When Fixing Goes Wrong: The Truth About Revision Surgery

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You're listening to the Confident Choice podcast with me, Dr.
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Roberto Garcia, a double board certified facial plastic and reconstructive surgeon.
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Honest conversations and expert advice about the decisions that make you feel your best.
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Well, welcome everybody to episode 11 of the Confident Choice. I'm your host, Dr.
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Roberto Garcia, and as always, we are broadcasting from beautiful Ponte Vedra
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Beach, where, well, actually, today's kind of overcast. We need the rain.
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My wife keeps telling me we need rain, and it's been super dry.
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As you guys probably know, there's been some fires in the Gainesville area,
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and then it's up in Georgia, right? There was something going on in Georgia. Yeah.
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Well, anyway, we've had quite a run in these last three weeks.
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I think you guys can all agree that the last three hosts or guests that we've
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had, I'm the host of the guests, last three guests that we've had have been
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fantastic. I thought Dr.
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Basil was a great addition and complimented well the, you know,
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kind of those non-surgical modalities.
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And it's just great to hear the perspective of somebody with a little bit different
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training than us, but still a very talented and gifted surgeon.
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And I was really quite honored to have him on our show.
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And I thought last or two weeks ago with my brother, really bringing the entire
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specialty of facial plastic surgery,
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kind of defining it and bringing these things to light and explaining how it was that we came to be.
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And I think that I'm so proud of our academy And I'm so proud of what we've
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always, what we've been able to achieve as facial plastic surgeons.
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And, and, you know, it's, it's kind of one of the things that my dad talked about.
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I won't get into dad's lesson yet. That's for later in the show. But just...
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Keep your head down and keep grinding. You don't need to scream.
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You don't need to be boastful. You never need to hurt another business or prevent
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another business from doing work.
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You just focus on your work and you do the best thing that you can possibly do.
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And I think that's been something that across the board has been taught at not
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only the academy level, but it's also being taught at the fellowship level that
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you can only really control what you have in front of you, right?
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And the patient that's in front of you, instead of worrying about what other
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surgeons are doing and whether they're taking food off your plate or whatever
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you might conjure up in your head, you're not helping the patient when your mindset is there.
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And so I've always had the mindset of, I don't care what other practices are doing.
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I don't care if people, you know, other specialties are doing surgeries that
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maybe aren't as specialized as we are.
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If they're doing good work, and I've said this before, if you're doing good
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work, you're doing good work. I mean, and it's just a fact.
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And so I thought that was a good kind of encircling of this specialty.
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And, you know, last week with Mrs. Goldman, she's incredible.
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Do you guys know what she does?
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Like, you know, she says she's a business person. You ever been to like a Smithsonian business.
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The museums and these big museums, like the Met or whatever,
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and you go to the gift shop and they have these puzzles of like artwork and
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stuff like that. She does those.
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She makes those, her company does those. So she's really gifted and she's done
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exceedingly well. Come to think of that, actually.
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We were in Gainesville this past weekend for my oldest daughter,
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Isabella. Congratulations, baby.
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Graduated from the University of Florida, advertising and marketing degree.
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And we were staying at my brother-in-law's house and they had a puzzle that
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we had bought them. It was a Florida Gator themed puzzle.
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And it's something like 12 dogs sitting on a couch watching a game and they're
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rooting and they're doing different things, but the color schemes of it are really challenging.
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Well, we built that puzzle this weekend, the kids and I.
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And of course, I left it on the table to show my brother-in-law that we're not
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all cretins and we can complete things like that in a very brief period of time.
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All joking aside, I think as we enter into the last part of this season one,
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and I have some really interesting ideas that I want to bring in in season two.
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And we're going to start bringing in different types of guests that maybe are
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outside of the realm of plastic surgery.
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I can't tell you how many people have come up to me and said,
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hey, can I be a guest? Can I be on your podcast?
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So we'll probably start bringing in other people. I get tired of hearing myself
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talk. I like listening to other people talk, believe it or not.
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But today, we're going to close out this season with what I think is a very serious topic today.
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And we're going to talk about what is revision surgery,
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what constitutes an appropriate revision surgery,
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when should we do revision surgery and what you can expect as a patient from
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any kind of revision surgery.
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Let me first define what revision surgery is because, you know,
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individuals have different, I guess, interpretations of what that word means.
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I consider revision surgery any kind of correction of something that is happening
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that we are considering after the face is healed.
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And generally, it's a year, okay? Now, I used to have this steadfast rule,
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and you might remember it, Laurie, that I wouldn't correct anything for a year.
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And then as I got older, I said, now, I know kind of around six months or so
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when I see something that I don't like, I know it's not going to really get
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better. And I'm not going to have a patient sit with something for six months
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and I'm going to correct it.
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So the definition is exactly that.
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Anything that you have to correct outside of the normal healing parameters.
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What is not a revision is when somebody is coming back four or five years later
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and wanting additional tweaking of a procedure.
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That should not fall within the calculation of a surgeon's revision rate.
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So when I look at what my revision rate is compared to what the national average is,
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and I'm going to get into certain surgeries have higher revision rates.
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And it really, if you were to think of what constitutes the elevated revision
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rate, it really comes down to surgeon experience, complexity of surgery.
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And believe it or not, guys, it's not always the surgeon's fault.
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Patients, and I think I've talked about this in prior episodes,
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Alyssa, where I've said you can have the same patient who I do a surgery on
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today and 10 years later I do the same surgery on.
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Again, not a revision, but a tweaking, so to speak, and the patient heals completely different.
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So what's going on inside of the person's body has a huge implication as to
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how they heal, and hence whether they might need revision work in the future.
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And so I'm always of the opinion, at least in my practice, that I don't skirt any kind of revision.
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And if I see something that's not right, and I see something that I don't think.
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Is what I envisioned for the patient, then more than likely I'm going to recommend
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to them, hey, listen, there's something here I don't like. We need to tweak it. Okay.
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And I used to be a little bit more bulldoggish with my revisions in terms of
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charging patients and whatnot.
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But, and there's every year at the academy meetings, there's always a discussion,
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should you charge for revisions?
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If you don't charge for revisions and you're accepting culpability,
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if you don't charged for by you charging revisions and you're telling the patient
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it's not your fault that this is a natural healing.
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I don't really get into all that. I don't really look at it as if I have to
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tweak something, it's my fault.
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The same way I don't blame a patient for, you know, potentially being their fault.
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It doesn't mean it doesn't matter, right? We're not keeping score.
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What matters is can we see a problem that needs to be corrected?
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Should it be corrected? And when will that get corrected. And in my hands and
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in my experience, I fix my own problems and I don't charge people for revision work.
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Now, the national average, or rather the national incidence overall,
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I think, did I just say this, what the percentage was?
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It's about 15 to 20%. And within that, rhinoplasty is the highest revision rate, okay, hands down.
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And due to the complexity of the surgery. And the fact that there's a lot of
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forces within the nose that can alter cartilages and bones and scarring in different
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directions. So it can certainly has a higher revision rate.
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I've never really calculated my revision rate, but it's certainly lower than that.
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What I do see a lot as a face specialist is I do see a lot of revisions of nasal work done elsewhere.
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And I don't really want to comment on who is doing this type of work or should
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they be doing this type of work.
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That matters nothing to me. I had this patient who had had rhinoplasty five times.
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Yeah. And really sweet girl. It's a funny story because she had no bridge at
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all. Now, the bridge is this part of the nose here.
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And due to the multiple surgeries, blood flow had impacted her nasal skeleton.
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And so she was really concave in this area here, calling it a saddle nose deformity.
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You may see that term if you ever look it up. But and she was exhausted.
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She had been to multiple places and she'd had multiple small procedures.
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And each time they were just kind of chipping away at the nasal skeleton of the nose.
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And ultimately, she came in. Now, the only reason I'm telling you this story
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is because we did what I consider to be a major reconstruction to her nose.
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And I thought it turned out really well. And so did she.
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She was on, she had this site on TikTok or Instagram. It's funny.
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She's such a sweet lady. And if you're watching this, hello.
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I have not talked to you in a couple years.
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And comment on my podcast. I always comment on your Instagram post.
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But anyway, the cool thing about this young lady is she has this, this.
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This Instagram channel, you remember this girl where she, she deals with a lot
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of people who have anxiety and they don't want to be scared at movies.
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So, you know, people like scary movies, but they don't like to be scared.
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I don't know. I don't get it.
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I don't, I don't really particularly care for roller coasters with drops.
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I just don't get on roller coasters with drops, but some people really like the theater.
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And so she would do like these spoiler uh things on instagram and so that people
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would expect and they wouldn't be jump scared or whatever it was when the time
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came in the movie and i thought it was really thoughtful you know like really
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thinking about people's emotions in these movies right,
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i mean i wish i would have known her when halloween or friday the 13th came
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out when i was a kid all right i still have nightmares over that amy you know
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you remember that michael myers was literally the scariest person.
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I'll never say, I've never seen Jamie Lee Curtis in the same light since that movie.
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But either way, so this was what she did. So she was a very bold person, right?
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And so she was out in front of a lot of people and she was doing,
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she was filming episodes every week and this really bothered her.
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And so the emotional impact of revision surgery, more importantly,
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you have to understand something.
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Your best chance at a surgery is the first chance. The moment you go into a
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second surgery, you have a 50% success rate, 50.
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And the higher the complexity, the lower the success rate becomes. Okay.
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Now I always tell patients, if you're going to revise something,
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make sure it's a small revision.
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Make sure it's a small tweak of a tip or a septal deviation or a small little residual bump.
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But when you get into a major reconstructive revision, like we did with this
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young girl and I prepped her for it, I said, your chances of success are less than 50%.
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And the emotional impact that that particular conversation gives to a patient is scary.
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Because now all of a sudden they're saying, hold on a second.
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The three other revision surgeons, they didn't tell me that.
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They said, yeah, yeah, I'll take your money and I'll fix it.
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And the onus is on us, and I'm speaking to all you facial plastic surgeons who
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watch this, always with revision surgery, under promise, and hopefully over deliver, okay?
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You don't want to tell, you don't want to promise patients anything.
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I don't care how talented and skilled you are, that patient's face is scarred.
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That patient's healing is unpredictable. And you have to assume,
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you can't assume that with a revision surgery, especially one where you think a surgeon did it wrong,
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you can't assume that in this particular case, like this young lady,
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that she had four bad surgeons, right?
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There was something inherently in her that was causing this malcreation of a
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normal aesthetic line to the nose.
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So I prepped her for that. And I said, listen, there is a strong likelihood
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that you're not going to get the result that you're looking for.
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We're going to strive for this and I'll do everything in my power to help you achieve that.
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And so there's a strong emotional like, oh, you know, here I was, I came to see this guy.
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I heard he's great at doing this. This is one of his specialties.
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And again, I do a lot of these revision surgeries, but I'm very upfront with
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people. I'm very honest with them.
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And I always kind of say, hey, listen, we got to go into this with kind of an open mind here.
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And I kind of see that with aging face. I mean, just yesterday,
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two of my facelifts were not, I don't want to call them revision,
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but they'd had facelifts in the past.
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You know, so these patients were coming back and they'd had facelifts with somebody
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else. No, one of them had had a facelift with me about nine years ago.
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The other one had had a facelift with somebody probably 15 years ago.
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And you don't know what you're getting into with that person who's had surgery somewhere else.
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While I may look at the operative notes and kind of get an idea and a picture
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of what I'm to be facing in this revision, it's very challenging because the
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surgeon may say they did one thing, but the way that the body heals is going
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to dictate something else.
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And so we always kind of try to take that into consideration.
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And there are times that I'll look at a revision and not because I'm afraid
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to take it on, but I just don't think the patient is emotionally ready and prepared
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to go through this roller coaster ride again.
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You know, and oftentimes I'll
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tell somebody, listen, why don't we just sit on this for a little while?
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You know, we don't have to jump into this right now. We can keep you at,
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it may not look great, but it's not a deformity.
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You know, if it's a deformity, I understand we need to do something sooner.
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But the fact that it doesn't look great and, you know, not super happy with it.
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You can probably wait. And I'll give you an example, actually,
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that happened today in clinic.
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This girl who I spoke to FaceTime consult, it was about two months ago,
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and she wanted her lower FaceTime.
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But at the same time, she said, or during the consultation, she said,
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you know what, I had a rhinoplasty in the past.
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I can't stand this dip here. I feel like he botched my nose.
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She even told me today that she reached out to the bot show,
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and they said they're not taking any new applications.
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Okay. She told me that today. So she drove all the way from Mobile to,
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for me to look at this area here and potentially fill it with something.
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So, and I had told her during the consultation, I said, listen,
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you can probably do something conservative that will really help you.
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You may not need it. In her head, she had this huge revision surgery already planned out.
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She's telling me all this money that she's saving and all this.
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And I said, why don't you just come see me?
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So she came today and I said, let's just try something.
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She had a dip here. She had a hump here. So I filled in with a little bit of
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a filler called Restylane.
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It's going to last me six months. I get it. I'm not looking for longevity,
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but I'm looking to see if we can get the aesthetics that we're after.
00:17:28.847 --> 00:17:33.227
Guys, I'm not kidding you. I injected a small aliquot of this.
00:17:33.307 --> 00:17:36.107
I massaged it into the area. She starts crying.
00:17:36.687 --> 00:17:39.947
She says, oh my God, I didn't never thought my nose would look like this again.
00:17:39.947 --> 00:17:46.827
And in my head, I'm thinking she worked herself up over something that was a
00:17:46.827 --> 00:17:49.907
10-second fix, you know?
00:17:50.147 --> 00:17:52.767
And so I said, so you like it?
00:17:53.107 --> 00:17:56.627
Oh, my God, I love it. This is exactly how I always wanted my nose to look.
00:17:56.747 --> 00:17:59.727
I said, all right, good. Save yourself a revision surgery.
00:18:00.267 --> 00:18:04.627
And in about six months, we'll come and we'll put something more permanent in here, and you're done.
00:18:04.647 --> 00:18:09.667
And you never have to worry about this again. And it was like this weight had been lifted off of her.
00:18:11.507 --> 00:18:12.387
And that...
00:18:13.130 --> 00:18:22.050
Ladies and gentlemen, all you guys, that is where the honesty and the virtue,
00:18:22.290 --> 00:18:25.430
the surgical virtue has to show up.
00:18:25.550 --> 00:18:28.390
You have to do something that's right for the patient.
00:18:28.630 --> 00:18:33.630
And telling her, oh yeah, you need a revision surgery, it's X thousands of dollars,
00:18:33.910 --> 00:18:36.650
isn't the surgically virtuous thing to do.
00:18:36.650 --> 00:18:45.830
And so I do think that taking into consideration somebody's emotions plays a huge part in this.
00:18:46.010 --> 00:18:51.290
So I think we're, you know, because we've covered a lot of stuff today,
00:18:51.330 --> 00:18:54.790
and this is kind of a deep, more serious podcast.
00:18:56.010 --> 00:19:00.630
And again, I think I've said this before. You go see a surgeon who says that
00:19:00.630 --> 00:19:03.170
they've never had this complication, they've never seen this,
00:19:03.270 --> 00:19:04.210
or they've never seen that.
00:19:04.770 --> 00:19:07.230
Two things are happening. and this is factual.
00:19:07.830 --> 00:19:11.010
They either, they don't have enough experience, which means they haven't done
00:19:11.010 --> 00:19:14.830
enough and they're lying to you. That's a fact.
00:19:15.370 --> 00:19:18.650
And you should ask your surgeon, have you ever had to do any kind of revision
00:19:18.650 --> 00:19:20.150
work in this type of area?
00:19:20.610 --> 00:19:23.950
And I have patients ask me that probably once a week. And I said, yeah.
00:19:24.410 --> 00:19:28.210
In fact, I would be concerned if I went to a surgeon who said,
00:19:28.310 --> 00:19:33.930
no, I've never had revision surgery because it has, yes, surgeons can have good
00:19:33.930 --> 00:19:35.630
and bad days. I get all that.
00:19:36.210 --> 00:19:42.890
But I pretty much do a very similar surgical entry into the face on my procedures.
00:19:43.090 --> 00:19:44.790
Okay. There's not a lot that changes.
00:19:45.270 --> 00:19:51.010
But what I cannot control is the protoplasm or the inner workings of that human.
00:19:51.912 --> 00:19:55.812
I don't know if that human has a collagen problem that they can't heal as well
00:19:55.812 --> 00:19:58.552
as the other one. I don't know if there's a nutritional problem.
00:19:58.712 --> 00:20:02.832
I don't know if they're, you know, vaping and they didn't want to say anything
00:20:02.832 --> 00:20:05.972
or they're drinkers and they didn't want to say anything or they're smokers
00:20:05.972 --> 00:20:07.272
and they didn't want to tell me anything.
00:20:08.092 --> 00:20:15.652
So, no, no, no. And this happens, right? And so then I get faced with the ramifications
00:20:15.652 --> 00:20:18.932
of a lot of these things that I didn't know going into it, right?
00:20:18.932 --> 00:20:23.352
And so as much as we try to ask patients and get all that information up front,
00:20:23.572 --> 00:20:26.132
those are the challenges that I can't see coming.
00:20:26.492 --> 00:20:31.452
And so I think a good take-home point from this is if you're ever faced with
00:20:31.452 --> 00:20:36.392
revision surgery, get your mind out of the finger-pointing game.
00:20:36.632 --> 00:20:40.312
Because all that's going to do is make you angry and keep you up at nighttime.
00:20:40.612 --> 00:20:44.372
And so I tell patients, they come in, they say, well, this doctor did this and that. I said, stop.
00:20:44.712 --> 00:20:47.792
We're not worried about things that happened in the past. The only thing we
00:20:47.792 --> 00:20:53.832
can control is what steps are in front of us and whether we should even consider taking those steps.
00:20:54.192 --> 00:21:01.792
So I'm going to close with, I found a really cool one the other day because
00:21:01.792 --> 00:21:05.252
I found myself telling it to my daughter who just graduated.
00:21:05.852 --> 00:21:13.772
And I said, man, I remember my dad telling me this one. And the idea of plan
00:21:13.772 --> 00:21:19.052
your work in detail and then you work your plan, right?
00:21:19.332 --> 00:21:23.312
And write it out, lay it all out. I think I've mentioned this before.
00:21:23.872 --> 00:21:29.592
When I was 20 years old on a napkin at a bar in Milwaukee, right?
00:21:30.694 --> 00:21:35.114
I wrote down what I wanted 50-year-old Roberto to look like.
00:21:35.254 --> 00:21:37.574
I'm not kidding you. I don't know what I did with that napkin,
00:21:37.594 --> 00:21:40.774
but I kept it for a long time. I moved so many times I probably lost it.
00:21:41.114 --> 00:21:45.314
And I said, all right, this is my goal at 50.
00:21:46.114 --> 00:21:50.954
What do I got to be at 40 in order to jettison me to that 50?
00:21:51.294 --> 00:21:54.574
What do I got to do at 30 to get me to that 40?
00:21:55.054 --> 00:21:59.114
Where do I have to be? What do I have to have accomplished?
00:21:59.114 --> 00:22:01.954
Accomplished and then what do I have to accomplish at
00:22:01.954 --> 00:22:04.734
25 and then 20 and then I even went
00:22:04.734 --> 00:22:07.554
to the micro level of all right what do
00:22:07.554 --> 00:22:10.214
I got to do this semester what do
00:22:10.214 --> 00:22:13.574
I got to do this month what I got to do this week and what do I got to do tomorrow
00:22:13.574 --> 00:22:21.394
and so I reverse engineered my plan now things have changed you know but for
00:22:21.394 --> 00:22:27.174
the most part I can tell you this guys if you in a detailed manner or you plan
00:22:27.174 --> 00:22:29.934
what you want that 50-year-old you to look like,
00:22:30.494 --> 00:22:32.434
and you work that plan back,
00:22:33.254 --> 00:22:35.654
nine times out of 10, you will hit it on the mark.
00:22:36.294 --> 00:22:42.974
So all you parents, pass this one on to your kids. Make them all get a piece of paper.
00:22:43.754 --> 00:22:49.394
And Amelia, that's a good example. We have Amelia in the studio today who's
00:22:49.394 --> 00:22:50.794
Alyssa's beautiful daughter.
00:22:51.354 --> 00:22:52.914
We're going to actually, your
00:22:52.914 --> 00:22:55.714
homework for next week, she's playing with a centipede thing right now.
00:22:56.962 --> 00:23:00.882
Your homework for next week is to give us what you want to look like when you're 25.
00:23:01.302 --> 00:23:05.902
Not look-wise, just what is Amelia going to be at 25?
00:23:06.462 --> 00:23:09.462
And you're going to work it backwards. And we're going to do a little test.
00:23:09.822 --> 00:23:12.382
I'm kidding. We're not going to tell anybody about it. All right,
00:23:12.442 --> 00:23:15.942
guys. Thank you so much. I love you all. This has been a great episode.
00:23:16.482 --> 00:23:20.722
And we've been working through a few glitches on Instagram, I've been told.
00:23:21.602 --> 00:23:25.342
Sound, audio, we got them all figured out. All right? We're newbies at this.
00:23:25.442 --> 00:23:28.842
We're figuring it out. I got the best team in the game working with me.
00:23:28.982 --> 00:23:31.742
So I appreciate the comments of positivity.
00:23:32.142 --> 00:23:35.502
So look forward to seeing you guys next week. And next week,
00:23:35.522 --> 00:23:38.442
we are talking, oh, yeah, this is a good one.
00:23:39.342 --> 00:23:43.382
Kind of gone full circle now. We've started off with what kind of things do
00:23:43.382 --> 00:23:47.182
you need to be, what's bringing you into the consultation?
00:23:47.842 --> 00:23:51.502
What's bringing you to seeking information? We've talked about a lot of these
00:23:51.502 --> 00:23:56.122
things throughout the season. and we're going to close out the season with what
00:23:56.122 --> 00:24:01.042
kind of questions do you now need to ask once you've decided that you want to
00:24:01.042 --> 00:24:02.382
move forward, all right?
00:24:02.462 --> 00:24:05.782
Where does your head need to be and what do we need to start planning?
00:24:05.902 --> 00:24:10.022
And we might actually even touch on what Jackie was saying last week about the
00:24:10.022 --> 00:24:16.042
nutritional plans and what we can do preoperatively and postoperatively.
00:24:16.342 --> 00:24:20.442
So thank you guys very much. Have a wonderful weekend. And remember,
00:24:20.702 --> 00:24:24.302
good decisions come from good information. Have a good day.