat without the scars associated with the usual tummy tuck procedures. Our primary focus is the safe removal of isolated pockets of fat to improve body contours. While the goal (fat removal) has always been the same, the methods of anesthesia for liposuction have changed through the years making the procedure more “patient friendly,” yet achieving the same contour results. Most of the technological advances are intended to make the fat removal easier and, even more importantly, an attempt is being made to tighten loose skin and improve the appearance of cellulite utilizing the latest surgical laser technology. Most plastic surgeons believe that the skin tightening effects have not been as impressive as the manufacturers claim. Each manufacturer slightly alters the laser platform so their product can be claimed as “unique” while there is no discoverable clinical difference in the final result. Laser assisted liposuction is marketed under any number of trademarked names including Smartlipo, Vaser, Slim Lipo, Cool Touch, etc. The marketing department of the manufacturer uses the trade names to market these laser liposuction platforms directly to the patients. The laser can be purchased by ANY practitioner, even those with no laser or surgical training. Regardless of the laser manufacturer, the practitioner is told that the patient referrals will be generated through their web marketing and the practitioner is allowed to use the trademarked name (Smartlipo) in their practice marketing efforts.
This marketing strategy is similar in design to the pharmaceutical companies who advertise their drugs directly to the public and offer the names of certain physicians who prescribe their products. All of these marketing schemes are evidently legal, but in the laser liposuction example, the machines are sold to any doctor with the money, training is offered but not required, marketing and patients are guaranteed without checking the doctor’s credentials. The red elephant in the room is that laser liposuction is inherently more dangerous than standard tumescent liposuction techniques and in many instances is performed by non-plastic surgeons who are damaging their patients because of a lack of basic education and the need to market the trademarked product that they own rather than choosing the proper technique for each individual patient.
Many of these doctors ask you to ignore their training and credentials and emphasize their marketing skills. In the final analysis, patient education is not advanced with unclear or even false advertising and many people have suffered as a result.