The Truth About Cosmetic Surgery Recovery

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

Kirstin (00:11):
Hey Dr. Koehler.

Dr. Koehler (00:14):
Hey Kirstin.

Kirstin (00:15):
What do you want to talk about today?

Dr. Koehler (00:17):
I dunno, it looks like you're at the library. You going to want to talk about some library books or what do you got?

Kirstin (00:22):
I have been doing some reading the past couple of days actually. I want to talk about surgery scaries.

Dr. Koehler (00:30):
Surgery scaries, what do you mean?

Kirstin (00:32):
Yeah, what are some of the biggest misconceptions that people have about recovering from cosmetic surgery?

Dr. Koehler (00:40):
The number one misconception with cosmetic surgery is people look at before and after results and I think the expectation is that they're going to have that after result like a week or two weeks or three weeks after surgery and it takes time to get to the final result. I mean, most photographs, at least on our website, the interval between the before and the after is probably at the earliest four months and sometimes longer. It does take some time and I know some people in social media that are really good about showing patients through their recovery process and I think that's helpful. But I will even qualify that with, for instance, I've had facelift patients that in three weeks look unbelievable. No bruising, looked great, but that's not everybody. And so we're all a little different and the misconception is your journey is going to be the same as somebody else's journey and that is not true.

(01:33):
And another, I don't want to say it's a misconception, but another, so if you're talking about the common things I guess that we see in the recovery process, these are things that we commonly see and maybe sometimes people don't expect. But definitely the emotional roller coaster is probably one of the top of the list. And in our little booklet of information, we definitely have a whole section on that and want people to read that because a lot of people go through that and I mean there's all this excitement that is built up to having the surgery, then people have the surgery and then they're going through discomfort and swelling and they can't find a comfortable position and maybe they've got kids and they can't deal with their kids the way they want to. And it's like all of these things are now all of a sudden what was something exciting has kind of become a nightmare for them or not a nightmare, but it's just not maybe how they envisioned it.

(02:27):
And then they look at themselves in the mirror and they're like, oh, they're swollen or bruised, or they don't look the way they think they should look because like I mentioned, they're thinking they should have the three month result in one week and it's not there yet. It can be very difficult for people and in particular I would say for facial procedures because, body stuff, you might still look decent and it's maybe still be swollen, but you can sort of see through that a little bit more. But like your face, you identify with your face a little differently and when you look at it and you go, oh my God, what did I just do to myself? There's panic mode starts to set in. And so I think especially for facial procedures, that emotional rollercoaster is probably maybe even a little bit more involved. And so I guess the first part of that is we try to make sure people understand that they're not alone and almost every patient goes through this to a certain extent and that the good news is you're going to come out on the other side.

(03:22):
And we also try to share that with family members that are taking care of them because they're going to be dealing with that in the house on a daily basis. And so they need to be encouraging and supportive, which is another big reason is when you choose to have this type of surgery because it's not necessary surgery, it's elective, it's really important to have, even if it's not your immediate family, but friends or somebody who's going to be supportive of you through this process. The last thing you need is somebody who's like, I told you not to do this in the first place and see what I told you so. And unfortunately, spouses sometimes can say that, and then you're in a position where it's like, well, you don't want to complain because you don't want to hear your spouse tell you again that, and you don't feel good. And so these things compound and so having somebody's supportive is really important to get you through this. And of course, obviously our staff are great and they're going to support you, but we can't be there all the time. We do some handholding here. We've seen some tears from time to time, but people get through it.

Kirstin (04:23):
Well, you mentioned that you put in the patient's pre-op booklet, the emotional rollercoaster and the fact that that's probably going to happen to them, and I don't think a lot of surgeons do that. I'm really glad that you mentioned that ahead of time and give those patients the opportunity to read about that and think about that because, you see so many times on Facebook groups and you mentioned face, but especially the breast augmentation groups, I don't think that some surgeons really explain the process of the drop and fluff or that your breasts on day three of surgery are not going to look the same that they will six weeks after surgery. And so sometimes people are really surprised to take their bra off and look in the mirror and they're like, oh my gosh, what did I do to myself? That's not explained to them ahead of time, so I'm really glad that you do that. Can you walk us through what the healing process looks like right after surgery or in the weeks following and then long-term? Or does it depend on the procedure?

Dr. Koehler (05:24):
It depends on the procedure. It depends a lot, but talking about the recovery process, I think there's some common things that we hear from patients that are common to all surgeries that kind of do apply that my nurses tend to get questions of, and in fact there's some other things like, okay, here's something that we'll talk about that most people, like this is not a discussion point before surgery, but constipation. It happens and it happens actually a fair bit and for a number of reasons, you get narcotic medicine during your anesthesia, although we do try to minimize all that. We have all these protocols now where we don't use very much narcotic at all to get people recovered quicker with less nausea and all these types of things, but you're still taking pain medicine and if you don't sort of plan in advance, you may be really straining, struggling.

(06:17):
We like to have people start on a stool softener before surgery because a stool softener takes a while to really work. And it's not going to make you go to the bathroom. It's just going to make the stool softer, so that's going to make it easier for you. We have a whole sort of little constipation protocol. We actually had to put it down on paper because it happens so often that here's what you do after three days, if you haven't been having a bowel movement, which is common, you're not going to have a bowel movement probably for two or three days. And for people who are really regular, they start stressing out after about three days and not going to the bathroom. And my older patients, they count the days by bowel movements. But anyhow, we don't want to throw their weeks off, but so we have a protocol that we give and then getting up and walking, drinking plenty of fluids, making sure you get some fiber in your diet.

(07:08):
I mean, all these other things that you can do to kind of help prevent constipation. But anyhow, that's a common post surgical problem that we deal with all the time. Another one is spitting stitches for procedures like tummy tuck or breast lifts and sometimes even facelifts, but more common in the body procedures. I think we use a lot of resorbable sutures and some of these sutures are very slow to dissolve sutures. What does that matter? Well, so sutures that dissolve quickly, it's good that they dissolve quickly, but they tend to create more inflammation. Sort of what happens during the dissolving a suture process, some inflammation occurs. And so a lot of times we tend to use sutures that dissolve either more slowly and sometimes we use sutures that don't dissolve at all to create the least amount of inflammation, but some of these sutures, if they're underneath the skin and they're slower to dissolve instead of dissolving, sometimes what happens is the body will tend to push that little suture, if it's close to the skin surface, and it'll push it to the surface and then we'll get a phone call saying, I've got an infection.

(08:13):
There's puss coming out of my incision site. A lot of times I would equate this to a pimple. If you've got a pimple and you squeeze it, what do you see? There's puss, but it's not an infection. I mean it is, but it isn't something like you don't need antibiotics for it. And in fact, once you've drained it, a lot of times that's all that needs to happen, and it's a done deal. Similar with a stitch. When a stitch gets close to the surface, it will remain, like you'll get maybe a little kind of puss type like drainage because until the stitch is cleared, in other words, you either like a doctor removes it or maybe it falls out or whatever, then it will heal. But until that time, it just stays irritated and it can have drainage. It can not look good. If we have people that have a stitch that comes to the surface, a lot of times they'll say, well, first of all, send us a picture.

(09:01):
Let's take a look at it. And nine times out of 10, it's totally nothing but it needs to be treated and you got to come see us and we'll pluck that little stitch out and problem solve. But I mean, these are things that you occasionally see and we try to let people know about that. Again, it's not super common, but it's common enough to where we just don't want people panicking and going, oh my gosh, I'm infected, or there's some major issue going on when really it's something minor. I guess the other really big things the nurses tend to see is calls about swelling and bruising. These are normal things like bruising. Talk to people about bruising because significant swelling and bruising may indicate a more significant problem like a hematoma or something like that. If people are concerned, we kind of tell 'em a few of the warning signs to look out for, which is typically if somebody's got a hematoma, there's pain that's not even touched by pain medicine.

(09:56):
There's significant swelling. If we're talking about breasts, one will be significantly larger than the other side, and then the bruising can be pretty intense too. So bruising and swelling can indicate a more serious problem, but a lot of times it's just normal. Numbness is another one that we talk about. Even with a straightforward breast augmentation, about 10% of people can have decreased sensation or numbness that can be permanent, but we see a lot of temporary numbness for sure in the first six weeks. It's really common for people like, oh, I don't have nipple sensitivity, or I can't feel my breast, that's normal. And if they have that numbness, typically if it's going to resolve is usually eight to 12 months, things are kind of back to where they're supposed to be. Another one would be asymmetry. So anytime we operate on two, two eyelids, two ears, two breasts, anything that there's a right and the left side, they may not heal the same way. With implants, sometimes if you're right-handed, maybe that muscle's a little bit thicker, a little stronger, or you're using that arm a little bit more so that implant may be a little slower to settle.

(10:57):
There can be lots of different reasons, but ultimately they may end up in the same position, but they may not get there at the same time. Another thing we always talk about, most people are not symmetric to begin with, so we try to point those things out ahead of time because we tell people, your breasts are sisters, they're not twins, they're not going to be afterwards, but we try to get 'em as close as possible and we try to recognize these differences between the right and left sides. But again, that's part of realistic expectations. You're not going to be symmetrical from the start, if you're not symmetric at the start, there's likely going to be some element afterwards. But people notice these things in symmetry acutely after surgery because they weren't looking at it the same way before. And so asymmetry, although it's like it might've always been there and we can see it in the pictures, I'm like, well, yeah, it's always been there, but you're looking at things differently in the recovery process, just like we talked about that emotional rollercoaster. You're analyzing it now. You're not just looking at your breast, you're analyzing it, and that's when you start to notice things. So things that might've been how they always were all of a sudden come to your conscious mind.

Kirstin (11:59):
Well, scars are also a big worry for people, so can you tell us what affects how they form and if there's anything that can be done to keep them as minimal as possible?

Dr. Koehler (12:11):
The things that we tend to do is we always try to close our incisions with the least amount of tension, so there's lots of different things that we do surgically to help with that. We use the best quality suture that we can get. There are some cheaper brands, less expensive brands, but we choose to use the ones that I like because I feel like I get the best results in my scars. And I mentioned earlier, we sometimes use sutures that are a little longer to dissolve. They sometimes have some issues with spitting, but they also create less inflammation for the most part. And so sometimes you end up with better looking scars. Definitely the wound care that the patient does after surgery, we don't let them do scar cream right away, but when we do either silicone sheeting or scar creams, and we have our recommendations there that we go through with patients, but if they're really good about doing that, we like them to use that for at least three months after they start doing it.

(13:01):
So usually you're not going to start scar cream for maybe three, four weeks after surgery, but once you start doing it, then we want you to do that pretty religiously for three months. And then in cases where people have abnormal healing, where they have thickened scars, we sometimes will do low dose steroid injections or even sometimes Botox injections into scars, believe it or not. And then there's some office-based therapies that we can do like intense pulse light microneedling, some laser treatments. So there's options there, but we don't start off with all of those. Those are kind of for if you're healing normally, just the things I mentioned earlier are just fine. If you're not healing the way we'd like you to, then we might need to step up the game and talk about lasers and microneedling and other things.

Kirstin (13:53):
Well, nobody wants to be in pain, so what are the best ways to manage people's discomfort after surgery, and then when does pain become a red flag?

Dr. Koehler (14:04):
The best way to manage discomfort after surgery is don't pick up the phone. No kidding. So we have a protocol that we use of medicines that some narcotic, some non-narcotic to really try to minimize discomfort, and I think the most important thing people need to understand is there will be discomfort. We'd love for you to have a completely pain-free surgery and for some of the more minor things, you may experience that, but for bigger procedures like body lifts and tummy tucks, it's a process and it's not pain free. And if you go into it thinking you're going to be pain-free, I hate to tell you, but you're going to be probably a little disappointed. We definitely do give medicines to assist with that, but really sometimes getting off of those narcotic medicines and onto some non-narcotic medicines can be some of the best things because people sometimes do not feel, pain medicine and muscle relaxants and things like that can make people feel kind of crappy in a different way and it can slow your recovery process. So we really do try to transition people pretty quickly off of the stronger medicines.

Kirstin (15:13):
I feel like with tummy tuck recovery, not sitting in my bed or not sitting in the chair getting up and moving, definitely helped with my pain a little bit.

Dr. Koehler (15:23):
Yeah, I mean, it's different for everybody, but definitely the more you get up and start to move, the more you start to feel comfortable doing it. If you just don't move at all, then when you finally do try to start to move, you're like, oh, yeah, it hurts too much. I'm not going to move. We know how important it is for you to move because you don't want to have problems with a blood clot in your leg or something because you just laid around and didn't do anything. So it's important to get up and move and you got to work through some of that pain. With breast augmentation, we give people stretches to to help allow the muscles to relax, and if you're good about doing those stretches, you're going to feel better more quickly. If you're like, oh, it hurts too much, I don't want to do it. Well, okay, but you're going to probably feel a whole lot better if you actually do the stretches and there's a reason we give you those stretches and it's to help you get through that process quicker.

Kirstin (16:09):
A big fear that some patients have is not loving their results. How often do you actually see that?

Dr. Koehler (16:16):
I mean, you occasionally see it, and I hate to say it, but the most common reason you would see something like that is, and we've talked about this before, but it's when maybe the patient didn't do it for the right reasons in the first place. And so when people, let's say, oh, trying to save this marriage, I'm going to go get breast implants, and then the marriage falls apart, and then they have regrets about getting the breast implants. And it really isn't so much the result, it's just like they spent the money with the hope of it was going to give them this job or this marriage or whatever the thing was, and if that didn't pan out, then there's disappointment and it gets tied to the procedure. So that sometimes happens, and then sometimes people just had higher expectations than what could actually be delivered.

(17:01):
Obviously, there's varying degrees of disappointment. Really the key to it is in the preoperative stuff, and that's where we talked about making sure that we're both on the same page as far as what we think the result can be. If you're showing your doctor pictures, had this happen before where I've had people say, well, I wouldn't look like this, and I'd be like, no, I cannot do that. I'm sorry. I can't. Your anatomy is totally different. I cannot do it. I want to get snatched my waist like this or something. I'm like, well, your hip bones sit up really high and you do not. I can't get it. There's not anything, I can't do anything differently surgically. I know what you want and I want to give it to you, but your anatomy is not going to let me do that. That's where the key is making sure that we are on the same page because when there's that disconnect where the patient says, oh, he told me he'd get me snatched, or I can get snatched, and then afterwards we're like, oh, and another common one, and I have to reinforce this a lot of times with tummy tuck patients is like visceral fat.

(18:00):
We carry fat in two places. The fat that's under the skin and then the fat that's inside the belly and the fat that's inside the belly, we cannot do anything about. That's a weight loss issue. And so sometimes we'll tighten the muscles, we'll tighten the skin, and when it's all said and done, yes, they don't have any loose skin, it's flatter, but it's not flat and there's like a curvature to it and people want that gone, and that's where we've had those discussions like, Hey, we talked about this, but you have visceral fat that we can't fix. So having those discussions ahead of time can help people maybe better prepare themselves for the result that they want, but sometimes people have selective hearing, we'll talk to 'em about visceral fat. We've got it in the chart, we've talked about it. It was a big discussion.

(18:48):
And then I think they just had higher hopes that even though we said they had visceral fat, that we were somehow going to be able to get them totally flat. And so that would be an example. I'd say a lot of times people are very, very happy that they've chosen this, and most people when they go to decide to do an elective procedure like this, they've spent some time really contemplating it and looking into it and talking to people, and I'd say, we don't deal with that a lot, that disappointment, but it's part of all things. You could go buy a brand new car and then the next day have buyer's remorse. You're like, oh, man, did I really need to, I don't know that I need a car payment, but I got this new car. It's kind of nice. So it can be like that too, right? They're happy and they're glad they got it done, but there's still an element of remorse because it was an expense that maybe they didn't need, cuz it's elective.

Kirstin (19:37):
How can patients keep their results looking great for a long time?

Dr. Koehler (19:41):
The one thing for, it doesn't matter what the procedure is, but keeping a stable weight, very important. More important for things like tummy tuck and liposuction, but even with breast augmentation. So keeping a stable weight will keep, hopefully your results more stable. Just living a healthier lifestyle. If you're a smoker, smoking, wrinkles, doesn't do a good number on your skin in general, those sorts of things, like bad habits like being out in the sun and we all like to get a tan from time to time, but if you're like a sun worshiper, you're not eating healthy, you're smoking a pack a day, those things are bad and they're definitely going to affect your results long term.

Kirstin (20:19):
Well, and you've mentioned before that, for example, just because you get a facelift that does not keep your skin from aging.

Dr. Koehler (20:26):
Yeah, you're never frozen in time, and that's the thing too. Let's talk about facelifts for a minute. So sometimes people say, well, how long would a facelift last? I'm like, well, that's really a loaded question, right? Because we continue to age, but we like to generally say that in 10 years time, the hope is that you're still looking better than before if you hadn't had the procedure. But if you do a facelift at 50 versus a facelift at 70, and then you follow each of those people for 10 years, I guarantee you the person that had it at 50 is looking much better at 60 as far as how much it relapsed compared to a person who had it at 70. Our life is a bell curve like this. When we're kids, it's like there's this steep change that occurs and then we get to our adult life and it's all this, and then we get older, and then it starts to do that again.

(21:18):
We kind of change early when we're young and we change a lot when we get old. In between, you can see those results last longer because of better skin elasticity, and this is just genetics, I mean, in our aging. And the other thing is I always tell people too, just look at somebody that you went to high school with. I mean, how often do you look at people? You're the exact same age, and you look at your friends and you're like, subconsciously, you're like, man, they look so good. Or I look way better than they do, because yes, we age similarly, but we age differently, and that's individual variances.

Kirstin (21:53):
Don't tell 'em but the people I went to high school with are starting to really look old.

Dr. Koehler (21:57):
30 year olds, they're kind of looking older.

Kirstin (21:59):
You got it.

Dr. Koehler (22:00):
Yeah.

Kirstin (22:01):
Okay. Okay. How much of a difference does pre-surgery planning make in avoiding complications afterwards?

Dr. Koehler (22:10):
I don't know if, it can avoid complications, because there are things that you're definitely not supposed to do. So if you haven't read your booklet, make sure you avoid certain things, then yes, you could run into problems. But I think the biggest thing with the planning is making sure you have what you need. So if we tell you, oh, we'd like you to have extra protein during your healing phase, well get some protein shakes. Or if you're going to need antibiotic ointment, go buy all these things ahead of time. You don't want to be needing it a week in recovery, and you're like, I don't feel like going to the store and I don't have anybody can go to get it for me, so I'll just skip it. That's what the planning process is important to make sure that you have all those things ahead of time. What does the saying go? Fail to plan. Plan to fail? Something like that.

Kirstin (22:54):
Oh, that's a good one.

Dr. Koehler (22:57):
Yeah. I didn't, that's not my quote, but.

Kirstin (23:00):
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. All right. Thanks, Dr. Koehler.

Dr. Koehler (23:14):
Thank you.

Kirstin (23:16):
Go back to making Alabama beautiful.

Dr. Koehler (23:18):
I will. Have fun at the library.

Announcer (23:23):
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.