Management of Medical Morbidities and Risk Factors Before Surgery: Smoking, Diabetes, and Other Complicating Factors

Abstract

Patients interested in elective cosmetic procedures often have comorbidities and suffer from medical problems that influence the operative plan and surgical outcome. In the history and physical examination, it is important for the surgeon to identify these areas and be familiar with the associated risks in relation to the planned cosmetic procedure. Common problems that influence plastic surgery and wound healing in general include cigarette smoking, diabetes mellitus, and management of common medications. Smoking is the most common cause of preventable death in the United States today. In addition to its impact on every organ system, it has many detrimental effects on wound healing. Patients judge the results of a cosmetic procedure by symmetry, contour, and minimal scarring; each area is adversely affected by cigarette smoke. In the article ''The pathophysiology of the toxins in cigarette smoke'' this is outlined, and their particular influence on poor wound healing is highlighted. Techniques for smoking cessation are explained and general guidelines to optimize the outcomes of cosmetic procedures on smokers are described. Complications of diabetes mellitus are seen in heart disease, stroke, blood pressure, ocular disease, kidney failure, peripheral vascular disease, and poor wound healing. There are more than 20 million diabetics in the United States today, and plastic surgeons must be aware of the pathophysiology and impact of diabetes on wound healing and recovery after cosmetic procedures. The normal stages of wound healing are described, and the commonly accepted molecular basis for poor healing and increased infection in diabetics is discussed. The cosmetic surgeon must be aware of these added risks and make his or her patients aware preoperatively. Further, the importance of tight glycemic control in the perioperative period is explored. The question of continuation of home medications during the perioperative period is a complicated issue. Although most medications are safe to take with sips of water several hours before a procedure, some are more controversial. The use of psychotropic medication including antidepressants is gaining popularity. These medications alter the levels of neurotransmitters in the central nervous system, and the combination with anesthetic agents used in the operating room is discussed. Oral contraceptive pills and hormone replacement therapy are commonly used agents in the cosmetic surgery population. In light of their association with venous thromboembolism, recommendations for use in perioperative period are discussed.

Versatility of Delayed Reverse Sural Flap for Reconstruction of the Distal Lower Extremity in High-Risk Patients

“…Smokinginduced hypoxia is enhanced by the actions of both nicotine and carbon monoxide. The hypoxic condition damages the normal wound healing process and results in an increased risk of infection and wound dehiscence 20 . Because our patients had significant medical comorbidities, we added a delay procedure to improve flap viability.…”

Patient Satisfaction Improves With Delayed Primary Closure of Dehiscence

“…3 Optimization of a patient's preoperative medical conditions-nutritional, renal, pulmonary, and hematologic status-is necessary for ideal healing. 4 Proper anesthetic and surgical techniques, under optimal sterility, will also improve outcomes. 5 Regardless of a physician's efforts to limit complications, spontaneous wound opening or wound dehiscence remains one of the most common to occur.…”

“…Optimization of a patient’s preoperative medical conditions—nutritional, renal, pulmonary, and hematologic status—is necessary for ideal healing. 4 Proper anesthetic and surgical techniques, under optimal sterility, will also improve outcomes. 5…”