Cosmetic Surgery In Turkey: A Case Report by Christine Talbot. SRN. MLD. DLT.
History:
Miss A has a comprehensive medical history which might in part account for a very protracted post operative recovery, further prolonged by previous cosmetic surgery in London four months prior to her trip to Turkey and a significant metabolic/endocrine history which is not conducive for effective lymphatic flow and function.
Childhood and early history:
Multiple fractures in childhood, teens and twenties:-
right upper arm, wrists x 3, right ankle, right knee cap, three metatarsals, left foot.
(Miss A’s mother said she could trip over a matchstick, her right leg is slightly shorter.)
Hashimotos, (diagnosed in early 30’s)
Wells Syndrome, Eosinophilic Cellulitis,(a rare disease only 80 cases worldwide)
First episode:- spread from face, arms, front of chest (formed plaques), legs front and back from hips to knees.
Investigation:- skin sample, anti-rejection therapy, no immune system, (said to have a non-functioning spleen)
Second episode:- bilateral erythema to lower legs.
AMD,
Age Related Macular Degeneration, ? familial.
Dysfunctional Meibomian glands.
Type 2 Diabetes. Non medicated.
Medications: Simvastatin, Fesoteradine 8mg, Levothyroxine 225 mcg daily, Vitamin D.
Surgical Procedures:-
Cholecystectomy, excision of gall bladder, (30’s)
Bilateral Orbital Decompression, Moorfields Hospital, (42 yrs)
18th November 2021, London:
Apronectomy, (Tummy Tuck), Brachioplasty (bilateral),
21st April 2022, Turkey:
Refashioning and augmentation of breasts with insertion of implants, facial uplift, lifting of eyelids and correction to left eyelid from previous surgery.
Post Operative Treatment:
6th December 2021
Manual Lymphatic Drainage first commenced following surgical procedures in London.
Miss A had lost 10 kilograms in weight but was left with large areas of sagging skin which needed to be removed.
Slow Healing:
Following surgery Miss A had retained a great deal of fluid and appeared at her first appointment with a large mons pubis drain in situ the substance of which was brown in colour. Her left arm swelled considerably and there was oedema down the right Sterno Cleido Mastoid and engorged axillae. Over time the swelling slowly reduced but Miss A felt as though her abdomen was going to burst with ongoing discharge from the abdominal scar tracking upwards towards a moist, reddened, sloughy umbilicus, the abdominal pelvic area remained solid and lumpy.
Fluctuations repeatedly reoccurred in all areas including the face, neck, axillary and popliteal nodes indicative of a sluggish venous and lymphatic return.
I was concerned in early March Miss A was to travel to Turkey for a preoperative assessment for further plastic/cosmetic surgery, her body was still struggling to normalise from the London surgery.
1st March 2022: Clinic, Istanbul.
Miss A undertook a consultation with a Turkish surgeon in London, said to have trained in cosmetic surgery in Ohio, USA. Whilst attending her clinical assessment in Istanbul the original quote from London had escalated but was still well below London prices. Although not too comfortable with this and Istanbul, Miss A was determined to go ahead with the surgery.
April 2022: Clinic, Istanbul
Face Lift, Breast Reduction and Augmentation with Implants.
Miss A’s post operative experience in Turkey was very traumatic. On removing the endotracheal tube the nurse failed to suction the back of the throat, this is standard practice. With cyanosed lips and frantically pointing to her throat Miss A remembers everything went black, the nurse did not comprehend and a respiratory arrest followed. Three further episodes with serious escalations in blood pressured occurred during the night. The following day Miss A was taken back to theatre to have needle aspirations to remove haematomas from her face, the surgeon blamed her for the emergency episodes claiming she was hypertensive, she emphatically informed him, she had never suffered with hypertension but these were related directly to her near death experience by his nurse failing to respond to her choking to death, he made no comment and walked off, she assumed he had not been informed. Despite these critical incidents Miss A was an inpatient for only two nights and was then taken to a hotel, her stay was extended due to excessive bleeding and she was far more swollen than anticipated. A nurse was assigned to the hotel to oversee the care of cosmetic patients, she was on call for any emergencies.
9th May 2022: Post Operative MLD.
I was shocked when Miss A appeared at my door, she said I would have my work cut out this time.
Observations:-
Dark blood stained/necrotic post auricular areas.
Stitches and scar lines along and behind the ears from the face lift.
Contusion (bruising) around the eye sockets, with stitch lines along the eyelids.
Extensive contusion(bruising) to the left side of her face and neck, less to the right,
The upper left lip was pulled downwards.
Both breasts were heavily bruised up into the latissimus dorsi and back, they were large and hard, the right breast was significantly more engorged, more painful and less mobile.
Miss A complained of an overall tightness in her head and face and her chest felt massive.
MLD Treatment:-
Deep Oscillation, Laser Therapy, Magcell and the Bowen Technique.
The objective was to restore effective vascular and lymphatic flow to reduce massive oedema and fibrosis, to aid scar and cellular repair and to alleviate all associated pain
Bowen Therapy aids self-healing and realignment taking a body out of deep shock.
Miss A had been subjected to a deep physical and mental trauma.
Both breasts were excessively large and swollen, with deep indented scaring on the underside, the scar on the inferior aspect of the right breast barely came together, these mammary glands required comprehensive lymphatic drainage and gentle mobilisation. The mandible, maxillary and neck areas were rigid requiring softening using laser therapy and deep oscillation, the throat was particularly tight and felt as though it was closing.
Both axilla were solid with tennis ball sized engorgement.
There was a marked, hardened haematoma in the left cheek giving a visible bluish hue, with tracking towards the left TMJ. The right cheek was less pronounced but still a visible blue hue and fibrosis.
Bilateral swelling to both eyes, more pronounced on the left and up into the eyelid. The left conjunctiva was significantly reddened and sore, the eye was not closing properly due to an over correction.
The overall tightness in the cranium and neck was treated with MLD and Bowen therapy.
Both post auricular areas were extensively treated with laser therapy, and the Magcell to encourage blood flow, gentle MLD moves with deep oscillation and Bowen therapy specifically utilising the Respiratory, Upper Respiratory and TMJ procedures to assist in respiration and TMJ alignment affecting the whole body. The blooded areas were cleaned regularly twice daily with hydrogen peroxide by Miss A and at each appointment. The doctor in Turkey later suggested the post auricular necrosis on the left would require a surgical debridement and skin graft under local anaesthetic in Turkey.
Miss A had seen practice nurses at her GP surgery, they had stuck plasters over the areas which were intended to soften and lift the dead tissue, the plasters mainly stuck to the hair and were non effective. The right sided necrosis was beginning to separate and lift of its own accord, I successfully debrided the area using sterilised Q Tips soaked in sterilised salt water with hydrogen peroxide 3% and irrigating the solution using a 5ml syringe .
Miss A was very stressed by the thought of returning to Turkey and further surgery causing another wound from a skin graft with more unknown healing processes. The thought of arranging all aspects of travel and a dog sitter was too much. I was not of the opinion there was any immediate urgency for this procedure, nor that Turkey was a good idea with Covid around in abundance. I considered the probability of a skin graft not being successful in that area or becoming infected as highly likely. I suggested we take a considered, conservative and common sense approach, I would use the same debridement technique as I had used for the right side which although difficult had taken thirty minutes to remove. The left was more adherent but within forty five minutes it totally separated. As with the right the new flesh was pink but the area was sloughing and mucky so was irrigated thoroughly and then lasered dry and a dressing applied. This method was very effective and repeated at subsequent treatments. Miss A was instructed on how to thoroughly clean both sites with hydrogen peroxide and drying on a low hair dryer heat and to self-apply dry dressings. The practice nurses had prescribed a course of prophylactic antibiotics (Flucloxacillin 500mg) which was wise aiding the healing process which was later repeated as the areas remained raw and oozed yellowish fluid for a while. However the use of the laser produced positive results sealing and drawing in the wound circumference. Whilst healing occurred the areas were very tight
Incorporated in all of the immediate post operative treatment requirements from surgery in Istanbul, Miss A also continued to need lymphatic drainage from the London surgery in November 2021 which had not resolved and was causing swelling in Miss A’s left leg, swelling in the arms and additional swelling and engorgement to both axilla.
Initially Miss A required three appointments weekly to reduce the overall body mass, to relieve pain, to aid gentle mobilisation of all affected areas and to offer advice and support through a challenging process of healing, physical change and to address any fears.
Miss A’s left eye failed to improve, the eyelid was very swollen, the eye itself was permanently reddened, and painful, it was later discovered crystals had formed underneath the eyelid. The surgical over correction had caused the left eye to fail to close properly, this lack of closing may account for various infection related issues, one of which was the Herpes Virus in the eye, Miss A was prescribed anti-viral medication and eye drops. Natural eye irrigation was less effective due to dysfunctional Meibomian glands. More seriously cellulitis flared up in the left cheek which was dangerously advancing towards the eye. I believe the source of infection originated from the eye infection tracking into the oral sinuses. Miss A had several appointments with Ophthalmologists and eventually a needle aspiration into the left tear duct drew off a lot of thick green pus.
Periodically Miss A complained of headaches and a strange sensation in her ear, this resolved when a foul discharge came from the ear. I suggested exudated muck had possibly entered during surgery and festered, I advised she had her ears syringed as any infected matter tracking up into the brain would be extremely hazardous.
Advice:
Miss A was shown effective self-massage techniques to gently mobilise and soften all engorged tissues and to work on the abdomen..
A cupping of the breast with two hands to do figure of eight movements to reduce the heavily engorged breasts and effect the bruised areas towards the latissimus dorsi were shown.
I showed Miss A how to bind the upper trunk and breasts with 12cm Comprilan short stretch compression bandages to relieve the gross engorgement in the breasts and back, this she could do at home between appointments giving relief.
I demonstrated the technique using the soft pad of the thumb to press up and around into the hard palate, to massage inside and around the gums and cheeks effecting inter oral drainage in order to reduce the solidity within the cheeks to relieve oral and dental pain.
I mentioned looking on You Tube for videos with specific mouth exercise videos and facial Yoga and to buy a Jade quartz roller and flat shaped plate to stretch the skin.
I thought a beauty massage machine with a vibrating head was a good idea for home massage in between appointments, plus a Pilates Prickle Ball could be used to gently break up consolidation by rolling the ball over raised engorged areas in particular the engorged axilla.
Miss A was familiar with fitness workouts and gym equipment, these were encouraged in moderation to continue if she felt able to do them.
Miss A had a little dog so walking would assist lymph flow.
Two Years On, May 2024:
Initially the main objective was to reduce all surgically associated swelling and attend to scar management. It is difficult to know whether the thyroid issues Miss A faces are interfering with and preventing a reduction in fluid retention, it is also difficult to assess whether the previous surgery in London has had an additional impact on fluid balance.
The return from Turkey and the state in which Miss A had been discharged was challenging at the outset, however over several months body engorgement was showing a very positive response, even the right breast which had been so grossly distended and hard had softened and was taking on a more normal breast shape. I am and have always been of the opinion the breast implants are far too large and are blocking effective flow through the chest to the axilla and neck. The thought of undergoing further surgery to have these implants removed is not one Miss A can face.
The left eye has improved but periodically issues re occur with pain, sensitivity and reaction to eye makeup and the potential risk of infection.
Miss A has had other infections unrelated to her surgeries which cause a generalised regression and increase in fluid volume. Equally Miss A has taken a couple of long haul flights which can leave her very swollen.
Since Miss A’s last Covid vaccination her body seems to have solidified, could this have dis-regulated thyroid function or have auto immune implications?
Practitioner Opinion:
I am not in a position to know were I to have lost a lot of weight, whether, what or how I would go about deciding and choosing which options to use to remove all the excess saggy skin and re fashioning, nor what factoring of costs would play in the location decision making.
It takes courage, surgeries are not without risk and in cases abroad the risks are far higher. Cosmetic surgeries are extremely expensive, what happens if it goes wrong, what happens if the end result is disappointing plus all the added aspects including a language barrier and the costing of any correctional surgery should complications arise?
Had deep oscillation and laser therapy not been available for Miss A, patient care would have been utterly formidable.
In Miss A’s case it was unfortunate she had to undergo the Turkish ordeal alone having previously arranged for a friend to accompany her. The endotracheal tube incident almost cost Miss A her life. With her head heavily swathed in bandages and unable to move due to excessive swelling, pain and stiffness Miss A could only drink through a straw, she said the aperture of her mouth was the size of an M&M, had she choked or vomited this could have been catastrophic. The demands and anxieties of foreign travel in normal circumstances are daunting, to cope and in this case alone following recent major reconstructive surgery is unimaginable.
It is notable as the only clinician attending to this lady on a twice to three weekly basis, that I was not contacted for my opinion by the Practice Nurses nor the Turkish doctor neither of whom had seen her following surgery.
This case and associated costs remain ongoing.
Miss A has kindly permitted the use of photographic images in her case study.
Essential Preparation on You Tube:
An American Plastics/Cosmetic Surgeon Dr Amir M Karam, talks in detail about the necessity thorough knowledge, preparation and research before undertaking any such procedures and to fully understand on waking from surgery it will not be the instant, miraculous recreation imagined and desired.
Facial image third day post op in Istanbul, alone in a hotel room with severe facial bruising and a right sided head drain in situ.
Image shows extensive bilateral breast engorgement with severe bruising
Image shows deep lateral bruising to right breast
Post auricular necrotic tissue
Successful debridement from left ear
An excellent result combining basic nursing skills with Deep Oscillation, QWL laser therapy and the Magcell
Read more Case Reports from Christine Talbot SRN. MLD. DLT
