Surgical staging is the purposeful splitting up of cosmetic operations into more than one operation. It is important, because smaller and shorter operations have significantly lower risks and complications than longer ones. Many people want to do more than one operation at a time. Sometimes this is safe, and at other times it might not be wise medically. This educational writing will review this topic of staging so individuals can safely decide on the best approach to their cosmetic procedures. This writing was written at the request of a patient from New Castle, DE.
I have patients who come into the office for consultation desiring many different cosmetic procedures. Many have lost weight, and they are interested in multiple procedures. Some people literally will say, “I am interested in a neck lift, arm tuck, breast lift, tummy tuck, and thigh lift.” It is common sense to many that this is too much surgery, and it is dangerous if it is all done at one operation. But the question is – what is safe and what is not? An extremely common procedure is a Mommy Makeover. This is the combination of breast and stomach surgery. This is also a large operation. Others want a facelift, neck lift, eye tucks, and rhinoplasty at the same time. Where do we draw the line? What is safe?
Length of Surgery Should be Less than 4 Hours
The medical answer is that cosmetic operations should be kept below 4 hours. It has been shown that long operations or the length of the operation can lead to increased problems and risks. It varies from person to person, however. Healthy people will be more likely to tolerate a longer operation, whereas people with other medical issues will have higher risks. These are called comorbid illnesses. It’s similar to what increases risks with the Covid-19 virus. Smoking, diabetes, heart problems, overweight, hypertension, and COPD would be other comorbid illnesses that would increase risks. A 4 hour operation might be safe in a patient with no other health problems. But if they have smoking, hypertension, or other medical issues than concerns for safety would suggest it is better to do a shorter operation and to stage the next procedures.
Long operations have significantly increased risks, as just described above. But the increased risks are not just a small amount, but dramatically increase in a logarithmic amount. A logarithmic increase means that it goes up in a strikingly large manner. For example, let’s look at the risks of blood clots. These are also called deep venous thrombosis (DVT), and it is the medical words for clots in the legs that can cause pulmonary embolism. The risk of blood clots is fortunately low for most cosmetic operations. Most patients should wisely follow instructions to minimize these problems, but they do not need to excessively worry. For patients interested in the best way to decrease risks of DVT. The next photo is a graph showing how the risks go up with longer operative times. They don’t rise slowly but in a dramatic fashion with times longer than 4 hours.
Blood Clots or DVT
We will now discuss blood clots in a hypothetical person considering a Mommy Makeover. Let’s pretend she is having a breast reduction and a tummy tuck. Blood clot risks are below 1% for most short cosmetic operations that are less than 2 hours. But this procedure with a breast reduction and a tummy tuck might be approximately 4-6 hours. This longer operation can have overall risks increased to over 5% ! If she stages the operations, which means doing one first and then the second one at a later date, her risks of blood clots changes significantly. If she stages them, the first operation has approximately a 1% risk followed by the same low risk again of 1% with the second operation. If she does the operations together, the risks logarithmically increase to over 5%. So are Mommy Makeovers dangerous? I’m not saying they are always dangerous. But we need to be aware of the risks and to consider staging when appropriate. Mommy Makeovers are performed every day by thousands of plastic surgeons safely. We need to learn about the risks of the operations we are considering and decide what is wisest. Sometimes patients will decide to stage the operations to get the lowest chances of problems.
What constitutes a long operation depends on the medical source. In general 4-6 hours would be considered a long operation. I am focused on maximal safety, so I believe the length should be 4 hours or less. You can never be too safe in my opinion! I will describe a situation to my patients to explain how we should think about the choice of staging or not. Let’s imagine a loved one needs a 6-8 hour operation for some serious medical condition. It is not elective, because it is serious like a cancer operation. That person and family have no choice and must do the operation. If a complication occurs, everyone knows that there was no choice except to do the long operation. However, cosmetic surgery is elective and optional. If we do a long operation and a complication occurs, doctors and patients might wonder why the operation wasn’t staged for safety. To repeat myself, safety is always one of the most important things to consider and to maximize. Staging often is the wisest choice.
Surgical staging adds safety!
Other Risks
It’s not just blood clots that are increased with longer operations and procedural complexity. Other risks increased are infections, blood loss, wounds, pulmonary problems, and recovery time. This association of long operations and risks has been extensively studied. One excellent study published in the Aesthetic Surgery Journal concluded that longer operations lead to greater morbidity. Morbidity is the medical word for risks and complications. The authors found that there was no change in complications until after 3 hours. At 4.5 hours there was a 3 times greater odds of problems. Most operations were combination operations meaning there was more than one operation happening. Operative times above 3 – 4 hours should be discussed with the patient and are a significant factor in surgical decision making.
Summary
In summary, many cosmetic surgery patients are interested in having more than one procedure performed at a single operation. Longer operations do have specific and defined increased risks. Operations longer than 4 hours are probably best avoided to maximize safety. Staging is the concept of splitting up the procedures into more than one operation. Staging operations is a wise and safe method when too much cosmetic surgery is desired at one time.
Please come in for a thorough consultation with me. I will review in detail your specific desires and wishes. We will come up with a safe and advanced cosmetic surgery plan tailored to you.
