Here, we deal with those post-operative complications that can occasionally occur with any surgical procedure. Complications, which are peculiar, specific or unique to a particular procedure, are discussed in more detail within the relevant entry.
The human body is a very complex entity. Despite our current knowledge, we are still only scratching the surface with our understanding of the many intricate mechanisms of its functions and behaviour. We have limited understanding and therefore limited control over the complicated healing process that starts once we down tools.
We rely on the intricate biological, physiological and immunological systems to interact in a controlled and synchronised manner to heal the tissues and give a pleasing cosmetic result with the minimum of scarring or tell-tale signs of surgery. We expect our bodies to do all this despite the magnitude of the physical assault inflicted by the surgery.
The complex mechanism of the healing process is usually the patient's best friend. If all goes according to plan, an area that has been operated on will heal quickly with the minimum of bruising and swelling, leaving a thin scar, barely visible to the naked eye.
On the other hand, the opposite can occur, through no fault of the surgeon, and the operated area may become excessively bruised with permanent pigmentation, persistent swelling or thickening of tissues and a very visible disfiguring scar. At worst, the post-operative appearance may be more disliked by the patient than the pre-operative: Revision surgery may be required in an attempt to improve the final result. Thankfully this doesn't happen very often in experienced hands but, when it does, it understandably causes the patient and surgeon concern.
Every surgical procedure carries a risk, even if performed by the world's best surgeon. It is therefore important for everyone who is contemplating cosmetic surgery to be fully aware of the possible complications that may occasionally occur. This will lessen the psychological trauma and disappointment should anything go wrong.
Nervous patients may be unhappy to take the risk of surgery once they have been informed of all the possible consequences. Bolder ones may be perfectly happy to proceed. In either case it is the patient's decision, and an ethical surgeon has a duty to give a balanced account of all the risks. In conventional surgery, a surgeon may well try to persuade a patient to have an operation because he believes it is in their medical interests to go ahead. The benefits to their physical health may well outweigh any risks. This is never the case in cosmetic surgery. By definition, it is not medically essential. Thus the patient alone must choose whether they wish to expose themselves to the risks of their procedure. Some patients find it difficult to translate numerical probabilities into factors that affect their decisions on a daily basis. For example, people who truly appreciate the chances of winning the lottery don't waste their money on a ticket!
Most of the complications that are described here only happen to a very few, unlucky patients. Indeed, cosmetic surgery is safer and more predictable than conventional surgery, mainly because the patients are healthy — or should be — before the operation. Serious post-operative complications are rare and, if they do occur, further surgery will often rectify or improve the result.
In order to appreciate why complications are unpredictable or indeed occur at all, we must appreciate that every human being has a unique genetic profile. Our genetic profile ultimately controls our health and the way we react to a given set of outside influences or stimuli. It also controls the way our healing process reacts and behaves. Flaws can sometimes occur in the healing process and can predispose to a poor result.
Scars
All surgical incisions heal by producing a scar. To make scars less obvious the surgeon tries to make any necessary incisions where they will not easily be seen, such as in natural skin folds or inside the hairline. It is wrong to think that scars will be invisible or that they will completely fade to nothing in time. The term 'invisible scar' should never be used. Wound healing is an extremely complex, biochemical process involving many variables. For this reason the final results of healing cannot be accurately predicted.
Once an incision is made and sutured (stitched) the surgeon has little control over the healing process.
Most scars will look worse (red and raised) for some time after the operation before they mature and become pale and level with the surrounding skin. In general, scars take six to 18 months to mature (in some cases, they can take longer). There will always remain a permanent mark, no matter how inconspicuous, where an incision has been made.
In some situations scars can heal unfavourably in certain people. Scars may become infected, stretched or thickened (hypertrophic or keloid) and may necessitate further treatment eg. steroid injections or scar revision to improve the Final cosmetic appearance. Even in someone who has never had a history of unfavourable scarring, the unexpected can occasionally happen and mar an otherwise good result.
Some areas of the body and some skin types are notorious for producing worse scars than others eg. over the breastbone. Where an incision is sutured under tension there is a good chance that the scar will stretch, for example, in abdominoplasty.
If a ten-centimetre incision is made on the forearms of 100 individuals and sutured in exactly the same manner, the final outcome after two years would give a variety of results. At one end of the scale the scar would be almost invisible. At the other, a thickened, raised and red hypertrophic or keloid scar would result This simple example also applies to more complex procedures; unfortunate healing such as this can thus give an unfavourable result to a procedure that has been otherwise expertly performed.
Infection
Infection can occur after any surgical procedure. Most commonly the wound (incision site) is affected. If the infection progresses, the adjacent and surrounding tissues can become affected. This condition is known as cellulitis. Further progression of the infection may lead to formation of a localised deep pocket of pus or abscess formation.
Fortunately, infection in cosmetic surgery is not common and is easily treatable, usually with antibiotics, rest and local hygiene measures. Abscess formation must be more vigorously treated, often necessitating further surgical intervention in the form of a drainage procedure. Abscess formation is extremely rare but can occur following some cosmetic procedures, such as breast surgery, abdominoplasty and liposuction.
Sometimes chest infections occur after surgery, especially in smokers and patients with previous chest or breathing problems.
Finally it must be mentioned that MRSA (methicillin resistant staphylococcus aureus or 'superbug' as it is labelled by the press) is increasingly becoming the scourge of our hospitals. If an MRSA infection is diagnosed, it can be extremely difficult to treat. It is rare in previously healthy patients who only spend a short time in hospital, which is the usual situation in cosmetic surgery.
Bruising and Swelling
This is the body's natural response to injury. Every surgical procedure is followed by a period of bruising and swelling, depending on the nature and extent of the surgery.
In general, the more expert and adept a surgeon is, the less post-operative bruising and swelling will result. This is because an experienced and slick surgeon will perform an operation or procedure with the least amount of imparted trauma to the tissues.
The patient's response to trauma is also an important part of the equation. Some people bruise more easily than others and this can be caused by variations in the fragility of their blood vessels and the levels of blood coagulation (clotting) factors. Most elderly people have more fragile blood vessels than the young. Low levels of blood coagulation factors can run in families, even without obviously diagnosable bleeding disorders.
Although there has been much controversy about its effectiveness, many surgeons recommend a course of arnica tablets both before and after surgery to help reduce bruising and swelling and to enhance the healing process.
Pain and Discomfort
Following any surgical procedure the patient will experience a degree of pain and discomfort. Although research has given us an increased understanding of the mechanisms of pain and its perception by the human body, the best we can still do is to give appropriate medication in an attempt to alleviate or reduce pain, especially in the immediate post-operative period.
The degree and duration of post-operative pain will depend on the nature of the operation and the patient's pain threshold. Little can be done at present to alter an individual's pain threshold. The standard painkilling injections and tablets usually suffice to alleviate this unpleasant sensation to a tolerable degree.
It is therefore extremely difficult if not impossible to describe accurately to patients beforehand the degree and duration of their post-operative pain.
Deep Vein Thrombosis
This complication is rare in patients undergoing elective cosmetic surgery. Deep vein thrombosis (DVT) results when a blood clot develops in one or more deep veins in the calf. It is possible for the clot to become dislodged from its origin in the calf and be transported by the bloodstream to the lungs (pulmonary embolus) where it can have very serious consequences. Patients with a previous history of post-operative deep vein thrombosis should warn the surgeon and the anaesthetist before the operation.
Women taking oral contraceptives may run a slightly increased risk of developing a deep vein thrombosis after some operations. There is some controversy about the benefit of stopping oral contraceptives before surgery. Many medical practitioners hold the view that an equal or even greater risk is incurred from the possible complications of an unwanted pregnancy upon cessation of the pill. Nevertheless, it is thought wise to stop oral contraceptives prior to certain operations. Every patient is assessed on merit before surgery and the surgeon should advise each patient accordingly.
Nowadays the best equipped hospitals and clinics have equipment that massages the calves while the patient is under general anaesthetic. In addition, it is now standard practice for all patients to wear anti-embolism stockings during and after the operation.
The incidence of DVT is very much reduced if patients resume gentle activity soon after the operation. It is not a good idea to spend several days in bed after surgery if it is possible to get up and move about. This is not to say that patients should strenuously exercise soon after surgery, as this is likely to have a very deleterious effect.
Allergic Reactions to Drugs and Dressings
Various drugs are given during a hospital stay in the ward or injected during the course of a general anaesthetic. It is important to avoid being given any drug to which you might be allergic. You must report any known allergy especially to drugs, dressings and foods to the nursing staff on admission to hospital. Severe allergic responses have to be dealt with promptly and effectively to avoid serious consequences.
Bleeding and Haematoma
Sometimes bleeding can continue after the end of the operation or restart again several hours after completion of the operation. It can either track to the surface and manifest itself as localised bruising or collect in a space or pocket deep in the skin. Such a collection of blood is called a haematoma and if it becomes large enough (expanding haematoma) it will be necessary to remove or evacuate it through a further procedure.
In certain cosmetic procedures an expanding haematoma constitutes a surgical emergency in that, if it is not treated promptly, irreversible damage to the surrounding tissue can occur. The best example of this is an expanding haematoma developing under the skin flap following facelift surgery resulting in 'flap necrosis' or death of the skin.
Drains
Sometimes small flexible tubes are used to enable collections of blood or other fluids to drain out from a wound. This reduces bruising and speeds recovery. They are removed a day or two after the operation. Modern drains are made of pliable plastic and remove easily without causing discomfort.
Problems with Urination or Urinary Tract Infection
Patients who are prone to urinary or kidney infections have an increased risk of this happening after surgery. This may be due to lying in one position for a prolonged period during the operation and its recovery, and also because drinking a lot of water is discouraged immediately before surgery.
Blood Transfusion
Blood transfusion is seldom required in cosmetic surgery. All blood is carefully screened by the blood transfusion service for any infectious agent before it is released for use.
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