Plastic surgery, like every other surgical specialty, relies on medical devices to create their desired results. In many ways, plastic surgery is a device-driven specialty as instruments and implants make possible many of its most well-known operations. One could argue that the hands of the plastic surgeon and their skill and experience who uses these pieces of medical equipment plays the most important role in what happens after surgery. But devices may also create undesireable outcomes that can happen regardless of how well the plastic surgeon performs the technical steps of the procedure.

Many plastic surgery operations can be thought of as either device-assisted or device-dependent operations. A device-assisted operation is when an instrument or devce is used to help do the surgery, either making it possible or serving to make the operation better. An example would be that of an endoscopic browlift. The endoscope makes this browlift operation capable of being done through a much smaller incision. The operation can still be done the conventional way but the device results in a procedural innovation.

A device-dependent operation uses an implant to create the final effects of the operation. In essence, the implanted device is the operation for without it the intended result could not be obtained. An example would be a breast augmentation. The implant is solely responsible for the surgical outcome. While the implant must be properly handled and placed by the plastic surgeon, the desired outcome could not be achieved.

While the differences between these two types of plastic surgery operations may seem subtle, there is one significant aspect in which they are quite divergent. And this difference is really important for patients to understand and appreciate. The complication rates and the risk of the need for revisional surgery is dramatically disparate between these two types of device-driven operations. There are substantially higher rates of revisional surgery for implanted devices than that in which the device merely helps do the operation.

The reason for these complication rate differences is that device-assisted operations rely on natural tissues for the final result while device-based operation outcomes are based on how one’s body responds to the implanted device. This would explain the revisional surgery rate differences, for example, between a facelift and a breast augmentation. Facelifts, no matter how they are performed, have a small incidence of the need for revisional surgery probably in the range of less than 5% in the first six months after surgery. Breast augmentation has documented revision rates of around 30% in the first three years after surgery. Many different reactions can occur to an implanted medical device. Only a few limited ones can occur from your own natural tissues.

Implanted medical devices have made numerous plastic surgery operations and great face and body contouring results possible. But they come at the risk of higher complication rates and the potential need for revisional surgery. The risk for problems and revisional surgery is also lifelong or as long as the implant is retained in the body. Thus lies the difference between device-assisted and device-based plastic surgery.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

Rhinoplasty (nose surgery) is one of the top ten procedures performed around the world in plastic surgery for men and women. Due to the tremendous complexity of nasal anatomy, the many different components of bone and cartilage which overlap and interdigitate, and the potential unpredictable forces of healing and scar contractures, rhinoplasty surgery results are rarely perfect. Like all plastic surgery procedures, it carries with it the risk of undesired aesthetic outcomes and the possible need or desire for revisional surgery in the future.

Historically, high revision rates particularly if one looked at very long-term results existed in rhinoplasty when the closed approach was exclusively used. Due to the now widespread practice of open approaches in rhinoplasty in the past 15 years, I am certain that the need for revisional surgery in rhinoplasty has dropped. With better visualization of nasal anatomy, an improved focus on conservative bone and cartilage removal, and improved suturing techniques with or without the use of cartilage grafts, rhinoplasty outcomes have become more predictable.

However, despite these newer techniques, the potential risk of the need for revisional rhinoplasty is not eliminated. As a general rule, I do not like to undertake revisional rhinoplasty until 6 to 12 months after surgery. While this is much longer than most patients would like to wait, it is important that you are operating on a ’stable target’. Meaning…let all the swelling and changes take place so you know what it really looks like. The initial problems that were seen may have become less of a visible or psychological concern or the problem may actually have gotten more noticeable or more of a concern. Either way, more time allows the decision for revisional rhinoplasty surgery to become self-evident.  Unless it is a major problem that a patient simply can’t tolerate, I would prefer to be on the longer side of this issue, closer to one full year after surgery. The skin over the nose is also much softer at this point and the tissues are closer to normal in their handling, although they will never be completely unscarred and always more difficult to handle than the first time.

While the need for secondary rhinoplasty is probably around 10% or less in most plastic surgeon’s experiences, the need for ‘revision of a revision’, otherwise known as tertiary rhinoplasty, is probably much higher than 10%. Fixing a previous problem, particularly if it is not a very minor one, is not easy and esults are more unpredictable than when the rhinoplasty was first done.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Indianapolis

The single most common aesthetic complication in liposuction surgery is irregularities or contour depressions. These aesthetic issues are not rare and are often present in very minor manifestations that are acceptable to most patients. They are most common on non-flat contour areas such as the thighs due to the use of a straight cannula around a curved surface. Artistic skill and experience lessens the risk of these contour issues but, even in the best hands, the risk of asymmetry and irregularities are possible.

 
There are two fundamental approaches to treating liposuction defects, further use of liposuction and liposhifting, fat grafting, or some combination of these two techniques. Liposuction is useful when the irregularity is caused by inadequate fat removal and a high area needs to be reduced to match the surroung area. Fat grafting is used in the opposite circumstance when too much fat has been removed and the area needs to be built up. Quite frankly, better results are obtained when a lipo-treated area needs to be reduced and this is easier and more predictable. When adding injected fat grafts, the results are much more unpredicable as the amount of fat that may survive is not predictable.

 
A modification of these corrective techniques is an amalgamation of both, known as liposhifting. In this method, the fat is sifted from the surrounding tissues into a hollow or indented area without actually removing it from the body. While this technique is theoretically appealing, it does cause a lot of trauma to the treated area and some residual hardness of the overlying skin has been seen due to the amount of undermining.

 
While it is always better to avoid these complications, an admixture of these corrective liposuction techniques consistently provides improvement, albeit not perfection.

Dr Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

There are hundreds of thousands of cosmetic procedures performed ever year in the U.S. The outcomes of these procedures can be influenced by two factors: how the body responds to the insult of surgery and the unpredictable forces of wound healing. As a result, undesirable complications can occur and the subsequent need for revisional surgery may be necessary.

In plastic surgery, the occurrence of complications presents issues that are different from most other types of surgeries. Unlike more typical postoperative problems such as infection or bleeding, the healing of the surgical site in a cosmetic procedure may be perfect but the desired appearance of the operated area less than anticipated. These two potential postoperative problems, difficulties with wound healing and suboptimal or less than optimal appearance, exposes the cosmetic surgery patient to the potential need for revisional surgery.

While the actual need for revisional surgery varies amongst the type of cosmetic
procedure performed and who performs it, it has been estimated that it averages around
15%. Some estimates are even higher. While revisional surgery is often minor, it can be
seen with this estimated number that the need for secondary surgery in cosmetic
procedures is not rare. Any cosmetic surgery patient needs to understand this risk and be
accepting of it.

When postoperative complications develop and the need for revisional surgery
becomes apparent, there is unhappiness on the part of both the patient and surgeon. The
cosmetic patient is dissatisfied as they never really anticipated that this might happen, no
matter how well disclosed this risk was before surgery. Surgical problems are usually
thought of as ‘something that happens to other patients’. The cosmetic patient is usually
entirely focused on the benefits of the aesthetic outcome, and not at all focused on the
statistical realities of surgery.

This approach, unfortunately, has been fostered by plastic surgeons themselves with the many promotional advertisements promising ‘weekend facelifts’, ‘scarless surgery,’ and other often unrealistic outcomes. As a result, cosmetic surgery is often not perceived as “real” surgery with associated risks.

 
Like the patient, the surgeon is equally not enthused about the need for revisional surgery. There are many reasons for such a response by the surgeon: from knowing that this is not what the patient expected, a perceived failure of their own skills and expertise, and how this result reflects on their own reputation and image. As a result of these opposing perspectives and even potentially conflicting agendas, a difference in opinion may develop between the patient and surgeon as to the need and advisability of revisional surgery. In these circumstances, patients often seek out other surgeons to undergo their revisional surgery, getting a ‘fresh’ perspective on the problem.

When needed, however, surgical revisions should be done in the proper
setting and under the appropriate circumstances. Certain minor revisions can be reasonably performed under local anesthesia in the office. This approach is simple and avoids the use of the operating room. Many times, however, this office approach to revisional surgery is ‘overused’ in an effort to save the patient further expense. As a result, the desired outcome may still be compromised as this environment (lack of good anesthesia, lighting, or equipment) may not permit what really needs to be done. In many cases of revisional surgery, the patient and surgeon needs to be willing to accept the additional arrangement and expense of an operating room to put themselves in a position where the procedure can be carried out properly.

In conclusion, the potential need for revisional surgery is a statistical reality. Revisional
surgery from cosmetic procedures carries with it an unfortunate combination of physical,
emotional, and often economic consequences. An open and understanding dialogue with
your surgeon, preoperative informed consent of the risks and consequences and patience
with the healing process, is the best way to prepare should the need arise for this potential
reality from cosmetic surgery.

Dr Barry Eppley
www.eppleyplasticsurgery.com
www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis