Not Reading Your Pre-Op Instructions? What Could Go Wrong?

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

Kirstin (00:08):
Hey, Dr. Koehler.

Dr. Koehler (00:10):
Hey, Kirstin.

Kirstin (00:11):
You want to know what we're talking about today?

Dr. Koehler (00:13):
What are we talking about?

Kirstin (00:15):
We're talking about being ready for surgery and things that patients can do to set themselves up for a smooth recovery.

Dr. Koehler (00:25):
Gotcha. All right.

Kirstin (00:26):
This is one of your favorite things to talk about.

Dr. Koehler (00:29):
Well, I don't know if it's my favorite, but it's an important thing, and I feel like when patients, they get ready to have this surgery and they put their whole process into your hands, they want us to carry them through this journey, and we do. We help them through it. But it's also one of these things like if you want a good result and good recovery, there's things that the patient themselves has to do, and it's important, and it's actually these little things that they do can really affect the course of their recovery. So yeah, we try to make a big deal about it because we can only control the factors we can control, and I can only educate, and that's what I try to do, educate patients so they make the best decisions.

Kirstin (01:19):
All right. We're going to talk about how much pre and post-op habits affect results. So we know complications are rare, but when they do occur, would you say that most are actually preventable?

Dr. Koehler (01:39):
It's tough to answer that. I mean, sometimes yes. I mean, sometimes stuff just happens, unfortunately. There's things like a person can have a bleeding after surgery and in surgery because of medications and things like that, their blood pressure may be sitting a little bit lower, but then when they wake up and their blood pressure comes back up or then they get nauseated, and there can be a lot of things that stimulate that. And that's not really anybody's fault. It's just, it's one of those things. So there are certain complications where stuff happens and there's not anything. Nobody could really prevent it, so to speak. But yeah, I think there's a lot of things that we can modify. There are definitely things that are preventable.

Kirstin (02:27):
All right. Let's talk about the pre-op period, and first we're going to talk about smoking. Why is it such a deal breaker before you have surgery?

Dr. Koehler (02:38):
Well, first of all, we're talking about elective surgery. So if you had to get your gallbladder out and you're a smoker, you need it out. It doesn't matter if you're smoking or not smoking, but we're talking about an elective surgery where you don't need to have the surgery. This is something you want to have done. And I can tell you from my years of experience, I hate a complication probably more than the patient does. Nobody wants one. But as a doctor, it bothers me, and it especially bothers me when it's something that I didn't have any control over. I can't not take that cigarette, I can't take the cigarette out of your hand. But definitely I'm very selective about certain surgeries. If you're getting a breast augmentation and you're a smoker, can you have the surgery? Sure. But there are certain procedures like a tummy tuck, a facelift, a breast lift, where we're compromising blood flow, and we don't want you to end up with a necrotic nipple or dead skin or any of that stuff, or wound problems.

(03:39):
So for certain surgeries, I just absolutely won't do the surgery if you're a smoker. And we will nicotine test you on top of that to make sure that you're not getting nicotine from any form. But the big thing with smoking is the carbon monoxide from inhaling it, the nicotine constricts the smaller blood vessels. And those smaller blood vessels are some of the things that we're relying on to allow the tissue to survive during compromised blood flow in the early stages of healing. And then a lot of the other byproducts that are a part of smoking and vaping and all that other stuff. So it's just really in general, if people have problems with stitches spitting out, wounds opening up, I mean, it happens on healthy patients too. It can happen, but there's no question that I see the extent of people who have stitches spit and stuff like that is much more common in people who, they may have quit for surgery and they maybe quit for six weeks, but they still have a little higher chance of these minor nuisance type problems. Again, it can happen to anybody, but skin loss and stuff like that, nobody wants to have that after an elective surgery.

Kirstin (04:49):
Well, and you mentioned a little bit about vaping and nicotine in general. You just want to clarify that it's all nicotine.

Dr. Koehler (04:58):
Yeah, gum, patch, I don't care. Gum, patch, whatever you want. However you're getting it.

Kirstin (05:05):
However you're getting it.

Dr. Koehler (05:06):
Yeah, however you're getting it. It's nicotine is bad. Now, some forms are worse than others, but still, it's all bad. I mean, we know that even just there's studies that look at the blood flow to the finger, and it's like one cigarette decreases. I can't even remember now the exact amount, but it's like it's a ridiculous amount, the blood flow decreases. And so it's, and sometimes people think, oh, I just had one. Well, that one, even if it affects it for several hours, that could be enough to push your flap over the edge.

Kirstin (05:40):
We just had a patient the other day that said she quit smoking for surgery and came in, she was an afternoon, and they nicotine tested her, and she was positive, and she was like, I only had one cigarette at lunchtime. I got peer pressured into it at lunch by a girlfriend. And I mean, I don't know whether she was telling the truth, but she was positive for nicotine after one cigarette. So, there you go.

Dr. Koehler (06:01):
Well, yeah, and unfortunately, I feel like sometimes people are like, oh, it's just one. I've been really, really good. I only had a handful. I had one or two. It's like, it's none. It's like zero. You need to have zero.

Kirstin (06:18):
Okay. So why is alcohol a no-go before surgery?

Dr. Koehler (06:22):
Yeah. Well, first of all, there's maybe a difference between those people that drink regularly and those people that maybe are more social, that only drink from time to time. I mean, yeah, if you drink very frequently, it's possible that you could have some liver dysfunction and other things. That's kind of less likely. But I mean, we see people like that. So yeah, it can affect clotting factors, but even just short-term drinking, like, okay, well, I don't drink regularly, but we went out and we had this wedding reception and we drank too much or whatever. I mean, drinking can affect platelet function. It can affect a lot of different of the mechanisms that affect blood clotting. And the bleeding is the big issue with alcohol. And certain surgeries, maybe it's not as big a deal, but some of these procedures are big, and it's not so much that the blood loss is a problem, but let's say you have the surgery, but then you continue to ooze afterwards, and now you get a hematoma. Well, now you got to come back to surgery to evacuate this blood and dry things up and figure out what was going on. So alcohol is a real no-no. And again, these are things that why are you doing it? This is a procedure you chose to have done. You want to get a good outcome. Can we not? Let's just hold off the alcohol for a couple weeks and you'll be fine.

Kirstin (07:49):
Yep. All right. Well, what about supplements and medicines? Why does it matter to tell your surgeon everything that you take, including supplements?

Dr. Koehler (07:58):
Yeah. No, this is a big one actually. We give a list of, I think there's a whole laundry list of things that are in there. Oh, don't take any of these things. But the reality of it is, I don't have any problems with supplements. And people like to take them for whatever. They're like, oh, this makes me feel better for whatever reasons, and that's great. But supplements are definitely one of these things. It's like, first of all, it's nothing's changing your life with that supplement that much that you couldn't go without it for a few weeks. And so two weeks, all the supplements, just stop 'em all. And even if you're not sure, just stop it. Because I'll tell you, there's so many of them that do cause problems. Again, mainly with bleeding, like ginkgo biloba, turmeric, I mean, there's a whole bunch of stuff.

(08:44):
And I ran into it. I think we talked about it maybe one time before on a podcast, but I was doing a facelift on a patient, and I mean, it was bleeding way, way, way more than typically should. And we got through the surgery fine. The patient ended up doing fine, but I talked to the husband and I was like, Hey, she really bled a lot, keep a close eye on her. And the next day we get to talking and we'll come to find out, well, she takes high dose turmeric because whatever. It's just what she likes to do. And yeah, that's probably what it was. But yeah, anything that you just don't absolutely need to take, you can get back on it after a couple of weeks after surgery, but nothing can be that important. And prescription medicines that you're taking from your doctor, we'll tell you which ones we think you need to come off of, but the stuff we don't know about, we can't counsel you on. And if it's something, sometimes I'm like, my nurses will be like, this person's taking this supplement. I'm like, I have never even heard of that supplement. I don't even know what that is. I'm like, just tell 'em. Stop it. Stop it. I don't know. We could look it up, but it doesn't matter. Just get off of it.

Kirstin (09:41):
Better to just be safe.

Dr. Koehler (09:43):
Yeah.

Kirstin (09:46):
Okay. Let's be honest. First of all, our pre-op booklet is the Bible. How often do you think people don't read it?

Dr. Koehler (09:57):
I don't know, but I do know some people. I had one lady, she brought it back with punctuation corrections, spell checked it. She's like a book editor. And she was like, I just want to point out that there's some conflicts in your book, on this page, it says this and this page, it says, I'm like, thank you very much.

Kirstin (10:14):
Did that hurt your feelings?

Dr. Koehler (10:15):
No, it didn't hurt my feelings, actually. But we've redone the book since then, but it was an older version. I didn't even write it. It was actually something, anyhow. But anyhow, she fixed those issues. But we've made a lot of changes. The book is important because it's really your go-to spot. And so many times when we know when people haven't read it because they're calling the office going, well, what do I do? I had this, I'm like, you obviously didn't read the book. It's in the book.

Kirstin (10:42):
Literally, it talks about everything. It even talks about emotions and the emotions that you're going to feel before surgery and after surgery and things people might say to you. And it talks about everything.

Dr. Koehler (10:53):
There's a lot of things like constipation or how you're feeling and all this. There's stuff in there for you as a resource. And then obviously, we're here as a backup. But if you go into that, actually the people that do read it, I feel like those patients recover so much better because when something happens, they're like, oh, yeah, I remember that. I read that in the book. That's common and normal, and okay, I'm not going to worry about it. And the people who are going, Hey, this is going on. We're like, yeah,

Kirstin (11:25):
We talked about it.

Dr. Koehler (11:26):
We talked about that. That's not a big deal. So we know who hasn't read it sometimes. But anyhow, it is a good resource. I feel like we've actually gone through it, revamped it, and made it to where it's answers most questions.

Kirstin (11:39):
Yep. Okay. So for the post operative period, let's talk about a few of those things. What is the deal with drains? Why do you use 'em?

Dr. Koehler (11:53):
Well, we like to not use 'em when we can, but drains are there. Anytime there's a potential empty space or there's maybe a surgery where we know that it's going to maybe typically be a little more bloody or oozy, we don't want blood to accumulate in those empty spaces or in those areas where it's ozy and the drain is just there to allow things to bruise less, heal quicker, and to not have that fluid accumulate. Because if it does, I mean, at some point it may need to be surgically drained. So we use drains for a lot of different things. But definitely the movement is when we can avoid a drain. We like to, patients don't like 'em. I don't like 'em. I don't like to have to take 'em out, but they're there for a reason. So we sometimes put those in and yeah, we will let you know if we need to put one. And it's just, yeah, a necessary evil. That's all it is. So,

Kirstin (12:43):
Well, I know from experience that tracking drain output is really annoying. So why is it important? Why do we tell patients to do that?

Dr. Koehler (12:52):
Well, we tell 'em to do that because we need to know if the drainage is slow enough to where we can take 'em out safely, that they're not just going to build up with fluid after we take 'em out. Because people can get things like seromas where the fluid continues to build up, and if we take out the drain too early, they're going to show up and they're going to have to see me two and three times a week for me to drain fluid off them. So until that fluid slows down, and that means numbing it up, putting a needle in there and draining it. So better to have the tube in there that's always in there, and then when the drainage drops down to the proper level. So don't cheat on your totals just to get your drains out. We need to know what the number is so that we can safely take 'em out, and then you won't have to hopefully worry about 'em.

Kirstin (13:34):
The true number.

Dr. Koehler (13:36):
The true number, yes.

Kirstin (13:39):
What sort of activity is helpful after surgery?

Dr. Koehler (13:44):
I mean, walking, walking, walking. So the big things, I think probably the three big things that I would say for any surgery, maybe more so for others, but we talked about smoking, so that's a big no-no, that people have to stop. And then the medicines, we talked about that. But infection, preventing infection. So washing with hibiclens, soap, we tell people to do that for their surgical sites, and at least the night before and the morning of and doing that properly, because we're going to do a surgical prep, that's important. But if you decolonize or get your bacteria counts down by doing those washes before surgery, it again makes your chances better of not having a surgical site infection, which can happen with any surgery. And then the last one is preventing blood clots. And that's the activity part, that's the getting up and walking.

(14:40):
So we don't want infections, we don't want blood clots, and we definitely don't want skin necrosis from bad habits like nicotine. So yeah, we encourage activity, getting up and walking, but early on, people can be affected by medication. So always make sure when you go from a lying position to a sitting position, you sit there for a minute. When you go from a sitting position to a standing position, you take a moment to just stay in that spot, make sure you're not going to pass out or get lightheaded, and then stand there for a minute and then go ahead and walk. Because sometimes people have had big surgeries and they get up too quick and then they pass out, and that's just not good. But getting up and moving is very important. It prevents blood clots, it helps you heal quicker. It's just a good thing to do.

Kirstin (15:29):
And with tummy tuck, for example, you're going to numb that person up really well. They're going to be numb for a couple days in their abdomen. So for example, I just feel like you feel really good the night of surgery once you start to wake up and be awake from anesthesia. So take a nice little hot lap around your island or your living room couch and get some muscles moving.

Dr. Koehler (15:54):
Yeah. Well, yeah, we definitely want to, walking is good. Just again, be smart about it. Take your time. If you're not ready, have somebody help you. Have them hold your hand or have a chair there. So if you can walk a little distance, if you need to sit down, you can. I mean, there's lots of things that you can do.

Kirstin (16:12):
Okay, what about pools and hot tubs and our beautiful Gulf Coast beaches?

Dr. Koehler (16:18):
No, no, no. There you go. So none of that stuff for probably six weeks until your incisions are fully healed. If you've got an open sore and open wound, you shouldn't be soaking in anything. Okay. Showers are fine, but even if your tub is clean, you're soaking in that water and your incisions aren't fully healed and something bacteria is going to get in there. And anyhow, we just don't want that. And some bacteria thrive in a wet environment, so we don't want that.

Kirstin (16:45):
Gross. When can most people expect to start feeling like themselves again?

Dr. Koehler (16:53):
I think a lot of people start feeling themselves after a couple of weeks, not a hundred percent, but usually most people are back to work and feeling pretty good. Depends on the procedure. Some people are much quicker than that. But really that really turning moment where people are asking us, Hey, can I work out? That's six weeks. At six weeks? Most people are like, man, I just want my regular life back. And so at six weeks, people are fine, fine. Two weeks for some, maybe a little longer for others. Just depends.

Kirstin (17:24):
So we sort of talked about it a little bit, but what things can go wrong if somebody doesn't follow the instructions that you give them?

Dr. Koehler (17:32):
Well, I mean, again, the things that we worry about, the bad things like a blood clot. Now we're going to each situation's different. Sometimes we give medicines to help people prevent blood clots. Some people aren't more at risk for blood clots. So we do an assessment of that and treat people accordingly. But if you're not up and moving, and that's always, sometimes people have a big surgery and the family members are being like, oh, don't get up. I'll take care of you. Just lay there. And the intention is good, but it's bad advice. You need to be up and moving. So a blood clot, if it happens in your leg, it's harmful, not harmful, but it can be harmful. If it goes to your lungs, it can be life-threatening. So those patients need to be on blood thinners until sometimes for months afterwards to take care of those clots.

(18:19):
But yeah, why not prevent it in the first place? So we talk about that, and there's other education things we talk about, but moving around. So that would be one. And then like I mentioned, infections. Those are the serious things. Blood clots and infections, those are the things that are, I think, primarily preventable. But wounds, those are the things we don't want. Poor healing wounds and smoking and poor nutrition, that's another one we don't talk about. But bigger surgeries, having good nutrition is really, like making sure you're getting enough protein and you're eating well, those are all important things for healing. So yeah, wounds that people get can result in very delayed healing. Sometimes when people have a wound, we'll have to do dressing changes, and it's not something people are like, oh, can you just not close that with stitches? And they're like, no, that won't work.

(19:13):
That'll just make it worse. So we've got to do dressing changes, and it takes time. And sometimes this can be on for a couple of months to get it to where it's fully healed, and then we'll let it sit, and then we have to come back at a later time and do a scar revision or other types of procedures to address that. So really we'd like to try to avoid that all from the get go. Again, I don't think it's all a hundred percent avoidable, but you just want to make sure as the patient that you did your part. That's to me, I'm going to try to do everything on my end. I just would like the patient to do the same. Make sure you're clean for surgery, that you've washed properly, they cleaned your belly button really good. These places that you don't think to clean often. Yeah, that's the main thing.

Kirstin (20:03):
All right. What is one thing that you wish every single patient knew before surgery?

Dr. Koehler (20:10):
One thing that every single patient knew before surgery. Hmmm. I dunno.

Kirstin (20:20):
Oh, I stumped you?

Dr. Koehler (20:23):
No, I'm trying to think what the one thing that they knew. Read the book.

Kirstin (20:31):
Read the book.

Dr. Koehler (20:32):
Read the book.

Kirstin (20:33):
Yes.

Dr. Koehler (20:34):
That's the one thing that I'd like.

Kirstin (20:37):
Answers are there.

Dr. Koehler (20:39):
Yeah. I mean, we spent a lot of time putting that together just so that, because you know what the other thing is? The nurses are really, really good about doing a thorough, going over everything and what to expect. But it's like a lot to absorb, and people probably take in 20% of that, and the other 80% they totally forgot, but it's in the book. So yeah, I think the one thing that I wish people would take away from the pre-op is like, it's there. That's all.

Kirstin (21:11):
Yeah. Okay. Well, when we say that patients are the MVP of their recovery, what do we mean by that?

Dr. Koehler (21:19):
What do you mean? MVP?

Kirstin (21:22):
They're in charge. They are the ones that are going to guide the healing.

Dr. Koehler (21:28):
Yeah. Well, they're the MVP in the sense that, yeah, they've got to take charge of all of it. And if they see a problem, they need to notify us about it, and they see something that doesn't look right. Or if we told 'em that's normal, that's okay. But if it's not, they need to reach out. And if they're having problems, they need to let us know. But they also need to be following all those instructions like we talked about, so that they can maximize their outcome and their recovery.

Kirstin (21:57):
If someone's feeling overwhelmed with all the dos and don't, where should they start?

Dr. Koehler (22:04):
Well, I think we just said it five times. The book.

Kirstin (22:07):
The book. Okay. Well, can I tell you mine?

Dr. Koehler (22:09):
Yeah.

Kirstin (22:10):
Get off of the Facebook groups. That's where you start. Get off Facebook.

Dr. Koehler (22:15):
Yeah, those things are good and bad in some ways. I get it that sometimes people find encouragement about their recovery, and now they start to go, oh, well, this person's experienced a similar thing. Okay, this is normal, whatever. But definitely, I hate to say it, but sometimes there's patients who are not doctors that are giving other patients advice, and sometimes it's terrible advice, and I don't even know where they're getting some of this information from. But anyhow, those groups, I would say, if your doctor told you not to do something, just follow what your doctor said or told you to do something like, don't listen to, somebody, some other doctors might have a different approach, but that's their prerogative. But maybe we don't all agree on that. Some people are like, no, I don't ever do that for my patients. I don't like that. I don't think it's a good idea. So

Kirstin (23:07):
I'm on several of those mommy makeover and tummy tuck groups, and some people's doctors tell them not to shower for a week, and they tell you all these things to buy, like you need a toilet seat riser, and one of those recliners that get you up out of the chair. All that stuff's ridiculous. You don't need any of that. Get off the Facebook group, just do exactly what your doctor tells you to do.

Dr. Koehler (23:34):
I don't even know what to say about all that .

Kirstin (23:35):
I'm serious. I had a whole list of stuff in my Amazon cart, and I asked the girls in the back, the nurses and scrub techs, I'm like, what do I need? And Laney was like, you do not need any of that. None of that. Don't waste your money.

Dr. Koehler (23:48):
No. I mean, I think some ideas can be good, and for certain people, things can be helpful if they have difficulties. But yeah, I would agree. The groups are, sometimes it's just too much. Too much. And again, don't look for, don't send a picture to your Facebook group and go, does this look normal? Or what do you think? Because well, who are you asking?

Kirstin (24:10):
Send the picture to your doctor.

Dr. Koehler (24:11):
Yeah, send it to us. We'll tell you if it's something to worry about. But not Mary who's never, she's got one tummy. She's had one tummy tuck, so she all she can compare it to is her experience. And it might be totally different,

Kirstin (24:25):
Which, by the way, we have a HIPAA compliant messaging system where you can send us 10 pictures if you want, and Dr. Koehler will look at them and the nurses will look at them for you. Please don't put it on Facebook.

Dr. Koehler (24:35):
Yeah, not a good idea.

Kirstin (24:37):
Okay. Any last bits of advice for people that want to heal well and love their results? I just got off on a rant. I'm sorry.

Dr. Koehler (24:45):
That's all right. Oh, no healing. Well, just again, nutrition is important, I think. Prepare for your surgery, right? When it comes to nutrition and all this stuff. Get your shakes, get your stuff, get all these things ahead of time so that now you're not scrambling afterwards and get your meals pre-prepared or order your meals in for the two weeks or whatever that you're going to be out of commission. Use a prepaid service for that. But yeah, I think we hammered all the things that are the most important. But just follow instructions.

Kirstin (25:20):
Are we going to do a juven plug?

Dr. Koehler (25:22):
Yeah. The juven is one of those nutritional supplements you use a lot in hospital wise patients, cancer patients, things like that. It's not a protein supplement, but it is nutritional supplement and things like arginine and glutamine and stuff that are going to help. And it's been scientifically studied and it's got research papers behind it, and we know that it works, and it doesn't affect issues with bleeding and other things. So that supplement, we give people a little thing that they can order it on Amazon and it's, yeah,

Kirstin (25:57):
It's over the counter. You can get it.

Dr. Koehler (25:59):
Yeah. You don't need a prescription for it. And I mean, it doesn't taste the best. I'll be honest. I've tried it and I'm like, hmm.

Kirstin (26:05):
Oh I liked it.

Dr. Koehler (26:06):
Did you? I dunno. I was not thrilled with it, but it wasn't bad. But I mean, it's not something I'd be like, oh, I really enjoy this. I might just incorporate this into my daily routine. I'm like, this would be the kind of thing like, okay, this can make me heal better. It's not that bad. I'll drink it. It's okay. But it didn't like, okay,

Kirstin (26:25):
You must not have had a good flavor. All right. 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 (26:40):
All right Kirstin.

Kirstin (26:41):
Go back to making Alabama Beautiful.

Dr. Koehler (26:43):
All right, I'm on it. Bye

Announcer (26:45):
Bye. 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.