The Postoperative Aesthetic Patient

In a postoperative evaluation of the patient who has had cosmetic surgery, one must not only evaluate the patient for early signs of complications, but also be attentive to the patient’s comfort level, questions, and desires. Always check the patient’s vital signs. A high heart rate, low blood pressure, and decreased urine output can herald an impending complication. In addition, ignoring high blood pressure due to pain can result in a hematoma formation. Hematoma formation not only may lead to life-threatening anemia, but also will compromise skin flaps and may lead to functional morbidity. Ask the patient if he or she feels pain more on one side than the other. This can often indicate a hematoma or infection – dressings should be removed and the wound checked (always remove dressings of patients who have had an otoplasty and complain of asymmetric severe pain). Assessing the patient accurately and proposing a concise and appropriate plan to the primary surgeon should be done prior to any intervention.

Abdominoplasty

Considerations

• Jackson-Pratt (J.P.) drain’s output

If the J.P. drain output is high and bloody and does not turn serous, consider a hematoma

Beware of low drain output and an enlarging/painful mass. Consider a hematoma. The drain may be clotted.

• Keep patient in lawn-chair or flexed position

Put sign above the patient bed to alert caregives of the desired position

Unplug the bed controls

• Incentive spirometry

Reduces atelectasis

• Deep venous thrombosis (DVT) prophylaxis

Get patient out of bed (OOB) with walker ± physical therapy postoperative day (POD) #1

Start Lovenox (Aventis Pharmaceuticals, Parsippany, NJ) 40 mg SC q.d.

• Abdominal binder

• Umbilicus viability

Small arms of delayed wound healing will eventually heal through secondary intention

• Keep the umbilicus clean

Hematoma

• Diagnosis

Asymmetric pain or asymmetric bulging of incision/abdomen

Increasing heart rate, decreasing BP, and decreasing urine output

Dropping hemogram

• Treatment

Strip drains and check serial hemoglobin and hematocrit (H/H) (q6h)

Bolus fluids NS 500 cc and increase fluid rate appropriately (beware of patients with cardiac history – overresuscitation could cause pulmonary edema and heart failure)

Hold all anticoagulants

Type cross and hold pRBCs in preparation of transfusion

Operating room exploration

Respiratory Distress

Pulmonary Embolus

• Diagnosis

ABGs (arterial blood gasses)

Look for hypoxemia, hypercapria, and respiratory alkalosis

High probability when low PaO₂ and dyspnea

Check for calf pain and swelling – if DVT is suspected, then request a duplex ultrasound

CT scan of the chest pulmonary embolism protocol

Elevated D-dimer

• Treatment

If you have a very high suspicion of pulmonary embolism then start heparin drip

Start patient on heparin or Lovenox

Heparin: Load with 80 units/kg bolus and then 18 units/kg/h infusion; check PIT q6h and keep PIT between 60 to 90

Lovenox: 1 mg/kg q 12h SC

Pulmonary Edema

• Diagnosis

CXR

Listen to patient’s chest

Check CVP if available; if above ~12, patient is volume overloaded

• Treatment

Start Lasix (Aventis Pharmaceuticals, Parsippany, NJ) 20 mg IV

Check urine output to keep intakes/outputs (I/Os) negative

Re-dose Lasix as needed

Monitor electrolytes

Overaggressive Plication

• This may lead to decreases in functional residual capacity

• This is more significant on patients with a history of asthma or COPD

• Treatment

First employ conservative management by changing the patient’s position and by respiratory core to include incentive spirometry and branchiodilators

Exploration in the operating room

Dehiscence

Small area

Reinforce with nondehisced areas with Steri-Strips (3M, St. Paul, MN)

Local wound care with wet to dry dressing changes

Future revision

Large Area

Operating room débridement and closure

Breast Augmentation

Hematoma

• Diagnosis

Unilateral pain, swelling, and occasional fever

• Treatment

Strip drains if present

Small hematomas – observe if the patient is asymptomatic

Large hematomas – evacuation in an operating room

Infection

• POD 5 to 10

• Assess patient for either superficial skin or implant infection

• Diagnosis

Leukocytosis

Warm erythema along wound

Rule out periprosthetic infection

• Order ultrasound/CT

Look for fluid collection or stranding/inflammation around implant

• Treatment

Superficial

Cellulitis can be treated with antibiotics

Clindamycin 400 mg PO qid

Clindamycin 900 mg IV q8h or Vancomycin 1 g IV q 12h + Cefepime 1 g IV q 12h for severe infections: also consider antibiotic therapy with equal oral or ID bioavailability (e.g., linezolid)