8. AVOIDING COMPLICATIONS

 Of the eight common complications discussed in Chapter 3, the avoidance of infection, hematoma, noticeable scars, asymmetry, numbness, deflation with saline, steroid atrophy, and implant rupture are fairly straightforward.

Avoidance of capsular contracture, the most common complication, warrants further discussion. If there were one simple solution to this question, we would all use it and there would no longer be a problem. The most important single fact to remember regarding this problem is that the severity is rarely symmetrical and breasts with capsule contracture are frequently only on one side.

When the problem is on both sides, one side is usually worse than the other.  Therefore, all theories of explanation of capsule contracture need include an explanation of this fact. It is not necessary to know the cause to avoid or to treat the problem, however.  Factors that will theoretically help to avoid capsule contracture are:

              1.  The type of implant used.

              2.  Subpectoral placement.

              3.  Avoidance of blood clots.

              4.  Avoidance of infection.

              5.  Exercises or pressure on the implants.

              6.  Steroids.

              7.  Avoiding tissue irritants and foreign bodies.

              8.  Creating a large pocket for smooth implants.

              9.  Textured implants. 

              10. Massage of smooth implants (used to be routine - not recommended anymore).

              11. Avoidance of operating on lactating breasts.

Of these factors, the type of implants, steroids, and subpectoral placement are discussed elsewhere. Here we will discuss the reasons and methods of avoidance of blood clots, infection, tissue irritants and foreign bodies and the purpose and technique of creating a large pocket and of postoperative exercises and massage of the implants. It is the universal observation of all who do this surgery that if there is a hematoma on one side, then that side will develop a capsule.

If the hematoma is not thoroughly and completely removed, the capsule will be quite firm, and if it is completely removed, the capsule may not develop. Therefore, we try to achieve meticulous hemostasis, not only to prevent hematoma, but also to prevent capsules.

Studies have shown that small blood clots occur very frequently around the implants, and that they are always unequal in size on the two sides. Since hematomas cause capsules, it is logical to place small suction drains in each patient to help prevent capsules, and some of our faculty do use drains for from three to five days in almost every case.

These suction drains are very small in diameter and can be used without producing any noticeable scar. A higher incidence of infection because of the drains has not occurred, and after four or more years experience with them in hundreds of patients, few continue to use and advocate them. They slightly add to the trouble and expense, but some are convinced that they reduce the incidence of capsules (although not nearly as much as textured implants do).

One study several years ago indicated a high incidence of Staph epidermidis from the cultures of breast capsules of patients undergoing open capsulotomy. This is normally a non-pathogenic organism, and present on the skin of everyone, so we can assume it is most likely a contaminant and not a known cause of wound infection.

To suppose that this bacterium just sits there around an implant causing a capsule two years or more after the surgery seems a bit incredible and has not been substantiated as a reliable finding. So unfortunately, it was probably a contaminant, and yet of course we must not allow any bacterial infection to occur around implants.

It is probably an organism that is in almost all breast ducts, especially after pregnancy. The implants are going to be in contact with breast tissue, no matter which incision and whether or not they are subpectoral. Therefore, they can get Staph epidermis from the breast tissue, which is a skin gland communicating to the skin. This may happen with the slightest trauma or during the normal pressure of sleep.

This can happen on one side as capsules usually do. But there is no antibiotic or prophylaxis that will prevent this two or more years later after surgery. Many cases of capsules begin as late as 5 to 20 years after surgery. No antibiotic irrigation at the time of surgery is going to have any effect on this. And even without the Staph epidermidis theory, pressure on the female breast can produce some milk-like material from the nipple even when pregnancy is years remote. And this milk alone, even if it were sterile around the foreign body - the breast implant - is enough to provoke a foreign body reaction and a capsule contracture.

Many surgeons irrigate with an antibiotic solution, and most give prophylactic antibiotics that would prevent skin type of wound infection as would be caused by Strep or Staph, such as an anti-staphylococcal penicillin, erythromycin or a cephalosporin.

Another universal observation is that dacron patches (fixation patches), cause capsules. Any foreign body, that causes tissue reaction can logically be expected to cause scar and  capsule formation, just as blood clots do.

 Also try to avoid cautery. To stop bleeding, cautery produces a third degree burn.  This causes scar, and the dead burned tissue acts as a foreign body.

We wash off all the prep solution, betadine or phisohex, because these are tissue irritants, and will cause reaction and scar leading to capsules. Also we avoid cotton and synthetic sponges that leave lint on the tissues around the implants, because this is very irritating to tissues. So my rule is never to put a sponge or lap sponge in the pocket. Hence the suction cautery may be useful. No sponge, just suction.

The purpose of creating a larger pocket superiorly and laterally more than absolutely necessary to get the implant into the correct position is based on the observation that capsule is the contraction of the pocket, and that if we have a large pocket to begin with, and use the implant as an obturator to keep the pocket distended, so that it will not contract, then a capsule contracture cannot form. This is only useful for smooth, and not textured, implants. Smooth ones can move in the pocket, but textured will not and remain fixed.

The idea of the exercises and massage is based on the observation that closed capsulotomy will work, and breaking the capsule with pressure will soften about two thirds of the patients with capsule problems. We don't recommend it anymore. The saline may deflate.

Many patients will tell you that they have been putting pressure on their implants, or their male friend gave them a firm hug, and they heard or felt a tearing sound on the firmer side, and it became soft again. This observation by a patient led to the closed capsulotomy in the first place.  Therefore most physicians would tell their patients that they must press firmly on the implants, daily for several years with the gel implants. No more. 

Fortunately for the surgeon, this finding that the patient should perform these pressure exercises on their breasts gave the patient some if not almost all the responsibility for prevention of the capsule problem. When the problem develops, very rarely can the patient honestly say that throughout the time when all was well, she regularly and vigorously followed the surgeon's instructions. Also, remember the Stay- Soft breast pressure device of just a few years ago.

 9. MANAGEMENT OF HEMATOMA

Whenever a patient reports in the immediate post-operative period, that one side is larger, more tender, distended and tense, a hematoma on that side is suspected. The patient is seen at the earliest convenient time, which may be determined by how much pain the patient is having, how concerned the surgeon is based on how much dissection was done, and how thin the skin is over the breast implant.

There are small hematomas and large hematomas with a lot of discomfort and pain due to pressure and tension. Whether large or small, there should be no danger of excessive blood loss since the bleeding is in a closed subcutaneous space. If there is undue tension, a peeling of the skin can occur, and there could conceivably be skin necrosis that could result in scarring and temporary removal of an exposed implant.

This can be avoided by early removal of the implant and the hematoma and replacing it at the time under sterile conditions.  Much less anesthesia and sedation will be required to remove the implant and the hematoma than was needed to do the surgery, because the dissection has already been done. It is my preference to do this under the same sterile conditions, with all the equipment the operation was done originally, and to remove the implant, remove the blood clot,  rinse the pocket with dilute hydrogen peroxide and antibiotic solution, control any bleeding, replace the implant and leave in  a suction drain, if there is any doubt about hemostasis. 

So to me a post op patient with one side larger than the other is one I want to see right now. The swollen side is more tender.

Normally the implants above the muscle transilluminate very well. The hematoma side, if it is blood, will not let light through. Just an ordinary flashlight in a dark room is all that is needed to test for transillumination. This is only a little less helpful if the implants are under the muscle. The muscle prevents the light going through. Some difference may still be seen with a significant hematoma.

As with most conditions, hematomas occur in degrees of severity. In every case there is some bloody fluid around the implant. But in most I would not expect a clot of more than 5 cc in size. When we had drains in place, the bloody fluid was not really a clot or a hematoma.

But the large hematoma that is rapidly expanding can fill up the breast with more the 500cc of clotted blood and can subject the skin to the possibility of necrosis. This is rare but a true emergency.

The usual hematoma is moderate, one hundred to three hundred ccs. And it requires removal. If ever you see a patient who has a hematoma of any significance that is not removed, you are talking the worlds hardest breast, hard like a rock. If you operate on it later, you will find a semilunar thick band of dense fibrous tissue 1 - 2 cm thick where the hematoma was lying and fibrosed.

It seems more trouble to go to the operating room again, but in the long run it is not. It is more trouble for you and the patient if you don't. Let's say you drain it instead. You put on some gloves, hurt her with the local anesthetic, hurt her opening the incision, and suction out blood and put in a penrose drain. You don't have a patient anymore. You have an enemy.

This drain is placed under local in the office without going to surgery, and this alternative results in having a bloody drain in her chest that does not get all the blood out, possibly leads to infection and loss of the implant and will continue to drain for 7 - 14 days. Plus you didn't relieve her pain or her concern.

Have you ever had a subungual hematoma from closing a car door on a finger or thumb or a hammer blow? I have. I couldn't sleep at night. So I have always had to drill or burn a hole in my nail to drain it. That's a lot of trouble and I wouldn't do it if the pain were tolerable. Multiply that pain by 100 and throw in the worry, the normal post op depression that accompanies cosmetic surgery, and the lack of support and sympathy our patients get.

This completely incapacitates the patient for that time. She not only can't go to work easily and can't drive about, but she also can't sleep at night, and can't even have a decent shower and shampoo.

While draining, sore, swollen and worried, she is uncomfortable and will be thinking of this messy draining problem every minute of every day. What she can do and will do is go to another doctor. And she will cry. You will lose the patient. She may lose the implant and have pictures taken that show her all lopsided and deformed.

She will go to a lawyer. And again she will cry.  And he will own this case on the contingency agreement he has with her. It may be the biggest case ever of his entire career. Don't kid yourself that you can just offer her a refund. He will want every dime you have ever earned and ever will earn over and above whatever piddly insurance you might have. And he may try to get your license as well as your past and future assets.

To avoid this very serious scenario, I would not let a person with a hematoma leave my sight until the hematoma is removed and she is closed up, pain free and back to normal. Not out of my sight. I wouldn't let her go home with a hematoma.

So I might not call out my assistants to open the breast after midnight, but then again I might if the patient were in a lot of pain or anxious or otherwise very inconvenienced by this, because you are going to have to do it anyhow. The earlier, the better. I wouldn't wait over the whole weekend and have the patient uncomfortable all that time. For as soon as that clot is out, the problem is over with.

The implant can remain in position or be removed and replaced if this is easily done. The larger the suction and more blunt the tip, like a 6 or 8 mm liposuction would be great. You want to be sure all the clot is out. A 2 mm is about too small but anything larger would do. Even the Yankauer suction with the tip removed. But the edges are a bit sharp. Or a larger nasal suction might do it. The lipo cannula is especially useful through the axilla.

However it is done and whether or not the implant is removed, all the blood must be removed, the bleeding must have stopped, and the irrigation return must be clear.

A pressure dressing is not necessary except for support and is applied as usual. The alternative of simply draining the hematoma through a small incision under local anesthesia is also all right, but the drainage of clot will probably continue for seven to ten days and can be a mess, and could lead to infection, which takes us to the next topic below.

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