What is a Preoperative Cosmetic Plastic Surgery Evaluation?

Posted by Dr. Hardesty

Cosmetic Plastic Surgery is “want to have” and “not need to have” surgery.  Thus, unfortunately not all patients may qualify based on their general health, associated medical conditions or medications they take.

Surgical procedures and administration of anesthesia are in general quite safe and considered low risk based on the newest and “state of the art” intraoperative monitoring technologies. However any surgical procedure regardless if it is for cosmetic improvement or required for a life threatening cause  does have inherent risks. The risks are associated with the normal response ones body experiences based on its condition and health limitations.

The common risks of Cosmetic Plastic Surgery are mostly proportional to the type of anesthesia, the invasiveness of the surgery, the total operating time, amount of intraoperative blood loss, age, weight of the patient and the  degree of postoperative pain.

Thus, we believe it is paramount and is well recognized that safe, efficient surgical procedure and anesthesia requires a patient who’s health is optimized.  Thus a “cookie cutter” approach to evaluate patients perioperative risks is not in the best interest of  prospective surgical patient. A customized preoperative evaluation based on the patients known medical history, physical exam and laboratory data. The other variables stated above will determine the extent of additional consulting and laboratory testing.

OVERVIEW

The overall risk for Cosmetic Plastic Surgery and (all be it a small incidence) related complications depends on individual factors and the type of surgical procedure. For example, advanced age and/or weight places a patient at increased risk for post surgical problems. Why? The reason: simply stated the older and heavier we get the greater the chance of having medical problems.

In general (and accepted medical standards) are those individuals that are in good health, normal BMI (weight) and under the age of 45 and without medical problems may only need a basic a medical review and labs.

In contrast patients  over age 45, those with medical conditions (regardless of age) and morbid obesity are recommended for a more extensive evaluation, also known as a medical “clearance” and recommendations to optimize the prospective patients safety of the procedure.

The overall risk for Cosmetic Plastic Surgery related  complications depends on:

1. Individual health factors
2. The type of surgical procedure.
3. The age of the patient
4. The weight of the patient

For example, advanced age places a patient at increased risk for complications. The reason for an age-related increase in surgical complications appears to correlate with an increased likelihood of underlying disease states in older persons. Diseases associated with an increased risk for surgical complications include respiratory and cardiac disease, malnutrition and diabetes mellitus.

Likewise, being overweight (a BMI over 30) incrementally increases the complication rate secondary to weight associated cardiac and pulmonary (lung) problems.

While the above increases (all be it small) risks, we believe here at Imagine Plastic Surgery, it is better to understand and make decisions on how to proceed with Cosmetic Plastic Surgery based on a complete preoperative evaluation rather than just guess work, luck and hope.

Thus when  indicated, regardless of age, weight,medical conditions or medications …consultations with additional and appropriate medical providers and laboratory evaluations should be obtained preoperatively to diagnosis, improve and optimize the patient’s health prior to surgery. These consultations should ideally not be done in a “last second” fashion.

GOALS OF A PREOPERATIVE MEDICAL EVALUATION

The ultimate goals of preoperative medical assessment (regardless of age) are to:

1. Evaluate if the patient is medically safe to have a particular surgery.
2. Recognize the patient’s increased surgical and anesthetic (if any) risks.
3. Optimize the patient both physically and mentally for surgery.
4. To return the patient to a functioning preoperative state as quickly as possible.

It is important to realize that “perioperative” risk for Cosmetic Plastic Surgery is multifactorial  and is a combination of but not limited to:

1. The baseline preoperative medical condition of the patient
2. The patients preoperative weight
3. The invasiveness of the surgical procedure
4. The type of anesthetic administered
5. Anticipated blood loss
6. Length of the surgery
7. Postoperative pain control

THE EVALUATION

The Board Certified Plastic Surgeon in San Bernardino will begin by reviewing of your general medical health and other  related conditions and performing a “specific and focused history and exam” of the particular anatomical area where desired cosmetic improvement is desired.

If Cosmetic Plastic Surgery is indicated, and in my practice here at Imagine Plastic Surgery, for those patients over age 45 or those (regardless of age) with significant medical history it will be required that a primary care giver or the patients specialists evaluate the overall medical condition of the patient and make any recommendations to optimize the surgical outcome prior to surgery.

Present, Past Medical History and Review of Symptoms

The medical history is key and  should include a past and current medical history, a surgical history, a family history, a social history (use of tobacco, alcohol and illegal drugs), a history of allergies, current and recent medication therapy, unusual reactions or responses to drugs, previous surgeries, and any personal problems or complications associated with previous anesthetics. In addition,

A family history of adverse reactions associated with anesthesia should also be obtained such as malignant hyperthermia.

The history should include a  review of systems to include diseases of the cardiovascular and respiratory systems are the most relevant in respect of fitness for anesthesia and cosmetic Plastic Surgery.

Should any unexpected findings have occurred or are found  it is recommended that they be further investigated prior to surgery.

Physical Examination

The physical examination should build on the information gathered during the history taking.

At a minimum, vital signs should be recorded and  a focused preanesthesia physical examination performed, which includes an assessment of the airway, lungs and heart. Any unexpected and abnormal findings on the physical examination should be investigated further before elective surgery.

Laboratory Evaluation

It is generally accepted that the clinical history and physical examination represent the best method of screening for the presence of disease. Extensive laboratory tests in patients who are apparently healthy on clinical examination and by their past medical history have not been found to be beneficial or cost effective.

Specific laboratory analysis should be ordered based on information obtained from the history and physical exam, the age of the patient and the complexity of the surgical procedure.

Specifically, besides a basic hemoglobin/hematocrit additional laboratory investigations should only be ordered only when indicated by the patient’s age,  medical status, drug therapy, the complexity or the nature of the proposed procedure. Extensive laboratory testing had not been found to medically necessary or helpful on a routine basis.

However additional and specific laboratory tests may be ordered based on information obtained from the history and physical exam.

Thus when indicated additional testing when completed and evaluated may clarify and help provide data for planning and optimizing one’s health prior to a surgical procedure.

Taken as a whole, these above factors will help indicate and decide if the proposed surgeries risks are outweighed by the benefits.

THE DETERMINATION: IS ELECTIVE COSMETIC SURGERY SAFE AND RIGHT FOR YOU?

I often quote “I earn my living by operating and my reputation by not”.

When indicated and upon receiving the above consultative services and laboratory tests are obtained and recommendations are made, I optimally will then meet several weeks prior to surgery to discuss the above findings with the patient in a non rushed appointment.

Taken as a whole, these factors (patients medical history, physical exam, laboratory investigation and consultative opinions)  will help indicate and decide if surgery risks are outweighed by the benefits.

If we agree (patient and me) that that the benefits out weigh the known risks, complications and the patient has read and signed the consent forms for their Cosmetic Plastic Surgery, and only then, will we proceed with the elective, Cosmetic Plastic Surgery procedure.

I believe the preoperative chart should include:

1. Documentation of the proposed surgery and the  condition(s) for which surgery is needed.
2. The assessment of the patient’s overall health status.
3. In co-ordination of primary care physician and/or specialists the recommendations to optimize any conditions that could cause problems both during and after surgery.
4. Review and discuss the preoperative evaluation found any or additional additional perioperative  risk factors.
5. Formulate and explain  the perioperative care plan.
6. Educate the patient about their Cosmetic Plastic Surgery: realistic expectations, anesthesia, and intraoperative care and postoperative pain treatments in the hope of reducing anxiety and facilitating recovery.
7. A frank discussion and documentation, via a multi page consent form of the common risks and areas of increased risk.
8. Instructing patients or have them to contact their pharmacist regarding cessation of any of medications that they are currently taking that may interfere with wound healing. In addition stopping any medications or drugs that may affect blood clotting (common examples: aspirin, Motrin, Elevee, Vit. E, etc.). In addition stopping any type of exogenous female hormones and all “over the counter” herbal supplements optimally a month prior but at a minimum 2 weeks prior to surgery. The stopping of smoking (of any kind) is a must for a minimum of 2 weeks prior and until all incisions are healed.
9. The morning of surgery the ingestion of most prescription medication  should be continued, although some adjustment in dosage may be required (e.g. antihypertensives, insulin, etc.)
10. Some drugs should be discontinued preoperatively: The monoamine oxidase inhibitors should be withdrawn 2-3 weeks before surgery because of the risk of interactions with drugs used during anesthesia.

CONCLUSION

All patients should undergo a “basic” preoperative evaluation and for those over the age of 45 or medical conditions a more extensive preoperative clearance, carried out in a timely preoperative manner, the results reviewed, the  risks and benefits discussed in detail.  If the  determination is made to go forward with surgery, one can rest assured that a systematic and careful evaluation was completed and the needed information obtained to make a informed decision of the surgical risks and benefits of Cosmetic Plastic Surgery outlay the risks.

While there is never a 100% guarantee of anything in life, however based on the preoperative evaluation and optimization of ones health status that a expected, safe, successful, unremarkable Cosmetic Plastic Surgical procedure and recovery will be follow.

In addition to the safety, a careful preoperative evaluation can result in additional benefits: reduction of costs, avoidance of hospital admission or shortened hospital stay, reduction or cancellations and increase of the patient awareness of surgery and satisfaction.

Cosmetic Plastic Surgery procedures are safe, predictable and rewarding surgical endeavors with highly satisfied patient results.

SUMMARY

The most important factor to consider is seeking the opinion and services of a skilled, experienced, record of safety and Board Certified Plastic Surgeon who are experts in Cosmetic Plastic Surgery techniques. The Imagine Plastic Surgery team uniquely provides the full array of both non surgical and surgical alternatives., thus filling our motto of “One Goal, Many Options”. For more information, call and schedule a consultation.