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Preparing for Surgery

Who is a Good Candidate for Plastic Surgery?

Before undergoing any surgical procedure, you should be in good physical health, at a stable weight without yo-yo dieting and drastic weight fluctuations, with a regular exercise regime and well-rounded diet with no major nutritional deficits.

Physical, mental/emotional and spiritual “health” is paramount to a successful outcome for any procedure! When you are planning to have Plastic Surgery, you should have the support (emotional and physical) of your family and close friends for assistance with some activities for your specific recovery period, as instructed by your surgeon.

You may not be an appropriate candidate for surgery if you are a smoker, if you have poorly-controlled diabetes or an inadequately treated major medical problem or if you do not have good overall “health” as described above.

Your past medical history and current medical status will be evaluated at your consultation. You may be asked to see your Primary Care Physician for a full physical examination and appropriate laboratory tests prior to being medically cleared for surgery.

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Why is Smoking a Such Problem When Considering Plastic Surgery?

Smoking is a major risk for wound healing problems and infection for any surgical procedure. Smoking should therefore be stopped At Least 6 Weeks Before considering surgery. Nicotine gum and nicotine patches are also not allowed, as nicotine is a “vasoconstrictor” (constrictor of vital blood vessels for healing) that can be detrimental to wound healing and can promote complications.

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What Actually Happens During Plastic Surgery?

Any Plastic Surgery procedure is a major operation and is optimally performed under general anesthesia. Although it is possible to perform some procedures under local anesthesia with sedation in an office setting, Safety is the number one priority for each of our patients! Surgery is usually performed at a fully accredited hospital, as an outpatient procedure in the main operating room (O.R.). Occasionally an overnight stay at the hospital is recommended if surgery will be more than a few hours or if multiple procedures are planned.

Your surgeon will be there to hold your hand and reassure you as you drift off to sleep. Positive thoughts and affirmations are encouraged in the O.R.; feel free to discuss this with us at your preoperative visit.

Once you are asleep, your chest (for breast procedures), abdomen or other body areas (for abdominoplasty, liposuction or free flap procedures), or face and neck (facial procedures) are prepped and draped using a sterile technique. Your head and arms are gently secured to enable changes in position from lying down to sitting upright during the procedure, helping to ensure the best possible result in all positions.

Please see the specific detailed information about each surgical procedure you are considering to learn more about what happens during surgery.

At the end of your procedure, a Drain will be inserted if necessary. Incisions are closed using dissolving “sutures” (stitches), and soft dressings or garments are placed while you are asleep. When you become aware, you will be in the recovery room and your procedure will be complete.

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Hi Dr. Horton: First of all I would like to personally thank you again for your excellent care. I am so grateful to have found you and know that I am one of the luckiest ladies in the world to be in your care. You truly understand my concerns. I am actually excited for surgery. I know that I can trust you and that I am going to be extremely happy with my surgical outcome. I have delayed this long enough and I am confident that the choices I will make will be the right ones. Thank you for being so wonderful!

How Can I Best Prepare for Plastic Surgery?

The realm of Plastic Surgery includes many wonderful and exciting procedures! However, to have the best possible experience, for the smoothest recovery and to limit any chances of complications, surgery should be done at a time in your life when “the waters are calm”.

In other words, you should be at a stable point in your life, both physically and emotionally. You should be at your healthiest, not be in the midst of any personal or professional chaos or other acute stress that could negatively impact healing or distract from what should be a positive and extremely rewarding experience.

Having Plastic Surgery is a personal choice and for many people, a very private decision. Yet, it is important that you have the support of at least one or two close friends or family members – your immediate circle that will be part of your “postoperative recovery team”. Let them in on your plans for surgery, and educate them about how they can help you afterwards. You should know who your supporters are, and to feel comfortable asking them for help with things you will need assistance with for a short period of time after surgery.

It is wise to bring a member of your recovery team with you to your preoperative visit at the office. They will also learn about how to best help you prepare for your procedure, what to expect the day of surgery, your temporary postoperative restrictions, and how to help facilitate your recovery. See our Postoperative Instructions section for more information on recuperating from Plastic Surgery.

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Adjustment of Body Image after Plastic Surgery

After any body-modifying surgery, no matter how minor, you will undergo a period of body image adjustment. Usually the change to your body is very exciting, one that you have been planning for some time! However, your brain needs time to adjust to your new body, and to accept your new body image. During this time, you can feel somewhat “out of sorts”, teary, anxious, or even slightly distressed. This is entirely normal!

We counsel our patients and their families about this phenomenon prior to surgery. It is important to keep watch for how you are feeling after surgery, and to allow yourself the time needed to fully recover physically, mentally, and emotionally after surgery. If you are feeling somewhat uneasy after surgery, give it time. Even major body changes will be incorporated into your body image as “the new normal”. This can take weeks to months, and we will help you through it. Our patients are uniformly delighted with their surgical results.

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What Are Potential Risks and Complications of Plastic Surgery?

Potential risks and complications include general risks related to any surgical procedure and those related specifically to the area of the body that will be addressed.

All surgical procedures carry with them the risk of Nausea and Vomiting after general anesthesia. You will be given anti-nausea medications preventatively while you are asleep. Additional medications will be given to you as needed if you feel nauseated. Any feelings of queasiness will pass within a few hours.

During surgery, blood vessels are delicately cauterized to prevent against Hematoma, a blood collection under the skin. The risk of hematoma is increased if you have bleeding after surgery related to increased heart rate or blood pressure, or if you have been on any blood thinners before surgery.

Seroma is the collection of wound fluid that occurs in the area of surgery (such as around a breast implant) for a few days up to a week or two after surgery. This fluid will be gently whisked away while you are healing by way of drains. Because seroma fluid is an excellent medium for bacterial growth, the use of drains greatly decreases the risk of infection and enables the smoothest recovery with the best results.

Some degree of Asymmetry of your breasts or from one side of your body to the other is likely present before your surgery. In fact, no two breasts are exactly alike, and many differ by a cup size or more naturally. This will be pointed out and documented during your initial consultation. Symmetry is always the goal for all types of Plastic Surgery, particularly breast surgery. For breast augmentations, occasionally different sized implants and/or additional surgical steps are required to help correct for preexisting asymmetry of the breasts.

Immediately after surgery, you can expect a temporary Change in Sensation in the area of the body that has been operated on. You will gradually regain normal sensation over many weeks to months. Occasionally, you may feel electric-like “zingers” or tingling sensations as your nerves “wake up” and generate spontaneous signals – this is completely normal! Be patient as your nerves recover; unusual sensations are a sign of nerve recovery.

After a breast augmentation, it can take up to a full year in some cases for nipple sensation to return. Loss of Nipple Sensation is possible after a breast reduction or a mastopexy. Depending on the degree of breast droop and essential reshaping, major rearrangement of the breast tissue may create numbness to the nipples that may take months or even longer than a year to resolve. It is possible you may not regain full sensation to the nipple after major breast surgery such as a breast reduction.

Contour Irregularities can occur after any body contouring procedure, including liposuction. Liposuction does not completely remove cellulite but can often improve preexisting contour deformities. Should subtle waves or ripples persist after liposuction surgery, correction can be done if needed in the office, often under local anesthesia.

A final RARE complication related to lengthy surgery under general anesthesia is the potential for blood clots forming in the legs, known as Deep Venous Thrombosis (DVT). To protect against DVT, double coverage protection is instituted: you will wear special medical compression stocking and you will have sequential compression devices (SCDs) placed around your calves in the operating room before your surgery. These preventative devices are on you for the entire surgical procedure and afterward until you are moving around on your own. The risk of DVT is generally over after the procedure – you do not need to continue wearing these devices at home!

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What are Special Considerations for Facial Plastic Surgery?

The decision to have facial Plastic Surgery is a personal and significant one. Like any surgical procedure, the potential risks of surgery must be weighed against the expected benefits in order to determine whether having surgery is indeed for you. What makes facial surgery unique is that the results are visible immediately after surgery, while surgery of the breasts or body can be concealed beneath clothing during the initial healing period.

For this reason, it is imperative to learn about all potential risks of facial Plastic Surgery, including both the common and very rare complications. Awareness of possible unfavorable outcomes and risks will help you make the decision whether surgery is for you, and will enable you to proceed fully informed and educated.

Specific Possible Risks of all Facial Surgery such as a facelift, brow lift, blepharoplasty (eyelid surgery), neck lift, rhinoplasty and earlobe surgery include the following:

Unfavorable scarring, bleeding (“hematoma”), fluid accumulation, infection, poor wound healing, anesthesia risks, correctable hair loss at the incisions, fluid accumulation requiring drainage after surgery, skin discoloration, bruising, skin sensitivity or temporary facial swelling.

More Uncommon Risks of Facial Surgery but those worth mentioning include:

Facial asymmetry, facial nerve injury with weakness or abnormal facial perspiration, skin loss, permanent numbness or other changes in skin sensation, loss of fat deep under the skin (“fat necrosis”), persistent pain, skin contour irregularities, “spitting sutures” that may spontaneously surface through the skin, become visible or produce irritation that require removal, unsatisfactory results including asymmetry, unsatisfactory surgical scar location, unacceptable visible deformities at the ends of the incisions, and the possible need for revisional surgery.

For those procedures that involve the Eyes and/or Brow, further rare but potential risks include eye irritation or dryness, eyelid disorders involving abnormal low position of the upper eyelids (“eyelid ptosis”), loose eyelid skin, abnormal laxity or rolling out of the lower eyelid (“ectropion”), difficulty closing the eyes, or “lid lag” (pulling down of the lower eyelid} that is often temporary. Many of these conditions are self-resolving but a minor revision may be necessary for correction if a complication should arise.

For Rhinoplasty procedures, specific possible risks include breathing difficulties through the nose (nasal airflow obstruction), sinusitis (infection of the sinus cavities related to internal swelling after surgery), cartilage or bone graft or implant migration (if used during a rhinoplasty), septal perforation, dissatisfaction with the cosmetic results, and the need for revision rhinoplasty.

As a general principle, the practice of medicine and surgery is not an exact science. While reliable outcomes and beautiful results are anticipated in most patients, there is no absolute guarantee of surgery. In some situations, a second minor procedure may be needed after a period healing to achieve the most favorable results.

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What are Special Considerations for Breast Surgery?

Breast implants are foreign bodies and carry a small risk of becoming infected. To prevent against Infection after surgery, a number of steps are taken: (1) you are given an intravenous antibiotic at the time of surgery, (2) you are sent home on oral antibiotics, and (3) drains are used to remove fluid around the implant while you are healing.

To prevent against even more rare late infection, we also recommend a single dose of prophylactic antibiotic before procedures involving bacteria (such as teeth cleaning, dental procedures, sinus surgery or colonoscopy). We ask that you avoid having your teeth cleaned or elective dental procedures for three months after breast augmentation surgery. See our section on antibiotic prophylaxis for more information about antibiotics and breast implants.

“Capsular Contracture” is hardening of scar tissue around an implant that occurs infrequently after breast augmentation. When an implant is inserted into the body, a scar tissue shell forms around it known as a “capsule”, which forms the lining of the implant pocket. Ideally, the capsule will be larger than the implant itself to allow for slight shifting of the implant within this space as the body changes positions, just like a natural breast. If excess scar tissue forms around the implant, the capsule may contract, leading to a firm feel to the breast, a change in shape, or if extreme contracture, pain.

Capsular contracture is usually either a result of infection or excess blood around the implant, each of which creates significant inflammation and signals the body to create excess scar tissue. To prevent against capsular contracture, we use preventative antibiotics and drains, and we educate you thoroughly both before and after surgery about breast implant massage.

Your surgeon will see you weekly for the first month after breast implant surgery to ensure that you are healing well and that your breasts maintain their soft and natural feel, without any problems. Should you develop a capsular contracture that is painful (exceedingly rare), additional surgery may be needed to surgically remove scar tissue. However, if you are a compliant with your postoperative instructions, your chances of developing capsular contracture are exceedingly slim.

A breast implant is a medical device, and as such may have a limited lifespan; it cannot be guaranteed to last a lifetime. At some point, the breast implant may require replacement via additional surgery if it were to “fail”. However, Implant Failure is not an emergency and is never a threat to your life or your health. Saline-filled implants can deflate, and your body will absorb the sterile saline fluid. Gradual loss of breast volume is a sign that a saline implant is slowly deflating. This is certainly not risky and does not pose any health hazard to you! A deflated saline implant can be removed and replaced with either a new saline implant or a silicone gel implant at your convenience.

Silicone gel implants can fail or “rupture”. This sounds very dramatic, but is in fact not the most accurate term to describe gel implant failure, as it does not explode! Silicone is an inert substance and is impermeable in the body, unlike saline. This means that if an opening were to occur in the implant shell, and if silicone were able to leave the implant lining, it would remain within the capsule of the breast. Loss of implant integrity is usually only a concern following major trauma to the breast (such as a high-velocity car crash or penetrating chest wound). An MRI scan can best visualize the implant shell and detect whether an implant is intact. If a gel implant shell is breached, removal of the device and replacement is recommended, but is not an emergency and can be done at your convenience.

If you are considering a breast reduction, please read our Breast Reduction Criteria Letter below.

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What Kind of Follow Up Will I Have after Plastic Surgery?

Long-term follow up is recommended after any type of Plastic Surgery. You will initially be seen a few days after surgery, and then in a week or two to ensure you are healing well, without any complications. You will then return to the office approximately 3 months after surgery, at 6 months postop, and yearly thereafter. For cosmetic procedures, there are no financial charges for these visits. The rationale for long-term follow up is to ensure that your beautiful results remain constant over time, and with future changes to your body such as age, weight changes, and pregnancy or breast feeding.

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Dr. Karen M. Horton, M.D. - Plastic Surgery, Physicians & Surgeons - Medical-M.D., San Francisco, CA