General risks and complications of plastic surgery.

Anaesthesia

Anaesthesia is a medical specialty, involving the delivery of expert care. Your specialist anaesthetist will discuss the risks with you. In Australia, well people have a very low risk of adverse event during anaesthesia.

Drug allergy and interaction

During surgical episodes, you will be administered several types of drugs. These are anaesthesia agents, antibiotics, and postoperative care drugs such as pain medications and anti-nausea medication.

You might already be on some drug therapy. There is a risk of drug allergy or drug interaction during or after surgery.

Some drugs you might be given may prevent normal functioning of drugs you’re already on, such as birth control pills, blood thinners and diabetes medications.

Blood clots/DVT/PE

Surgery lasting longer than an hour can increase your risk of having an episode of venous thromboembolism (VTE). This is generally a blood clot forming in the large veins of your calf – a deep vein thrombosis (DVT).

It occurs where venous blood flow is sluggish during the period of limited mobility around the time of surgery. It is more likely to happen to patients who are susceptible, and because surgery itself makes the blood slightly stickier. Some people have underlying medical conditions, often genetic, which make their blood stickier and more likely to clot during surgery.

Plastic surgery is generally not a high-risk specialty for the development of DVT. Pelvic operations and orthopaedic operations carry a greater risk. You can get a DVT in other circumstances, for example pregnancy or on a long plane flight.

In my practice we take measures to help prevent DVT for all surgery lasting longer than an hour, which is almost all procedures. These include compression stockings, external calf compression pumps, and usually a mild blood-thinning agent called Clexane®.

People at high risk receive more blood thinning treatment, and may need pre-surgery consultation with a specialist haematologist.

The potentially serious consequence of a DVT is that if there is a large clot in a calf vein and it is dislodged, it may travel through the blood system to the lungs where it gets trapped. This is called a pulmonary embolus. When very large, these can be life-threatening.

If a DVT does occur, treatment is needed with blood thinners, and admission to hospital may be necessary.

In 25 years of plastic surgery practice, I have seen several serious DVTs and fewer than five pulmonary emboli cases, in over 8,000 cases or so. I have never personally seen a death from pulmonary embolus.

Bleeding

Bleeding can occur after any surgery. This is because blood vessels are severed in surgery, sometimes hundreds of times in an operation. In my plastic surgery practice, small vessels less than 1mm are usually cauterised with a diathermy. Larger vessels are usually clipped with little stainless steel clips called ligaclips®. Very infrequently, a vessel will bleed again after cautery, or a vessel may be missed if it is temporarily stopped and can’t be seen. If a vessel begins bleeding again it can cause a haematoma – a pooling of blood in the tissues around the bleeding vessel.

In most of my plastic surgery operations, the risk of a haematoma is around 1%, or one case in 100. They are usually easily fixable, but if they are large they may require another anaesthetic so that the operative site can be re explored and the clot removed.

Infection

Wound infection can occur after any surgery. In plastic surgery, it’s uncommon, and usually easily treated with antibiotics or wound drainage.

If there is an infection when an implant is present, the implant will usually need to be removed. This is a distressing complication. Because the implant has no blood supply, if it is contaminated in the infection it is not sterile and so it must be taken out. It can be put back during another procedure a few months later, when your body has completely sterilised the operated area, and after the implant has been removed.

Pain

Most plastic surgery operations are not especially painful, and pain management is quite easy. Abdominoplasty or tummy tuck is an exception to this, and in this case a specific pain management plan is made.

However pain tolerance varies widely among individuals and some people need more pain relief than others.

Planning for post-operative pain starts pre-op. Good communication and understanding of the planning sets you up for a good experience.

In surgery, I use local anaesthetic infiltration extensively for all surgeries, so you will most often wake up comfortable.

For procedures such as tummy tuck – our most painful procedure – if a rectus sheath muscle repair is part of the operation, pain pumps and patient controlled pain relief via the IV drip will be used postoperatively. These allow for good management of the pain and a fairly comfortable patient

In all operations, strong painkillers may be needed at the start, but over a short time, usually one to three days, you’ll be able to reduce the strong painkillers and manage on simple analgesics such as Panadol® and Nurofen®.

Wound healing

Wound healing complications run from a spectrum of generally good healing with some minor wound annoyances, such as a stitch abscess or minor separation – to a major wound breakdown with separation of part of the edges of the wound, the death of a piece of tissue at the wound edge, or some fat under the skin (fat necrosis).

Wound healing complications in my practice are rarely major. They are usually treated with dressings and allowed to heal. They will slow down the healing time, and that’s all.

If complications are major, with a larger wound separation or skin loss, further surgery is generally required.

A wound healing problem may end up with a poor scar, which requires revision later.

Fat necrosis

In plastic surgery, we often move tissue around. Sometimes the blood supply of the tissue is temporarily reduced by moving it. The tissue will survive and recover – it is just part of the process.

Fat cells are quite sensitive to reduced blood supply, so occasionally, the piece of tissue in general survives, but within it, patches of fat cells can die and become hard and lumpy. This is called fat necrosis and it is generally harmless. But little lumps of fat necrosis might be hard and tender for months, and if they are large they might need to be removed.

In plastic surgery, the most likely procedure to have fat necrosis is a breast reduction.

Poor scars requiring further treatment or revision

Most scars are good, and over a year or two they fade to be pale and fine. Some scars heal poorly, and are imperfect. Sometimes they naturally become thick and poor because of the genetics of the person.  These may need treatment by medical means, or further surgery.

What should I do if I experience a complication?

The role that you play in your own recovery is vital to a good experience of surgery. Be sure to follow the simple instructions we give you and remember that they are there to help you recover fully as quickly as possible.