Expert Commentary: Philip Lambruschi, M.D, FACS - 7-13-2009

The fairly recent trend of multiple surgical procedures being performed in a single episode has come about in the last ten years or so. This trend is due to the ability of surgeons to complete procedures safely and more efficiently, thanks to technology, and the increased difficulty for patients to be absent from the workplace. With multiple operations, there are pros and cons. The obvious pros are a single surgical episode with a single recovery and a single administration of anesthesia. Every surgeon has an individual like and dislike of procedures and in my estimation, the biggest concern that a patient should have is the amount of time that the surgery will take to complete. Most multiple cosmetic surgery procedures are done under general anesthesia (heavy sedation).


My rule of thumb is very simple:  no patient should be under general anesthesia for more than four hours for an elective operation.  Statistically, it has been shown that there is no difference in complication rates with multiple procedures until the surgical time becomes an issue.  And, of course, longer surgical time also implies more blood loss.  There was a notorious case here in Chicago where a boyfriend of a well-known widow underwent eight or nine hours of surgery and died, basically, from blood loss under the skilled hands of the plastic surgeon and anesthesiologist.
 
In the past, it was felt that abdominoplasty with liposuction had a much higher rate of complication than performing the procedures separately.  But indeed, if you separate these two procedures, tummy tuck or liposuction alone, the actual complication rate together is less than the complication rates separately.  For lengthy operations, many safety issues have to be addressed.  Obviously, blood pressure, oxygenation, temperature, the patient's fluid intake and output, all need to be monitored and followed quite closely.  Many times a great deal of skin is exposed during cosmetic surgery procedures, and blood loss, with lowering of the core body temperature, can go on to dramatically increase complications.
 
Interestingly enough, many surgeons have different speeds at which they do procedures and there are some cosmetic surgeons, even board certified plastic surgeons, who can take two or three times as long to do the same procedure as another surgeon.  In my practice, I have a partner who is also a board certified plastic surgeon, and together we can do procedures in a shorter amount of time with less blood loss due to two surgeons working together.  In most cases, the removal of the excess tissue does not take much time, but the sewing up of the long incision is very time consuming if it is to be done well.  Two skilled physicians sewing at the same time can reduce the surgical time by as much as 50%.
 
The "extreme makeover" shows that were done on television, I thought, were egregious.  Eight to ten hour operation times or longer are definitely malpractice in my book.  Should anyone of those patients have had a major life-threatening complication, I have no doubt that there would have been many surgeons who would testify against the duration of the surgery.
 
Since the patient does not move while under anesthesia, the possibility of pressure ulcerations of the heels or buttocks/scapular areas are possible and the incidence of blood clots goes up which can be prevented with sequential compression devices during the operation.
 
The bottom line is that this issue is a very individual call.  But certainly, safety of the patient should be the absolute motivating factor and I think four hours is generally considered to the safe limit for doing an elective operation on a healthy, cosmetic surgery patient.
 
Philip G. Lambruschi, M.D., F.A.C.S.


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