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 Dr. Hunstad |
"We must have a comprehensive approach towards our patient in the perioperative period if we expect to have good outcomes. Simply put, we can do the perfect technical operation and end up with unsatisfactory results," says Dr. Hunstad, associate clinical professor of plastic surgery, University of North Carolina at Chapel Hill.
"As cliché as it sounds, we have to 'look at the entire patient' with respect to his or her history, expectations, lifestyle and nutrition. It is within the preoperative visit we gather this information and tailor our counseling accordingly," he says.DIETARY CONSIDERATIONS Most Americans are likely to have a reasonable diet that provides adequate protein, vitamins and minerals, and this generalization may be particularly true for the population presenting for cosmetic surgery (those who are relatively motivated to engage in a healthy lifestyle). Nevertheless, in Dr. Hunstad's practice, all patients undergoing any cosmetic surgical procedure are started on a regimen of vitamin and mineral supplementation two weeks preoperatively.
"Nutritional deficiencies are likely uncommon among patients seeking cosmetic surgery. Still, the supplementation is very effective for eliminating any deficiencies in iron, trace elements and minerals, and we take this step as an extra precautionary measure to optimize healing," he says.
Patients who present for body contouring procedures after massive weight loss following bariatric surgery, and particularly those who have undergone a bypass procedure that profoundly affects absorption, require more careful consideration in terms of nutritional evaluation and counseling, says Dr. Hunstad, who is a board-certified plastic surgeon practicing in Huntersville, N.C.
He says for the same reason that a bypass procedure enables greater weight loss than restrictive bariatric surgery, patients who undergo gastric bypass are more likely to have nutritional deficiencies and metabolic and hematologic abnormalities, including low hemoglobin and protein, that can compromise healing after cosmetic surgery.
"A much more extensive preoperative laboratory analysis is indicated in bypass patients to identify abnormalities and enable proper intervention to optimize their nutritional and metabolic status and facilitate proper healing," Dr. Hunstad says.
Additionally, all patients undergoing a significant body contouring or liposuction procedure deserve a comprehensive preoperative laboratory evaluation based on the recognition that these aggressive surgeries create a significant physiological challenge.
"Determining the metabolic condition of these patients preoperatively is very important for safe surgery, and any deficiencies identified must be corrected preoperatively," he says.
Otherwise, there has been a trend in plastic surgery toward scaling down the preoperative workup, which is consistent with protocols being followed in other surgical specialties.
"Historically, patients presenting for surgery would routinely undergo an extensive preoperative diagnostic evaluation, including serum chemistry, hematocrit, urinalysis, EKG and chest X-ray. However, recognizing that routine testing presented unnecessary costs, the American Society of Anesthesiologists reassessed this practice and introduced an algorithm designed to optimize the yield of meaningful information by taking into account whether specific tests were indicated based on the patient's age and past medical history," Dr. Hunstad says.
THE TOPIC OF TOBACCO Counseling about smoking cessation is also important for cosmetic surgery patients. Aside from the implications for the patient's general well-being, there are adverse effects of smoking on skin aging and wound repair to consider. Smoking accelerates skin aging, causing dermal thinning and increasing pigmentation. Its effects on wound repair are of greatest concern in patients undergoing a facelift, mastopexy and abdominoplasty, as those procedures involve significant tissue undermining that compromises blood supply to the skin, Dr. Hunstad says.
"Smoking exacerbates the reduction in blood supply because it causes vasoconstriction, and the blood that reaches the skin is also less nourishing because the carbon monoxide generated by smoking displaces oxygen from hemoglobin," he says.
THE VALUE OF EXERCISE Reinforcing the value of exercise for maintaining weight loss is important in bariatric surgery patients. Otherwise, because cosmetic surgery patients are focused on their appearance and already motivated to look good, most are already engaged in regular physical exercise. These patients are particularly well-represented among the population seeking body contouring after massive weight loss that was achieved by reduced calorie intake and increased exercise.
"These are my favorite patients. They are very goal-oriented, self-motivated and generally physically fit, and they are likely to be physiologically ready for surgery and can be expected to do well," Dr. Hunstad says.
Patient interest in physical fitness also has a downside, because these individuals can be very anxious to continue exercising as soon as possible after their surgery.
"One of the questions I am asked most often by cosmetic surgery patients is, 'When can I get back to the gym?' While patients can try to be very persuasive in getting you to modify postoperative activity restrictions, it's important not to deviate from one's best judgment about what is appropriate," Dr. Hunstad says. "We try to allow a return to a pre-existing exercise routine in as reasonable a time frame as possible, but underscore the need for a waiting period, recognizing that noncompliance of patients or allowing them to rush back to the gym too soon can slow down and prolong the postoperative recovery."
