Do longer surgeries have a higher complication rate?

A common question around here from patients is whether they can combine surgeries – say, a tummy tuck with liposuction and a mastopexy – as one might be wanting to do in a “mommy makeover”.
To answer this, we have to look at things from 2 different angles:
1) legal – what do the Florida regulations permit, and
2) medical – what do the studies looking at surgical complications find.
First of all, the applicable Florida regulations for office-based surgery state that the “maximum combined duration of anesthesia shall not exceed 8 hours.” Not much of an issue there, unless somebody is planning a surgical marathon.
From the medical literature, the answer to the question relating complication rates and duration of surgery is, surprisingly, not 100% obvious. Since there hasn’t been a prospective randomized study in plastic surgery patients, we only have studies from other types of surgery, and retrospective reviews to examine. So hold on, I’m going to summarize a few studies – it’ll only take a minute….
Data against long surgeries:
– increased overall complication rates with longer anesthesia / surgery times in multiple studies in the anesthesia, cardiac surgery, orthopedic surgery, and urology literature. In particular, the study from the British Journal of Urology found a fourfold increase in non-urologic complications with anesthesia durations > 6 hours.
– increased rate of DVT (deep vein thrombosis) and pulmonary embolism. For example, in one orthopedic study, these potentially life-threatening complications were 3.5 times more likely when the anesthesia duration exceeded 3.5 hours for hip or knee replacement surgery, which are infamous for high rates of DVT’s. More recently, the Caprini risk factor stratification system for DVT’s showed prolonged anesthesia times to be an independent risk factor for DVT and PE.
– increased pulmonary complications with anesthesia times greater than 2.5 hours, in both normal patients, and especially in those with pre-existing chronic lung conditions. There are multiple studies which have shown a correlation between pulmonary complications (such as post-op pneumonia) and duration of anesthesia, for multiple different sorts of surgeries.
– increased rate of surgical site (wound) infections with longer surgeries.
– higher incidence of unplanned hospital admissions
– higher incidence of postoperative hypothermia
Data supporting combination surgeries
– no increased risk seen when facial surgery operations were combined, in a study performed at Yale University. Anesthesia / surgery duration was not associated with increased risk in this study when surgeries under 4 hours and over 4 hours were compared.
– no increase in the complication rate when aesthetic tummy and breast operations were combined in a study from a private clinic in California. However, in this single-surgeon study, all surgeries were less than 6 hours in length.
The bottom line: Combination surgeries can be performed safely, in selected patients. Despite our best efforts at prevention & prophylaxis, DVT, pulmonary embolism and pulmonary complications of anesthesia are lingering issues related to longer surgeries with general anesthesia. And when these problems occur, they can be devastating, requiring hospitalization or even ICU admission.
So, there is an upper limit, and each surgeon has to make up their own mind about what that is, until the day comes when we have really solid scientific evidence to guide our decision-making. For my own point of view, I do not typically recommend combinations of surgery exceeding 6-7 hours of planned surgery time, even for healthy patients, especially when one of the procedures is an abdominoplasty.
I really feel it is safer to divide up the surgery into two stages, if the length of surgery exceeds this 6-7 hour number. I realize that it’s a major inconvenience for patients to have two separate recovery stages, so I don’t make this recommendation lightly…I make it solely for reasons of patient safety. (It’s certainly not for my convenience.) I know that I have lost business because of it, and that patients sometimes go to someone else who promises to do it all in one day.
I certainly don’t want to gamble with your health – nor do you want me to rush through your procedures!! I much prefer to be a meticulous craftsman than a speed demon, when it comes to cosmetic plastic surgery!
So, going back to the original question: I commonly combine a breast augmentation (approx. 1 hour procedure) or a smaller mastopexy with a complete tummy tuck (3-4 hours). But I will not generally combine a major breast reduction or complex mastopexy (3-4 hours) with a full tummy tuck (another 3-4 hours), as I feel the lengthy 7-8 hour anesthesia / surgery time is too worrisome, even for healthy people.
As always – safety first.