What They Don’t Always Tell You
Cosmetic Medical Care Risks, Complications, Outcomes, Satisfaction Rates, and the Dissatisfied Patient
Any patient undergoing a cosmetic procedure can develop a complication, and any person considering a cosmetic procedure must be willing to accept the possibility of a complication or a bad final result. With proper planning, however, the risks of either occurrence should be low. Most complications of properly performed cosmetic procedures are minor and can be managed without further surgery or hospitalization. This section will review the most common potential early complications, both local (that is, related to the procedure site itself) and systemic (affecting the body as a whole and which could develop after any major procedure performed with general anesthesia). I will also discuss late complications, which are significant problems that affect long-term results.
Complications are a double whammy for cosmetic medical patients because their occurrence risks deforming a normal body part, and their treatment may not be covered by regular health insurance. Prospective patients should check their insurance policies and may wish to consider purchasing separate complications insurance.
RISK FACTORS
The following are significant risk factors for the development of complications after any major surgery. All should be identified in advance, and most can be controlled or eliminated.
• Smoking. Smokers have a higher risk of complications after facelift and other surgeries where there is signifi cant disruption of tissue blood supply. Many surgeons will not perform any elective surgery on smokers. Smoking impairs healing, and these effects persist for a year after a smoker quits; therefore, a smoker contemplating elective surgery should quit smoking well in advance. Patients using nicotine patches to help them quit smoking also need to get off the patch before surgery because nicotine in any form constricts blood vessels and thereby prevents oxygen and other nutrients from getting to damaged tissues.
• Multiple procedures. Patients undergoing multiple simultaneous procedures are thought by many to be at increased risk for complications, although the studies on this issue have been inconclusive. What is certain is that adding procedures often increases anesthesia time, drug requirements (including local anesthetics), and blood loss, and may contribute to surgeon fatigue.
• Long anesthesia. Certain surgeries require a patient to be under general anesthesia for many hours. Aside from the possible risks associated with long operative sessions, a lengthy anesthesia often means that the patient will require a prolonged period in the recovery room and is unlikely to be ready for discharge until the next day. Patients contemplating such a scenario should be certain that they will be cared for in an appropriate facility until they are ready to go home. • Unrealistic expectations. Patients who have unrealistic expectations regarding the pro cess and results of a cosmetic intervention are guaranteed to experience distress and disappointment. In the short term unprepared patients can be emotionally undone by the pain, swelling, deformity, and incon venience. In the long term these same patients can be intolerant of inevitabilities such as scars, numbness, and imperfect results.
• Previous surgery. The most important reason to shop carefully for a cosmetic surgeon before having any surgical procedure is that the physician you choose has, during that fi rst operation, the best opportunity to provide you with a good result. All revision surgeries, whether or not performed by the original surgeon, are carried out on already damaged tissue, may take longer, may require more anesthesia, and may even cost more than the original operation.
• Body image problems. Body dysmorphic disorder (BDD), a body image problem that can cause severe anxiety or interfere with psychological or physical functioning, is estimated to occur in approximately 5 percent of the general population and is thought to be more prevalent in the group of people who seek cosmetic interventions. People with known BDD are clearly at high risk for dissatisfaction after cosmetic procedures, and most physicians try to identify and avoid performing cosmetic procedures on people with this condition.
COMPLICATIONS
Early Wound Complications
Infection
Wound
Any injection site or surgical incision can become infected. A wound infection is suspected in the presence of redness, swelling, increased pain, and sometimes pus draining from a portion of the incision. Wound infections are treated with antibiotics and sometimes with early suture removal. Redness and mild irritation confined to the area directly around stitches or staples usually represents a skin reaction to the suture material rather than infection. Antibiotic ointments sometimes cause redness and rash and may need to be discontinued or a substitute recommended.
Serious infections, although uncommon after cosmetic procedures, can be detrimental to the final result. Even minor infections can adversely affect the quality of the scar in the involved area.
Abscess
An abscess is a collection of infected fluid (pus) and dead tissue inside the surgery site. An abscess usually presents as an area of redness, swelling, and increased pain, and the patient often has a fever. Occasionally an abscess will drain spontaneously through an incision or elsewhere through the skin, but in most cases surgical drainage is required. Small, uncomplicated abscesses can be drained in the surgeon’s office; others entail more extensive surgery in the operating room under anesthesia. If an implant is present, it usually has to be removed. Deep abscesses are rare after cosmetic procedures but occasionally develop after breast surgery, abdominoplasties, and other body-contouring procedures. Regardless of how drainage is accomplished, in most cases the surgeon will also prescribe antibiotics to treat any remaining infection.
Generalized Skin Infection
Extensive skin redness, increasing swelling, increasing pain, and fever may indicate a serious infection of the entire surgical site and body part. This is an extremely rare but very serious problem and requires immediate evaluation by a physician.
Fat Necrosis
Fat tissue has poor blood supply compared with other body tissues, and the term “fat necrosis” describes fat that does not survive an injury. Fat necrosis is a partic ular problem after breast reduction and other body-contouring procedures, in which extensive incisions are made through fat. A patient with fat necrosis will develop symptoms resembling those of an abscess, including fever, pain, redness, and swelling at the surgical site. Antibiotics are usually prescribed in case infection is present. Drainage of an area of fat necrosis may also be necessary. Small areas of fat necrosis may never drain but instead leave firm areas that take months to soften.
Skin Separation
If skin incisions are closed under tension, the skin edges can separate (wound dehiscence) because of swelling that develops during the first few days after surgery. Draining infection, fluid and blood collections, and fat necrosis can also create openings in incisions. Small areas of wound separation can be managed with dressing changes and wound care; and the long-term effect on the scar may be minimal. Larger areas of separation are more likely to have a negative effect on the appearance of the final scar and may eventually require revisional surgery.
Skin Necrosis
Skin necrosis means failure of skin to survive because of poor blood supply or severe infection. Major skin loss is rare but not impossible after cosmetic surgery, especially after operations such as facelifts and major body-contouring procedures that require extensive elevation of large areas of skin. Factors that increase the risk of skin necrosis include a heavy smoking history or previous irradiation to the site (such as for acne or cancer), prior surgery at the same site, development of a large blood collection (hematoma) under the skin after surgery, and surgical technique.
Bleeding, Hematoma, Seroma, and Bruising
Excessive bleeding is not common after cosmetic surgery. If bleeding does occur, it may be the result of unsealed blood vessels or of a previously undiagnosed bleeding problem. Other patient risk factors include recent pregnancy, which particularly increases the blood supply of the breasts, and recent use of medications that interfere with blood clotting.
An occasional patient will develop a collection of blood under the skin called a hematoma. Untreated hematomas can lead to prolonged swelling, pain, firmness, and skin necrosis. Some patients develop seromas, which are collections of fluid (serum) that ooze from the cut surfaces inside the surgery site after the bleeding has stopped. Small hematomas and seromas are absorbed in time and do not require treatment. Larger hematomas and seromas require drainage, either in the office or in the operating room.
Bruising, although not a complication per se and to be expected after most invasive procedures, including injections, can be especially annoying for patients undergoing what they thought was a minor, “lunchtime” procedure.
Early Breast Complications
Nipple Loss
Nipple loss refers to failure of the nipple and areola to survive. Fortunately, complete nipple loss is a rare occurrence after cosmetic breast surgery.
Chest Cords
An occasional patient will develop a painful cord (superfi cial phlebitis) under the skin in her lower chest after breast surgery. This cord represents an inflamed, sometimes clotted vein. The cord may take weeks or months to resolve completely.
Milk Drainage
Women who were pregnant or have breast-fed within a year before breast surgery may have residual breast milk inside their milk ducts and may have milky drainage (galactorrhea) from the nipple or through the incisions for a short time after surgery. Rarely, a woman who has not been pregnant recently may have milk drainage and may require hormone evaluation.
Unanticipated Breast Cancer
Rarely is a breast cancer discovered during an elective breast operation. All women planning to undergo cosmetic breast surgery should have breast evaluation preoperatively. Complications of Injectables The risks and complications specific to Botox and filler injections are discussed under those subject headings later.
Systemic Complications
Anesthesia complications
When anesthetics are administered by qualified physicians or nurse anesthetists in accredited facilities, complications are uncommon and in healthy patients rare. In fact, properly performed anesthesia has become extremely safe in this country. Because of the inability to obtain accurate statistics about what happens in private offi ces, no one knows how many anesthesia-related complications have occurred that are related to the performance of cosmetic procedures. Nonetheless, there are many indications of an unacceptably high number of complications and deaths after cosmetic procedures and it appears that many of these adverse events may have been preventable. Complications can develop after the administration of topical, injected local, sedating, and general anesthetics. They range from the minor (for example, nausea or sore throat from the breathing tube) to the serious (for example, inadequate replacement of fl uid and blood loss, drug reaction, heart attack, or seizure) to the devastating (for example, stroke or death). Even topical and local anesthetics have killed people, usually as the result of unintentional overdosage.
Lungs
Atelectasis
Atelectasis refers to the collapse of small air sacs in the lungs and is fairly common in patients who undergo general anesthesia. Significant atelectasis can cause shortness of breath and fever. Atelectasis that persists can evolve into pneumonia.
Pneumonia
Untreated atelectasis or a preexisting respiratory problem can lead to a lung infection (pneumonia). Pneumonia is rare after cosmetic surgery.
Heart Problems
In healthy patients, cardiac complications during or after cosmetic procedures are rare but can occur as the result of inadequate fl uid replacement, drug reactions, or drug overdoses. Patients with known heart disease may need to be started on drugs called beta blockers before surgery and may need to undergo their procedures in a hospital.
Blood Clots
Deep Venous Thrombosis
A blood clot in a deep leg vein is a serious problem and is most likely to occur in patients who undergo long anesthetics or who have a prior history of deep venous thrombosis (DVT). Deep vein clots cause leg swelling, but more importantly, a clot can break off and lodge in the lungs (pulmonary embolism [PE]). The factors that increase a patient’s risk of DVT and pulmonary embolism are the use of contraceptives, hormone replacement, a family history of thrombosis or embolism, a genetic predisposition to blood-clotting disorders, and any preexisting swelling or other signs of poor vein function in the legs.
Pulmonary Embolism
Blood clots that pass through the heart and lodge in the blood vessels of the lungs are called pulmonary emboli. Pulmonary emboli can be fatal. Patients with a history of DVT or PE are at a higher risk for recurrence of these complications and require preventive measures when undergoing any type of major surgery. The treatment of DVT and PE usually includes blood thinners, but as a general rule patients who are on blood thinners should not undergo major elective surgery unless the blood thinners can be temporarily stopped.
Urinary Retention/Bladder Infection
Some patients have difficulty with bladder emptying or urinary tract infections after general anesthesia, especially if large volumes of intravenous fluids are given. Urinary retention may require bladder catheterization or medications. If a surgeon anticipates that surgery will take more than three hours, the patient may undergo insertion of a catheter at the beginning of the procedure. Urinary tract manipulation increases the risk of bladder infections, especially in women.
Late Complications
Problem Scars
The body heals all but the most superficial injuries by forming scar tissue. However, the scarring process is difficult to control, and scars can be of poor quality. In the absence of a complication, the quality of scarring is almost entirely a function of the patient’s genetic tendencies and the location on the body of the incisions. Existing scars are the best predictors of future scar quality.
Some patients form scars that remain red, raised, and painful for months or years. These hypertrophic scars are most common in young, often fair-skinned patients. However, they can occur in patients of all ages and skin types. Hypertrophic scars usually improve in time but may require treatment. Unfortunately, treatments are not always effective. Surgical revision alone is rarely helpful. Other treatment options include locally injected steroid medication, steroid tape or cream, silicone sheeting, pressure garments, laser treatments, and radiotherapy.
Keloids are thick, cauliflower-like scars that grow beyond the borders of the original incision. Keloids can be considered scars in which the switch that starts the pro cess of scar formation is stuck in the “on” position. Keloid scars are a concern for all patients but more so for people of color. They are more common in younger patients, and the propensity to form keloids tends to run in families. Keloids are related to but are not the same as the more common hypertrophic scars. Both types of scars may be painful or itch. Keloids are difficult to treat and may be impossible to control. True keloids cannot be treated with surgery alone because they may recur in a more severe form. Injected steroids and/or radiation therapy may be helpful alone or in combination with surgical excision. Fortunately, keloids rarely develop after cosmetic procedures, with the notable exception of ear piercing.
Skin pigment alterations
Permanent alteration of skin color can occur after many cosmetic procedures. Procedures causing inflammation, such as sclerotherapy of veins and injections of certain soft-tissue fillers, and any infection involving the skin can leave in localized darkening of the skin. Deep chemical peels and ablative laser treatments can cause permanent loss of skin color. Scars after surgery are always a different color than the surrounding skin, regardless of the patient’s skin type. Pigment loss is a partic ular concern to people of color..
Numbness
When you sense your body, you include a certain amount of space around it. Researchers call this the “buffer zone.” Numbness of a body part after surgery changes the contours of the buffer zone and can cause psychological discomfort until the numbness resolves. Permanent numbness can be especially troubling until the patient’s body image adjusts. Facelifts and brow lifts are particularly prone to causing bothersome numbness.
Contour Problems and Asymmetries
No surgeon can guarantee perfect symmetry or a partic ular contour. Most people have some degree of body asymmetry that might become more noticeable after a cosmetic procedure. Mild asymmetries caused by cosmetic surgery are common and should not be considered complications. If there are technical problems during a procedure or if a patient develops a major complication, there may be a more significant permanent discrepancy in the shape, size, or position of mirror image body structures. Further surgery will likely be required to correct this type of problem.
Need for Further Surgery
There are two time periods after a major cosmetic operation when a patient might need more surgery. First, additional surgery may be required in the early healing phase if, for example, an implant is improperly positioned or if the patient develops a major complication, such as significant bleeding, severe localized infection, major fat necrosis, or skin loss. Second, a problem may become evident after the initial recovery period that significantly compromises the aesthetic goal. For example, a patient may have significant asymmetry, a positioning deformity (for example, a nipple that is too high), a shifted or failed implant, incomplete or overcorrection of a contour, or some other failure to meet the goal. In those circumstances secondary surgeries may have to be delayed for months until initial healing is complete, scars have matured, and the final nature of the problem assessed.
Secondary procedures may be performed under local anesthesia or may require another general anesthesia. Health insurance may not cover any procedures, even if they are needed to treat complications. The success of additional treatment will be severely compromised in situations where the patient and surgeon cannot agree on an attainable goal.
In some cases, treatment of an undesirable result requires surgery that is more extensive than the original procedure. For example, an overly aggressive rhinoplasty that leads to collapse of the nose may require extensive bone and/or cartilage grafting to correct. If a patient undergoing breast reduction surgery develops signifi cant fat necrosis, she might need an implant to correct the resulting breast deformity and asymmetry. If her nipples have been positioned too high, corrective surgery may leave vertical scars on her upper breast above her areolae. Revisional surgery can also be much more diffi – cult technically than was the original procedure, and not all surgeons are experienced with the extraordinary surgery sometimes needed for a successful major revision.
Tags: Anesthesia complications, Atelectasis, Body image problems, Breast Cancer, Chest Cords, Deep Venous Thrombosis, Early Breast Complications, Fat Necrosis, Generalized Skin Infection, infected fluid pus, Long anesthesia, Milk Drainage, Nipple Loss, Pneumonia, Satisfaction Rates, Skin Necrosis, Skin Separation, Urinary Retention/Bladder Infection, Wound Complications