Assessing Surgical Risks
While surgery is incredibly commonplace, and is probably safer than driving to work or going into town everyday, there are always risks associated with its undertaking. When the operation is medically necessary (improving function or decreasing pain), the acceptance of surgical risks is usually taken much more ‘lightly’, the alternative options are usually worse than the potential risks. Cosmetic surgery, however, carries with it a completely different set of risk considerations from most any other type of surgery. The operation is completely elective, it is changing appearance and self-image only and improving very little of any medical function, and the patients on average are much healthier and often younger as well. As a result, when a tragic event happens after cosmetic surgery, such as death, it is much more noteworthy (although no more tragic) than a similar event happening after a hip replacement or cardiac bypass surgery.
The most recent reported death of a famous singer’s mother brings all of this to mind. While I have no information as to exactly what procedure she was having or what caused her demise, it likely involved some form of body contouring surgery, perhaps liposuction or a tummytuck. I say this because most deaths or severe medical complications after cosmetic surgery are overwhelmingly from body surgery, not facial surgery. Long hours of surgery can be done on the face without significantly affecting bodily functions. While we don’t like to think of our precious faces this way, but they are peripheral to most major bodily functions, are only operated on the very outside, and are proportionately a small surface area compared to the rest of the body. Due to an excellent blood supply, facial infections are rare and bleeding after surgery rarely poses a problem of ‘bleeding to death’, such bleeding is however very disruptive and deforming to the intent of the operation. This is in stark contrast to body surgery where the surface area of surgery is much greater. Issues of temperature control (avoiding hypothermia), adequate fluid levels, control of bleeding points, and the quality and nutritional status of the patient’s tissues became much more important. In body surgery, liposuction (particularly high volume) is a common culprit in postoperative complications and deaths. While there are no large incisions made, the trauma to the unexposed tissues under the skin is enormous. As the amount of fat removed gets higher, the body temperature drops, major fluid shifts in the tissues occur, and blood may stagnate in the calfs, running the risk of throwing a clot to the lungs. A most serious complication to be sure. Because liposuction is often part of an overall body contouring procedure, such as breast reduction/augmentation, tummytuck, etc., the operation can be quite extensive, perhaps too extensive in some cases. The length of surgery and the amount of trauma induced, in some higher risk patients, may tip the balance towards major complications.
It is up to the surgeon and patient to have an open discussion about what operations should be combined and for what length of time. The patient is often very enthusiastic, almost euphoric at times, as to everything they want in one procedure. Patients calculate the economics of one operation and recovery, the surgeon must calculate the risk. When I was younger, I would often do longer operations (6 – 8 hours) and do combinations of procedures that I would not undertake today. I have learned that it is just cosmetic surgery……more can be done later. Safety takes precedence over economics. It is much better to have the opportunity to have two uncomplicated recoveries. As a result, I won’t do cosmetic operations that take longer than 5 to 6 hours, involve excessive amounts of fat removed, and urge major body contouring cases to stay overnite to be properly monitored and cared for. I have grown particularly vigilant in body surgery of keeping the patient warm through surgery, their calfs massaged during the case with automated squeezers, and double-checking what medications (particularly herbal) they have been on prior to surgery.
Dr Barry Eppley
Indianapolis, Indiana