Patients considering cosmetic and reconstructive surgical procedures should have the opportunity to learn and to participate intelligently in decisions that can affect their lives, and should have realistic expectations. In addition, they should receive clear guidance regarding the negative as well as the positive aspects of such surgery. The informed patient will benefit more from his or her consultation with the surgeon*.
NOTA: The word “surgeon” refers to both men and women.
This booklet is aimed at preparing the patient and complementing medical consultations prior to surgery. It is intended to facilitate communication between the public and the medical specialists who provide these services.
Plastic surgery is a surgical specialty whose aim is to remodel certain body structures in order to improve their function and appearance.
Reconstructive plastic surgery is concerned with facial deformities, limb re-implantation, surgery of the hand, maxillo-facial and cranio-facial surgery, burns, congenital malformations, and tissue loss from trauma or surgery for cancer.
Aesthetic plastic surgery, on the other hand, is the branch of plastic surgery which is concerned with form and appearance. Its aim is to improve the appearance of certain areas of the body that are “unpleasing” in size or shape due to genetic or acquired causes. For example, aesthetic surgery techniques are employed in the correction of facial or eyelid wrinkling, nasal remodelling and reduction, breast augmentation or reduction, correction of protruding ears and, more recently, reduction of fat accumulation in certain areas of the body.
A plastic surgeon is a surgical specialist who has completed a minimum of four years of study and training in surgery after receiving a medical degree. He or she is thus specifically qualified to practise reconstructive and aesthetic plastic surgery. You may verify that your surgeon is a qualified specialist in plastic surgery by contacting the Canadian Society of Plastic Surgeons (1), in Quebec, the Québec Association of Specialists in Plastic and Aesthetic Surgery (2), the Canadian Society for Aesthetic (Cosmetic) Plastic Surgery (3) or the Royal College of Physicians and Surgeons of Canada (4). Your provincial College of Physicians and Surgeons will also be able to help you.
The techniques employed in aesthetic surgery are derived from those used in reconstructive surgery. In fact, aesthetic surgery is an extension of reconstructive surgery. It requires competent surgical skill, a sense of harmony of the body parts and good aesthetic judgement on the part of the surgeon.
Is aesthetic surgery for you? Your surgeon may feel that he can help you now, or he might advise postponing surgery until certain problems can be overcome. He may, on the other hand, feel that such surgery is not in your best interest and not recommend it. Your psychological make-up, motivation and physical health must all be taken into consideration in making the decision. Patients must be aware of the psychological impact of this type of surgery. They must clearly understand that there may be a significant difference between what can be done and what they expect. In brief, your surgeon and you must be on the same wavelength.
Motivation may vary from one person to another. You may simply want to feel better about yourself or you may think, for example, that surgery may improve your chances for professional advancement. These are good examples of valid motivation. On the other hand, aesthetic surgery will not salvage a disintegrating career or marriage.
Successful aesthetic surgery will improve the well-being of people by enhancing their appearance.
It is not always possible for a surgeon to fully satisfy a patient's requests and wishes. Surgeons have to contend with different individuals with varying characteristics. Many factors do not permit comparison of the results from one with those of another. Ideal cases showing apparently spectacular results, often seen in the media, may elicit false and unrealistic expectations. Your physique and body proportions limit the anticipated results from the available procedures. Therefore, do not expect to look like a movie star... Look for improvement in yourself while remaining yourself.
The plastic surgeon is neither a superman nor a magician. The final word belongs to the patient who has to heal from his or her surgery. Healing in surgery is a very important factor and each patient heals differently. If a person has a tendency to form excessive scars, the surgeon cannot prevent their formation. Some scars may be revised and improved but they cannot be prevented even if the surgery is performed in the best possible manner.
The ultimate decision to undergo aesthetic surgery requires complete understanding and agreement between the patient and the surgeon. It is the patient's duty to fully inform himself or herself regarding the procedure, and the physician's responsibility to provide the best possible services in the light of present knowledge. However, the end result of any surgery can never be fully predicted.
Some plastic surgery procedures depend on specialized medical implants. These implants do not always last a lifetime and may require removal or replacement. Such items are not exact substitutes for original body tissue. They have limitations which are part of the trade-offs for this type of surgery. It is in your interest to learn the basic facts about these implants. The implantation of a prosthesis entails long-term commitments on the part of the patient. These vary depending on the nature of the surgery and the condition of the patient. It is the patients' responsibility to comply with their physician's directives to avoid unnecessary risks and problems as well as to undergo periodic examinations.
Your plastic surgeon may take pre-operative photographs: they form an integral part of your medical file. They are helpful in identifying the problems and in planning appropriate surgical corrections. They also are very helpful in the post-operative period to remind both patient and doctor of the exact original appearance.
Patients sometimes ask to see pre-operative and post-operative photos of other patients in order to form a better idea of the expected results. Some surgeons will not do this, because they believe that showing such photos presents the solution of a specific problem in one person which may not be at all related to another patient's condition and thereby be misleading. Some patients thus tend to entertain false hopes regarding their eventual results. It is necessary to realize that what appears on a photograph or a TV screen and what may be done in a specific case are two different things. Other surgeons think that showing pre-operative photos can give the patient an objective idea of the proposed correction. It is for you as the patient to discuss it with your surgeon.
At the first consultation, the surgeon will discuss possible alternatives, his plans for the eventual surgery, the contemplated results, scarring, post-operative recovery, risks of complications and also possible future small revisionary procedures. Costs will also be discussed. A full medical history will be obtained. The patient is fully informed of what to expect of the surgery and the possible risks of complications in order that he or she may make his or her decision with a full knowledge of the facts. The surgeon will be pleased to answer any questions and the patient should be free to request additional consultation at any time to receive further explanations.
A complete physical examination, some laboratory tests and sometimes special tests will be required. Any healthy person can safely undergo an aesthetic surgical procedure. However, some cases will need special management. For example, a person who has had a heart attack in the past may be able to undergo some procedures if certain precautions are observed.
It is imperative to abstain from any medication that contains acetylsalicylic acid (aspirin) for two weeks before and one week after the operation, as it increases the risk of excessive bleeding during and after surgery. Here is a list of medications that contain aspirin: Acetophen, Advil, Alka-Seltzer, Anacin, Anadol, Anaprox, AAS / Astrin / AAS Bayer, Asasantine, Aspergum, Buckley's, Bufferin, Coricidin D, Coryphen 325/650, Darvon, Dristan, Ecotrin, Entrophen 5, 10 and 15, Excedrin, Fiorinal (C 1/4, C 1/2), Frosst (217-222-292), Ibuprofen, Idarac, Instantine, Madelon, Midol, Motrin, Nervine, Norgesic, Novasen, Oxycodan, Panadol, Percodan, Phenaphen, Robaxacet / Robaxisal, Supasa, Veganin.
Other medications or new products not listed here, and some natural products, may also contain aspirin or interfere with blood coagulation. It's up to you to check.
It is also recommended not to take anti-inflammatory medication such as Naprosyn, Indocid, Motrin, Orudis or Voltaren. If in doubt, ask your doctor or pharmacist.
Some medications such as Atasol, Tylenol, and others do not contain aspirin and may therefore be used for pain relief instead. You must stop taking any cold remedies prior to surgery.
Important - If you are on special medications or are allergic to some medications (penicillin, Xylocaine, etc.), it is important that you advise your surgeon. You should also tell him about any previous surgery either under local or general anesthesia. Tell the surgeon if you were nauseated in the immediate post-operative period or if you had any other problems upon waking up from anesthesia.
Tobacco- The toxic substances contained in tobacco decrease circulation of the blood. Minute blood vessels may contract and deprive the skin of sufficient blood supply, thus leading to actual loss of skin. These substances may also lead to formation of bad scars. They may cause nausea and coughing in the immediate post-operative period, increasing the risk of bleeding. It is strongly recommended not to smoke for two weeks before and two weeks after surgery. Nicotine substitutes like Nicorettes and others are also contra-indicated.
Alcohol - Alcohol may interact with some medications so you should not take any form of alcohol from two weeks before surgery to two weeks after.
Obesity - An obese person should lose weight through a well-supervised diet and maintain normal weight before considering aesthetic surgery. Failure to do so may result in complications and possible failure of the procedure.
The following is a summary of the different types of anesthesia used in aesthetic surgery. Your surgeon will explain in greater detail the type of anesthesia planned, depending on the kind of surgery you are to undergo.
Local anesthesia - With this form of anesthesia you are not put to sleep. It is similar to the type of anesthesia used by the dentist. The agent used is a liquid that is injected into the area to be operated on, causing it to become numb. Adverse reactions to local anesthetics may occur but they are very rare. This type of anesthesia allows you to recover rapidly and go back to normal activities sooner.
General anesthesia - With this form of anesthesia you are put completely to sleep. The drugs that do this are administered by a specialist who is fully trained in anesthesia. He will then maintain control of anesthesia throughout the operation. Several techniques are available and the one chosen will depend on the operation to be performed.
Nota - It is important to assess the state of your teeth before surgery. Do you have caps, crowns, bridges or a partial or complete denture, or loose or damaged teeth? It is necessary to tell this to the anesthetist as he will have to insert a tube in your throat when beginning the anesthesia.
Following general anesthesia you may experience minor problems such as a sore throat or loss of memory for short periods. It is therefore mandatory that you go home from hospital with an accompanying person. You should refrain from driving for several days and abstain from alcohol. Do not make important decisions for a few days. Sometimes after general anesthesia patients may experience bad dreams.
Neuroleptic anesthesia - This type of anesthesia is a combination of local anesthesia and sedation. You are put into a light sleep and also receive a tranquillizer to reduce anxiety. It is used mostly for facial and breast surgery. It is also mandatory to have someone accompany you home.
Hospital stay - The type of surgery and the risk of complications will determine the duration of your hospital stay. This will be reduced to a minimum without compromising your safety. You may either go home the day of your operation (after spending a few hours in the recovery room) or you may require a few days of hospitalization. Either way your surgeon will have discussed this with you prior to the operation. However, if you recover more slowly, your surgeon may want you to stay in the hospital or clinic for a longer period.
Nota - In summary... Rest well during the days prior to surgery... Do not drink alcohol... Do not smoke... Go to bed early the night before your operation.
Please remember - If you are having surgery under general or neuroleptic anesthesia :
• Abstain from any food or drink as of midnight the night before (no, not even a sip of water!).
• If you must take any medication during the days preceding your surgery, tell your surgeon about it.
Some possible complications
Internal bleeding (hematoma) - Any type of surgery may result in bleeding in the operated area. This may be due to a temporary increase in blood pressure such as occurs due to coughing. It could also occur from the effects of medication such as aspirin. Internal bleeding is usually manifested by acute swelling of the area, discoloration of the skin, pain and a feeling of tension.
If the accumulation of blood is a small one, your surgeon might decide to allow it to be absorbed by itself. However, if it is large, he or she may drain it.
External bleeding - This is easily detected. Blood is seen coming through the incision and may leak through your dressing. It may be either actual bleeding or an accumulation of liquid coming out through a surgical drain. External compression of the wound usually stops it. If it continues the surgeon might have to stop it after reopening the incision.
Infection - Any surgical wound can become infected. An infection usually will become apparent a few days after the surgery. The signs are pain, redness, heat and swelling. Antibiotics and dressing changes usually readily control it. On rare occasions hospitalization may be needed to control more significant infections.
Tissue loss (necrosis) - When blood circulation is inadequate to bring sufficient oxygen to the tissues, some may be lost. The skin will become discoloured and form a dark dry crust that will eventually become black and fall off. The underlying normal tissues heal by themselves. This may leave a wide scar. Skin necrosis is not infrequent in patients who smoke, but it is uncommon in non-smokers. The surgical procedures most susceptible to this loss of tissues are face-lift, mastopexy (breast lift) and abdominal lipectomy.
The recovery period following aesthetic surgery is usually fairly brief.
Complete physical recovery may take a month or more, no matter what operation is performed. Complete healing depends upon many factors. These include the type of surgery performed, the area of the body on which it was performed, and the healing capacity of the patient. For example, a patient who undergoes correction of a nasal deformity may be presentable two weeks after surgery.
However, swelling disappears gradually and full mobility of the tissues may take up to a year to return fully. Some minor itching and “pins and needles” sensations may be felt in tissues as they heal. Many months are required before the final result is attained.
The normal healing of wounds is a physiological process which continues to take place in the depths of the tissues for many months before final resolution. At first, the surgical scar is not very obvious. Then it becomes red and somewhat elevated for about three months. It then becomes paler, softer and flatter and reaches its resolved state in six to twelve months. Aesthetic surgery has its limitations. Any time the skin is opened and it heals, a scar of some kind results. This may be a good scar or a conspicuous one, but there is always a mark of some kind.
Each individual's healing is different. Some form fine white lines while others will form heavier ones. The surgeon has no influence on the actual formation of a scar. We have already mentioned certain factors that can influence the quality of healing, such as smoking, infection and hemorrhage. The main mechanisms of wound healing are not yet fully understood; thus the factors that may lead to formation of a conspicuous scar are not yet known.
Very heavy (hypertrophic) scars or keloids are uncommon. They are found most frequently on the front of the chest, the abdomen, and shoulder areas. Bad scars occur infrequently on the face. Dark-skinned people such as Blacks and Orientals are most susceptible to the development of hypertrophic scars.
If a bad scar develops there are some methods of treatment which may be of value. Your surgeon can advise you about this. Local pressure, silicone gel sheeting, radiotherapy or cortisone topically or by injection may be used. There are some new oral medications which also may be of value.
Exposure to the sun will not help scar maturation. On the contrary, a young scar may undergo changes so that it becomes more visible and pigmented if exposed to the sun's rays. Do not expose yourself to the sun until your surgeon says you may.
In Canada none of the provincial health insurance plans pays for cosmetic surgery. Surgical procedures aimed at correcting a functional problem are covered. Some procedures which may appear to a patient to be cosmetic in nature are, in fact, covered. These may include reduction mammaplasty, surgery for fat removal in very obese persons and removal of excessive breast tissue in males. Your surgeon will be able to tell you at your first visit if your surgery may be covered by government health plans.
The expenses of cosmetic surgery include the surgeon's fee, the anesthetist's fee, the cost of hospitalization or the use of the operating room, plus the cost of any prosthesis or accessories such as special garments required during the post-operative period. If small surgical revisions are required the policy varies with different surgeons. You should discuss this before surgery.
It is important to realize that although aesthetic surgery is designed to improve the appearance, it cannot accomplish miracles. Aesthetic plastic surgery has its limits and cannot ensure social, professional or matrimonial success. It is rarely able to change one's social life. Those who seek the benefit of aesthetic plastic surgery should do so for their own personal satisfaction, not to please someone else.