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RISKS OF SURGERY

Surgeons refer to the unintended things that can occur during or after surgery as complications. We divide the risks or complications of surgery into those common to any operation and those especially relevant to the operation being undertaken. It is also important to identify risks that could have serious consequences for health, and those that are not a serious problem but which may delay, but not significantly affect the final result.

The complications which are considered as general complications, possible in any operation are discussed below. The commonest and most serious risks specific to each procedure are discussed under that procedure. However, these web pages are not exhaustive and this is not a substitute for discussion with your surgeon. Indeed no discussion will ever be as exhaustive as to cover every possible unexpected consequence that the complexities of the human body and soul can conspire to produce on rare occasions.

One cause of problems after surgery is not the potential complications, but dissatisfaction with a less-than-perfect result. This means that expectations must be understood by both surgeon and patient, and much of any worthwhile consultation will be focused on this. If expectations are unreasonably high, then an unsatisfactory outcome maybe more likely and therefore some adjustment in expectation is wise before deciding to proceed. The very nature of cosmetic surgery is such that very few will have the “perfect” result and is best approached hoping for substantial improvement. However, most surgery is trouble free, achieves pleasing results and has a happy outcome. Even when things do go wrong, they usually are of minor consequence and easily managed for most people, provided surgeon, patient and hospital work together for the best outcome.

General Complications

Asymmetry

If you look closely enough most of us are asymmetric (left side different to right side) in one or other aspect (e.g. one ear slightly more prominent than the other, one breast slightly larger than the other), this is normal variation and doesn’t worry most of us. Interestingly this often becomes noticeable only after surgery. It is worth pointing out that post operative swelling can affect areas differently and any decision on whether to undergo further surgery to try and correct this needs to be balanced with the risks/benefits of further surgery and should wait at least until the swelling has completely resolved.

Bleeding

Bleeding occurs during all surgery and measures are taken during surgery to minimise this and at the end of surgery to stop it completely. However, there is sometimes a small degree of oozing into the dressings for the first few hours after surgery. This usually stops of its own accord without further treatment. Occasionally bleeding can be more troublesome and may necessitate a short return to the operating theatre to remove a haematoma (collection of blood) and stop the source of bleeding. In some cases bleeding can occur days or even weeks after surgery and this can sometimes be due to the onset of an infection. Rarely, a pre-existing and unrecognised problem with blood clotting causes bleeding. More commonly an oversight to disclose the use of aspirin or some forms of analgesics or even some herbal remedies can be the cause of prolonged and sometimes troublesome bleeding. It is unusual for anyone having cosmetic surgery procedures other than for extensive bodycontouring, to require a blood transfusion. Very rarely, bleeding can be a serious problem which can jeopardise vision for example, in which case an urgent return to the operating theatre would be necessary.

Bruising & Swelling

A small degree of bruising and swelling is normal after surgery, although measures are taken during surgery to minimise this, such that it is often negligible. Bruising, where it has occurred, goes through a characteristic colour change and is usually completely gone by between 7-10 days.

Contour Irregularity

Following surgery or filler injection, swelling and bruising in itself can lead to irregularity of the contours or an impression of lumpiness. This will usually settle after a few weeks. During liposuction it can be particularly difficult to remove an exactly even amount of fat from an area and even when swelling has subsided it is possible to be left with some irregularity, although this is often more easily felt than seen.

Death

The ultimate risk is extremely rare as a result of cosmetic surgery. A combined health evaluation will be undertaken by both your surgeon and anaesthetist and any decision to proceed with surgery will be taken after a discussion regarding any specific risk factors. Depending on the risk factors and the type and duration of surgery, measures will be taken during and after surgery to minimise the possibility of developing deep vein thrombosis (blood clot in the legs) and pulmonary embolus (blood clot in the lung) which is the commonest cause of death following elective surgery. In addition, we know that the contraceptive pill, long distance travel before and after surgery, smoking, family history, previous pelvic or leg surgery and several other factors can increase the risk of developing blood clots and hence the reason it is important to disclose a full medical history to your surgeon and anaesthetist.

Dog Ears

A “dog ear” is the name we give to the little mounds of skin which are sometimes present at the ends of a scar following surgery. This is usually the result of your surgeon trying to minimise the length of a scar. They often reduce or settle down completely with time. If they remain after a period of settling has been allowed, then they can usually be reduced at a later stage as a simple local anaesthetic procedure.

DVT

A Deep Vein Thrombosis is the formation of a clot usually in the leg which can break free to cause a clot in the lung (see “Pulmonary Embolism & Death”)

Heamatoma

See “Bleeding”

Infections -Implants

Any implant whether breast, joint replacement, heart valve, etc. can become infected. Fortunately, this is not common but can occur at the time of surgery, weeks, months or even years after they have been placed. Occasionally this situation can be managed by treatment with antibiotics and cleaning around the implant. However, the most common outcome of this problem is the complete removal of the implant, treatment of the infection followed by a period of healing (sometimes several months) to allow the tissues to return to the optimum condition before replacing the implant.

Infections – Stitch

A stitch (suture) is essentially a foreign material (albeit carefully manufactured) through the skin which can sometimes become infected like any other foreign body. This could cause a small area of redness and possibly some fluid to discharge. This usually resolves upon removal of the stitch. Occasionally stitches placed below the skin can cause a slightly deeper infection or cause an abscess which would need to be drained.

Infections –Wound

A wound infection is not very common and can vary from being very minor, having little or no long term consequence to quite major or even life threatening. Fortunately this is very rare. Wound infections are usually the result of interplay of factors such as location of the wound, type of procedure, tight wound closure, patient health factors and smoking. This can often be treated with appropriate cleansing and wound dressings, or it may require antibiotics and a return to the operating theatre.

Nerve Injury

It is almost impossible to perform any surgery without cutting nerves. Having said that, the majority that are cut are very small and the consequences are usually minimal if noticeable at all. For instance there may be a small area of altered sensation or numbness adjacent to where an incision has been made. If noticeable at first this usually improves or disappears with time.

Occasionally nerve damage can be more of a concern in the immediate post operative period. For example after a face lift or brow lift the nerves which supply the muscles of movement can be affected, leading to a weakness in the muscles that move the eyebrow, eyelids or lips. This can be quite distressing, but it is important to realise that in the great majority of cases where this does happen, it will return to normal within 2-4 months. Very rarely the damage to the nerves can be permanent.

Numbness

See “nerve damage”

Pain

Pain after surgery is common and affects everybody differently. However it is rarely severe enough to require more than mild painkillers. Measures such as injecting local anaesthetic even when you are under general anaesthetic are taken during surgery to minimise discomfort.

Pulmonary Embolism

A pulmonary embolism is a blood clot in the lung which is a serious and potentially life threatening event which usually results from a clot breaking away from a deep vein thrombosis (DVT) in the leg.

Scars

Almost every surgical procedure on the skin will produce a scar. Some will heal such that they can hardly be seen, others can heal to produce less pleasing or frankly troublesome scars. No surgeon should guarantee a good scar as we do not know precisely what factors determine the development of a good or poor scar, but we do know that some skin types and certain locations on the body are considerably more prone to producing poor scars. There are two main types of troublesome scar which we recognise: The “hypertrophic” scar is a thickened, angry looking and often itchy and sometimes painful scar which is confined to the boundries of the original incision. It can be provoked by a wound infection or wound opening resulting in delayed healing. This type of scar usually improves of its own accord with time.

The “keloid” scar is one which extends beyond the original incision or wound and is a difficult type of scar to deal with. Fortunately they are relatively rare, although we know that black and Mediterranean skin types have a significantly higher risk of developing this type of scar. Unlike hypertrophic scars, they do not resolve of their own accord.

Seroma

Wherever skin has been lifted or moved, there is the potential for fluid within the tissues to leak out and collect under the skin. This collection is known as a seroma. Although measures are taken to minimise the risk of this, it occurs more commonly after some procedures such as abdominoplasty (tummy tuck) or breast reconstruction. If a seroma does occur it usually disappears without treatment. However, if there is a large volume, the process can be speeded up by simply draining the fluid through a needle during a clinic visit. This may have to be repeated on a few occasions.

Skin necrosis

All operations to some degree tend to reduce the blood supply to parts of the skin. This is rarely a problem as the training we receive as plastic surgeons teaches us the blood supply of the skin in the different body areas and the degree of “plasticity” which the skin can cope with. However, if the blood supply to the skin is compromised sufficiently it may die (necrose). This is an uncommon occurrence, however, there are a few factors which can increase the risks of this happening: The most important of these is SMOKING, as the substances which circulate in the blood after smoking, constrict the tiny blood vessels which supply the skin with oxygen. Even the effect of one cigarette can cause skin to necrose which would have otherwise survived. For this reason your surgeon will insist for any surgery which significantly affects the blood supply of the skin, that you stop smoking for 6 weeks before and after surgery. Wounds that become infected also have an increased risk of the skin dying and this is one of the reasons why you may receive antibiotics during and after your surgery. Small areas of skin necrosis are usually dealt with by dressings care. Sometimes a return to the operating theatre is necessary to remove the dead skin and replace it where appropriate.

Undesired result

This is possibly the most perplexing area for both patient and surgeon and is particularly relevant to cosmetic surgery, so much so that books and scientific papers have been written on the subject. Often a patient will have a very clear idea of what they wish to achieve with surgery and the surgeon will have a very clear idea of what is achievable. Reaching a consensus between these two views prior to surgery is the area where much of the initial and subsequent preoperative discussion should focus and surgery should only proceed when agreement has taken place that surgery can largely or wholly meet expectations.

The outcome of some operations such as breast augmentation can be quite well predicted and will look very close to the final result soon after surgery. Others, such as rhinoplasty(nose job), have both an inherent degree of unpredictability and the final outcome can be masked for several weeks or months by wound healing and swelling which resolves more slowly. You should be reassured and supported by your surgeon and nurse through this period. Usually there will be substantial improvements and the vast majority of patients are very happy with the outcome of their surgery and this will be agreed upon at appropriate post operative visits. However, sometimes, the patient is not satisfied with the result and it is at this point that the relationship built between surgeon and patient becomes paramount. If a patient is unsatisfied with the result after healing has taken place and swelling resolved, then a debate occurs as to what may be done to improve the outcome. This again comes down to discussion between patient and surgeon, and a sensible surgeon and a sensible patient should accept some compromise rather than operate and reoperate in a cycle of diminishing returns in pursuit of elusive perfection.

Wound breakdown

Most incisions made in the skin are stitched to optimise healing by holding the wound edges together sufficiently long enough to allow healing to occur. Healing is variable and depends on many factors such as patient age, their general health, SMOKING, the area of the body involved, tension of the tissues and infection to name a few. Most of the time healing progresses uneventfully. However, occasionally healing is slow or compromised by one or more of the factors outlined and wounds open up before healing has occurred, causing the wound edges to separate. This usually then heals slowly across the gap, and further suturing is rarely indicated or required. However this can leave a less than optimum scar which may be amenable to scar revision at a later stage.

Wound discharge.

It is quite common for some fluid to discharge from between the edges of a wound. This can vary from minimal seepage which just stains a dressing to a large volume if a significant collection has built up which then bursts through a weak part of the wound. This can be quite distressing for a patient but is rarely a serious event. It is usually better that this fluid discharges to prevent a build-up of fluid under the skin and occasionally your surgeon may elect to remove a collection of fluid before it discharges through the wound. In a small proportion of cases, the collection can become infected and this may require treatment with antibiotics or occasionally a short return to the operating theatre to clean the wound.

Plastic & Reconstructive Surgery
Cosmetic & Non-Surgical Treatments