What Do I Need to Do Before I can Have Plastic Surgery?

Dr. Franco: Welcome back to “Plastic Surgery Untold.” I’m Dr. Johnny Franco, also known as “Austin Plastic Surgeon.” We’re making our comeback at the studio. We’ve been several months hiatus and so excited to be back. We got the anchor, Travis Osborne with us, also known as “Celebrity anesthesia.”

Dr. Osborne: What’s up? Good to be back, man.

Dr. Franco: We got a few special guests today some of you may notice, if you’re watching us on YouTube on the radio, I’ll let you guys know we’re missing one “Austin’s most beautiful man” Gilberto Saenz. He either had a photo shoot a Tupperware party to go to, still unclear what his prior obligation was. But we have two great guests to help fill the shoes of one, Austin’s most beautiful man. Number one is Dr. Kevin Chang, who actually was my mentor. And we’ll get into that a little bit later as he was a resident when I was a med student, but Kevin Chang does internal medicine for Baylor Scott & White and so holds down the front out there.

Dr. Chang: Very good. Thanks so much for having me.

Dr. Franco: We’ll get a little bit more into what you do at the hospital in just a bit. And then we got another special guest for those of you that listen on a regular basis for those of you that don’t shame on you guys. But we got one, the captain El Fernando Rodriguez.

Fernando: Well, thank you for having me Dr. Franco, it’s good to be on camera and not just behind the scenes.

Dr. Franco: I like your mask plug you got a little Austin plastic surgeon mask there. And Fernando, for those of you guys that don’t know is one of our practice administrators. And so I think it’d be cool for him to give us a little bit of an insight of a behind the scenes of the practice. But we’ll circle back to that because today, we have Dr. Chang with us because we’re actually gonna talk about pre-op needs. And we’ve alluded to this during anesthesia and some other things of how you can best prepare for your surgery. But we thought, why don’t we bring somebody that actually does this, because this is typically who we will refer you to if you had issues if you needed something to get a little fine-tuning. You know, before you go on a road trip, you’re gonna take your car and get a little fine-tuning, making sure everything’s perfect for the trip, the same thing for surgery, wanna make sure everything is just right prior to the surgery. So we’ll make sure that we do that. That’s why we get labs. That’s why we get different things. And so we’ll walk through that process and kind of maybe better understand why we’re doing it, which I think will help motivate people to wanna do it a little bit more. But before we jump into that, Dr. Chang, can you tell us a little bit about what you do on a day-to-day basis? And maybe we’ll tell the PG version about how we met and connected.

Dr. Chang: Yeah, absolutely. So, I’m Kevin. I am formally trained in internal medicine. And I have a secondary background in something called medical informatics as well. And yeah, and I basically trained in Austin, did a chief year, did my fellowship and then joined Baylor Scott & White back in 2010. And after a series of various roles, I am now kind of leading the Hospitalist Group out of Temple Texas. I should say, before we go too much further on that I can’t really officially represent Baylor Scott & White during this meeting. But I think everything we’re gonna, be talking about today is pretty general and common in terms of medical knowledge. So happy to be here. And that’s what I do.

Dr. Franco: And unfortunately, we only have 40 minutes, so we’re only gonna scrape the surface of the Dr. Chang knowledge. And for those of you that don’t know, and I alluded to a little bit, when I was actually a med student here in Austin at the old Breckinridge Hospital, Dr. Chang was actually my chief resident and so, you know, he has to take some of the blame and credit for where we are today. Fernando, maybe DSN a little bit tell us a little something about you. And again, PG version of how we met.

Fernando: So me and Dr. Franco met back in…we haven’t been able to agree whether it was the summer of 2004, or the summer of 2005. But needless to say, it was when Dr. Franco was a med student learning from Kevin other tricks of the trade. But yeah, we, you know, met down at a party that we had both been invited by separate friends and somehow one way or the other our paths crosses, and next thing I know I was under the wing and protection of Dr. Franco’s social community. I’m a little bit of an introvert like he said before I’m the man behind the curtain kind of deal. I assist him with the operations and administrative functions of More Beautiful You, but, or “Austin Plastic Surgeon” as we are now re-branding ourselves. And it’s been interesting because I do the very most important thing at the office, I make sure everybody gets paid on time gets paid correctly. So if you want a rebellion on your hands, don’t pay people on time, or screw up their pay. So I keep the troops in line with that kind of stuff and in many other projects.

Dr. Franco: And I’m sure they appreciate it. And then “Celebrity anesthesia,” I was gonna ask you to catch us up on what you’ve been doing but you’ve been actually extremely active on your social media. So I feel like I already know for the five people in the world left that don’t follow your Instagram. Can you catch us up on what you have been doing besides running without your shirt on?

Dr. Osborne: Just a lot of running without my shirt on. No, we…

Dr. Franco: For those of you that are listening, he, unfortunately, does have a shirt on today, so sorry about that.

Dr. Osborne: We haven’t been too crazy at the house. Last time we spoke, I guess, we were we went out to New Mexico for a long weekend. That was about a month and a half ago. And, or the last time that we were on here, we speak all the time. But yeah, other than that, I mean, just living the quarantine life, trying to stay fit, trying to stay active. I’ve been working a lot, business has been super busy. Surgeries are kind of at an all-time high right now from a plastic standpoint, which is kind of wild. We can you know, touch on that at a point too if we want to, but other than that, just staying busy, staying active.

Dr. Franco: Didn’t you have a pet possum or something?

Dr. Osborne: Oh, my, gosh.

Dr. Franco: Over this time? Is that a fact or fiction? Is that too early to ask this question?

Dr. Osborne: No, no, that’s a fact. Maybe two weeks ago, my wife was out of town on a blogger thing for a couple of days at Your Trendy Therapist. I hadn’t gotten a chance to plug her yet, we’re only two minutes into this episode. So she was out on a blogger trip. I was at the house by myself, got two big dogs in the house. I got to take them outside. We’ve got a deck out back and Pete, our big Sheepadoodle he’s 90 pounds starts just going crazy the second I let him outside, like walk out what’s going on? I look down and between the slits in the deck, I can see the biggest possum I’ve ever seen in my entire life. He’s just living under there. So we named him Henry. He was chilling for about a week until we made enough noise, stomped on the deck and I’ve sprayed water down there made his life uncomfortable. He moved on to greener pastures.

Dr. Franco: But the greatest part of that story is the one you left out where you were jumping up and down on the deck like a crazy man.

Dr. Osborne: Okay.

Dr. Franco: The neighbor goes, “Hey, are you okay?”

Dr. Osborne: I thought we were gonna leave that out. But since you brought it up. I called an exterminator service, trying to figure out, you know, Animal Control somebody please help me get this possum out from underneath the deck. And the guy was like, “Look, it’s gonna be $200 for me to come out and set a trap then we got to, you know, take it somewhere else. It’s another 150 bucks.” Like, “All right, man. What else are my options?” He was like, “Look, what I would do is just make it uncomfortable for him to live. Jump around on the deck. Make a bunch of noise, spray water down there. Clap your hands. And he’ll wanna leave.” So without really thinking…

Dr. Franco: Do you think this is legit? Or do you think he’s like, “What crazy stuff can I get this guy to do?”

Dr. Osborne: He was Bs-ing me I’m sure that was some prank call from a radio station or something I’m gonna be…

Dr. Franco: You fell for it.

Dr. Osborne: Oh, yeah. So before I know, you know, I hang up the phone immediately. Okay, I got to get rid of this possum. So, of course, I’m shirtless just got done with the run, dogs are outside barking like crazy. I am jumping up and down on my deck in the backyard clapping my hands, spraying water. And the neighbor from next door walks out goes, “Hey, Travis is everything okay?” I’m just like, “Oh, my, God, these people think I am going to the loony bin.”

Dr. Franco: And on that note, why don’t we give you some advice on how to prepare for your surgery. Let’s jump into it and then we’ll have Kevin jump in a minute and then we’ll pepper him with some questions. But for anyone that’s come to our office or had a plastic surgery procedure, it varies from office to office and, and there’s some different guidelines depending on what procedure you’re having, what type of anesthesia you’re having. And hopefully, Travis will jump in on that in a little bit. And then also, depending on your age, and other medical history we’ll really dictate what you do or don’t need to do. I think the point I wanna get across right off the bat is that we’re doing this for your safety, we’re not doing it to torture you. And while it seems very cumbersome, if we didn’t care about your best interest long-term, we would just say, “Ah, forget it, just do whatever.” And so I think a lot of these hoops are made to make this process enjoyable, safe, and as smooth as possible for you. So I’ll tell you what we do in our office and then we’ll let Kevin jump in and kind of go into depth about some of this. And then he’ll hopefully highlight a little bit about why sometimes we started down an initial process and unfortunately, sometimes when you look for stuff, you find things. And then that’s why we end up needing to get you to your PCP, internal medicine, cardiologist, hematologist depending on what exactly is going on.

So in our office at a minimum, depending on your age, everybody gets a CBC and BMP which is basically checking your blood levels, your electrolytes. Once you get over a certain age, we do require an EKG which to check your heart again, you know, surgery, anesthesia distress you a little bit to make sure that that’s perfect and there’s no underlying issues depending on how active you are, you may or not may do your own stress test on a daily basis. Other things that we do for some patients, especially if we’re doing breast surgery after a certain age, we’ll have people get mammograms to make sure that we don’t find any surprises during surgery. Because again, all of this is to make stuff as smooth as possible for patients. And I’ll let Kevin Chang take over. And then hopefully, “Celebrity anesthesia” can jump in with some of these things. And why they’re important to him and I is, a lot of times when we have questions about surgery or something and whether this is something we can proceed with. Him and I will talk about patients all the time, typically in conjunction between someone like Dr. Chang, myself, and “Celebrity.”

Dr. Osborne: Absolutely.

Dr. Chang: Yeah, absolutely. So I think actually, you hit a lot of those high points there already. I think the major things to call out here are one to reiterate that, yes, absolutely, pre-op management clearance, if you will, risk stratification, all of that is really done for essentially maximizing your success, both during and after surgery. And so as you’ve already alluded to some of these pre-surgical tests, like the CBC, the BMP, and so forth, definitely it is basically to get a better look at your health, if you will, as a whole. So making sure that there are no major unanticipated findings, I think would be one thing. The second thing is that from a risk standpoint, one of the things that we…or a couple of things that we worry about, you know, very highly for any surgery is the risk of any cardiac or heart issue or heart side effect. The other one would be a stroke. So basically, between those two things are kind of the ones that we worry about the most.

So, yeah, maybe I would just say that, and also further say that the history part of this is also equally important, right. So some of this is the labs, it’s the testing and so forth. But then the other part is history taking. So we would look for things such as, you know, have you been having more shortness of breath lately? Have you been having sort of unexpected chest pain or chest discomfort that maybe you just didn’t go talk to anybody about? Likewise, have you been noticing a decrease in your functional activity? Like, do you normally go out for, you know, morning jogs and then over the past couple of months, you haven’t been able to do as much? All those things are kind of clues, if you will that maybe something may not be super optimal. I would also say other things that we…

Dr. Franco: So something for patients to know is that if they have any of these symptoms, very important to bring up to their plastic surgeon, primary care. Because if you bring up these types of things to me, and people are just worried about getting their surgery canceled, rescheduled. This is why we try to do stuff far enough out in advance because if you start talking to me that you’re having shortness of breath, you’re having a problem going upstairs. This is stuff where I would get you over to someone like Dr. Chang right away. And it may be nothing. It may be that we’ve been on quarantine we just haven’t exercised in four months. But it may be something and a lot of times they can be easily fixed. Sometimes somebody needs to be put on a medication, sometimes you just need to be examined and make sure. It’d been interesting what stuff we found and how even whether or not you proceed with plastic surgery I feel like the life change it’s made in their overall health. We found people from these basic labs who were undiagnosed diabetic. And I’ve had somebody come back a year later and say, “Hey, I feel so much better. And I didn’t even know why I was feeling so bad.” And their sugars were in almost the 300, you know, and so, but it slowly happens over time where you sometimes don’t realize that it’s going on and all you know is you don’t feel right, but you have no idea why.

Dr. Chang: Sure. Yeah.

Dr. Osborne: Dr. Franco, I loved the analogy that you made a few minutes ago just to bring it back up but of getting the car tuned up before a long road trip. And that’s one way that I like to think about preoperative and perioperative management of patients. You would never just drive from Austin to New York City, just pick up and go without checking your car, if you haven’t checked on your car for the past two years, right? You’d make sure that oil was changed. You’d make sure the tires were rotated, all your fluids, belts, all that stuff was good to go before you embark on the, you know, 2,000 plus mile road trip. I kind of think about the same thing with surgery. Like you said, if somebody is hypertensive, all we may need to do is start them on an ACE inhibitor or change meds around for them or maybe just have them watch their diet and exercise whatever. But sometimes it is small changes that we can do to optimize that patient outcome before we embark on that long-distance road trip or surgery.

Fernando: And Dr. Chang, the question I have for you would be why is it important to stop certain medications before your surgery? That’s one of the things that I’ve discovered over my 20 years in the healthcare industry is that they ask you to stop, you know, whatever type of medication you may be taking. But what’s the concern with that?

Dr. Chang: Yeah, that is a great question. And I can see how, initially that might be a little bit confusing, right, because here we are talking about making sure we’re optimizing things and making sure that you’re good to go for surgery. And then you run into the situation where, on occasion, your provider may ask you to stop taking something. And Travis is gonna know this, I think, very well. But from a medicine standpoint, really the big thing here is that we understand when a patient is undergoing a surgical procedure they are being exposed to anesthesia, for example, IV fluids and so forth. And there is a certain amount of stress that comes sort of naturally from the surgery. And so there may be instances where yes, to minimize some of that stress, and to also avoid some potential complications or side effects with the medications received, etc., during and after surgery that we might ask to temporarily hold certain things. And there’s a huge spectrum there, I’m only just touching the very surface here. But you know, in some cases, it could be just a matter of holding off on certain diabetic medications, it could be a matter of holding off on certain things that are what we call non-essential medications. And then, of course, there’s a whole nother branch of this, which is another probably a whole nother lecture by itself on blood thinners and so forth, you know, that we would ask to hold-off.

Dr. Franco: And I think this is super important, where you discuss with your plastic surgeon, your primary care, because a lot of times when you see your primary care, they’ll make recommendations to us. And so they’ll send me, “Hey, I think they should stop this on a certain day.” Because you also don’t wanna do the flip side, going back to the very beginning and just stop everything. Because if you come in, the day of surgery, and you stopped your blood pressure medications a week before and you’re having a facelift and your, you know, blood pressure is 200 over 100. I don’t wanna end the surprise here, but you’re not having surgery. Kidding. And so if you have any questions, I think it’s super important to talk with your surgeon, your primary care doctor, and let them help work with it. Because some we stopped at different times. And some of it depends on what time your surgery is and whether you’re doing it in the hospital or what specific tests you’re having. So no question there’s no way we can go through all of it. But depending on the procedure and what you’re having, blood thinners are definitely something to make sure you always discuss with your surgeon about timing. I know sometimes when people are a little bit more high risk, I’ll get the hematologist or primary care involved and we’ll discuss the timing to stop and restart blood thinners again, based on Dr. Chang’s kind of risk stratification.

And sometimes, you know, after we talk, the decision is that the risk especially in my field, where it’s elective plastic surgery, the risk is too great to take people off blood thinners because well, the percentage may be very low. I always try and think about if this was my wife, my sister, what would I recommend for them? And so, you know, even small percentages sometimes are things that we really need to seriously think about. And it’s funny because when you see Dr. Chang, when you see “Celebrity anesthesia” and when you see myself, you get asked the same questions three or four times. But sometimes we have something just in a touch different way that it may spur, “Oh, yeah, I do take this med. Oh, yeah, I have had a DVT in the past.” Because those are some of the things and maybe Dr. Chang can talk on some of them because the biggest things that I see that we have to postpone surgeries for is low blood levels. And a lot of times sometimes people have heavy menstrual periods, low iron, other things like that.

And so we wanna make sure that people are in a good spot where if we do lose a little bit of blood, which we typically actually lose a lot less than people think if you watch our Instagram @austinplasticsurgeon. A lot less than they think but that’s one reason and a lot of times we can get that situated either between the OB or their primary care and in terms of whether it’s an iron whether it’s an OB issue or something like that. Undiagnosed diabetes and maybe you can touch base why controlling diabetes and then even the hemoglobin A1C, which gives us a bigger picture is so important. Do you mind touching on that one? Because I think that’s a huge one.

Dr. Chang: Of course. Yeah. So yes, absolutely. So diabetes is one of these things, right, where, of course, it’s a very well-known chronic medical disease but specifically related to surgery and kind of the perioperative management piece of this. One of the reasons it’s so important is because there’s a direct impact and correlation between how well diabetes is controlled versus wound healing that comes afterwards. And so, you know, again, we kind of said in the very first part of this, that all this stuff is really to optimize and maximize your chances of success, both during and after surgery. And so this is just one more piece. It’s to say that, you know, we don’t wanna knowingly go into a situation where we feel that the risk is high, and potentially set people up for failure. Obviously, we want people to be successful throughout the process.

Again, back to the diabetes question. Well, there’s plenty of evidence out there. And you mentioned the hemoglobin A1C. The A1C, by the way, just for folks who are listening is essentially a test that measures the average sugar, if you will, for the past few months, our red cells have a turnover rate of approximately three months at a time. And so the A1C is a good measure of the average sugar during that time period. So, yeah, anything that we can do, and especially if we’re talking about, you know, I would hope that most of these situations are non-emergent, right, like urgent, non-emergent, more elective situations.

Dr. Franco: Sometimes getting breast implants, when summers coming it’s urgent, it is urgent.

Fernando: It can be an emergency too for some people.

Dr. Franco: I mean, Fernando needs these calf implants, like ASAP, those with the little legs, some little legs.

Fernando: Or maybe pec implants. Dr. Franco, pec implants.

Dr. Osborne: I can do that too.

Dr. Chang: Yeah. But you know, short of something catastrophic like that, we, of course, would wanna…we would really encourage that to take the time to get these things under control, again, so that your body has the best chance of success moving forward.

Dr. Osborne: Sure. I totally agree with that. To touch on that analogy again, would you drive to New York or California from here with half of your oil missing? No, you wouldn’t. So it’s just about getting things teed up and making sure that we’re as safe as possible and moving into that perioperative phase.

Dr. Franco: And Dr. … Go ahead, Capitan. Go ahead.

Fernando: Well, I was gonna ask Dr. Chang, does diabetes have an effect on how fast or how this wound heals and the scarring afterwards? You know, I’m a Hispanic male, and I’ve noticed that some of my scars don’t always heal as nicely as others. And I don’t know if that’s because of the amount of sugar in my blood, I’m a pretty sweet guy.

Dr. Franco: That’s surprising with your vegan diet.

Dr. Chang: So what I can say is for sure is that the control, if you will, of diabetes, the management of diabetes definitely does impact the speed as well as the efficacy of wound healing. The way to think about that is in situations, if there is really severely poorly controlled diabetes, it actually does hamper your immune system. And that’s really part of, you know, what we’re talking about with all this stuff. So optimizing that and getting your immune system up to par and giving your body the best chance to heal and recover from surgery is really what we’re talking about. The scar question I may have to defer to Johnny I’m not quite as familiar about that specific piece, but…

Dr. Franco: I think it ends up becoming almost like the second fold of this because if you have a spot that gets an infection, if you got a spot that opens up, now you’re gonna have a wider scar. Now you’re gonna have a wound that needs to heal, you’re gonna have a thick scar. So I don’t know that it truly makes the scar bigger itself but if you have, it’s the sequela of a non-well healing wound.

Dr. Osborne: Sequela. Love that.

Dr. Franco: It’s my word of the day, I looked it up this morning.

Dr. Osborne: And Dr. Chang, one other thing to touch on what diabetic management or you know, high blood sugar in that perioperative phase is setting yourself up for a nosocomial infection or a surgical infection post-op.

Dr. Chang: Yeah, absolutely. No, that’s a great point. So, again, kind of back to that sort of immune system functionality, if you will, all this is related. So you can imagine or I think you can think of this, in some sense that, again, if there is kind of long-term, poorly controlled diabetes, and we just happen to find it. We actually do somewhat in many ways consider that an immune-suppressed, sort of…I’m blanking on my words here, immune-suppressed state, right. So it would be somewhat as if you were taking some other immune suppression medication. We don’t equate those exactly literally, but we do really do consider poorly controlled diabetes as high risk for infections that otherwise people may not necessarily get. And you kind of mentioned the nosocomial thing, absolutely. You know, again, going through a surgical procedure, being around the settings, just having things being done to the body definitely is a risk to develop an infection. And so, again, we wanna minimize that as much as possible.

Dr. Osborne: Sure.

Dr. Franco: And “Celebrity”, I wanna circle to you because I think sometimes we went to… back at the beginning, we were talking about opening up about if you’re having some type of issues in terms of shortness of breath, those type of things prior to surgery. But also medications or maybe non-prescribed medications that sometimes people take and leave off their list. Because if it comes to the day of surgery, and you’re interviewing the patient and somebody’s maybe using some recreational…

Dr. Osborne: Something. Yeah.

Dr. Franco: Stuff. There’s some of these drugs that do affect your heart and other stuff that would cause them to be canceled the day of.

Dr. Osborne: Sure. And, you know, those are things when I go talk to patients, I ask them, you know, any illicit drug use, do you take anything that is non-prescription that is a medication, or that is a drug. And I’m not saying that, because I’m the police, I really don’t care what people do in their free time. But there are certain…

Dr. Franco: You do care about their safety.

Dr. Osborne: I do care about their safety. There are certain drugs and certain medications and certain, you know, non-prescription things that people take that have an impact on how much catecholamines that they have floating around in their bloodstream. Which can help them produce a sympathetic outflow or sympathetic surge to protect their body and will not let their heart rate get too low or their blood pressure bottom out. When you do have things like chronic cocaine usage and chronic methamphetamine use, we actually suppress it. It almost eliminates your circulating catecholamines like epinephrine and norepinephrine, which are things that your body uses to fight low blood pressure or a low heart rate. And the things that we do in surgery, and especially anesthesia, they have vaso-dilatory or blood pressure lowering and heart rate lowering effects. So we actually rely on those circulating catecholamines to help produce a response or mount a response to lowering the patient’s blood pressure.

Dr. Franco: And I think this is super important, again, going back to being upfront at the beginning with your plastic surgeon, because, you know, we can typically figure out a system to get you off things to get you into a good spot. If I have questions, I’ll pass those on to someone like yourself ahead of time. And that way we can make sure because our ultimate goal is that when they get to the surgery center, everything’s rolling pretty smooth.

Dr. Osborne: Sure.

Dr. Franco: I mean, it’s heartbreak for everybody if you have to come to me and be like, “Hey, John, can I talk to you for a minute?”

Dr. Osborne: Totally. And I think, you know, we touched on illicit drugs a second ago. But things like Phentermine, or, things like diet pills. I mean, we’ve met before about patients saying, “Oh, hey, I’ve got this patient they’re having a tummy tuck in two months. They’re currently on Phentermine for weight loss, what do we need to do?” Then you and I sit down, and we say, “Hey, you know, they need to stop at this certain date. That’s the safest, that’s what literature recommends.” And again, we’re just teeing those patients up for a good outcome and a good overall experience with their surgical care.

Dr. Franco: And I think that’s a great point because I think a lot of people forget either stuff that’s prescribed for weight loss or other stuff because they think it doesn’t matter. Or even off the shelf supplements because a lot of supplements have some benefit but they’re in the blood thinner category. And so if we’re doing full-body lipo, you know, now you’re taking something that just because it’s off the shelf, or it’s natural, or these type of things, some of them, they’re not bad enough themselves, but they maybe have a side effect that is detrimental to your surgery. So just important to list all those things with your primary care and plastic surgeon.

Dr. Chang: Absolutely. I couldn’t agree more. If there’s one thing that I would sort of, take away from all this, is that transparency is key. And really, you know, even if we can’t control for every single variable and every single possible thing out there, but at least we can have the conversation in an informed way. And, you know, and part of that is just being sort of very transparent with information because if we don’t know, it doesn’t get brought up. We may ask, but the answer may be no, then we can’t really start those conversations, right. And so yeah, transparency is key.

Dr. Franco: Can I talk and I’d love to get both “Celebrity” and Dr. Chang’s opinion on this is one of the big ones that scare me, especially when we’re talking tummy tuck, facelift, breast lift, breast reduction is smoking. And I just think it’s such a variable they can…it’s something we can control, but something that can really have devastating outcomes for people.

Dr. Chang: Yeah, absolutely. So I would say and you know, so because I work in the hospital, of course, I’m having this conversation a lot so. Smoking is one of those things where it clearly can be very challenging, right? Because by the time we see folks, a lot of times, it’s been a long-term habit. It’s just been a long-term thing that people have been doing. And it’s very challenging, right? And this is true, probably for most habits that we develop over time. I would say similarly, and equally as important as everything that we’ve already discussed up until this point. Smoking has a lot of detrimental effects on your body, clearly, right. And we all kind of probably have heard this in some ways and as medical professionals, we think about this a lot. But not only does it increase your risk for all kinds of stuff such as cancers, and, you know.

Dr. Franco: Cardiovascular.

Dr. Chang: Yeah, cardiovascular disease, and so forth blood pressure issues. But there is also an issue between smoking and wound healing as well. So this is really paramount. I would say that, in between all the cardiovascular stuff we talked about, the smoking piece is also really important. We really try to be very transparent about this. I mean, I tell people all the time, and, you know, so there’s a spectrum here, right? It’s the heart stuff it’s the wound healing stuff. But then obviously, there’s also a lung component to this too. And, you know, again, we haven’t really gotten to the whole COPD conversation yet. But that is actually, in the world of perioperative management that is an important thing. Because if you do have some sort of lung disease going into things, we definitely wanna optimize that, and sometimes that requires a conversation with anesthesia before the surgery so that we don’t get into trouble during surgery.

Dr. Franco: Sure.

Fernando: And Dr. Chang would you say that true, for people that vape as well?

Dr. Chang: Yeah, so vaping is interesting. There’s…

Dr. Franco: Dr. Chang, I wasn’t gonna do that to you but thank you, Capitan for torturing Kevin in this very difficult topic.

Dr. Chang: Yes. So I think, the general sentiment out there is that you know, and it’s swung back and forth a bit, but I think vaping is definitely considered harmful. So there’s, I would probably give the same general recommendations regarding vaping as I would with smoking, and that is simply to just stay away.

Fernando: Right. Fair enough.

Dr. Osborne: I’m right there with you cannot echo that sentiment enough. And one thing that you touched on was, you know, COPD and perioperative management of patients with chronic lung disease, whether it’s COPD, fibrosis, you know, other lung diseases that are out there, asthma, reactive airway, disease, whatever. Those are things that we do touch on and anesthesia does get involved in preoperatively. A lot of times, that’s more with inpatient cases and stuff that’s being done at the hospital that’s slightly more high risk that needs to happen for urgent or emergent procedures. For those cases, you know, we’ll meet with either internist or the surgeon, and get them pulmonary function test. Things that are gonna help us identify what’s the risk of staying intubated postoperatively? What is their risk of needing CPAP in the perioperative phase? Or, you know, needing to have their care transferred to a higher acuity of care somewhere like an ICU or a medical, you know, post-surgical unit. So, for us this stuff that we’re doing at the surgery center, we’re typically not doing chronic lung disease patients for that reason, because we don’t have the ability to escalate care unless we transfer them out to a hospital.

Dr. Franco: I think for us, for me as the plastic surgeon, a couple of things, and you guys have touched on a ton of these. There’s kind of the long-term effects and stuff that we can’t see in terms of the cardiovascular, the pulmonary damage that’s slowly done over time. And then there’s the very acute you know, smoking attacks the very small vessels in the skin and I actively tell people every time you smoke, that’s an hour of blood flow that’s not getting into that skin. And so some of the studies in the plastic surgery literature have shown that if you can even stop one month before. Just one month completely entirely stop smoking, no nicotine patches, no vaping, no, nothing, that your wound healing gets above 80% of what it was prior to smoking. So typically, you know, for doing any type of tummy tuck, facelift, anything that causes some skin elevation, you know, will make people be off for a month before and a month after. Unfortunately, a lot of times when people smoke their partners, significant others around them smoke as well. Secondhand smoke can also be detrimental. So I think it’s just making sure that that kind of the whole situation around you is in a situation for success.

Dr. Osborne: It’s funny Dr. Franco and I have talked about this several times before and when I go in to see patients I always, you know, my first thing is like, “Look, I see here that you smoke, my little shout out today or my PSA is gonna be today’s a great day to quit. I think you should as you should every day.” But specifically working with mostly aesthetic patients and plastics patients. When I tell them, “Look, if you stop smoking, your wound will heal better. It will scar better, you will look better from an aesthetic standpoint postoperatively.” Then, all of a sudden, they buy-in, “Really? Wait really?” And I know Dr. Franco echoes that and all of his pre-ops and everything too. So yes, stop, stop, stop smoking before you have surgery.

Dr. Franco: Fernando any other burning questions that you have for “Celebrity anesthesia” or the mentor Kevin Chang?

Fernando: So for “Celebrity anesthesia,” the question I would have is that when you perform the actual injection of the anesthesia into a person, is it harder to put them to sleep or to wake them up? Which is the more complicated aspect of it? Because depending on the body size, it’s how much anesthesia you need, and how long the surgery lasts is, depending on how long you need them to be asleep. So I’ve always wondered, you know, which one’s harder?

Dr. Osborne: So I think that’s a little bit of a multi-factorial question. Obviously, it is more difficult to put somebody to sleep that is unhealthy or that needs emergent surgery because I don’t have, you know, everything in front of me before we get started to really see what does that patient look like on paper? How healthy are they? How sick is their heart? How healthy are their lungs? That kind of stuff. If I’m at the hospital, and I’m taking a call or something and I have somebody that comes in from a motor vehicle accident, that’s missing an arm and has lost a lot of blood, sometimes putting that person to sleep may be harder than waking them up. Because I’ve got to be so careful with blood pressure management and, you know, perfusing their brain and making sure that they’re not too anemic, and that they have a blood carrying capacity for that oxygen.

When we’re doing plastics and when we’re doing you know, stuff that’s outpatient, for the most part, the wake up is probably slightly more challenging than putting someone that’s completely healthy to sleep. But once you’ve done it, it’s kind of like, an art and science, there is no exact way to wake somebody up anesthesia wise, you can turn it off, and you can wait for them to completely wake up and then remove the breathing tube. That’s not the prettiest way to wake up. And it’s not the most comfortable. So you want somebody that’s gonna find that happy medium that knows how to balance that anesthetic appropriately and make that a nice linear smooth wake up for the patient.

Fernando: Now, I know that in the surgeries that I’ve had in the past, I’ve never… I just wake-up and it’s like, “Oh, I’m awake.”

Dr. Franco: Watching “Celebrity anesthesia” put someone to sleep and wake up is like watching a show on Broadway. I mean, it’s artistic, it’s just artistic.

Dr. Osborne: I bet.

Dr. Franco: “Celebrity” any other take-home messages for people about pre-op concerns, issues from your anesthesia standpoint, I feel like we’ve touched on a lot of the really big ones.

Dr. Osborne: We did touch on most of it. Another thing that we didn’t touch on was NPO guidelines.

Dr. Franco: Oh, that’s a good one.

Dr. Osborne: That means nothing by mouth.

Dr. Franco: Nothing like getting your surgery canceled because of a good breakfast.

Dr. Osborne: Right. And again, just to echo what you and Dr. Chang said a minute ago, we’re not doing any of these things to be bad guys, we’re not trying to be mean, we’re not trying to make you hungry. I don’t like being hangry either people. But we’re doing that because when we do general anesthesia, or even sedation or monitored anesthesia care, there’s always the risk that it converts to general anesthesia. Anytime we do general anesthesia, we put you to sleep, and all of your airway reflexes are lost. So if you have something go down the “Wrong pipe” you can’t cough, you can’t protect your own airway. So we try to eliminate the possibility of you having anything in your stomach and decreasing the amount of gastric contents that are in there produced naturally. So that’s why we tell you not to eat or drink anything. We give you certain timeframes for that. So I would say please respect those timeframes, or else your surgery will get canceled. Again, not to be mean, that’s for your safety. The other thing, Dr. Chang talked about medications to stop or hold or take pre-op, make sure that your… Don’t listen to…don’t follow exactly what we’re saying with that. Please make sure that you talk to your specific provider, your internist, and your anesthesia provider and plastic surgeon, those things need to be made specifically for each patient in each situation.

Dr. Chang: Agree. Fair enough.

Dr. Franco: Because one of the people taking care of you really know what your true needs are, and what may be right for one person won’t be right for the next.

Dr. Osborne: Completely.

Dr. Franco: So that’s a great, great, great point, the NPO. And then, if you have questions, consult with your specific provider for sure. Dr. Chang, any last words, things that we’ve skipped, forgotten? I think one thing I think that sometimes people don’t realize is we’ll send them to someone like you who’s either internist, PCP, family doctor, and then I think they get frustrated. And I don’t wanna burden this too much but at least touch base. And then they get maybe frustrated because you may refer them to a hematologist, a rheumatologist, a GI, a neurologist, can you maybe just touch base why we do that?

Dr. Chang: Yeah, absolutely.

Dr. Franco: A cardiologist.

Dr. Chang: Yeah, definitely. No. So it’s and you know, at the risk of sounding, just kind of repeating some of the same themes. It really just depends. So the whole point of looking into some of these things is to either one detect something that we may not have known about. Or two optimize something that is preexisting before you go into surgery, and so that just totally depends. I mean, if you have, for example, pre-existing heart conditions, some sort of really high grade, what we call arrhythmia, that’s basically a disturbance in the heart rhythm. We wanna get that under control before we send you off to surgery because we don’t want you going into the OR, and then having some sort of fatal event or some sort of serious event that leads you to, you know, post, like, for example, for ICU care.

So yeah, there’s and you’ve kind of highlighted several of those. But obviously, you know, if we’re sending you to a cardiologist, it’s usually something for either a rhythm issue or preexisting heart disease or unstable heart disease, right, we call might call unstable angina. Or to get a stress test, for example, because you may need some cardiovascular intervention, you know, prior to surgery. Or, and I would say there’s a spectrum to this, right. The worst-case scenario is we find something and it’s pretty significant. It’s pretty serious. And that actually precludes you from having surgery, right. But we would rather know that upfront, rather than at the time or after surgery clearly. So that’s the reason for all this. I would say the same thing, again, with GI, with pulmonary, with any other subspecialty, we might refer you to. It’s the same kinds of conversations it depends on the nature of the underlying conditions or things that we may not have known about before. And the same types of conversations. You know, yeah, I would probably just leave it at that.

Dr. Franco: Well, I really, really appreciate you guys, because I think this has been a phenomenal topic. And it’s something we’re probably gonna link to our website and do as part of our pre-op stuff. Because I think these are a lot of questions and topics that people get all the time. But now, I’d like to jump into a little thing that we like to call fact or fiction. And so Dr. Chang, if you don’t mind we’ll just ask you a couple of rapid-fire questions here. Fact or fiction, you’re a new Dad?

Dr. Chang: That’s a fact.

Dr. Franco: Tell us a little bit about Aaron Johnny Chang.

Dr. Chang: So yes, his name is Aaron John Chang. We’re very happy, proud new parents. This is our first child. He is just a little over three… Yeah, he’s literally three weeks and a day old now. He did come just a tiny, tiny bit early although he was term. We were…I was at work this was a few weeks ago, I was at work. And my wife’s name is Claire. And she texts me and she’s like, “Oh, you know, I just talked to the OB, and she wants to induce today.” And I was like, “You need to call me.”

Dr. Franco: This is not a tech situation.

Dr. Chang: I was like.

Dr. Franco: “Hey, how’s the day going?” “No, it’s fine nothing going on.” “Oh, really? Okay.” “I’m getting induce today.” “Oh, yeah? That’s cool.”

Dr. Chang: I was like, “Oh, that’s great. I agree with you.”

Fernando: I hope you saved the text, Kevin.

Dr. Chang: Yeah, I still got it.

Dr. Franco: You need to print that and put that up on the wall somewhere. Fact or fiction. I was your greatest medical student ever.

Dr. Chang: That’s definitely a fact.

Fernando: You sure it’s not a fiction? You sure it’s not part of Dr. Franco’s imagination?

Dr. Franco: Can we jump to a little thing I like to call behind the bovie. And so this is a section where we talk about something that happens in surgery that maybe nobody knows about. Travis, anything behind the bovie in terms of pre-op stuff that people probably don’t know? And I got an idea if you don’t have one on the tip of your tongue.

Dr. Osborne: I mean, I think we touched on a few of those things during our talk, but you know, me and you actually spend a lot of time on the phone during the week discussing patients that we have coming up. And anytime that there’s a question or somebody that, you know, you have anything that’s out of the ordinary, we talk about that, you know, a week or two before the case a couple of months before the case, depending on when it is. Whether that’s a strategy for keeping those patients on their blood thinner medications or what our approach is, but yeah, a lot goes on in the background for a pre-op assessment.

Dr. Franco: That’s exactly what I was gonna do. I don’t think people realize that in terms of some of the other prep work, especially when something you know, specific is going on. So I think that’s a great one. Do we have a quote of the day? There’s no Gilberto for you to compete with so gotta bring the thunder.

Dr. Osborne: I actually have one ready, right. This is a Benjamin Franklin quote. I think it’s relevant to what we’re talking about today. “By failing to prepare, you are preparing to fail.”

Fernando: Wow, very nice.

Dr. Franco: Damn, damn.

Dr. Chang: Wow.

Dr. Franco: Well, that’s kind of what I felt with Fernando when I texted him at six this morning and I asked him to review his script, I was like, “Don’t prepare to fail Fernando.”

Fernando: As a former Boy Scout, I would say one of my models is, be prepared. So I try to be as prepared as I can, but when you only give me a couple of hours, it’s kind of hard.

Dr. Franco: But Fernando you should be used to this. I usually spring stuff on him on the last minute that’s like the status quo.

Fernando: He’s like, “Do you have 30 seconds to take care of this?” Like, yeah, that’s an hour project.

Dr. Franco: Well, I wanna thank Fernando for joining us. I wanna thank Dr. Chang for joining us. And of course, “Celebrity anesthesia” is like the anchor of this show. So he’s always here. I appreciate him keeping his shirt on and not distracting Fernando overly as they’re sharing an office today. I thought today was absolutely incredible and I appreciate everybody so please stay tuned, we’ll get… “Plastic Surgery Untold” will be available on iTunes, iHeart wherever you get your favorite podcasts and we got more episodes coming soon. Talk to you guys later. Bye.

Dr. Osborne: See you.

Dr. Chang: Awesome.

Fernando: Bye-bye.

About The Author

Dr. Johnny Franco
Men need love to!Episode 23: Modern Mommy Makeover, 3-Dimensional Body Sculpting


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