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Cosmetic Plastic Surgery and Diving

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Cosmetic Plastic Surgery & Diving

By Wesley Hyatt, Senior Editorial Assistant

Editor's Note: This is part one of a mulipart article and covers only the most common surgical procedures. Read more about other surgical procedures as well as non-surgical cosmetic procedures on the DAN website www.DiversAlertNetwork.org/alertdiver. Due to many issues involved in breast augmentation, it will be examined separately in a future article.

Thinking about toning up your looks, but worried it will prevent you from scuba diving?

Don't be afraid, at least in terms of recovery time from plastic surgery. Some procedures require no wait, others generally three months or less. With planning and foresight, you can have surgery far enough in advance that it will not affect your diving excursions, from a nose job to liposuction (the removal of body fat). "I can't think of any cosmetic plastic surgery that would be a contraindication for diving," said Edward Golembe, M.D., director of the Hyperbaric and Wound Healing Center at Brookdale University Hospital in Brooklyn, N.Y. A DAN referral physician, Dr. Golembe is familiar both with plastic surgery and scuba diving.

Still, plastic surgery is surgery, with inherent risks. It's done mostly for beauty, not health. It's not covered by most insurers. A person undergoing any procedure must be realistic about what it involves, what it can accomplish and what can go wrong with it, whether it's a general concern or related to diving.

The Numbers

Even given all that, the number of people choosing cosmetic plastic surgery is exponentially growing. According to the American Society for Aesthetic Plastic Surgery (ASAPS), from 1997-2003, the total number of cosmetic procedures increased 293 percent. Surgical procedures increased by 87 percent, and non-surgical procedures increased by 471 percent.

The ASAPS claims nearly 8.3 million surgical and non-surgical cosmetic procedures occurred in America in 2003, with 22 percent of them surgical and 78 percent non-surgical. The most popular surgical procedures were liposuction (384,626 procedures), breast augmentation (280,401), blepharoplasty or eyelid surgery (267,627), rhinoplasty or nose jobs (172,420) and breast reduction (147,173). The most popular non-surgical procedures were Botox(r) injections (2,272,080), laser hair removal (923,200), microdermabrasion (858,312), chemical peels (722,248) and collagen injections (620,476).

Women comprised 87 percent of cosmetic plastic surgery patients in 2003. However, the number of men having cosmetic procedures increased 31 percent from 2002. People ages 35-50 comprised 45 percent of the total procedures; ages 19-34, 24 percent; ages 51-64, 23 percent; ages 65 and over, 5 percent; and ages 18 and younger, less than 3 percent.

Clearly there is a demand for plastic surgery. It's mostly done in people's spare time. So is recreational scuba diving. To balance the need to accommodate both, the following information gives an overview of common cosmetic plastic surgeries and how long (and in some cases why) divers must wait after they are treated before resuming scuba activities.

These recommendations come from both Dr. Golembe and another DAN referral physician familiar both with plastic surgery and scuba diving, Dr. Ralph Potkin, medical director for the Beverly Hills Center for Hyperbaric Medicine in Los Angeles, Calif. Dr. Potkin consulted with fellow plastic surgeon Dr. Steven Zax for his answers and, as he noted, "First and foremost, these remarks are generalizations, and each case needs to be individualized and the cosmetic surgeon should be involved in the decision making. Also, these recommendations are based on favorable, uncomplicated healing."

Besides risks given for each procedure, all surgeries' potential risks include bleeding, reaction to the anesthetic and infection. Risk of complications can be reduced by following your surgeon's instructions before and after the surgery.

The Procedures and Their Wait Periods This lists only the most commonly performed types of cosmetic plastic surgery. For example, according to the American Society of Plastic Surgery, only 4,211 leg lifts (to eliminate loose, wrinkly skin on the gams) were performed in 2002, or .01 percent of total cosmetic procedures performed that year. With that minute amount done, it is not included. Keep in mind that this only summarizes what is involved with these procedures. Surgeries done on outpatient bases let patients go home the same day of the operation; those with an overnight hospital stay allow the medical staff to monitor the recovery.

BLEPHAROPLASTY (lower eyelid surgery)

Goal of Procedure:

To remove puffiness of bulging fat and skin found in the lower eyelid from age and other factors ("bags under your eyes") for a younger, rested and alert look.

What It Involves:

For traditional lower lid blepharoplasty, an incision is made along the lash line and smile creases. Excess fat, muscle and skin are removed. Fine sutures are used to close the incision. Permanent stitches will be removed three to five days after the procedure.

People with a pocket of fat beneath their lower eyelids may not need to have any loose skin removed; they may have their surgeons recommend a transconjunctival blepharoplasty, in which an incision is made inside the lower eyelid, leaving no visible scar. Transconjunctival blepharoplasty only reduces the puffiness and does not tighten the skin in the lower eyelid region.

Length of Procedure, Recovery Time and Possible Complications:

Depending on the technique used and the extent of the repair, lower lid blepharoplasty generally takes about 1-3 hours. It can be performed on an outpatient basis, in the hospital or in an ambulatory surgical suite, under either general or local anesthesia.

At first incisions are usually red and somewhat bumpy. Eventually, the resulting scar should become flat and inconspicuous. The swelling and discoloration around the eyes will gradually subside, and the patient will start to look and feel better each day. Bruising typically disappears within seven to 10 days. Within the first week a patient will be allowed to use makeup to conceal any discoloration, if so desired.

A patient's vision may be somewhat blurred for a few days or longer. His or her eyes may be temporarily sensitive to light for a month or so, and he or she may experience excess tearing or dryness. Some receive eyedrops to help relieve any burning or itching.

For the first week after surgery, patients should avoid activities that dry the eyes, including reading, watching TV, wearing contacts and using a computer, and they should also wear dark sunglasses for a couple of weeks to protect the eyes from the wind and sun. Excessive blinking can lead to increased swelling. The eyes may tire easily for several weeks; frequent naps are helpful. Drinking alcohol can lead to fluid retention and delay recovery.

Also, for the first three or four weeks, patients should avoid any activity that increases blood flow to the eyes, including bending, lifting, crying and participating in sports.

Waiting Time From Procedure Until Diving: About three weeks, says Dr. Golembe, as diving falls into the sports category previously listed. Dr. Potkin recommends six weeks and notes divers can face problems with their mask fit after the surgery.

FACE-LIFT

Goal of Procedure:

To remove excess skin and tighten the skin for a more youthful appearance. However, a face-lift cannot fix wrinkles.

Ideal candidates have skin that is elastic, able to stretch and heal. Other factors that make a good candidate are individuals with sagging cheeks, heavy lines from nose to mouth and jowls along the jaw line. A strong and well-defined bone structure and realistic expectations make someone a good candidate. A well-lifted face can last from 12 to 15 years.

Smokers must quit both two weeks before and at least two weeks after the surgery, as smoke constricts the blood vessels in the face that are important for the healing process. This also means avoiding areas with smoke.

What It Involves:

There are at least eight different established procedures of doing face-lifts. Here are the basics for the most popular versions:

The basic or traditional face-lift involves incisions made at the hairline. Incisions are the access sites at which the surgeon performs a facelift. Excess skin is removed. The skin is then gently pulled and tightened over the face, then incisions are closed with stitches.

For the "mini" lift, a small incision is made in front of the ear. Then, a small area of skin is lifted. The "mini" lift works well for targeting areas in the face that are showing early signs of aging.

The weekend face-lift removes excess chin fat with liposuction and tightens the loose skin with a laser. The laser is used inside the neck on loose tissue that often adds a heavy look under the chin with the jowls. This technique does not remedy deep lines above the jaw line. Rather, the heat from the laser constricts the fat cells and tightens the surrounding tissue. The area then becomes firmer. The operation time is usually no more than 90 minutes. Local anesthesia or sedation is used. Its name comes from the fact that many patients have the treatment Fridays and have the bandages removed Monday.

The endoscopic face-lift lasts for three to four hours, and often general anesthesia is used along with an endoscope (a camera-like narrow tube with a bright fiber optic light on one end that lets a doctor view the area on a TV monitor). A superficial endoscopic face-lift has the skin elevated by incisions at the hairline, then pulled and pleated (folded at the incisions). Over several weeks, the pleats disappear above the hairline and behind the ear. As with a mini lift, no tissue is removed after the incisions. A deep endoscopic face-lift frees the original attachment of the skin into a more toned state to the facial bones. Tissue and muscle are secured higher and in a pulled back position. This is not a good procedure if one has saggy skin, especially in the neck.

After an endoscopic face-lift, there is less pain and swelling and a faster recovery time. This is due to smaller incisions; consequently, the incisions heal faster with less chance of scarring.

Length of Procedure, Recovery Time and Possible Complications:

Most traditional face-lifts take 4 to 6 hours and use general anesthesia. Sterile dressings and bandages are applied to secure the head and neck area and prevent infection. Tubes used for draining are usually removed after the first 24 hours. Stitches are usually removed in seven to 10 days.

For the first 24 hours, a cold compress should be used to avoid swelling and bruising. The bandages and stitched areas should not get wet, as this could cause infection. An infection usually appears as a pimple on the cheek, and one should see a doctor immediately if infection is suspected.

The head should be elevated by pillows to reduce swelling, and, initially, motions such as swiveling the head should be limited. Too much pressure or stretching from activity can result in a less than desirable appearance. Walking will aid the healing, but a patient should not bend over for three weeks after the procedure.

Often there is general discomfort and bruising. There should be no major pain or swelling. Bruising varies but usually fades after a few days. Many patients experience a sensation of tightness or numbness due to slight damage to the nerve fibers. After six to 12 weeks, the nerve fibers will grow back. In rare cases, numbness can last up to nine months.

Patients should have an assistant who can help rotate the cold compress, prepare meals, etc. The patient should be on a high-protein, vitamin-rich liquid diet for the first 48 hours, as chewing promotes swelling and bruising. Preservatives, which promote swelling, should be avoided.

For a speedy recovery and best results, a patient should not engage in sex or heavy exercising for a month. Sex and exercising increase the blood pressure and can result in bleeding or stretching of stitches. Even talking or moving the jaw can dislodge the stitches and should be avoided right after the surgery.

After the first dressing is removed, the patient's face will be swollen and bruised and the hair matted from the antiseptic solution. Patients must wait until two days after surgery to shower and then should have an assistant to help them.

Many patients are very tired after surgery and lose weight from a decrease in appetite and an increased metabolism from healing. The more sleep they get, the faster they will heal.

Blood pooling beneath the skin happens in 5 percent of traditional and endoscopic face-lifts. Usually the collection of blood is small and heals spontaneously. In the first 24 hours after surgery, a hematoma (large amounts of blood elevated under the skin) may occur and result in increased swelling, pressure and discomfort. A doctor can easily treat it, but it should be treated immediately.

If too much skin is removed, the incision sites will close tightly; this can result in too much pressure on the skin. This widens the skin and results in a wider scar. Patients may also lose permanent sensation in their faces. Some hair loss from tension on facial skin may damage the hair roots.

Waiting Time From Procedure Until Diving: About two to three months.

LIPOSUCTION

Goal of Procedure:

To remove unwanted fat tissue by a suctioning technique.

It is better to think of liposuction not as weight removal but as a contouring procedure. In women, common areas for liposuction are the hips, thighs, stomach and neck. In males, common areas are the "love handles" (male flanks), stomach, chest and neck.

Liposuction does not cure obesity. A limited amount of fat tissue can be removed safely from the human body. Liposuction can actually damage an obese person's looks, as the removal of a portion of fat from the body can give an unbalanced or unnatural appearance.

What It Involves:

There are several methods. The tumescent technique can reduce postoperative bruising, swelling and pain. Before liposuction is performed, areas of excess fat are injected with a large amount of a saline fluid containing a dilute solution of adrenaline and local anesthetic. This minimizes blood loss. Tumescent liposuction requires three times as much injected fluid as what is aspirated. This fluid causes the sections of fat to become swollen or firm and allow the liposuction cannula to travel smoothly beneath the skin as the fat is removed.

Tumescent liposuction offers fewer skin irregularities, less bleeding, reduced bruising and a faster recovery than other liposuction methods. It is performed as an outpatient procedure for four to five hours. Since the patient is awake under local anesthesia during the operation, he or she can sit or stand during the procedure, which allows the surgeon to check the status of the patient and the progress of the contouring. The drawbacks are that while fluid overloading is relatively safe, it can result in congestive heart failure. Toxic effects of the adrenaline and / or local anesthesia can occur. However, it has been proven to be safer than traditional liposuction techniques.

Super-wet liposuction is similar to tumescent, but less fluid is used, usually the same amount of fat that will be removed. Approximately 8 percent of the fluid lost through super-wet is blood versus only 1 percent being blood lost in tumescent. The procedure takes one to two hours to perform, and since there is less chance of too much fluid being introduced into the body, super-wet liposuction is safer than tumescent.

Ultrasonic assisted liposuction (UAL) uses ultrasound high frequency waves to break up the fat prior to its removal. Ultrasonic energy delivers a combination of vibratory mechanical energy and thermal energy to subcutaneous fat. Currently, this procedure is still undergoing long-term studies as UAL has been associated with increased risks of complications including skin burns, fluid accumulation and burning pain. However, given the large amount of fat that can be handled in the process, some patients favor it.

Power-assisted liposuction (PAL) uses advanced instruments used to perform the surgery (the "power" in its title). Power-assisted liposuction uses a mechanical cannula that efficiently removes fatty tissue with increased precision, less bruising and a faster healing time. It's used in conjunction with super-wet or tumescent techniques. According to medical experts and patients alike, power-assisted liposuction is gentler than traditional liposuction and is preferred by patients. Surgeons have also found that this procedure is easier for them to perform and leads to better results.

Length of Procedure, Recovery Time and Possible Complications:

Recovery depends upon the liposuction method, but most require a compression garment either to help close the incision sites to prevent scarring (as in traditional liposuction) or absorb fluids draining from the incision areas (as in tumescent liposuction). A compression garment is tight fitting and holds the area of the body firmly. It should fit comfortably and allow the use of absorptive pads underneath. For the first three days after surgery, it must be worn typically for 24 hours. Often, more than one compression garment is needed. A patient is responsible for getting a compression garment as his or her recovery product.

With the discomfort, bruising and swelling the first three days after surgery, the compression garment helps to prevent the formation of seromas, or collections of the watery part of the blood. Depending on the procedure, most patients return to work after three to four days.

To assist in recovery and to avoid dehydration, patients should drink plenty of non-alcoholic fluids. They should not use bandages, ice packs or heating pads over the liposuction area. They should take it easy the first week to prevent exhaustion and get help when first removing a compression garment or taking a shower. To avoid infection, patients should not soak their body in water for at least a week after surgery.

Liposuction patients' skin will naturally reshape and tighten over the sculpted area. This is part of the healing process. Depending on the technique used, there may be slight waviness or visible scars.

Beside previous complications given, liposuction has a risk of blood clot formation in the legs. The removal of too much fat can result in excessive blood loss and create an unnatural and undesired appearance.

Some patients have liposuction on more than one body area at a time, for cost, convenience and other reasons (a patient needs only one vacation from work for recovery, results in a more balanced and natural look, etc.). But there are definite risks: a prolonged exposure to general anesthesia; the removal of too much fat from the body, leaving skin sticking to underlying structures and looking unnatural; a significant amount of blood loss and surgical trauma to the body; and a prolonged and more painful recovery process. Someone considering multiple procedures should speak with a doctor for more information.

Waiting Time From Procedure Until Diving: "That varies so much," Dr. Golembe says. "It's the amount of lipo removed that affects it." Dr. Potkin concurs. Dr. Golembe recommends a minimum of three weeks to up to three months, the longer period obviously for those doing large amounts of liposuction.

RHINOPLASTY ("nose job")

Goal of Procedure:

To improve the appearance and possibly the function of the nose. Rhinoplasty can correct a variety of conditions including a large nose, a hump on the bridge, an undesirable shape of the nasal tip or a narrow or wide span of the nostrils. To complement other facial features and to provide a balance of proportions, both frontal and profile views of the nose are corrected. Rhinoplasty can also correct breathing problems caused by narrow or partially obstructed nostrils.

What It Involves:

Incisions are made inside the rim of the nostrils. Sometimes, tiny, inconspicuous incisions are also made on the rim of the nose. Soft tissues of the nose are then separated from the underlying structures, and the cartilage and bone causing the deformity are reshaped.

The nature of the sculpting depends on the particular problem. If the size of the nose is being reduced, the nasal bones are carefully fractured toward the conclusion of the procedure. Breathing problems may be improved through a procedure called septoplasty, where the obstructions are removed. Another type of soft-tissue surgery, alar narrowing, adjusts the width of the nostrils.

To perform a rhinoplasty, surgeons use the open or closed technique. The open technique includes an incision across the columella (the strip of tissue between the two nostrils that is the lower part of the nasal septum). This technique allows a surgeon to completely visualize the internal structures of the nose and place sutures precisely where they may be required. With this type of rhinoplasty, the swelling takes significantly longer to subside, and some of the tissues may be unnecessarily disrupted. The scar is usually quite small and fades rapidly. The closed technique does not require an external incision, heals more quickly and does not disturb the tissues as much as the open technique.

Length of Procedure, Recovery Time and Possible Complications:

Rhinoplasty usually takes one to two hours in a hospital or outpatient surgical suite with a general or local anesthetic. If the size of the nose is being reduced, a splint will have been applied and the nose will be packed lightly with medicated gauze. After three to five days, the splint and packing will be removed. Sometimes, only tape supports the nose while it is healing. The stitches are self-absorbing and do not require removal. By the end of the second week, all splints, bandaging and stitches will have been removed.

If an incision is made across the columella, surgeons place skin stitches, which require removal in three to five days. The need to do this is usually identified and discussed fully prior to the procedure, and is usually necessary in only about 5-10 percent of patients.

Patients usually resume normal light activity and return to sedentary work after a few days. It will take about a month before the nose is completely healed to allow full physical activity.

In the first 24 hours after surgery, the patient may experience some pain that requires a mild analgesic. After that, there is usually just a feeling of pressure and stuffiness. Patients will look puffy and swollen and, to reduce the swelling, they will need to keep their heads elevated above the level of their hearts for the first few days. Bruising around the eyes usually happens and peaks around 72 hours, subsiding in 7-10 days. Cold compresses help to reduce the swelling around the eyes. Some patients have a little bleeding and need to change their gauze bandages a few times a day for the first several days.

Patients need to be careful to not blow their noses for about two weeks and avoid bumps to the nose for about six weeks. Eyeglasses should be taped to the forehead, off the bridge of the nose, for the first month.

Patients may not feel completely back to normal for several weeks. The nose might be numb, especially if there have been considerable changes made to the tip. Patients should use extra sunscreen and be gentle when washing their faces in this period.

It is common to feel dissatisfied with the appearance of the nose in the immediate post-operative period, when the nose is still quite swollen, and much of the detail is still not visible enough to appreciate. The elasticity of the tissues, the blood flow, the thickness of the skin and the appearance of the nose will change significantly during the first three months, even up to the first year or two.

Waiting Time From Procedure Until Diving:Three months.

Dr. Potkin notes that pressure of the facemask, nasal congestion and the ability to equalize are potential issues, especially pertinent to divers who have had this surgery.

Other Surgeries and Their Wait Times

  • Abdominoplasty ("tummy tuck") - About three months.
  • Breast lift - Two to three months.
  • Breast reduction (female - mammaplasty) - Two to three months.
  • Breast reduction (male - gynecomastia) - Two to three months.
  • Brow lift - Six to eight weeks to three months, depending on the procedure.
  • Otoplasty (ear surgery) - Three to six months.

    Some Final Advice If you're a diver wondering about a surgical cosmetic procedure not covered here, ask your surgeon to call DAN for advice, Dr. Golembe says. The DAN Dive Safety and Medical Information Line is open weekdays 9 a.m.-8 p.m. Eastern Time (1400-0100 Greenwich Mean Time), except for U.S. holidays, to handle such information. The number is +1-919-684-2948 (or 1-800-446-2671 toll free in the United States and Canada). Or, have your physician email DAN at www.diversalertnetwork.org/contact/email.asp?re=Medicine.

    References: www.cosmeticplasticsurgerystatistics.com/statistics.html www.plasticsurgery.com www.plasticsurgery.org (c) DAN - Alert Diver September / October 2004