An Unspoken Concern
While most plastic surgeons will outline the risks of having an elective surgical procedure performed, very few tend to speak directly to the issues regarding safety and post operative complications. Often, a surgeon will make a general statement regarding the risks of surgery, such as, "All surgery carries risks which includes, bleeding, infection, difficulty breathing, swelling, clotting, and other illnesses in a small percentage of patients," and then move directly into talking about the benefits of the procedure. Patients need to inform themselves of the actual risks associated with cosmetic surgical procedures, especially the risk of a stroke or cerebral vascular accident (CVA). As a physician, I understand that there is no value in frightening our patients without cause. Yet I still firmly believe that patients should never be too quick to decide on an elective surgical procedure without fully realizing the potential for devastating complications.
Patients and physicians alike need to recognize that most patients who are receiving some sort of cosmetic care are generally considered to be healthy individuals. Thus, neither patient nor physician is necessarily ready for the onset of a complication. This fact alone can make a complication much more serious than if the very same complication arose during a medically necessary procedure. For instance, even during a routine knee surgery, physicians do not see their patients as completely healthy, and are more guarded against the onset of blood clots or other risk factors for stroke.
While the approximated one to two percent of cosmetic surgery patients who will experience a stroke seems like a very limited number of patients, the effects of these strokes can be devastating
Who is at Risk?
Few patients really consider themselves at risk for a possible stroke because they associate the condition as an event that occurs to people over the age of 55. While in some cases age does bear a factor, it is far from the determining factor of a stroke. In fact, a healthy 65-year-old woman can be less likely to have a stroke than a 35-year-old woman who is undergoing invasive cosmetic surgery. Patients should understand the causes of a stroke in a post operative environment in order to assess more realistically their level of risk. However, as a physician I can testify to the fact that sometimes there simply is no way to ascertain why a stroke occurred for one individual and not for another with the same health history, the same risk factors, and the same surgical procedure.
Most post operative strokes occur when a blood clot dislodges, which typically occurs in the lower section of the body. This blood clot then travels through the body and may lodge itself in the brain or more commonly the lungs. This action of a blood clot traveling through the body post surgically is commonly referred to as an embolism and usually arises from a larger blood clot that usually forms in the lower body known as a deep venous thrombosis or "DVT". DVT is a prime concern for surgeons, and can be considered a precursor to a stroke.
Understanding the Potential Danger
Blood clots generally become trapped in either the lung or the brain when they break free from other parts of the body. When the blood clot becomes caught in a blood vessel in the brain, it results in a CVA or stroke. When it becomes trapped in a blood vessel in the lung it is known as a pulmonary embolism or PE. Either condition is life threatening and can carry serious consequences.
While blood clots and strokes are a significant risk for all patients having any type of invasive surgery, plastic surgeons run into a unique scenario that generally makes it a little more difficult for our patients to get treatment and help in a short amount of time. Incidents of blood clots and stroke can happen anywhere between several hours post operatively up to about ten days after surgery. Thus, these incidents rarely occur within a medical environment and usually happen at home. Patients who remain in the hospital or a medical center after a medically necessary procedure are more likely to have these incidents in the hospital.
Patients, who are going to experience a cosmetic procedure, or any type of surgery for that matter, should familiarize themselves with the general symptoms of post surgical pulmonary embolism or stroke. Symptoms that include shortness of breath, chest pain, disorientation, and sometimes even a sense of altered mental status are likely either to be related to a pulmonary embolism or a stroke. Patients and physicians alike should also understand the basic risk factors for these complications and prior to a surgical procedure. While there are still studies being conducted, which will help determine a patient's risk level in the future, there are some pretty basic factors, which point to a likely candidate.
Risk Factors For Patients
Women are more likely to experience these types of complications than men, as are smokers. There are numerous medications, which place patients at a higher risk for postoperative blood clots, including but not limited to hormone replacements and birth control pills. Weight plays a significant factor as does the level of activity the patient generally participates in. Patients who generally lead a sedentary lifestyle are at a higher risk. Obese patients are at an even higher risk. Increased age and a previous history of deep venous thrombosis are more obvious risk factors. Patients who have a current diagnosis of cancer are at a particularly high risk.
Reducing the Risk Factors for Safer Surgery
Whenever a patient is booked for surgery in my practice, I always insist that they have a medical clearance by an internist to help determine their general risk level for elective surgery and the possibility of medical complications, which includes the risk of abnormal blood clotting. I also take into consideration the type of surgery that I am performing on the patient. In general, surgical procedures that have a longer operative time and involve body contouring carry a higher risk than those that are minimally invasive and are performed on the head and neck. The internist will review a list of current and recent medications, as I do myself, and will verify that the patient is physically fit to tolerate the procedure that is desired. There are still no guarantees, but knowing a patient's medical history, their obvious risk factors, and having a second pair of eyes look over the same information that I am presented with, ensures that I am taking all possible precautions.
I also use something known as pneumatic compression boots for every patient undergoing any surgical procedure and I urge other physicians to do so as well. These boots are able to keep the muscles of the lower extremities moving in a fashion similar to walking, which can help prevent blood clots. I insist that my patients carry on an active lifestyle, to help prevent DVT formation and to directly assist with both preoperative and postoperative care. Proper positioning in the operating room allows for additional prevention of blood clot formation as well.
Physicians and patients need to understand that the potential for serious complications related to cosmetic surgery can be devastating. Knowledge is power and education can help reduce the number of blood clots and such rare but devastating complications as strokes that occur after surgery. With current research and education practices, we should be able to reduce the number of post operative strokes and blood clots over the coming years.
Dr. Robert Silich is a New York board-certified plastic surgeon in private practice. Dr. Silich is Clinical Assistant Professor of Surgery at Cornell University Medical College and specializes in all areas of aesthetic surgery with particular emphasis on facial rejuvenation and minimally invasive surgical techniques. Robert Silich MD is the author of the popular Plastic Surgery Blog.
