Only recently, cosmetic surgery could be practised by any doctor but now it is carefully regulated and one needs to be a graduate plastic surgeon approved by the French Order of Doctors after being validated by the other official bodies (the Société Française de Chirurgie Plastique Réparatrice et Esthétique: SOFCPRE, Société Française de Chirurgie Plastique et Esthétique: SOFCEP).
Cosmetic surgery nevertheless remains a very different type of surgery with possible restrictions and complications that make it necessary to take the same (or even more) precautions than for other types of surgery.
THE DECISION TO OPERATE
There are several stages to taking this decision:
THE FIRST CONSULTATION
- This takes place in the surgeon’s office; it is essential and compulsory (for medico-legal reasons); it is not conceivable to operate on someone who has not been seen before the operation. There is even a compulsory fifteen-day cooling off period between the first consultation and the operation.
- During this consultation you can explain to the surgeon the body part you do not like and that you want to change.
- That is why it is important, before this consultation, to analyse what bothers you, rather than to arrive, as some people do, by asking: “in your opinion, why have I come to see you?” This is a very dangerous attitude because the surgeon’s perfectionist view could find a host of imperfections for correction even though these do not worry you and could risk giving you a new complex and destabilising you.
- In fact, the aim of cosmetic surgery is not necessarily to make people look perfect (assuming that perfection exists) but to make people feel comfortable in their own skin. So it is important to correct what bothers you and not what bothers the surgeon.
- During this consultation, depending on what is bothering you, the surgeon will let you know that his correction is “reasonable” in your case (that is not always the case) and if so, the various options (medical or surgical) open to you.
- You will therefore ultimately have to make a choice between various types of scarring or techniques depending on the desired result and the limitations or complications to be considered.
- At the end of this consultation you will leave with literature that again explains the various interventions suited to your case, the documents you can read at home at your leisure so you can “take stock” of what you have been offered and possibly discuss it with the people around you. In fact, while it is important to find out what those close to you (husband, wife) think, you should also pay attention to the negative opinions of certain people who are, by nature, “against cosmetic surgery” and who will try to dissuade you from having the operation that, sometimes unconsciously they themselves would like to have had (but which they do not dare to do).
- The decision to have an operation should therefore be taken after careful thought and you can also seek the advice of another surgeon if you do not feel confident.
- Once you have decided, you should telephone the doctor’s office to arrange a second consultation and possibly a date for the operation.
- At this second consultation, you can again discuss with hindsight the various operating possibilities before making a final decision.
- You will be given various documents about the intervention, the pre-operative report, the anaesthesia consultation as well as a cost estimate and an enlightened consent form to be signed before the operation.
THE PRE-OPERATIVE REPORT
- As in the case of any surgical intervention, a cosmetic surgery operations involves taking precautions and producing a pre-operative report. The purpose is to ensure that this intervention is, in your case, without particular risk. In fact, it is impossible to ensure the absence of complications. Unlike vital surgery, cosmetic surgeons avoid operating on anyone displaying risk factors (age, smoking, serious heart problems, etc.) as this would significantly increase risk from the operation.
- The pre-operative report consists of an anaesthesia consultation (if possible with the anaesthetist who will put you to sleep) the purpose of which is to detect any operative contra-indication. This will be done by means of a clinical examination and possible additional tests (blood tests, consultation with a cardiologist, etc.). During this consultation, the anaesthetist will explain how the anaesthesia will be performed and sometimes you will be asked to choose between different techniques (local anaesthesia, local anaesthesia improved by the use of neuroleptanalgesia that will allow you to feel “out of it” or general anaesthesia.
- He/she will provide you with an anaesthesia record that must be brought with the results of the examinations prescribed on the day of the operation. The consultation must take a sufficiently long time before the operation to enable these tests to be completed so that the results are known so that the operation can, if necessary, be postponed or even cancelled.
- Certain other pre-operative examinations, such as a mammogram or an ophthalmic consultation may also be necessary. A preadmission record must be created at the clinic for which you must attend (or do so by telephone if you live a long way away) to reserve your room.
You will usually be admitted to the clinic in the morning of the intervention.
- Depending on the type of anaesthesia, the length of time taken for the intervention and the type of operation, hospitalisation may last for a few hours (day surgery) or for several days.
- If drains are necessary, they will usually be removed at the clinic before you leave, but in certain cases you can leave and have them removed later in the doctor’s office.
- Before you leave the clinic, you will be provided with instructions about what to do subsequently.
AFTER THE OPERATION
- Dressings of the operation wound will be changed in the doctor’s office once or twice a week until scarring is complete (generally one to two weeks); if you live a long way away, it is possible to ask a nurse near your home to do this but you must assure yourself that she is familiar with this type of surgery.
- Ecchimoses (bruising) and œdema are normal after any type of surgery and these will disappear within one to three weeks in general.
- You should avoid sporting activity until complete healing of the scar and in general during the first month.
- Avoid allowing sunlight to fall on the scar while it remains red and in general, avoid staying in high temperatures (and avoid sweating too much) until the wound has completely healed and the bruising has disappeared.
- After the scar has healed, several visits will be made to the doctor’s office to check that all is well; if you live a long way away you can send photographs via the Internet.
- These can be prevented by making the right set of choices for the operation indications and sometimes it is necessary to accept the surgeon’s opinion who, in your particular case, may advise you not to have an operation because the “benefit/risk” ratio is not reasonable (better to be disappointed about not being able to be operated on than to be disappointed because you were operated on).
- It is also important to reduce the frequency of complications by complying with the pre- and post-operative instructions that have been given to you (stopping smoking, resting, etc.) because too many people consider cosmetic surgery to be like a simple visit to a beautician.
- Despite all this, as for any surgical procedure, certain complications cannot be totally avoided; it is crucial to detect them and if you are in the slightest doubt, to contact the surgical team who will be treating you until they are resolved (you will never be reproached with telephoning if you are worried).
- These are common in other types of surgery but are fairly rare in cosmetic surgery due to the fact that contra-indications in patients that are at risk are not operated on. Complications include those relating to the anaesthesia, and they can be mentioned to the anaesthetist during the pre-operative consultation.
- PHLEBITIS could be present if there is pain in the calf.
- If there is the slightest doubt, a Doppler scan of the veins will confirm the diagnosis and treatment with an anticoagulant will be started to prevent the migration of the blood clot resulting in the much more serious PULMONARY EMBOLISM. This complication is rare in cosmetic surgery, but there must be an awareness of it in abdominoplasty or if the operation lasts for a long time, especially if several operations are combined. It can be prevented by the wearing of compression socks or stockings during the port operation to prevent venous stasis, preventive anticoagulant treatment, peri-operative pressotherapy and a control Doppler scan before the first ambulation after the operation.
As with all operations certain complications may arise:
EARLY POST-OPERATIVE COMPLICATIONS
- BLEEDING of the operation area, which is manifest when the drains are abnormally full of liquid in the first hours after the operation. This may require a return to the operating theatre to perform haemostasis.
- HAEMATOMA: unlike simple ecchymosis (bruising), this is manifested by a swelling and tension that is generally painful in the area operated upon (the drains may have become blocked) and this may require more surgery.
- SEROMA: this is when lymph collects under the skin. It generally requires several punctures to be performed in the doctor’s office to prevent a cyst forming.
- INFECTION: a difference should be made between the simple rejection of a re-absorbable stitch, which manifests with a slight leakage of serous fluid on the dressing (but which will heal in several days) and a genuine infection of the operation wound which is generally accompanied by a fever and, if there is deep collection that does not drain automatically, it may require surgical removal and drainage.
- NECROSIS of the skin and SEPARATION of the operation wound. This generally occurs in smokers, hence the importance of stopping smoking at least one month before and after an operation that involves significant detachment of the skin; it will delay healing and will require daily changes of dressings from the start, lasting for several months. The final scar, even though it often shrinks a lot, will of course be of lesser quality.
SUBSEQUENT COMPLICATIONS (several months after the operation)
HYPERTROPHIC OR CHELOID SCARS
Normally, a scar remains red for several months (sometimes for one or two years) before turning pale, but if it is prominent it is known as a hypertrophic scar if it eventually loses colour in six to eight months or cheloid if it persists. The best treatment for hypertrophic scarring is prevention by compressing them with sheets of silicone gel and a compression garment (corset, bra, etc.) for several months. Once the scar appears, intra-scar cortisone infiltrations will need to be applied and the compression should continue if the scars do not reduce. In the case of true cheloid scars, which generally mean that the skin is diseased, repeat surgery can be attempted but the results are usually disappointing and there are frequent relapses.
DISRUPTION TO SENSITIVITY (hyper or hyposensitivity)
This is frequent around any scar or any area that was detached. It generally lessens after a few months but can persist in certain cases.
IMPERFECTIONS IN THE RESULT (asymmetry, partial correction, relapses, irregularities, loosening of the skin etc.). Differentiation should be made between:
Imperfections that were foreseeable before the operation, due mainly to a morphological anomaly that cannot be corrected (certain forms of asymmetry or bone deformities, poor skin quality, etc.) for which pre-operative maintenance should make it possible to assume they exist (or the operation might be cancelled) since they cannot be corrected.
Logical imperfections will occur after an early complication (infection, necrosis, etc.) and these might justify correction through another intervention once the immediate consequences of the complication have stabilised (there is a need for patience because they improve significantly over time).
Unforeseen imperfections are part of the hazards of any intervention. They may be a source of disappointment and might also require another operation.