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Surgical Care

Surgical Care

Modern surgery should be geared towards obtaining the best possible outcomes with the lowest risk to the patient. Important factors which are associated with an increased rate of complications from surgery include increased body weight, elevated blood pressure, the use of non-steroidal agents, steroids and or accutane and uncontrolled diabetes mellitus. In view of the above, all patients are screened for these factors in the office and the problems are addressed and optimized prior to surgery. Specifically, we treat obesity utilizing a regimen we call ‘The 3S’s’ ( South Beach Diet, sugarless home, stationary bike: exercise 3x’s weekly  to a heart rate of 125 for 45 minutes ) together with very low dose medication of phentermine which is combined with toperimide and which are taken together orally. This regimen often leads to a weight loss of 1-3 pounds per week. Before surgery blood pressure is often elevated due to the stress of the event. We use clonidine to control this phenomenon, which works by lowered stress related blood pressure at the brain level. We encourage patients to make sure they take their usual blood pressure medications on the day of surgery with a sip of water.

Before Surgery Smoking

Nicotine is a powerful blood vessel narrowing chemical. High blood levels are found in cigarettes products because of ammonia based chemicals within. Facelifts, breast surgery and abdominoplasty, for 4 weeks before surgery are not allowed one cigarette, pipe, chewing tobacco, vaping containing nicotine or any nicotine containing products including gum, patches etc. For other procedures a minimum of 2 weeks without a single nicotine product. Surgeries will be cancelled even on the day of surgery if this safety rule is not strictly followed, ie not even one nicotine product in the time frame listed above.

Before Surgery Medications

Take all usual meds day of surgery with sip of water 4 hours before procedure.

Exceptions ( ie. do not take these ) include:

  1. Non-steroidal agents: aspirin/Excedrin/mediprim, naproxen/naprocin/aleve, ibuprofen/motrin/advil
  2. Insulin and oral hypoglycemia agents: this should be discussed and time-tabled with the MD
  3. Birth control pills should be stopped 3 weeks before surgeries lasting greater than  45 minutes duration
  4. Oral steroids can be continued but only if the patient receives 20-30,000 Units of vitamin A orally starting one week or greater before surgery.
  5. Accutane should be stopped 6 months prior to surgery

The Before Surgery Clinic Visit

This is called the ‘preop’ visit.

  1. During this visit you should receive all the medications by way of prescription, hand written, called in or byemail ‘Escription’ to your pharmacy
  2. You should have read, signed and received a copy of the consent forms related to the procedure(s) you will undergo.
  3. After Surgery Pain Control should be discussed including the importance of always taking pain medication with food should be reinforced in order to reduce after surgery nausea and vomiting. Other methods to control pain will also be discussed including Exparel– a 3-4 day lasting anti pain injection and a transcutaneous local anesthetic Pain Pump to the surgical site which lasts usually 6 days.
  4. A physical exam including a blood pressure check focused on your heart and lungs will be performed.
  5. Appointments for the next 2 visits after surgery will be written and given to you
  6. This is an opportunity for you to raise any and all questions you have related to the surgery. It is not a time to discuss new procedures or to change the procedure. If that is the case it would be better to contact the office immediately to discuss new choices and it may be better in such a case to defer surgery until these new concerns or requests have been addressed by way of another consultation.
  7. A history of family member who had leg deep vein clots or clots of blood in the lungs should be discussed with the MD. The MD will provide you details on how to prevent clots, what are the symptoms and signs of clots and what to do re immediate emergency room visits if you suspect you might have a leg or lung clot.
  8. The MD will go over with you use the use of stool softeners, anti-vomiting suppositories, how to advance the diet from ½ strength Gatorade to regular diet after surgery, the use of probiotics to avoid yeast infections including incisional infection as well as preventing colitis after using oral antibiotics. The general rule is no solids for 8 hours before surgery and no ½ strength Gatorade or water for 4 hours before surgery for adults.
  9. Scar management will be addressed during the second after sugery visit and all the necessary products are stocked in office including anti-scar silicone tapes and silicone applicator sticks.

After Surgery Nausea and Vomiting

‘PONV’ protocol refers to the standard use of a after surgery protocol including the use of at least 2 IV anti-vomiting medications and a dose of intravenous steroids. After surgery medications for home, which are included in the prescriptions given to you during the before surgery clinic visit  include Compazine suppositories. These are placed every 6 hours per rectum and counter the side effects in at least 15% of persons of nausea and vomiting associated with narcotics including Norco, Vicodan, Percocet. The most important measure you can do is to make sure you take these pain medication only after eating and never on an empty stomach. Further, the use of non-steroids in the first 10 days after surgery not only can lead to bruising or bleeding but may cause  gastritis, gi ulcer or even bleeding from the stomach or duodenum especially if taken on an empty stomach.

Home Care: The Nurse

All patients who undergo abdominoplasty with or without breast surgery will go home from the Surgery Center with a LVN ( Licensed Vocational Nurse ) or RN who is specially trained in patient care after surgery. This highly skilled person will monitor breathing, blood pressure, vitals signs, oxygenation, the use of the incentive spirometer to prevent lung base collapse, your surgical bed positioning, pain pump positioning, legs for swelling and will be in communication with the doctor in case of any irregularities and will on an as needed basis pick up prescriptions and food or medical supplies for the patient. You and your family will be trained to manage drains and wound care if necessary. The LVN will stay with you until the following day and will not go home until the family are sure of what will be required from them to make you comfortable and for the home environment as ideal as possible for recovery.

Home Care: Positioning and The Surgical Bed

Most people who want a tummy tuck or a breast reconstruction using the lower abdomen (TRAM flap ) would like to remove as much skin and fat as can be done safely. This requires a very specific positioning of the patient. The back must be up by at least 45 degrees and the knees up from 20-45 degrees. So called ‘jack-knife or beach-chair position’. This position is created in the operating room, kept while transferring to the recovery room, kept when going home in the car and further when arriving home the bed is set up for the maintenance of the position. The surgical bed is ordered several days before the procedure and the company is in contact with you for delivery and and later for pick up. The first 2-3 weeks it is a necessity to prevent wound tension and break down in the supra-pubis. The idea of using pillows or a lazy boy can not provide sufficient continuous knee up to be sustainable for the necessary 3 weeks until you can stand upright without tension or difficulty.

Home Care: The Pain Pump, Exparel, & Muscle Relaxants

Home Care: The Pain Pump

Not to be confused, a pain pump is not the same thing as an intravenous patient controlled analgesic pump. The pain pump is a small tube, the size of spaghetti which is placed between the skin and the underlying tightened muscle in the case of a tummy tuck which drips 2-4mls of a local anesthetic agent until the reservoir is empty, usually 4-6 days later. The reservoir is kept in a nylon bag around your neck until it is time to be removed. The little silicone tube is taped to the skin with a clear sterile dressing and is painless to remove. This pain pump is the difference between waiting for the next or pain medication dose versus perhaps not needing any oral narcotics, ie minimal Norco usage.

Home Care: Exparel

Exparel is an injection into the surgical site: muscle, soft tissue and under the skin of a local anesthetic agent bupivacaine which is contained in a lipid package.

The effect is a slow release over 4 days. This means the levels of the local anesthetic in the blood are not high but the levels in the tissues where you would have pain are enough to make you comfortable while at rest for 4 days. For some patients they may not need to take any pain medications and for patients following breast surgery it is ideal to have no tubes addiing fluid to the implant pocket. It is not uncommon for patients to require less narcotic derived pain medications when using this medication, which could possibly help prevent drug dependency especially in younger patients.

Home Care: Muscle Relaxants

Flexeril is a muscle relaxant which is particularly helpful during the first 4 days after surgery. It works well for pain associated with movement. After an abdominoplasty, submuscular breast augmentation or any procedure where the muscle has been manipulated the majority of pain in the first few days is associated with muscle spasm. It is not uncommon for patients to require less narcotic derived pain medications when using this medication, which could possibly help prevent drug dependency especially in younger patients.

Home Care: VTE information

Any patient who has having a surgical procedure over 45 minutes is at risk of developing a clot in their leg or pelvis and then the clot has the potential to migrate to the lung and obstruct the blood flow to the lung which can lead to hunger for oxygen or damage to the lung, even possible death. So there are 3 imprtant things to be aware of before surgery:

  1. how to prevent a deep vein thrombosis (DVT) and pulmonary embolus (PE) or together veinous thromboembolism (VTE). The prevention includes using “ The Rule of 3”, easy to remember since all have the number 3 associated: leave your below knee TED stockings on for 3 weeks continuously, these stockings which will be placed on you just before surgery in the Surgery Center; use the incentive spirometer by inhaling to 1,500mls ( the device will be given to you in the recovery room after surgery and it is marked to ‘1500’ ) to be used 3 times an hour when you are awake for a minimum of 3 days, and make sure you get up and walk a minimum of 30 paces: twice the length of your foot, 3 times a day.
  2. How to recognize the symptoms and signs of VTE: the most common compliant for DVT is swelling of a calf and or foot and shin with pain in the calf which is worsened when you curl your toes upwards. Regarding PE, the most common symptom is dyspnea- which means difficulty breathing, this could be from rapid, shallow, tight, painful breathing or air hunger at rest or worsened with excursion. Regardless of which of the above you experience it requires an immediate visit to the nearest Emergency Room. If the above symptoms are significant then an ambulance may be required and driving yourself to the emergency room is not advisable.
  3. The presence of the symptoms and signs including but not limited to the above must be immediately evaluated in the nearest Emergency Room and this may involve an ultrasound of the leg, a cat scan of the chest and some blood tests. Treatment of VTE is almost always completely successful providing it is addressed early.

Home Care: Drain Management

The LVN will show you how to empty your drains twice daily. Providing the output is not excessive, ie filling up in a matter of a few hours, you are not required to chart output. The day of your office visit after surgery do not empty the drains, ie OK to empty the night before but not day of visit. However, if you have any concerns please call the doctor’s service number for further clarification. It is important to make sure the little silicone plug is placed inside the top tube to ensure the vacuum is held. If the bulb looks round and not collapsed then the vacuum has been lost and the remove the plug, then squeeze the bulb until collapsed and then replace the plug.

First Clinic Visit

During this visit the main objective is to make sure the wounds are healing and to perform a dressing change when indicated. Hand surgeries often will require a longer time before dressing change and drains are usually removed 1-3 weeks after surgery but not on the first visit. Any issues re medications should be addressed and refills can be given to you. Remember because of the recent concerns over narcotic abuse we can not call in to a pharmacy opiate / narcotic based pain medication. The prescription must be handed directly to you or your family representative. Then you will be required to have your family member go to the pharmacy in person to receive the prescription.

To find out more about available treatments and procedures, request a consultation with Dr. Moulton-Barrett at one of his Bay Area offices. Board certified plastic surgeon Rex Moulton-Barrett, M.D., offers advanced care and procedures for Bay Area residents. He has offices in Alameda and Brentwood, CA.



Alameda Location:

2070 Clinton Ave, Alameda, CA 94501


Brentwood Location

1280 Central Blvd, Suite J-5, Brentwood, CA 94513