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In November 2010 Professor Simon Kay was named as one of Britain’s top 50 doctors by The Times a position he had already achieved in a previous poll 5 years earlier.

 

Risks of Surgery

Introduction

All human actions carry some risk, and yet for most of the things we do in day-to-day life we never stop and evaluate the risk. We don’t make a judgement (risk assessment) as to whether or not to accept the risk and go ahead with whatever we are doing. This is probably because most things we do carry only very small risks of doing us harm, and often the risk evaluation for a common action is so familiar to us we do it without conscious thought. For surgery however it is essential practice to explain risks to patients so that they can balance the chances of benefit from surgery against the risks. In general it is held that patients should know about the risk of adverse events that may be common (occurring in more than say 1% of cases) or that are so serious that even if less common might reasonably be taken into account when making the decision to proceed or not.

Surgeons refer to the inadvertent or unintended things that can go amiss during surgery as complications, and in this section I detail some of the complications of aesthetic or cosmetic surgery and offer some guidance on how to evaluate them.

Surgeons divide the risks of surgery into those common to most operations (General complications), and those especially relevant to the operation being considered (Specific Complications). I suggest it is also valuable to identify risks that could have serious consequences for health, and risks that are not a serious problem and may delay the final result but not significantly impair it. The fact that cosmetic surgery is not essential means it is not worth taking any unnecessary risk, and it is for this reason that I urge patients to have surgery in a properly equipped and staffed hospital where emergency help is at hand in all its forms in the very unlikely event it should be needed.

The list of risks and complications I attach below is not exhaustive, and the human body (and mind) and the surgery it requires are so complex that even for experienced surgeons something new can be expected from time to time. However I have tried to list common complications of surgery and indicate their general or specific nature, and whether they are minor or major in consequence, or common or rare. I hope this is useful but it is a starting point not a substitute for discussion with your own surgeon or me. You may find it helpful to print out this list and bring it (or take it) to the consultation with you.

Cosmetic surgery is quite special in that it is never essential, and is never an emergency. This means that there is always time to evaluate the risks and benefits of surgery and there should never be any pressure to go ahead without being certain the risks can be managed and are worth taking. In practice I suggest patients ask themselves, for each risk or complication, “If that happened to me, could I cope with it?” Obviously. if the answer is “No!” and the risk is common, surgery is unwise, even though most of the complications that can go wrong are ones that with support from surgeon, nurses, and family, prove to be a nuisance or a delay but not a danger.

One cause of problems after surgery is not the potential complications, but dis-satisfaction with a less-than-perfect result. This means that expectations must be understood by surgeon and patient, and if they are unreasonably high, then some adjustment is wise before deciding to proceed. The language we use in this respect is interesting. Few patients would be thrilled to have an “average” result, but on refection, and by definition, half will have a better-than-average, whilst half will be below average, however good or poor the average is! We can immediately see that few will have a perfect result and if you will only settle for a perfect result there is a high chance of disappointment. I think it is best to go in for surgery hoping for the best but able to cope with complications and a less than perfect result, provided it has given substantial improvement. Surgeons are generally (in my experience) very self-critical people who demand a lot of themselves and will certainly strive for the best result in every case, but nature, surgery, and the human factors in patient and surgeon, can conspire against achieving this.

Having said all this, 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.

Common Complications

Common Complications

Alopecia

Common but rarely extensive enough to need treatment.

Procedures affected:
- Brow Lift
- Face Lift
- Any scalp surgery

This refers to loss of hair near a surgical wound. It can result from tension in the skin-closure reducing the oxygen delivery to the hair follicles and causing them to die or shed their hair, or from direct injury to follicles (hair roots), which leave the scalp skin at an angle and so can be cut by an incision in the skin. Minor degrees of alopecia beside a scar are difficult or impossible to eliminate.


Asymmetry

Common.

Procedures affected:
- Breast surgery
- Abdominal surgery
- Eyelid surgery

- Nose surgery
- Prominent ear surgery
- Liposuction

All humans, and probably all animals are asymmetric: that is to say different on the left from the right. Most of us do not recognise or worry about this, and it is common to find that only after surgery will people begin to notice, in a self-critical way, any asymmetry. Some patients even go as far as measuring one side against the other, and not surprisingly will always find a difference. Of course no one wants to be greatly asymmetrical, but minor inequalities are normal, and to be expected. Whether asymmetry is worth further surgical risks to correct depends on how noticeable it is and how much is involved in correcting it. Good advice is often to live with a minor difference for some time before deciding, since all surgical results fluctuate to some degree in the first few months: this is particularly true of breast surgery.


Bleeding

Common.

Procedures affected:
- All surgery

All surgery causes bleeding, and of course all surgeons try (usually successfully) to control this. Means for controlling bleeding are very well developed and very reliable, but even so it can persist after surgery, or even start afresh. In some cases this will produce bruising and slow resolution of swelling, but in other cases it will result in rapid swelling of the wound as blood collects beneath the skin. Known as a haematoma, this collection of blood may be distressing or alarming and may even be painful. In general and with few exceptions any such collection should be released and the bleeding point found and stopped.

The occurrence of a haematoma does not imply that bleeding was missed at the first surgery: several causes of sudden onset of bleeding within the first 24 hours after surgery are known, including swings in blood pressure, or physical manoeuvres and in some patients so called “secondary” bleeds may occur hours, days, or even a couple of weeks later. This is particularly so after breast augmentation. Very rarely, a hitherto unknown condition may cause a patient to bleed, although this is most unusual.

A small amount of blood can look a lot to the unaccustomed eye, but after cosmetic surgery bleeding is never in my experience life-threatening, and almost never requires more than a brief return to theatre. Sometimes if a wound is generally just oozy beneath the skin a drain tube may simply take away blood or prevent it from accumulating and in some cases this is a wise precaution (although drains can cause their own problems and so are not universally used). The need for blood transfusion is extremely rare after cosmetic surgery.

In one or two circumstances (especially after facelift or eye surgery) bleeding can have more serious consequences and it is for this reason that many surgeons will keep patients close at hand for 24 hours after such surgery to ensure return to theatre can be swift in the rare circumstance of a bleed.


Wound discharge

Common - usually not serious.

Procedures affected:
- Breast lift or reduction
- Abdominoplasty
- Face lift

Sometimes fluid may discharge from between the edges of a wound. This may vary from a slow seepage to a sudden gush if a seroma has built up which then burst through a weak part of a wound. This can be alarming for the patient and also embarrassing or awkward, but is usually not serious. As a general principle it is better that fluid of this sort discharge than be bottled up beneath the skin where it can form the basis of an abscess, but it is also wise to contact your surgeon or care nurse to discuss this. Usually no treatment is needed although if the discharge is foul in nature the possibility of infection requiring treatment may be raised.


Dog ears

Common.

Procedures affected:
- Abdominoplasty
- mastopexy
- breast reduction.

Dog’s ears are the little pleats that can occur at the end of long scars, and are sometimes persistent as small bumps. They occur if the surgeon decides to limit the length of scar (in the interest of keeping it as small as possible) and usually they will lessen or resolve completely. Sometimes they require later reduction, usually under local anaesthesia. Where they occur at the innermost extent of a scar beneath the breast it may be better to accept a dog-ear than extend the scar into the visible cleavage area.


Haematoma

Common.

 

Procedures affected:
- Almost all surgery. See bleeding.


Infection: wound

Common. Not usually serious.

 

Procedures affected:
- Any surgery creating a wound in the skin.

Any wound can become infected. In recent years much attention has been devoted to hospital acquired infection including MRSA and necrotising fasciitis (“the flesh eating bug” of tabloid fame.). In practice each is unusual, and the necrotising fasciitis extremely unusual. MRSA and other hospital-acquired infections are still treatable, and many are brought into the hospital by the patient themselves. Serious infections from this cause are rare, and dressing care and if necessary the use of specialised antibiotics will resolve the infection.

But most wound infections are simple to treat and a healthy body will resolve them without complex treatment. In general wounds under tension (such as abdominoplasty) and long wounds or wounds in moist areas such as the armpits or groins are more likely to become infected, but such infections are still rarely serious and more of a nuisance than a health risk.


Implant irregularity

Common.

Procedures affected:
- Breast augmentation.

Breast implants are soft bags containing silicone gel usually, (although some contain salt water). Because they are soft they can in some positions crease or fold and this crease may be visible or palpable through the skin, particularly in very thin women. At each end of a fold the edge of the fold may even feel like a lump and cause understandable alarm. No surgeon will resent a patient worried by such a finding coming immediately back to clnic to be seen and if possible reassured, and in time patients learn to recognise these irregularities as normal.

More troublesome is the rippling that can occur in a soft breast implant and may be visible at the front of the upper part of the breast when the patient leans forward. Again, this is more common in thin patients, with soft implants above the muscle. Most cases do not need treatment: just as well since treatment may not be simple. It may be possible to exchange the implant for a firmer type, although this has its own disadvantages which may include a visible edge to the implant or a clearly palpable implant. In other cases the implant may be disguised beneath the muscle: not a natural place for breast tissue but sometimes a worthwhile compromise.


Numbness (loss of feeling)

Common. Rarely serious.

Procedures affected:
- Breast augmentation
- breast reduction
- facelift
- brow lift most other surgeries to some small degree


Pain

Common but rarely severe

Pain after surgery is common but hard to measure and very rarely is it severe enough to require more than mild painkillers. Anaesthetists and surgeons take care to minimise pain by using techniques such as supplementary local or regional anaesthesia administered during the main general anaesthetic.


Scar: hypertrophic

Common.

Procedures affected:
- Any operation on the skin

Hypertrophic scars (“hyper” means excessive, “trophic” refers to size, or development) are scars which become enlarged, raised red “angry” and broad. They are usually itchy and may even be painful. We do not know why some scars become hypertrophic or even keloid but some known risk factors can be identified. Some parts of the body are more prone to develop such scars, and include the area in front of the beast bone, the collar bones, the outer aspects of the shoulders and upper arms and the front of the forearms. In addition some skin types may be more prone to such scarring, including the very pale freckly skin type and some dark skins as well as some eastern skin types.

Some wound types may predispose to poor scarring, and in particular wounds that have been infected, or have healed slowly and been open during healing. But for most cases of hypertrophic scarring no cause is found, and the same scar may be hypertrophic in one part and fine and of excellent quality in another part. No surgeon will guarantee the quality of a scar, although of course all will strive to produce the finest scar possible.


Seroma

Common.

Procedures affected:
- Abdominoplasty
- some breast surgery
- thigh lift.

Wherever a space is left beneath the skin fluid can seep from the tissue and cause a small accumulation of fluid. This is termed a seroma, and in some cases (especially after abdominoplasty) the fluid may be voluminous enough to require sucking out with a syringe in clinic. This is a simple almost painless procedure that may need to be repeated. This is very common after tummy tucks (abdominoplasty) and has no common long-term detriment.


Stitch infection

Common. Minor.

Procedures affected:
- Any operation with stitches.

Any foreign object in the body can act as a focal point for infection, and stitches are no exception. If a superficial stitch become infected the skin around it gets red, swollen and may discharge some yellowy fluid. This usually resolves if the stitch is removed and no further treatment if needed.

Sometimes stitches are placed beneath the skin to strengthen the wound in an attempt to prevent it widening or gaping. If one of these becomes infected then that infection may form a small abscess and need to be drained and the stitch removed. Nowadays we use many absorbable sutures and some of these release chemicals that kill germs as they slowly resorb into the body, so reducing further the risk of this common minor but irritating complication.

Rare Complications

Rare Complications

Breasts too large

Rare.

Procedures affected:
- Breast reduction
- breast augmentation.

To measure exactly the volume of a living breast is very difficult, as can be seen by the different cup sizes recommended to the same woman by different bra sellers. Although complex scanning methods have been tried, and complicated formulae developed, in the end estimating breast volume relies on experience. So too does deciding on a new volume after either reduction or augmentation. These are difficult things to convey from patient to surgeon and back again, and not surprisingly sometimes the result after surgery is larger or smaller than the patient expected. Immediately there is one point to make: breasts that are too large after surgery may get smaller as swelling resolves, and the patient may also get accustomed to the size. Breasts that are too small will not get larger without help, although again the patient may get used to them in time.

In reduction it is usually possible to get a good idea of final size by manually excluding part of the breast when discussing size. In augmentation it is a less certain process, and here I am usually guided by whether the patient wishes to look natural or not. If they do (and most do) then I will undertake to place test implants whilst the patient is asleep, and stop when the size gets so great that the shape or breast looks unnatural. If the patient wishes to look unnatural (which some do) then sizing is more difficult, but in clinic placing a trial implant in the bra can give a good but approximate idea of the likely final size.

Plastic surgeons are often very experienced in looking at breasts and assessing them, and unlike their patients they may see many hundreds of different breasts a year. Even so it is possible to mistake a patient’s wishes and both sides should try very hard to find an agreement on volume and the acceptable range before surgery.


Breasts too small

Procedures affected:
- See “Breasts too large”


Capsular contracture

Rare.

Procedures affected:
- Breast augmentation.

When anything artificial or alien is placed inside the body, the natural defences form a “wall” of tissue around it. Breast implants are no exception to this rule, and in years gone by, the bane of breast augmentation was that the wall or “capsule” the body formed around the implants would often become firm and then shrink down and squeeze the implants making them feel hard and round and painful. This is known as “capsular contracture” and was previously responsible for a lot of unsatisfactory results in breast augmentation. In an effort to reduce the problem many implants were placed behind the pectoral muscle (which both disguised the hardness and probably helped prevent it by pressure on the capsule from the muscle) with mixed success. However modern implant types and atraumatic techniques have greatly reduced (but not eliminated) this problem. It still occurs in a small percentage of patients but usually so mildly as not to require reoperation. Some believe that the risk of this happenoing can be reduced by not smoking.

When capsular contracture does occur it is not usually due to poor surgery but simply bad luck. Although some drug treatments have been effective in the past the side effects (particularly of liver damage) have discouraged doctors from using this treatment. Instead, in severe cases, reoperation to remove the capsule and sometimes to place the implant deep to the muscle is required. This is a greater procedure than the original operation and deciding to go ahead must be weighed carefully against the benefits since even after this surgery recurrence of the capsular contracture may happen.

The position of an implant deep to the muscle is not a natural place for the bulk of a breast to lie, and it is for this reason that many surgeons have abandoned this as the first choice in such surgery. However it may prove preferable to repeated contracture and your surgeon will discuss this option.


Contour defect

Rare.

Procedures affected:
- Liposuction.
(Very Rarely in abdominoplasty, breast reduction and rhinoplasty)

Liposuction is the process of sucking fat out from the layer beneath the skin using some form of hollow probe. Many different techniques have been described but almost all require the injection into the fat of substantial amounts of specialised fluid to reduce bleeding and ease the aspiration and the break-up of the fat. This in turn can produce some distortion in the area being liposucked and it occasionally happens that the suction probe removes slightly too much from immediately beneath the surface. Liposuction is not a precise image-guided technique and human skills are at its core. If some contour defect does occur it is usually so slight as not to warrant reoperation, but if necessary fat transfer can sometimes be used to reduce the degree of the defect.

Liposuction imbalance may also be a cause of asymmetry (see above).

Rarely contour defects may occur after abdominoplasty (especially if large amounts of abdominal fat are cut away or liposucked) and after breast reduction where the same problem can arise.

Contour defects after rhinoplasty are rare and may be due either to death of a small area of cartilage or over-resection of the cartilage or bone. Sometimes a defect may in fact be caused by an adjacent prominence were not enough bone cartilage or fat has been removed. It is of course important to be sure of which cause applies before any attempt at correction.


Corneal abrasion

Rare.

Procedures affected:
- Eye face or nose or facial surgery

The transparent window at the front of the eye is called the cornea and as anyone who has scratched it or had a grain of dust rub it will know, it is extremely sensitive. In some operations it can be inadvertently scratched causing an abrasion, which is painful but usually self-limiting. To avoid this many surgeons now use special contact lenses placed when the patient is asleep to protect the cornea, and this injury has become even more rare as result. If a scratch does occur it usually resolves within 48 hours with simple antibiotic ointment, pain relief and a cover for the eye.


Scar: keloid

Rare.

Procedures affected:
Over diagnosed and a term usually used incorrectly. Any operation on the skin.

Unlike hypertrophic scars, keloid scars are rare, but even so are often over diagnosed and the term misused. A keloid scar is one that grows or mushrooms in size to extend beyond the boundary of the original wound. In other words it actually extends the area of wound or scarring beyond what was there originally and can come to look like a cauliflower or mushroom, and in the worst cases is a cluster of bulbous hard shiny appendages that hangs from the site of the original scar. This is very rare, thankfully, and is a property of the skin of that patient at that time in that part of the body. It is unpredictable, unless the patient has had a previous keloid scar, or has a family history of keloid scars, but it should be considered in some patient types. Some African skin is very liable to keloid scars (and indeed in some ethnic groups this fact was used to decorate the skin). Like hypertrophic scarring, the cause of this thankfully rare condition is unknown, but is usually related to an intrinsic and undetectable property of the skin itself.


Skin necrosis

Rare - Serious.

Procedures affected:
Almost any operation where skin is “moved or rearranged” such as abdominoplasty, facelift, breast lift or reduction, thigh or arm lift.

Plastic surgeons spend many years learning the limits to which skin can be stressed before it dies (necrosis is just a Greek way of saying death!). In early times this was crucial to allow them to heal wounds by transferring flaps of skin (usually now done by microsurgery). Some operations devised by plastic surgeons (such as face-lifting and abdominoplasty) involve raising flaps of skin and moving them and in some circumstances some of this skin may die as the blood flow becomes more and more tenuous and unable to sustain the life of that piece of skin. This is a serious complication, not because of health risks (which are small) but because it mars the result and may require surgery to replace the skin that has died. Dead skin is also liable to become infected.

The blood flow in the skin is very susceptible to tobacco smoking, and the effect of a single cigarette can be remarkable in reducing the blood flow and tipping a piece of skin on the threshold of dying over the edge. For this reason most plastic surgeons insist that patients for such operations stop smoking several weeks before surgery, and a moments reflection will show that it would be truly foolish to mislead your surgeon about your smoking. He or she has your best interests at heart when asking about smoking and balancing for you the risks and benefits of surgery before making a recommendation, so be accurate in your response!


Undesired result

Rare.

Procedures affected:
- Any operation to change appearance.

The idea that someone might not like the final result of their surgery is a worrying one, but it does sometimes happen. In most cases of cosmetic surgery the surgeon will have a very clear idea of what to expect and will convey that to the patient. The patient will also convey what he or she wants, and between them they will agree whether the patients expectations can be largely or wholly met. In some operations there is an inherent element of unpredictability, and the best example is rhinoplasty (nose job). Here the surgeon can leave the patient at the end of the operation with the result intended but healing, swelling and unpredictable elements may make minor differences that can be enough to change the final result.

In other operations such as increasing or decreasing the size of breasts, the surgeon has to understand the patient’s wishes and aim to get as close to them in terms of final size as possible. But as with many things in life, until you “wear” your new breasts it is impossible to be certain they will be absolutely right for you. Usually they will however be substantial improvements, and the debate then occurs as to whether they are improved enough to need no more doing, or whether they need revision. This again comes down to discussion between patient and surgeon, but in general perfection is something few can guarantee, and a sensible surgeon and a sensible patient will accept some compromise rather than operate and reoperate in pursuit of elusive perfection.


Wound breakdown

Rare - Not usually serious.

Procedures affected:
- Any wound.

Almost all incised wounds in the skin are then sutured or stitched to speed their healing. Some wounds are closed under tension (such as in abdominoplasty) and this means that the healing must be advanced and itself weld the edges of the wound together before the stitches are either removed or absorbed. If healing is slow this may not happen and the wound edges separate. Since the speed of healing is very variable depending on many factors such as the age of the patient, their health, smoking and the area of the body involved, it follows that on occasions healing will not be sufficient to support the wound and some gaping or separation may occur. This usually then heals slowly across the gap, and further suturing is rarely required, and may in fact be a bad idea, bottling infection inside the wound that otherwise could discharge freely onto a dressing. When healing finally succeeds the resulting scar is often red and hard, but matures in time into a soft white scar that may or may not befit from revision.


Hernia

Rare.

Procedures affected:
- Abdominal surgery.

In abdominoplasty or tummy tuck, the muscles of the abdomen sometimes are lax, usually from previous pregnancy or massive weight loss. These can often be tightened, but sometimes a hernia may also be present. A hernia is a condition in which the contents inside the abdomen pop through a weak spot and form a blister or pouch containing fat and sometimes bowel, under the skin. Typically this pouch will expand as the patient coughs or strains (because these actions increase the pressure inside the abdomen). Hernias that are repaired during abdominoplasty can recur, and when the muscles are strengthened with stitches, they can also occur if one of those stitches breaks or tears. These events are rare and reoperation for this reason is very unusual indeed, and not generally health-threatening.


Implant hardening

Rare.

Procedures affected:
- Breast augmentation, See Capsular Contracture.


Implant leakage

Rare.

Procedures affected:
- Breast augmentation.

In the 1980s a scare arose from the idea that breast implants might leak or rupture and spill their contents into the breast tissue. Breast cancer is such an ever-present fear for women and so emotive in its consequences that this had all the ingredients for a good going scare story. In response some countries banned breast implants containing silicone and others monitored the use of implants especially carefully.

Great scientific effort was made to determine if there was a real risk to women from these leaks, and in the meantime the media storm was fuelled (and vice versa) by court settlements in the USA for sums that many of us found astounding, not least because they seemed to be awarded without scientific foundation for the belief that leaking implants were dangerous.

In the end the dust settled and reason prevailed. The story is told in an illuminating book called Science on Trial by Marcia Angell, former scientific editor of a respected medical journal, but I will distil the key points here.

All implants leak or “bleed” some of their contents into the surrounding tissues. This is quite different from rupturing when massive amounts of gel may leak from an implant. In practice very small amounts may also “sweat” their way through the envelope of the implant into the pocket in which the implant sits and this tiny amount is then contained by the capsule of the implant (see capsular contracture for a explanation of this structure). The question is, does this small bleed of silicone gel do any harm? At present and after many years of looking for such harm the conclusion is that it does not. The subject is constantly under review, but at the time of writing (late 2008) the USA has re-allowed silicone beast implants, and no evidence of harm has emerged from any studies around the world. (see safety of silicone on this web site).

Implant rupture is rare. In older implants the envelope containing the gel used to dissolve over many years, or was so insubstantial that it came apart at the points where it was welded, and free gel leaked in large amounts. I have seen such leaks in patients who have come after many years for implants, placed before my time, to be changed, and found that when I came to exchange for modern implants free gel was present within the cavity contained by the capsule, but no harm had ensued. Modern implants are made to a much higher specification, learning lessons of the past, and such dissolution is very unlikely.

However implants can rupture in accidents or if pierced by needles (say during a breast lump biopsy) and if the injury has also breached the capsule of the breast then silicone gel can leak into the breast tissue itself and cause minor problems. For this reason if you have implants and suffer a serious blow to the breast it is wise to have the implants checked, and this can be simply done with an ultrasound scan.

Some manufacturers recommend that when implants have been present for 10 years they should be checked or exchanged for sake of caution. At present there is little evidence to support this with modern implants, but your surgeon will discuss this with you.


Infection: implant

Rare.

Procedures affected:
- Breast augmentation.

It is surprisingly unusual for a breast implant to become infected, even if the wound becomes infected. In fact most infections that I have seen around implants appear to have arisen some time after surgery, certainly several weeks and may well have been blood borne, that is to say they arise because the bugs we all carry from time to time in our blood come to rest on the implant. A similar situation occurs with other implants including artificial joints.

In some cases the implant can be retained and the infection controlled by cleaning around the implant at surgery and with antibiotics. However the more conventional treatment is sadly to remove the implant, treat the infection and then when all has resolved replace the implant. This is obviously very traumatic for the patient and is a risk that must be considered before surgery. In most practices it is rare but causes significant distress until the implant can be replaced, often after several months.


Nerve injury

Rare.

Procedures affected:
- Facelift
- Brow lift
- Serious complication.

All surgery cuts nerves but usually these are so fine that the consequences are not severe. For instance all scars have some numbness next to them, and after abdominoplasty the whole lower abdomen may be numb. But this is usually of no serious consequence even if it is permanent.

In face lifting and brow lifting however the nerves that can supply movement can be damaged, as can the nerve that gives feeling to the ear. In the case of the ear some improvement may occur with time, and the same may happen with the nerves of movement. The injuries themselves are rare: in the case of face-lifting they may cause weakness of brow elevation on one side, (the same with brow lift) or weakness of mouth movement on one side, sometimes reminiscent of a stroke. This is exceptionally rare and the overwhelming majority recover with time, perhaps over 2 or 3 months. Nonetheless they are frightening and distressing and every patient undergoing these procedures should know about this small but serious risk.

Lastly in brow lifting however performed, the scalp may become numb after surgery and this may remain so permanently.

Very Rare Complications

Very Rare Complications

Dry eye

Very rare.

Procedures affected:
- Eyelid surgery.

The eye is normally kept moist be a clever combination of wet tears and a very thin film of grease, which prevents the wet tears from evaporating too easily. This combination depends on the constant activity of the secretory glands in the eyelids and orbit, and on the tear drainage system. In some diseases these can become unbalanced and patients have to supplement their natural tears with artificial tears. This can then be exacerbated by eyelid surgery, or a mild case of dry eye (one not normally needing treatment of even known about by the patient) can then become troublesome. Often this flare-up of the condition is temporary, but your surgeon will carefully ask about eye symptoms before surgery. It is rare for patients to require treatment for dry eye and very rare for any treatment to be needed beyond a few weeks, although air-conditioned environments are especially troublesome to patients with this condition, and flying may be be especially irritant for a few weeks after eyelid surgery for this reason.


DVT

Very rare - Serious.

See. “Death”


Ectropion

Very Rare.

Procedures affected:
- Eyelid surgery.

Ectropion is the medical term for out-turning of the lower eyelid. It can occur naturally (for example in bloodhounds!) but is seen after some lower eyelid surgery. I can arise from a number of causes, and these can cause either full-blown out-turning with the red lining of the lid visible (exceptionally rare in my experience) or slight lowering of the lid margin, which may result in the condition described by the technical term “scleral show”. (The sclera is the white part of the eyeball and is not normally visible below the pupil to ay significant extent, but may be so visible if the lower lid is retracted).

Ectropion has two main causes after surgery. In patients with loose lower lids some shrinking of the raw area beneath the skin where surgery has been conducted may pull the lid down. Whilst very unusual, when it occurs this is usually reversible and gets better spontaneously in a few weeks, so that early surgical correction is unwise.

In other patients the lid is loose and the removal of skin is sufficient to cause Ectropion, usually of a mild degree. Correction may be very difficult and may even require returning some new skin to the lid, or tightening it in the horizontal direction. In some patients the surgeon may decline to undertake eyelid reduction because of the risk in a loose eyelid of this happening, or he or she may suggest a compromise procedure removing little skin and addressing bagging alone.


Extremely rare

Extremely Rare Complications

Death

Very very rare!

Procedures affected:
- Any operation.

Death from cosmetic surgery is extremely rare in the UK. In some reports from other countries death has occurred through surgery in unregulated or unsafe environments. Cosmetic surgery is surgery, and all surgery has risks. To minimise those risks it should be performed only in healthy people or after a sensible and careful health evaluation, and discussion of the risks posed for that patient. The most likely cause of unexpected death after any surgery, not just cosmetic surgery, is pulmonary embolism following deep venous thrombosis. This is the result of stagnant sluggish blood flow in the legs causing clots within the veins, which may then break loose and be carried in the blood stream to the heart and lungs where they can cause obstruction of normal function and, very rarely, death. For this reason all surgeons take the risk of DVT seriously and use a variety of methods to avoid it, which may include blood thinning medication, compression stockings, mechanical pumps whilst anaesthetised (to keep leg blood flowing) and so on. We know that smoking can increase the risk of DVT, and so can long journeys prior to surgery. If you plan to travel for three consecutive hours or more in the weeks before surgery, including car an air journeys, you should notify your surgeon. Some illnesses also have bearing on the risk of DVT, especially active cancers, leg injuries or surgery to the limbs or pelvis, and all your medical history and medication should be disclosed.

In the light of this knowledge your surgeon and anaesthetist can discuss your particular risk, and whether any special measures are needed, or indeed whether surgery is appropriate. Many other activities we take for granted carry a small risk of death (motor travel for instance) and long haul air travel carries a risk of DVT and death, but the risk for a healthy person having elective surgery is very very small, albeit real, and so we must always be alert to ways to reduce that risk further.


Pulmonary embolism

Extremely rare. Very serious and can be life threatening.


Ridges on implant

Unusual. Rarely serious.

Procedures affected:
- Breast augmentation.

Breast implants are made of gel contained within a shell of pliable silicone rubber (sometimes the filling is salt water i.e. saline, but the shell is still silicone rubber). This shell is like a balloon filled with fluid and it can b filled to the point of being tense, or be less full. The less full it is the softer it will feel (in general) but the more likely it is to crease or form ripples in certain positions. In thin patients these may be visible or palpable through the skin. Usually this is not severe enough warrant revisionary surgery, but when it is, that may take the form of a firmer implant (which have their own disadvantages in terms of unnatural feel or palpable edge) or replacement of the existing implant in a deeper location under the muscle of the chest wall (This is not a natural position for breast tissue but is sometimes used either to disguise the feel of an implant or to reduce capsular contracture.

©Simon Kay, Consultant Plastic Surgeon 2008


Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) and Breast Implants: latest news as of Summer 2017.

Rare.

Procedures affected: 
- Breast augmentation.

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