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4. Outpatient Center or Office setting

Whether or not the surgeon or the patient chooses the hospital or the office depends on factors of safety, health, costs, opinions, and prejudices too numerous to thoroughly discuss. Just as good a result may be obtained with either location, but for the surgeon who is not accustomed to giving local anesthesia for various procedures in an office surgery suite, setting up an office operating room for breast procedures alone is not practical.

 This operation lends itself well to either local or general anesthesia, and the most important consideration is the safety of the patient, then the patientís comfort, and finally, the overall quality of care and result that will be obtained in each different setting. This may depend on the location the surgeon usually uses.

 

5. General or local anesthesia

  While this decision will depend mostly on the surgeon's desires, the patient at times may have a real preference. Hardly ever though, is the patient willing to forego safety or suffer the pain of an inadequate local anesthetic to save a few dollars.  Unless the surgeon is practiced and confident in providing safe and adequate local anesthesia, the general anesthetic may be the best choice. The surgery can still be done as an outpatient and as an office procedure in the fully equipped office surgery suite.

 

 6. Subpectoral or subglandular

Whether or not the implants will be placed beneath the pectoral muscles or between the muscle and the breast tissue is almost always going to be determined by the surgeonís recommendation. However, we discuss this with our patients and try to fully inform them of the reasons for our preference in their particular case. These reasons will be more fully described in chapter seven.

 

B. COMPLICATIONS

 

  The next point of information we supply our patients is a brief explanation of the common standard complications with the approximate following rates of occurrence:

 

          1.             Infection                                                                                      1%

          2.             Hematoma                                                                                   4%

          3.             Noticeable scars                                                                         10%  

          4.             Asymmetry                                                                                 10%

          5.             Numbness                                                                                   10%            

          6.             Deflation with saline                                                                     30%

          7.             Excessive firmness                                                                       50% 

          8.             Steroid atrophy, implant rupture, pneumothorax, seroma                   2%

          9.             Shape problems, position, double fold, synmastia                           10%

          10.           Blue window, extrusion                                                                    1%

          11.           Palpability and immobility                                                                20%

          12.           Rippling                                                                                          50%

 

These complications are explained and mentioned in the written consent forms the patient is asked to sign before surgery, copies of which are in your workbook.

 

1. Infection, 1 %

Actually, in more than 500 consecutive operations performed on an outpatient basis in an office surgery suite, there have been only three post-operative infections from the surgical procedure in the immediate post-operative period.

Still, it is a very good idea to have the patient understand what happens with an infection, because it can happen anytime and is not necessarily within the control of the doctor, especially when the operation is performed in a hospital. Some of the infections can occur later (perhaps years after surgery), and could be related to trauma or minor injuries such as a scratch. Such trauma can induce infection, beginning in the skin of the chest and spreading into the breast.

Other infections have been related to hospital-performed surgery or surgery in the presence of previous silicone injections, or with silicone extravasated into the tissues from a ruptured implant. Also, primary breast infection or mastitis (which may or not be related to nursing, but frequently is), may occur.

At times a breast implant begins to extrude years after surgery due to a possible foreign body type reaction or apparent indolent chronic infection around the implant. Whenever there is infection around a breast implant, it is best to remove the implant, and leave it out until all the infection is completely gone and the tissues are soft and pliable again.

This would take a minimum of three months for most cases, and six months or more when there is induration, gross pus, resistant organisms or an otherwise bad or difficult infection. The patient with an infection finds this very hard to accept, especially when there had been no warning that this was a possibility.

The idea of having only one implant in place for six months or so is not appealing to the person who was so motivated to look better as to voluntarily under go this surgery. Generally once it is determined that an infection exists around the implant, it is best not to temporize and give antibiotics to delay the inevitable.

While it is not impossible that antibiotics will allow the implant to remain and not be removed, the chances of this are very small, somewhere in the range of less than 1%. And while the weeks go by and the swelling, redness and pain return every time the antibiotics are stopped, and the expense and complications of taking the antibiotics are taking their toll, the patient may become more and more depressed, anxious and angry.

Not only is the unhappy prospect of having the implant removed looming in the future, but the presence of the persistent infection is ever-present. This is an uncomfortable illness, with tenderness and redness and perhaps fever and fatigue. If the implant is doomed to be removed, then this discomfort and illness is unnecessary and should be avoided by early removal of the implant.

It is better to do what is needed quickly and forthrightly, and then by the time the patient on antibiotics would be getting depressed and angry over the prospect of losing the implant while having been on antibiotics for about six weeks, the patient who has been without an implant all that time is already well and free of pain and swelling and is scheduling the date to have herself restored with a new implant.

Patients tend to be more accepting of this scenario when they are forewarned of this possibility, and the patient who is treated decisively tends to have more confidence in her treatment and is more likely to remain with the same surgeon.

 

 

2. Hematoma, 5%

Hematomas occur fairly frequently. They are said to occur more often in redheads, patients who have taken aspirin, ibuprofen, vitamin E or estrogens, and in those patients with elevated blood pressure.

Other causes are coagulopathies, and excessive heat or exertion after surgery. It can be explained to the patient that this is a result of a blood clot around the implant due to a broken blood vessel usually within the first three weeks after surgery.

The patient may also be reassured that this is not life threatening, either from the blood clot going to the lungs as an embolus or from blood loss, since it occurs within a closed space. If hematoma occurs, the patient will notice swelling of one side, with pain, tenderness, firmness and bruising or discoloration.

Small clots occur without any of these signs. Sometimes the normal side without the hematoma will transilluminate much more than the side with the hematoma, distinguishing the clot from a seroma or fluid around the implant. The patient with these signs is seen, either within a few hours or within a day, or as soon as possible, depending on the level of discomfort. For one breast to have more bruising or discoloration and more swelling than the other is expected and normal.

The patient who will need evacuation of a hematoma will usually be moderately or very uncomfortable with a hard swollen breast on one side. As soon as it is determined that a significant hematoma (in my opinion, any of a size to reduce transillumination and cause symptoms) exists, it is either drained or the implant is removed under sterile conditions, with eradication of the hematoma and implant replacement.

If the hematoma is drained, it will not all come out. A drain will probably be left in place for a number of days, requiring the patient to stay home or wear sterile pads in her bra to collect the drainage for up to a week. And still with drainage, some may remain behind to cause capsule contracture. Another consideration is that while it is draining, infection is always a possibility, which could lead to removal of the implant for months.

If the patient, when seen, can wait until the next morning (which usually only requires reassurance and adequate pain and anxiety relief), the implant can be removed under sterile conditions in the operating room.

The hematoma is completely removed. The pocket is flushed with dilute peroxide, which can eliminate some of the discoloration, and the implant is replaced and the crisis is over. The patient is recovered in a few hours, and can return to usual activities the next day with little bother and no mess.

 

3. Noticeable Scars, 10 %

Someday one of our patients is going to have a hypertrophic or keloid scar that is quite noticeable and troublesome. Others will be self conscious of scars that may be almost imperceptible. The location of the incision is important in preventing scar formation.

The areola skin is much less likely to have a hypertrophic scar or keloid than the peri-areolar skin. The axillary incision is the most hidden, and it too seems much less likely to form a thick scar than the infra-mammary incision.

In a patient who is not known to heal without visible scar formation from other surgeries that have been done on them, the inframammary or periareolar sites can give very unattractive results. Sometimes a single revision can make a lot of improvement, and in other instances, the scars persist and are troublesome.

Scars of the areolae that are lighter in color than the color of the areola can be tattooed to match, and this works well, especially in the person who persists in forming a white line in the areola in spite of the most carefully performed revision.

Only a few patients will need revision. The incidence of 10% is arbitrarily chosen to include patients with almost invisible scars who still feel they are noticeable. Actually 100 % have scars, and whether or not they are noticeable is a matter of opinion.

 

4. Asymmetry, 10%

As with scars, all breasts are to some extent unlike. It can be mentioned that God made no two snowflakes, grains of sand or anything else we can see alike. Whether or not there is significant asymmetry is a matter of opinion.

It is advisable to mention this possibility to patients prior to surgery, pointing out asymmetries that already exist. We try to make the breasts more symmetrical with the operation. The one factor that can be controlled is volume.

We can use implants of different volumes to help correct asymmetries in size. Another factor is the position and shape of the infra-mammary fold that can be made more equal when indicated, and this may help the appearance quite a bit.

Factors that cannot be controlled with augmentation alone and would require other surgery are the size and position of the areola, the protrusion of the nipples, pigmentation, shape, and many other inequalities and asymmetries.

One of the best ways patients with a certain shape can tell what kind of result they are most likely to have is to see before and after photographs of patients who have a shape similar to theirs before surgery.

 

5. Numbness, 10 %

Many surgeons will say they have no problems with numbness, and this is partly because the surgeon cannot feel it and he is unaware of it. It is not the surgeon's personal problem, and yet it may be a patient's problem. All patients have a little bit of numbness with almost any surgery when there is an incision.

With augmentation mammoplasty the most common numbness occurs in the lower half of the breast inferior to the areola, especially when there was not much breast tissue to begin with and the infra-mammary fold is lowered, or if a large implant is used.

This mostly goes away and doesn't bother many patients. Numbness of the nipples does bother some patients, and occasionally the sensation of the nipples is very important to the patient, and they need to know there is a risk it may be reduced, or even absent (though rarely).

The nerve to the nipple primarily comes from the fourth intercostals nerve, and should be preserved if at all possible. In testing patients who have noticed some numbness (and I often ask), I cannot remember ever seeing complete anesthesia when a pinprick of the areola is given. Probably the trans-axillary sub-pectoral and the umbilical approach cause the least numbness, and the other sub-pectoral approaches may result in less numbness than pre-pectoral. However, numbness occurs with the subpectoral approaches too.

The areola incision itself does not increase the incidence of the complaint, and need not be avoided for that reason. Most sensation returns in one year, and may continue to return for up to two years, and the patient with early numbness should be reassured.

 

6. Deflation with saline implants, 30 %

While the incidence is not exactly known, the deflation rate with saline implants is so high that in spite of the other advantages of their use (i.e. no gel bleed, softer than gel, lower capsule contracture rate), they are seldom used. Even with combination implants, when the saline makes up more than 10 % of the volume, a unilateral deflation usually means another operation.

Probably the pre-filled saline implants with no valve will have less of a deflation rate.

 

7. Excessive firmness, 30 %

Capsular contracture is the major complication of breast augmentation with a wide range of incidence reported. The most widely quoted classification of grades of firmness is from Baker (P&R Surg Vol. 65, No. 1, Jan 1980). The incidence in Baker's series of grades II to IV was 27% or more (especially since there was not a long follow-up period recorded and the fact that sometimes capsules do not appear for 2 years post-surgery).

This was in spite of up to 40 mg of Kenalog instilled into the pocket of each side, antibiotics, etc. The prevention and treatment will be more thoroughly discussed elsewhere.

What the patient needs to know is her chances of having this problem, what can be done for it, and what it will cost. I show the patients an article by dear Abby that quotes a 50 % incidence of hard breast implants, and the case of one patient who had the implants removed in disgust because of the hardness.

My patients are assured that if they ever want the implants removed, I will do it for them at very low cost to them. To my best knowledge, in spite of the hardness problem, all my patients still had them in, and had elected to keep them even though there had been some problems.

This was true until 1992 with the FDA saline scare. Since then, four have had the implants out and not replaced.

The reason I offer to remove them at very low cost is that I don't want them to have to go somewhere else to have it done. I want to follow the patients with breast implants and keep in contact with them, especially those who have had some complication or who are in some way displeased with the results.

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The American Society of Cosmetic Breast Surgery 2017    Last modified: June 23, 2017