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 Dr. Obagi |
BLOOD THINNERS Blood thinners can significantly impact aesthetic outcomes in cosmetic surgery. Aspirin, Coumadin (warfarin, Bristol-Myers Squibb), fish oil, vitamin E and Plavix (clopidogrel bisulfate, Bristol-Myers Squibb) are commonly taken by patients with CV disease. Cosmetic surgery patients taking these medications who undergo certain cosmetic laser procedures can have an increased risk of bruising because of the increased bleeding during and after laser surgery procedures.
"Patients on blood thinners will get more bruising from the pulsed dye laser and from other short-pulsed lasers such as Q-switched lasers. Patients on Coumadin who undergo a pulsed dye laser procedure will particularly show more bruising at lower energy settings," says Suzan Obagi, M.D., associate professor of dermatology and director of the Cosmetic Surgery and Skin Health Center at the University of Pittsburgh Medical Center, Sewickley, Pa. "Sometimes, medication cannot be stopped to normalize their PT or PTT levels before such procedures, and though this is not even a relative contraindication, patients need to be informed about this so that there are no surprises post-procedure."Blood thinners are a non-issue for minimally invasive procedures such as nonablative laser procedures. However, for patients undergoing ablative laser resurfacing procedures, taking Coumadin, aspirin or Plavix is considered to be a relative contraindication. According to Dr. Obagi, stopping medication about a month before the procedure can have a significant impact on cosmetic outcomes in terms of bleeding post-procedure and prolonged bruising.
SELF-MEDICATING It is not uncommon that patients self-medicate with blood thinners without consulting a physician on account of a positive family history of heart disease or hypertension. According to Dr. Obagi, a detailed drug history here can prove to be invaluable.
To be sure, patients taking prescribed Coumadin or Plavix likely have a diagnosed and documented disease for which they obviously require these therapeutic medications. Here, cosmetic surgeons wary of the potential implications that these medications can have on cosmetic outcomes may opt to perform nonsurgical interventions that cause less trauma to the tissues, as opposed to surgical interventions, which are associated with a risk of increased bleeding.
"Instead of doing a facelift on a patient that cannot stop Coumadin or Plavix, we may opt to utilize Thermage (Solta Medical) as a noninvasive tissue-tightening device, and at the same time use fillers to fill the targeted areas. Though this approach may still cause some bruising, it will not cause huge hematomas or put the patient at risk for significant complications during or after the procedure," Dr. Obagi says.
CONSIDERING CHOLESTEROL Patients with CV disease may also be taking statins or other cholesterol-lowering agents to combat plaque buildup within their arteries. However, these agents can affect the lipid barrier in the stratum corneum and dry out the skin.
According to Dr. Obagi, cholesterol-lowering medications, particularly at higher doses, can cause significant xerosis, rendering the skin much more prone to irritation and more reactive to commonly used creams. These patients can pose a bigger challenge because their xerosis will typically be from head to toe.
"Our main concern, for the most part, is the facial cosmetic procedures that we want to do. In these patients, we need to balance 'retinizing' their skin with Retin-A (tretinoin, OrthoNeutrogena) or Tazorac (tazarotene, Allergan), medications that we routinely use to build collagen in our cosmetic patients. We need to try to balance that by adding in a heavy moisturizer," Dr. Obagi explains.
Inducing dermatitis characterized by red, peeling and flaky skin is the intended goal when retinizing a patient's skin. In these patients, Dr. Obagi may incorporate heavier moisturizers during the day to combat some of the effects that may become exaggerated from the evening application of the retinoid.
"These patients will also likely require higher doses of alpha-hydroxy acids in their morning cream regimen on account of the dry, flaky skin which is not adequately turning over in the stratum corneum. Therefore, we need to add alpha-hydroxy acids to break up the bonds between the cells and get them to shed much faster," Dr. Obagi says.
PACEMAKERS AND MORE According to Dr. Obagi, patients with CV disease undergoing cosmetic surgery may have pacemakers and implanted defibrillators that can sometimes interfere with some of the noninvasive tissue-tightening devices. Additionally, electrocautery units commonly used for intra-operative hemostasis in cosmetic surgery may cause a demand pacemaker to be triggered and turn off, or cause a defibrillator to misfire, if the electrocautery frequency is misinterpreted as an arrhythmia. Therefore, it behooves the cosmetic surgeon to make a checklist and be aware of the interactions that these devices may have before performing cosmetic surgery procedures.
DISCLOSURES: Dr. Obagi reports no relevant financial interests.
