"We have lots of patients who travel (and) desire several procedures at the same time," says David Matlock, M.D., adding that these routine requests for combined surgical procedures prompted he and his partner, Alexander Simopoulos, M.D., both of the Laser Vaginal Rejuvenation Institute of Los Angeles, to perform a retrospective analysis of safety and complication rates in long-duration combined procedures in their patient population.
QUESTION OF SAFETY "When you have a patient who's having a hysterectomy, it's not that uncommon to also get a request to remove fat," says Dr. Matlock, who teaches other OB/GYNs, urologists and aesthetic surgeons his proprietary Laser Vaginal Rejuvenation and Designer Laser Vaginoplasty procedures at the Laser Vaginal Rejuvenation Institute of America.If a surgeon doesn't do liposuction, that surgeon should recruit a team member who can, Dr. Matlock says. "We (OB/GYNs) have a full complement of services we need to provide to the patient," he says. "When I teach (surgeons), I tell them they need to align themselves with a good plastic/reconstructive surgeon."
The relationship works both ways, he says. "Normally, the OB/GYN is (also) a good referral source to the plastic/reconstructive surgeon."
Drs. Matlock and Simopoulos have a regular long-standing relationship with John Diaz, M.D., a Beverly Hills plastic and reconstructive surgeon who performs the plastic surgery portions of their combined procedures.
However, Dr. Matlock says this: "If an OB/GYN is calling in a plastic surgeon to perform a procedure at the same time he or she is performing other vaginal procedures, the safety data does not exist in the literature. That plastic surgeon may hesitate to join the OB/GYN in the operating room to assist in performing a combination of procedures, he explains.
There is published data available on combined plastic surgery with hysterectomies, Dr. Matlock says, but there's also an increase in pulmonary embolism, and it's generally not advisable to do a tummy tuck with a hysterectomy.1,2
There's also a general belief that longer surgery times — beyond four or five hours — increase the chance for complication rates, Dr. Matlock says. "That's the consensus out there," he says, adding that that is why he and his partner decided to take a look at it.
"We want to make sure that it's safe," he says. "We want to make sure none of these procedures are increasing the complication risk of anything else or in general increasing the complication rate. That's why we wanted to do it."
A PILOT STUDY In the study, Drs. Matlock and Simopoulos reviewed 47 female patients' charts from September 2005 to September 2006 who underwent combined plastic and gynecologic surgery that lasted an average of five or more hours. Plastic surgery procedures included blunt suction lipectomy, autologous fat transfer to the buttock, abdominoplasty, lipoabdominoplasty, breast surgery and face surgery. Gynecologic surgery included anterior or posterior colporrhaphy, reduction labioplasty, autologous fat transfer to the labia majora and perineoplasty.
Patients were excluded if they had a hysterectomy as part of their combined procedures, had a BMI greater than 35, were heavy smokers (more than a pack per day), had diabetes, had peripheral vascular disease or used psychotropic medications.
Drs. Matlock and Simopoulos compiled patient demographic information, American Society of Anesthesiologists physical status level and anesthesia type, estimated blood loss and operative time. They evaluated major complications (death, myocardial infarction, deep venous thrombosis, pulmonary embolism, hemorrhage requiring transfusion) and minor complications (hematoma, seroma, infection, skin necrosis and tissue dehiscence).
In their analysis, the doctors found that almost half (43 percent) of patients were from out of state or country, with an average age of 39 years (range, 22 to 53). The average BMI was 24.4 (range, 18.7 to 32.9). All patients had an ASA score of 1 and received general anesthesia.
There were no major complications and only minimal minor complications related to the gynecological surgeries (nine cases of perineal or clitoral hood dehiscences) and plastic surgeries (two cases of axillary/umbilical cellulitis, and one case each of areolar hypoesthesia and of suprapubic skin necrosis). All minor complications were effectively treated on an outpatient basis.
Drs. Matlock and Simopoulos found that long-duration plastic-gynecologic surgery was safe in their specific selected subset of patients, with only minimal complications.
1. Voss SC, Sharp HC, Scott JR. Obstet Gynecol. 1986;67(2):181-186.
2. Perry AW. Ann Plast Surg. 1986;16(2):121-124.