What are the general recommendations and precautions for a patient considering cosmetic surgery?

General Recommendations for Cosmetic Surgery

Patients considering cosmetic surgery must undergo thorough preoperative evaluation including assessment of medical contraindications, realistic expectations, psychological readiness, and understanding of specific risks including infection, scarring, and pigmentation changes—with darker-skinned patients (higher Fitzpatrick phototypes) at significantly elevated risk for dyschromias and post-inflammatory hyperpigmentation. 1

Preoperative Patient Selection and Counseling

Medical Contraindications to Assess

• History of collagen vascular disease (especially scleroderma and lupus erythematosus) represents an absolute contraindication due to potential for significant morbidity from impaired wound healing 2
• Prior therapeutic radiation to the surgical area contraindicates procedures due to compromised tissue quality 2
• Pregnancy must be excluded before any elective cosmetic procedure 2
• Active skin conditions with Koebner phenomenon (vitiligo, lichen planus, lichen sclerosus) require disease stability for at least 12 months before any surgical intervention 3

Psychological and Expectation Assessment

The most critical preoperative evaluation involves assessing the patient's realistic expectations, motivations, and how treatment choice will affect their sense of self-esteem, sexuality, body image, and overall quality of life. 2 This discussion must include:

• Long-term survival and functional outcomes 2
• Realistic probability and consequences of complications including local recurrence (for oncologic procedures) 2
• Psychological adaptation including fear of adverse outcomes and attitudes toward potential revision procedures 2
• Cosmetic outcome expectations and sexual adaptation 2

Multidisciplinary consultation is mandatory before major procedures, including evaluation by a surgeon experienced in the natural history of the condition being treated, and early consultation with a reconstructive surgeon for those considering reconstruction 2

Psychological consultation should be considered for all patients, particularly those undergoing body-altering procedures like bilateral risk-reducing mastectomy, given potential negative impacts on body image, relationship quality, and sexual function 2

Preoperative Preparation Protocol

Skin Preparation (24-48 Hours Before Surgery)

• Patients must shower or bathe (full body) with soap or antiseptic agent before surgery 2
• Perioperative nasal and full-body skin decolonization should be considered when possible 2
• Surgical site skin preparation must be performed with alcohol-based antiseptic agent unless contraindicated 2

Hair Removal

• If hair removal is necessary, clipping is the only acceptable method 2
• Shaving must never be performed as part of routine clinical practice due to increased infection risk 2

Jewelry and Nail Polish

• Remove all nail polish and rings before surgery 2

Antibiotic Prophylaxis

• Implement antibiotic prophylaxis using agents effective against staphylococcal and Gram-negative bacteria for procedures involving arterial reconstruction or high infection risk 2
• For Staphylococcus aureus carriers, nasal decontamination is recommended, though clinicians must consider potential side effects and costs when choosing between alternatives 2

Intraoperative Technical Principles

Incision Planning for Optimal Cosmetic Results

• Curvilinear skin incisions following Langer's lines achieve the best cosmetic results in most locations 4, 5
• Critical exceptions: use radial incisions at 3 o'clock and 9 o'clock breast positions and lower breast, particularly when skin removal is necessary 4, 5

Closure Technique

• Skin must be closed with subcuticular technique 4, 5
• Preserve subcutaneous tissue with separate closure to improve cosmetic outcomes 4, 5
• Never reapproximate tissue in a manner that appears adequate when supine but causes distortion when upright, as this creates excessive tension and poor cosmetic results 5

Hemostasis

Meticulous hemostasis is critically important, as hematoma formation complicates postoperative evaluation, makes imaging interpretation difficult, and can lead to unnecessary interventions due to evolving scar tissue 4, 5

Postoperative Care and Wound Management

Wound Dressing and Care

• Consider patient preferences and costs when choosing dressings 2
• Negative pressure wound therapy should be used for high-risk surgical incisions (e.g., complex extremity procedures) to reduce deep surgical site infection risk 2
• Avoid negative pressure wound therapy following orthopedic surgery until safety is established in this population 2

Bathing and Wound Cleansing

• Consider early versus delayed bathing based on water quality and type of wound closure (primary versus secondary) 2
• Consider the patient's general condition including comorbidities when determining wound cleansing protocols 2

Infection Prevention

• Implement general strategies to reduce cross-infection including strict hand hygiene protocols 2
• Use existing evidence-based guidelines for infection prevention 2

Supportive Skin Care Protocol

Sun Protection (Essential for All Procedures)

Broad-spectrum sunscreen with high SPF against UVB and high protection against UVA (especially long UVA) is essential for all treatment modalities, particularly for prevention and improvement of pigmentation disorders 1

Pre-Procedure Skin Preparation

Supportive skin care management to prepare, cleanse, and protect the skin is recommended to optimize outcomes 1

Post-Procedure Care

Post-procedure skin care with healing and anti-inflammatory ingredients is recommended to speed regeneration and wound healing while minimizing scarring and downtime 1

Adjunctive skin care with antioxidant, anti-aging, and lightening properties may enhance skin benefits 1

Special Considerations for High-Risk Populations

Darker Skin Types (Higher Fitzpatrick Phototypes)

Individuals with darker skin are at significantly higher risk of dyschromias, notably melasma and post-inflammatory hyperpigmentation, which requires aggressive preventive measures including strict sun protection and consideration of pre-treatment skin preparation 1

Patients with Autoimmune Conditions

Screen for associated autoimmune conditions (such as thyroid disease in vitiligo patients), as failing to do so can have negative consequences 3

Common Pitfalls to Avoid

• Never perform surgical treatments in patients with active Koebner phenomenon or recent disease activity 3
• Avoid extended use of potent topical steroids beyond 2 months due to risk of skin atrophy 3
• Do not overlook the psychological impact of visible cosmetic changes, as this can worsen patient outcomes 3
• Never base surgical decisions solely on imaging findings without histopathologic confirmation when indicated 2
• Ensure breast reconstruction does not interfere with appropriate surgical management of underlying conditions—the reconstruction process should never govern timing or scope of appropriate treatment 2