Elizabeth (who prefers to use an assumed name) describes her successful search, at age 44, for a more relaxed, youthful look. “The tipping point for me came when I was walking through a department store and caught a reflection of myself in a mirror and saw my grandmother’s face looking back at me,” she recalls.

“For years I tried Botox and every eye cream and every type of concealer there is to soften or reduce the visual impact of the bulging bags under my eyes—with no real success (see photos). Over a ten-year period, these growing bags of fat simply made me look older and tired. And when I looked in a mirror, those bags of fat actually made me feel tired! Clearly, I needed another solution.”

And she found it, thanks to the surgical skills of Dr. Cynthia Gregg, of Cynthia Gregg Face and Body Specialists in Cary. But it was not a simple solution—because Elizabeth has both diabetes and lupus.

“Among the more challenging aspects of my work,” notes Dr. Gregg, “are the risks involved when a patient has an underlying disease, such as diabetes.

“Diabetes patients,” she explains, “have significantly higher risks from surgery because of their high blood sugar levels, especially when the disease is not well controlled. There is an increased risk of infection, slower wound healing, and potential kidney and heart problems. So it is critically important that we evaluate each patient’s case carefully, make sure they are aware of these increased risks, and—most importantly—that we get clearance from the physician helping them manage their diabetes. This really is a team effort.”

Protective Procedures

“Of course we would never ask a patient to do an elective procedure that will affect them in a negative way,” says Dr. Gregg, “so we designed, step by step, exactly how we would proceed to protect Elizabeth’s health. We carefully coordinate a patient’s medicine, whether it be insulin or an oral medication with surgery and intravenous fluids.

“I always ask patients with diabetes to bring their own glucometer with them, to measure their sugar levels, because it’s calibrated to them. We also have a glucometer here and keep dextrose and all emergency supplies we may need. The goal of course is to maintain safe blood sugar levels.

“Elizabeth was highly motivated to do this procedure in a safe way. And we made sure that Elizabeth, like all patients with diabetes, was the first case in the morning.

“In all such cases, we check their glucose level before we begin the procedure, during the surgery, and again in recovery—and if we need to give them anything through their IV to optimize their glucose level, we can do that.

“Elizabeth and I agree that she had a really excellent outcome. Some diabetics are faced with slow wound healing, and an increased susceptibility to infection. We keep these factors in mind when planning and carrying out any surgery.”

Her New Look

“It’s true,” says Elizabeth, “I think I look great. I feel like I have my 30-year-old eyes back. And I don’t look tired, even during times of the day when I actually am tired. My eyelids aren’t as heavy, so my eyes look bigger and brighter.

“One other aspect of this also really impressed me. Dr. Gregg wanted to make sure this entire procedure was a team approach. She asked me to inform my endocrinologist and my rheumatologist about these plans for surgery, and make sure they were in agreement with moving forward. And she also wanted to make sure my blood sugars were in good control prior to the surgery, because diabetics can sometime have an issue with healing—it can be slower and more difficult. So I felt very safe in her hands, physically, aesthetically, surgically, and emotionally.”

Many Diseases Pose Hidden Surgical Risks

Diabetes is just one of many diseases that require special caution for Dr. Gregg. “High blood pressure is an example of a fairly common condition that involves multiple elevated risks,” she says. “There’s an increased risk of bleeding, poor wound healing, and infection. So, for these patients we’ll ask for medical clearance and additional testing before proceeding.

“Another thing we have to pay attention to are the risks that certain medications pose because of their potential interaction with anesthesia. Immunosuppressive medications—such as those used for ulcerative colitis, Crohn’s disease, or rheumatoid arthritis—can pose serious problems, not only for anesthesia, but because of increased bleeding. So, patients need to stop these medications before and after surgery—something that can be difficult because they’re taking them for pain relief. It’s always a process of evaluating such risks and determining the safest path forward.”

Teamwork

Perhaps the most important key to successful surgery for high-risk patients, says Dr. Gregg, is teamwork. “A recent particularly challenging case illustrates this. This patient—who I’ll call Susan—has Von Willebrand’s disease—a genetic bleeding disorder that prevents blood from clotting properly. It’s the most common inherited blood-clotting disorder in humans.

“Susan wanted to do a face lift, which is a little concerning because one of the biggest risks with a face lift in women is a 7 percent chance of a hematoma. Her disease increases that risk significantly. So, typically, I would say no to such a patient.

“But when she came to me, she had done her homework. She had already talked to her doctor—a hematology oncology fellow at Duke—who had agreed to work with her—and me—on this. He had designed a great plan to meet Susan’s very specific needs. Because even though she had a mild form of the disease (she didn’t really know she had it until just several years ago), she still had all those risks. And we had to be very, very careful when we did her surgery.

“Her doctor’s plan was demanding—but very effective. We all had to alter our schedules a little bit, to allow for a special treatment at Duke immediately before the surgery here. But the procedure went well and her recovery has been excellent. So, even in complicated, high-risk situations, it can be possible to have safe, successful surgery. And the team effort is key.”

When Surgery Is Not an Option

Sometimes, acknowledges Dr. Gregg, “the risks in such cases outweigh the benefits of a surgical procedure. It means adding the trauma of surgery to a body already struggling with a serious disease. In those instances, we’ll say ‘no’ to surgery. Happily, there are many anti-aging options that do not require surgery.

“The advances in non-surgical cosmetic treatments and therapies are extraordinary,” says Dr. Gregg. “And we offer what I like to call a rich ‘buffet’ of options. There are multiple layers. We start on the outside, with highest quality skin care. Then, there are many tools—including microneedling, laser resurfacing, chemical peels—to improve your skin’s quality, texture, appearance. Botox and fillers offer excellent options to reduce wrinkles and replace volume. Many, many options!”