Once It’s Done, Can It Be Undone? The Truth About Revision Cosmetic Surgery

Announcer (00:02):
You are listening to Alabama the Beautiful with cosmetic surgeon, Dr. James Koehler and Kirstin Jarvis.

Kirstin (00:11):
Hey, Dr. Kohler.

Dr. Koehler (00:12):
Hey, Kirstin.

Kirstin (00:14):
Do you have any idea what we're talking about today?

Dr. Koehler (00:17):
No clue.

Kirstin (00:18):
We are talking about what happens when patients change their mind or something happens and they need a revision.

Dr. Koehler (00:27):
Patient's changing their mind. That never happens.

Kirstin (00:30):
No, never. Okay. Before we get into it, do you want to tell us what you do before, during, and after a surgery in order to prevent a revision from happening?

Dr. Koehler (00:40):
The best prevention for revisions is first of all, making sure that we're all really clear on the plan. Let's just say in the event of a lift and an implant, let's give that example. Maybe the patient's wanting an implant size that I'm like, that's maybe getting a little bit big for what your tissues can handle and so on, so forth. But the patient's wanting to proceed with a bigger implant. And then there's this whole discussion, well, well, I don't know for sure if it would bottom out. I mean, I'm just saying I feel like the tissues might not support this and everything else. So then we want to try to prevent that. Well, the way to prevent it would be if I'm saying, look, I think that's getting a little bit big. Let's maybe stop here and if you want to go bigger later, we can do that.

(01:21):
We just don't want your implants to bottom out, cuz that's not a surgical thing necessarily. It can be a tissue quality thing, muscle quality, all these types of things. So there's no real, like making sure the plan is good and that we're all aligned on what the plan is. That's the first thing. Making sure that we're all clear on the expectation where the scars are going to be, what they're going to look like, so that, again, we're all on the same page. The pre-op appointment is an especially important appointment, and the patient typically spends a fair bit of time. It's sometimes an hour, but it's a lot of time with the nurses going through the do's and don'ts. So if you don't want to get a hematoma or bleeding in surgery, there's a whole several pages of herbal medicines, supplements, other things that you absolutely cannot take. It's interesting to me sometimes how people are like, well, what about my ginkgo or my whatever?

(02:16):
I'm like, do you really, really, really need that? I mean, I'm all for, I'm not against herbal supplements and all that stuff, but we know these things can cause bleeding problems. And if it's that important to you, would you really risk bleeding for taking your ginkgo? And we talk about this stuff and put it in our surgical packet because it's a serious, it's serious, we want you to follow instructions, so you need to listen very carefully. There's all sorts of things like for instance, infection. Definitely think that's a preventable thing. Can it happen? Yep, it can. And there's a whole slew of combination reasons why it could happen, but at least you want to take the things that are in your control out of that equation, which is like we tell people to wash or shower a hibaclens soap the night before, the morning of.

(03:01):
And for some people, if they're like healthcare workers or they work in a prison or something like that, they might be exposed to MRSA, which is a nasty bacteria. And we might say, oh, well, we also want you to swab your nose in addition to doing all these showers, and we're going to start earlier than just the day before and the morning of. So there's things that you can do to minimize the risk of certain things. The biggest ones for you that you can minimize is the risk of bleeding by avoiding certain medicines that we don't want you to take. And the risk of infection by making sure that you've cleaned yourself appropriately and that where you're going to stay, what you're going to be around. I don't want you around a bunch of barnyard animals after you've had it done. I mean, we want you to be in a clean environment.

(03:43):
And other things, like for instance, sometimes people are like, well, I like to take tub baths and I just like a tub bath. I feel like I get cleaner or whatever. Well, we don't want you in a tub bath because I don't want you soaking your incision and there's bacteria in that water. You can shower. So again, these are all in the instructions, but paying attention to instructions is a big deal. I remember one time I had a patient thought it would be okay to get in the hot tub and it would help cuz they had liposuction on their back and they had a tummy tuck, and they just thought it would feel better. It may have felt better until it got a nasty infection from what was in the water. It was clearly a waterborne bacteria. And anyhow, very frustrating. So those are things that you could avoid by just following instructions.

(04:24):
There's lots of stuff that we do on our end, but that's on us, and these are the things that are on you. That's probably another, other things when we're talking about some of these bigger surgeries, like the risk of blood clots after surgery, that's a risk. And we give people medicines to take after surgery, and we are very specific at what time you need to take those medicines and for how long. That's a really critical thing. I mean, it doesn't guarantee you won't get a clot, but it sure does significantly reduce that possibility. And so then obviously getting up and walking, you'll always hear for major things like tummy tuck and body lifts, we want you up and moving. And that's to prevent things like blood clots. So those kinds of complications, a lot of these things are actually quite preventable. And I know without going into lots of details, things that we do in our office to keep people properly warmed, to prevent things like infection and blood clots and giving people blood thinners before certain procedures. We do all of these things and these are all done for your safety and to prevent complications.

Kirstin (05:22):
Are there ever reasons why patients may change their minds? Specifically talking about breast augmentations, maybe they just no longer want implants? Do people ever give you reasons like that?

Dr. Koehler (05:35):
Yeah, I mean, some of them are kind of funny. I mean, I've had some older ladies that they've had their implants for, I dunno, 30, 40 years. And they're like, oh, I loved them at the time, but it's that time, I'm ready for these to go and my neck hurts, my back hurts. Just these have got to go. And I've been together with my husband for 50 years, he doesn't care. I want him out. And it may have been good at a certain time in your life and then you're like, okay, I want 'em out. We've talked about this before, but sometimes the reasons people do surgeries can be for the wrong reasons. And so if it didn't save their marriage or their relationship and then they want 'em out, they never really wanted 'em in the first place. So that there are lots of reasons why. Or sometimes people are just like, oh, I thought it was going to look different.

(06:17):
And I actually, I don't like how this looks. I really would like the way I looked before. People do change their mind. And when we go through implant sizing, we spend some time doing that. But I jokingly, it's like with my wife, it's like, okay, she puts the couch somewhere and then we're like, now let's move it over there. I'm like, okay, you like that? Yeah, no, it's got to go back over here. And I'm like, okay. So a couch, we can move back and forth, but breast implants, it's a surgery, right? It's not like, yeah, tried it, I tried this size, I think I should go smaller. Okay, alright. We go smaller. No, actually I like the other ones better. So I mean obviously there's expense, the risk of surgery, all that kind of stuff. So we do want to try to nail things down. So things like sizing for surgery, we spend time making sure that we get you where you want to be. Those are ways, again, to try to minimize the likelihood of having to go back and do more things.

Kirstin (07:14):
What about tummy tucks? Are there ever people that want to redo anything about their tummy tucks?

Dr. Koehler (07:19):
I think sometimes people want to have a second tummy tuck, but I don't know that I get too often like, oh, I wished I didn't have my tummy tuck. Because most of the time people are very, very happy with doing their tummy tuck.

Kirstin (07:30):
I agree.

Dr. Koehler (07:31):
I've had the situation where a woman thought she was done with kids or whatever, and then again, go through life and maybe they get divorced, got remarried, and now all of a sudden they want to have another child with their new spouse and then they do. And now all of a sudden the tummy tuck doesn't look like it did. And so they're wanting to do a second tummy tuck. So that would be some reasons why people do it again. And sometimes it can be difficult to do a full tummy tuck again, so anyhow.

Kirstin (07:59):
BBLs, the big booties we're in now, we've talked about recently maybe big booties aren't so in as they were.

Dr. Koehler (08:06):
Got to be careful with trends. Breast implant size changes over the years. Sometimes bigger breasts are more fashionable, and then people are like, I want implants, but I just like them, the smaller type of implants. So I mean, that's fine, things change. But for BBLs, I've had to liposuction people's buttocks and it sometimes can be hard and some things are just not easy to put it exactly where it was before. It's always going to look a little different. But yeah, we've definitely seen a trend of for BBLs more for shape, not so much for size, although there will be increases in size. But it's a lot of times now just trying to get the shape a bit better.

Kirstin (08:46):
As far as complications, like revisions for complications, there are some examples for breasts, like capsular contracture or ruptures. Do you want to talk a little bit about that?

Dr. Koehler (08:57):
Yeah, we definitely do revision surgeries for those things. Capsular contracture is a situation where your body abnormally produces excess scar tissue around an implant. We believe that the bacteria within the ducts of the breast plays a role and can create a biofilm of bacteria on the implant. And your body reacts to that by forming more scar tissue. It's not an infection, it's just like it's bacteria within the body. But anyhow, when that happens, that requires, it can get firm distorted in shape. And so the treatment is to go in there and remove that scar tissue, take that implant out that has that biofilm on it and put a new implant in. And then there's some other things that we can do at surgery to kind of help minimize the recurrence, but there is a significant potential recurrence rate with that. So yeah, that's one of those lifetime risks of implants where it's like a lot of times people think, oh, I'm six months out from surgery, everything's good, I'm out. I'm free and clear. And you kind of are, but it could happen a year from now. It could happen 10 years from now. You don't know when. It's a cumulative risk over time. And so if you have your implants long enough, you probably will get capsule contracture, but it could be 20, 30 years. And I've seen that.

Kirstin (10:07):
Do revision surgeries come with more risks than the first time around or is it about the same?

Dr. Koehler (10:12):
They can. I mean, a pretty common thing for us is doing repeat breast lifts. So people had a breast lift and actually now they need another breast lift and maybe they also want an implant to help give them some shape and fullness. Well, the way that a breast lift works, you're not cutting the nipple off, but you are removing tissue and you are potentially interrupting the blood flow to that nipple. And that could happen with the first surgery and you don't really know how much the blood supply is really affected. And then you go back and now we're going to do another lift and there's a risk of decreased blood flow to the nipple in a primary surgery. But now we don't know. And it's definitely, it's an increased risk when you go into certain revision surgeries. There's this discussion about, hey, there's more risk with this.

(11:00):
And same thing, like rhinoplasties, I dunno, I think it's estimated, I don't know, somewhere 10 to 20% of primary rhinoplasties end up getting a second rhinoplasty. And that's okay. I mean, sometimes revisions happen and that can happen, but you don't want to be doing third and fourth time rhinoplasty. As a surgeon, I don't even do, if somebody has had three rhinoplasties, don't come see me because that risk is way too high. And I would say, you know what? You need to see somebody who that's all they do is rhinoplasty, that's it, nothing else. And even that, it's not like they have any magic because the problem's all still the same, but at least you know, went to somebody who's like, that's their sub sub, sub sub specialty. Having a skilled surgeon is very important. I would never say that that's not a valuable thing, but there's so much more that's sort of outside the realm of it's not in the control of the doctor.

Kirstin (11:54):
Are there any procedures that you cannot reverse or something that is just the most difficult to reverse?

Dr. Koehler (12:01):
Nothing is really truly reversible. I can't think of a single thing that I would say that's, well filler. You can quote reverse filler, you inject that and you can reverse it. But surgically everything carries a scar. It may be a small scar, but there's a scar. I had a patient that got her implants out and breast looks really quite fine, normal, but there's still the scar from the original surgery, so that's not gone and you can't erase scars. Difficult, treating difficult scars can be very challenging, like keloid scars. We'll talk about scars for a minute because there's the normal healing of scars and there's a wide variation there. I have some people, you look at them in six months and you're like, wow, you can barely see the scar. And then I have other people who are healing what I would call normally, but at six months it's still red, it doesn't look bad, it's not raised or anything like that.

(12:55):
But then you see that same person a year and they may look as good as the person at six months, but the timeframe is different for everyone. So some people can look better quicker, but sometimes the ultimate outcome for both of those people could be the exact same. It's just how soon do they get there? So that's one thing. But the thing we look out for is there's kind of two types of problem scars. There's hypertrophic scars and there's keloid scars, and they're not the same. Everybody calls a raised scar a keloid, and that's just not true. So a raised scar or a thickened ropey scar is a lot of times we would call that hypertrophic scar. And all that that means is that there's been increased collagen formation, abnormal inflammatory reaction, and that's resulted in a scar that's raised. And for some of those hypertrophic scars, like okay, let's say it's been well after the surgery, it's fully healed, but they've got this raised scar.

(13:48):
Okay, well we can do a scar revision and since we know that this person maybe has a abnormal healing response, maybe we use a different type of suture that causes less inflammation, or maybe we use a suture that we actually pull out. So there's nothing, there's less resorbing sutures because the way that sutures dissolve is through kind of inflammatory processes and it breaks down the suture. And so some sutures cause more inflammation and some sutures cause less. We can do some things differently. And then there's some medicines that we can inject at different points in time in the healing to kind of prevent that hypertrophic scar from coming back. So that's something we can treat. And then there's topical stuff and all sorts of things. Keloid scarring is quite different. That has a genetic component to it. We see it in lots of races, but it tends to be more common in African-American skin.

(14:34):
And so if you've ever seen somebody who had their ear pierced and then they've got looks like a grape hanging off their earlobe that was not put there for show, that is like a reaction, a scar reaction to having their ears pierced. And so what it is is it's a thickened and a raised scar, but it goes beyond the borders of where the injury occurred. So in an ear piercing, I mean that big area, that's not where the piercing was. That's well beyond where the piercing was. So those types of scars can be very difficult to treat. And sometimes we have to even resort to things like low level radiation therapy, a lot of injectable like chemotherapy type drugs to kind of help prevent these scars from getting too thick. You might not prevent the keloid completely, but you can maybe minimize it and maybe not end up with such a huge scar. So those are two different things. Everybody calls it raised scar a keloid, even I hear doctors saying that, but that's just not the same thing. So scar management is something that we can do things upfront and if we know you have issues with healing, we can have some discussion about things afterwards to try to help you through the process.

Kirstin (15:36):
Okay. Anything else you want to add?

Dr. Koehler (15:38):
Yeah, I mean, I just think revision surgery, the only thing I'll say when I have people that need revisions, if your doctor says this cannot be done in one operation, which is sometimes quite common with more difficult revisions, we're like, okay, this problem, I can make it look a lot better, but we are going to have to do it in steps. Again, we've talked about this before as well, but people don't like to hear multiple, I don't want to hear three procedures. I want to hear one procedure, one recovery. If you visit two doctors and one says, oh yeah, I can do it all one operation, and the other one says, yeah, I can do this, but I think it needs two or three procedures. I'm not saying the one that says two or three is correct, but that's when you can definitely get another opinion.

(16:18):
People that are wanting to do multiple procedures, you've got to understand not necessarily a financially motivated decision. It's truly because if it's a complex problem, sometimes to not create a bigger problem, we got to do baby steps. So that's something that I would maybe point out to people is that revision surgery is not like the original. And sometimes they're just things like, for instance, if a nipple is placed way too high or something, sometimes you can't really recover from that. You can't move it down. There's lots of things that are not really fully reversible, but we can sometimes make 'em look better. Expectations.

Kirstin (16:57):
Expectations, word of the day. Okay. Do you have a burning question for Dr. Koehler or me? You can leave us a voicemail on our podcast website at AlabamatheBeautifulpodcast.com. We'd love to hear from you. Thanks Dr. Koehler.

Dr. Koehler (17:13):
Thanks, Kristin.

Kirstin (17:13):
Go back to making Alabama beautiful.

Dr. Koehler (17:15):
I'm on it.

Kirstin (17:17):
Got a question for Dr. Koehler? Leave us a voicemail at AlabamatheBeautifulpodcast.com. Dr. James Koehler is a cosmetic surgeon practicing in Fairhope, Alabama. To learn more about Dr. Koehler and Eastern Shore Cosmetic Surgery, go to easternshorecosmeticsurgery.com. The commentary in this podcast represents opinion and does not present medical advice, but general information that does not necessarily relate to the specific conditions of any individual patient. If you enjoyed this episode, please share it and subscribe to Alabama the Beautiful on YouTube, Apple Podcast, Spotify, or wherever you like to listen to podcasts. Follow us on Instagram @EasternShoreCosmeticSurgery. Alabama the Beautiful is a production of The Axis, theaxis.io.