Why the Plastic Surgery Results Are Sometimes Not as Expected

The nature of human tissues: Plastic surgery goals are to improve aesthetics and/or function; however, there are limitations. Unlike it is oftentimes portrayed by the media, plastic surgery is not magical, and not everything can be reshaped or improved to the degree that patients and surgeons may want. Human tissues are not like clay, which can be precisely molded and manipulated, and its new shape does not change over time. In contrast, it is difficult to reshape soft tissues (like fat) because of the lack of structure to them (think about trying to reshape something made of Jelly). Harder tissues like cartilage are easier to reshape, but unlike clay, the new shape can change over time. For instance, cartilage can warp and bend to a degree after surgery, making final results somewhat unpredictable. Moreover, both soft and harder tissues are still affected by external forces like gravity (forcing down, like in aging), skin elasticity (forcing inwards), and nutrition, among others, which further reshapes them over time.

As you can see, based on the examples above, biologic tissues have living cells that do not behave in a totally predictable way and are affected by external factors. Human tissues are dynamic, constantly changing in the microarchitecture, which eventually leads to macroscopic (visible to the eye) changes over time. Talented and experienced surgeons are trained to predict to a degree the behavior of the tissues and oftentimes slightly overcompensate (or overdo) surgeries in order to attain better long-lasting results and increase predictability. Nevertheless, it is impossible to have full certainty over outcomes. An example is if patients develop wide or keloid scars or pigmented scars after surgery. Some patients get them, some do not, and even some get them on one side of the body but not on the other. The patient is more responsible for the quality of scars than the surgeon, assuming a proper plastic surgery technique was used for closure. There are patients that heal beautifully with almost imperceptible scars and others that don’t, despite being closed with exactly the same technique and sutures.

The complexity of healing: It is likely clear to most people that not all results in any surgical specialty are great, not even from a great surgeon. There is a very famous phrase from an unknown author which says, “the only way for a surgeon to avoid any complication is to not operate.” Why is this, particularly in plastic surgery? The answer is multifactorial. There could be systemic complications (e.g., from anesthesia) or at the surgery site (e.g., infections, wound healing problems). Systemic complications are very rare and minimized by using standardized protocols. Surgery is very popular because systemic risks are exceptionally low in healthy individuals, and protocols (such as PCP clearance prior to surgery) have evolved to minimize them. On the other hand, what causes surgical site complications? The answer is again multifactorial. Smoking and obesity are well-known causes of wound healing problems. Therefore, we avoid doing aesthetic surgery in patients with these conditions. Medical problems such as diabetes, hypothyroidism, autoimmune diseases, immunosuppression, and malnutrition, sometimes not even known by patients (or subclinical), can also affect healing. This is why we require a PCP clearance in patients older than 40 years old in an attempt to discover and treat those conditions prior to potential surgery.

The reality: If you understand the above, it is easier to comprehend that despite our best efforts, complications will occasionally happen as it is practically impossible to 100% exclude any of the multiple problems affecting healing. I have seen a few patients in whom we caught a medical problem after surgery after we requested their PCP runs tests to investigate the issue. Despite this, it is not always possible to know why something happened, and unfortunately, we can only speculate. I am writing this statement after years of experience in practice and after a recent episode with a patient. She had a breast reduction/lift procedure. She is about middle age, and surgery was uneventful. Three weeks later, she was doing great. However, five weeks after surgery, the wounds opened up slightly. This case was very rare, but not the first time I saw it. It is not clear what happened, and I even discussed the case with colleagues, but no one had an answer. The first question that came to mind was if the wounds and tissues were too tight. The answer is no, given if this was the case, this situation would have happened much earlier, as soon as the sutures were removed, which is about a week after surgery when the tissues have not still attached together. In fact, at week five, you do not typically need sutures because scarring should be strong enough to hold the tissues together. So, what happened with this patient? The answer is not clear, but we hypothesize that she belongs to the tiny and rare category of patients that may have had hypersensitivity to some of the internal sutures used, plus perhaps some unusual healing reaction modulated by some mild autoimmune disorders that she had a history of. Of note, stress can also modulate the immune and healing systems.

I have had another patient with a similar reaction in the past. In these cases, we let the wound heal by itself with basic wound care (a few weeks’ time), and she eventually healed with some wide scars. Some months later, she underwent a scar revision procedure, and the results were good, as if no healing issues ever happened. A year later, she was very happy but wanted slightly larger breasts and underwent a breast augmentation. The initial wound healing issues, despite temporary (felt like an eternity at that moment), were a thing of the past, and fortunately, her outcome was not compromised. The lesson to learn and the message to patients is: most of the time, by far, complications (at least significant) do not happen. Occasionally they do, and some of them, we don’t know why they happened. This is why it is important to book surgery with enough time for recovery (3 months at least), and do not rush things just before a significant social/life event, where you may also be stressed. If complications happen, they may not necessarily affect the final outcome. Perhaps the most important take-home point that most people don’t know is that a surgeon needs to be competent and experienced not only in doing the procedure but in handling the complications. You are establishing a relationship with a surgeon to not only do your surgery but to be proficient, knowledgeable, and with as much as possible experience in handling potential complications. Unfortunately, there are many dubious low priced, so-called “cosmetic” plastic surgery practices in south Florida with questionable quality, staff, and practices. Therefore, a legitimate board-certified (hyperlink aca) plastic surgeon with experience matters.