Friday, January 2, 2009

The Implications of Herbal Medications on Plastic Surgery


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A majority of otherwise healthy individuals currently are regularly taking herbal medications. This may be with multivitamins and or the usual heart or blood pressure etc medications. I myself regularly take glucoseamine and multivitamins. Although many associate these herbs with being more natural with less side effects than pharmaceutically manufactured prescription medications that is not actually true. Especially in the high doses frequently taken these herbs can thin the blood preventing clotting, prevent healing after surgery, have dangerous interactions with medications given at surgery etc. I have personally had to cancel surgery in the middle of an operation because of bleeding that could not be stopped because the patient took goldenseal or high doses of vitamin E within a few days of surgery without telling me. Vitamin E especially in high doses dramatically thins the blood.

Here is a list of commonly used herbal medications and their associated problems:



Garlic
This common herb reduces atherosclerosis and blood pressure through its anticholesterolemic and blood vessel dilating effects. However, its active ingredient, allicin, prevents platelet aggregation and increases the risk of bleeding during and after surgery. A case of spontaneously bleeding in the brain from garlic use has been reported.

Gingko
This popular herb is taken for dizziness, pain on walking due to peripheral vascular disease, sexual dysfunction, dementia and memory improvement/loss. Gingko prevents platelet activation which increases the risk of bleeding during and after surgery. There have been reports of spontaneous bleeding in the eyeball and the brain caused by its use.

Ginseng
Popular in Asia, this herb has been used to treat stress and imbue virility. Ginsenosides block platelet aggregation and prolong blood coagulation time. High blood pressure, vomiting, nose bleeds, and Stevens-Johnson syndrome have also been documented with this herb. Finally, ginseng has the potential to cause low blood sugar and should be avoided in diabetics. This can be especially problematic in surgery patients who routinely do not eat for many hours before surgery. potentially leading to labile glucose levels intraoperatively, especially because preoperative patients have been fasting. Ginseng has been ascribed responsibility for one death when it was combined with ma huang. I had a patient who developed hematomas (collections of blood under the skin) because of ginseng use around the time of surgery that I was not informed about.

Ginger
This fragrant herb has been prescribed for dizziness, motion sickness, nausea, and vomiting associated with pregnancy. It can increase the time it takes for blood to clot after a cut.

Feverfew
Used to treat migraine headaches, feverfew acts to inhibit serotonin release and inhibit prostaglandin production. It also hampers blood coagulation. Feverfew may induce withdrawal symptoms if abruptly discontinued. These symptoms consist of nervousness, tension, headaches, insomnia, stiffness, joint pain, and tiredness. The amount taken needs to be slowly tapered down prior to surgery in order to avoid withdrawal symptoms.

Kava
This diverse herb, made from the plant Piper methysticum, has been used as to treat anxiety, for gonorrhea treatment, and for certain skin disorders. It depresses the central nervous system and increases the effect of medications given during surgery such as valium or versed. It also can cause blood vessel dilation with decreased heart function leading to low blood pressure.

St. John's Wort
This ubiquitous herb is also known as hypericum perforatum and is used to treat mild to major depression, anxiety, and sleep disorders. Its action on nerves increases the effect of local anesthetics and medicines given to relax a patient at surgery. It also increases the metabolism of prescribed medications including blood thinners, anti-rejection medications for transplant patients, calcium channel blockers used for high blood pressure and the heart medication digoxin so the blood levels decrease and the medications become less effective at their usual doses. It can result in skin photosensitivity which is particularly problematic in patients undergoing laser treatments of the skin.

Valerian
This herb acts as a sedative and is used as a sleep aid. It increases the effects of sedatives administered during anesthesia and its withdrawal may increase anesthesia requirements.

Ephedra
Also known as ma huang in China, ephedra is used to treat flu, colds, bronchitis, low blood pressure, and respiratory ailments such as asthma. This drug has become increasingly popular among cosmetic surgery patients; one study identified 18 percent of cosmetic patients as taking this herb. It contains ephedrine, pseudoephedrine, and methylephedrine, and causes an increase in blood pressure and heart rate. Ma huang can lead to stroke, seizures and heart attacks if given with certain anesthesia medications. Multiple fatalities with this drug have been documented.

Echinacea
These herbs are members of the daisy family and may be used to increase energy and activity in patients suffering from arthritis. Many people take it to prevent or treat colds as there is some belief that it stimulates the immune system. There is a documented case of allergic reaction when combined with general anesthesia. It decreases the effectiveness of immunosuppressants. Finally, liver toxicity is a possibility if combined with other anesthetic agents.

Dong Quai
Dong quai is prescribed for menopausal or menstrual complaints. It contains Coumadin (a commonly used blood thinner) derivatives, which work against vitamin K. The risk of bleeding with this is quite high.


Licorice Root
Popular for heart and gastrointestinal problems, licorice root may lead to high blood pressure, salt retention, low blood potassium, and generalized swelling. It disrupts the body hormone responses to stress with possible adverse consequences after major surgery particularly if there is a complication.


Mafesian
An analgesic for joint pains and arthritis, mafesian binds to sodium channels in nerves and leads to continued nerve excitation. This in turn leads to abnormal heart beats and compromised breathing, which may be made even worse by the stress of surgery and anesthesia.

Goldenseal
This herb is a laxative used in patients suffering from constipation. As such, it may cause blood chemical imbalances and should be discontinued before surgery along with other laxatives. Blood tests should be obtained 2 to 3 weeks after these drugs are stopped to verify normal blood electrolyte levels before any surgery is performed.

Milk Thistle
This medication is thought to protect the liver, modulate the immune system, and be an antioxidant. Cirrhotics and patients suffering from gallbladder disease or hepatitis have embraced this alternative medication for relief. The active agent is silymarin and it is thought to reduce insulin resistance and lower cholesterol. However, similar to goldenseal, a laxative effect has been reported, which can disrupt blood electrolyte levels. There are also reported headaches, which can increase nausea and vomiting after surgery.

The take home message is when you talk to your doctor before any type of surgery, cosmetic or otherwise, make sure you tell him or her every medicine you take including all vitamins and any herbal medications. The best advice is to stop all medications including herbal ones unless they are required heart, blood pressure etc medications at least 10 to 14 days before any surgery. In some cases you will be told to not take anything by mouth after the midnight before surgery except your blood pressure medicine the morning of surgery. It is vital that you follow these instructions to minimize the risk of complications and maximize the chance of a good result.


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