Some years ago I performed a full face restoration for a woman patient of mine. The facial and body changes that come with aging, are, generally, not well liked by the resident human, much less well accepted.
These are long operations, mostly because of the detail work, and an obligatory amount of fiddling that I have to do to come away with a great result, at least surgically, and esthetically for sure.
So, as is my practice, I saw her the next day.
It was one of those “doorway diagnoses”.
There was the dreaded hematoma!
Her left cheek was big and tense and discolored.
It’s no accident the hematoma is high on the list of “classical” complications from any surgical operation, not so much because of its frequency, (I’ve had five in my career thus far), but because of its effects, none of which are good.
For the plastic surgeon, the fearsome foursome of Surgical complications include: hematoma, infection, skin necrosis (patchy skin death), and bad scarring (atrophic, hypertrophic or keloid). You can’t do this plastic surgery kind of work and not worry about complications. It’s Damoclesian.
And that list doesn’t even include the raft of Esthetic complications that can and do happen, and with much greater frequency after an esthetic operation.
Was it the devil, or a bolt of lightening, or poor judgement, or a bad decision, or some combination thereof.
It could also be “negligence”, but that’s for another outing.
I don’t do negligence.
And anyway I do a lot of Expert Witness work, and “negligence” would look bad on my resumé.
Had I not done the operation, the hematoma would certainly not have happened. But I’m a pretty good plastic surgeon, and refusing to do operations, is a poor strategy.
As with any physician…Yes Virginia, plastic surgeons are physicians….as with any physician, I am the decisions I make. Happily these decisions and judgements come easily to me, since, (I think) I’m the best plastic surgeon on the planet. But then, any plastic surgeon, worth his salt, should think the same thing, or get outta Dodge. All that’s academic anyway because whatever the outcome, it’s all on me. I like it that way.
So we have this hematoma, begging for attention; and I need to know why – one of the more underused questions by otherwise intelligent humans. I need to know why, because it may affect the treatment. The “why”of it all, will not, however, keep us out of the operating room, but I might prepare differently if I knew.
Although this is about hematoma, it’s really about the ugly practice of finger pointing …usually by the doctor, at the patient, who, in this case, probably, and actually, did “cause” the hematoma. Finger pointing often known as “blaming” is not a good thing, either ethically, or practically. Sure, smokers get lung problems, but blaming should be left where it belongs: with family and friends.
Here, no question, the hematoma has happened…sounds a little like Haim Ginott.
My instructions for before operation, included stopping all herbal supplements, because some can cause bleeding.
To tell you the truth, I don’t know which ones do and which don’t, so I worry about all of them.
No herbs for at least a week before surgery.
She didn’t know Ginkgo was an herbal, and maybe lots of people don’t.
Well, it is, but it should do as advertised – make the taker smart enough to know it is an herb.
A bit unfair perhaps, but I was certainly annoyed in my concern. But hey, now I really need her on my side, more than ever, because we are going back to the operating room. Blaming the sick and the poor is neither good practice nor good ethics.
So, in my annoyance, I let her off the hook, baited with only a mild rebuke.
She thought it might have been the Green Tea, which was also on the list; but Green Tea has Vitamin K and to that extent it would cause clotting rather than bleeding.
I have had five hematomas in my entire career, thus far and don’t want any more. If you’ve gotten this far and don’t know what is a hematoma, let me tell you.
For one thing it’s, at least two extra months of healing.
The hematoma is a collection of blood (from bleeding) in a confined space.
Not to get too far down the rabbit hole, some other things about about blood. It has red cells that carry oxygen, which in turn are carried along in its own ecosystem of blood plasma, which is filled with a lot of nutrients. It services all parts of the body. Would that Cable were so good. And the heart just keeps on keeping the blood circulating.
Way back, In the time of the Humors – a gift from Galen, the other 2000 year old man – there was no such thing as a blood circulation. The human was a mixture of Humors. Naming the Humors is a bit easier than naming the Seven Dwarfs – other people always forget Doc and Bashful.
So the Humors are: Black Bile, Yellow Bile, Phlegm – a word I hate to hear, much less say – and Blood. William Harvey, (1620), put an end to all those puppy dog tales by just wondering about the purpose of those valves in the veins – the “why” of it all.
So blood belongs inside the blood vessels (veins and arteries). When it gets outside, it’s toxic to the surrounding tissues. It’s why the bruise – a hematoma-in-waiting – is tender and painful. Those two are not the same: tender and painful, I mean.
If the hematoma is not fixed….evacuated, washed out, it can be bad, like causing the overlying skin to die, (necrosis), and that’s really bad.
But you have to stop the bleeding, (hemostasis), after the hematoma is cleaned out: this, so the hematoma doesn’t come back.
But the bleeding from herbals, is from everywhere that Mary went. This hematoma was not one of those classic bleeds from a cut arteriole, re emerging from the elastic retraction that kept it from view during surgery.
So in this case, the “why” of the hematoma forced added the need of a little bit of luck for a good result – i.e. no recurrence.
So call in the staff
General anesthesia, since she had nothing to eat. it can also be done, but less comfortably, under local anesthesia.
Scrub up, gown and glove, and wash out all the hematoma, which, happily, was mostly clotted.
But when I got down to fresh tissue, it was bleeding. Not a lot, but from a lot of places.
A little time, more irrigation, and it calmed down.
A couple of soft drains, a compression tape dressing, a few fixation sutures, and the obligatory homage to the godhead, and she was good.
In the time to come, she was voraciously apologetic. I stopped this quickly, so we both would have an easier time of it during the weeks ahead. Her ultimate result was great, but only after four months of hand holding.
Thanks for listening