Impact of Decision Processes and Surgical Planning

Chapter 7 details principles and methodologies that optimize surgical planning. Surgical planning and the decision process define and limit the potential success of every surgical maneuver. Every suboptimal or unnecessary surgical maneuver increases bleeding and tissue trauma, increases operative time and costs, increases medication doses intraoperatively, decreases the predictability of the outcome, and increases risks of complications and reoperations. The key for surgeons is to identify and optimize surgical maneuvers that are proved to impact outcomes, and eliminate all maneuvers, techniques, and adjuncts that are unnecessary and unproductive.

Surgical planning and the decision process define and limit the potential success of every surgical maneuver

Unnecessary and unproductive surgical maneuvers are not harmless, and while many alternative techniques allow surgeons to perform breast augmentation many different ways, defined sets of proved processes and techniques deliver optimal recovery and outcomes. Surgeons’ willingness to continually reevaluate established practices, implement proved processes, and eliminate unnecessary and unproductive practices determines patient recovery, outcomes, and reoperation rates.

Every decision that a surgeon can make before entering the operating room positively impacts potential patient recovery and outcome

Every decision that a surgeon can make before entering the operating room positively impacts potential patient recovery and outcome. With current proved processes for operative planning and implant selection that are peer reviewed and published in the plastic surgery literature, operating times for an uncomplicated, primary breast augmentation should not exceed 45 minutes. The cost of making decisions in the operating room, especially decisions that could be made preoperatively, is substantial. Unnecessarily prolonging operative times may seem inconsequential to some surgeons, but lack of optimal planning and inefficiency during surgery are not inconsequential to patients who experience increased costs, increased doses of anesthetic and narcotic medications, and prolonged recovery with unnecessary morbidity.

Currently available systems and decision processes for preoperative implant selection ^3,⁵ eliminate any need for sizer implants in routine primary augmentation, and reduce or eliminate the costly practice of surgeons ordering multiple sizes of implants for every breast augmentation

Some of the most inefficient, time wasting practices intraoperatively relate to implant selection and the use of intraoperative sizer implants. Currently available systems and decision processes for preoperative implant selection ^3,⁵ eliminate any need for sizer implants in routine primary augmentation, and reduce or eliminate the costly practice of surgeons ordering multiple sizes of implants for every breast augmentation. In addition to unnecessarily increasing operative times and costs, routine use of sizer implants increases risks of pocket contamination, may increase tissue trauma and bleeding, and has no proved necessity or efficacy in valid scientific studies.

Virtually every decision that a surgeon makes looking at photographs in the operating room could have been made preoperatively and recorded on the operative planning form, increasing efficiency and accuracy

Operative planning is most productive and least prone to errors of omission when surgeons complete defined forms ^3,⁵ that record objective measurement data and record decisions and operative plans, and then have these forms available in the operating room for every breast augmentation. Having standardized, preoperative photographs in the operating room is also helpful, but virtually every decision that a surgeon makes looking at photographs in the operating room could have been made preoperatively and recorded on the operative planning form, increasing efficiency and accuracy.

Direct Vision Access and Pocket Dissection Techniques

Blunt and blind (no direct vision inside the pocket) dissection techniques unquestionably increase tissue trauma and bleeding and decrease the accuracy of pocket dissection compared to techniques that perform pocket dissection under direct vision, with or without endoscopic assistance. While blunt dissection and blunt, blind dissection techniques remain in common use, no peer reviewed and published studies and no live surgery demonstrations have ever documented equivalent patient recovery and outcomes compared to more controlled, accurate, and efficient direct vision techniques.^1,^2,^6,⁷

Inframammary and periareolar incision approaches allow surgeons to perform all areas of pocket dissection under direct vision control, but some surgeons continue to use digital or blunt instrument dissection techniques, citing the speed and efficiency of blunt dissection techniques. In reality, blunt dissection techniques cannot compare with optimal electrocautery dissection techniques with respect to efficiency, because the former produces bleeding which the surgeon must control, while the latter prevents bleeding before it occurs and routinely allows surgeons to develop an entire pocket via the inframammary approach in less than 4 minutes.^2,^4,⁷ The author’s experience with blunt dissection for axillary augmentation⁸ and subsequent experience with optimal electrocautery dissection techniques^2,⁹ has produced conclusive evidence that blunt dissection techniques are more inefficient, prolong operating times, and significantly increase morbidity and prolong recovery compared to direct vision, electrocautery techniques.

Current endoscopic instrumentation enables surgeons to perform all areas of pocket dissection in axillary augmentation under direct vision control. For optimal recovery and outcomes, surgeons should avoid any blunt dissection whatever in axillary augmentation, and use optimal endoscopic instrumentation ⁹ to optimize control, minimize tissue trauma, and minimize bleeding.

For optimal recovery and outcomes, surgeons should avoid any blunt dissection whatever in axillary augmentation, and use optimal endoscopic instrumentation ⁹ to optimize control, minimize tissue trauma, and minimize bleeding

Despite claims by its proponents that the umbilical approach for augmentation provides equivalent outcomes to direct vision approaches, current descriptions of surgical techniques for the umbilical approach do not allow surgeons direct vision control inside the pocket during pocket dissection. Dissection techniques are blunt and blind, and recovery data are not equivalent to techniques that use direct vision techniques.^2,^7,⁹

Incision Length

“Short scar” is a highly marketable term in breast augmentation, but certain facts are inarguable: a smaller incision decreases a surgeon’s field of vision, makes many surgical maneuvers more difficult, and subjects prefilled implants to greater stresses during implant insertion. Obviously, no surgeon wants to create excessively long scars, but optimizing accuracy and minimizing damage to prefilled implants requires that surgeons prioritize adequate incision length over bragging rights and marketing concerns.

With inflatable implants, surgeons can reasonably limit incision length to 3.5 cm. Incisions less than 3.5 cm are largely illogical, even using endoscopic instrumentation, because shorter incisions increase risks of wound edge trauma, and compromised scars.

With state-of-the-art form stable, silicone gel implants such as the Allergan Style 410, incision lengths should be longer to facilitate exposure and implant insertion while avoiding damage to the implant. Implant dimensions and volume determine optimal decisions of incision length for form stable implants. When planning incision length for the form stable Allergan Style 410, to minimize risks of device damage and reoperations,⁴ surgeons should plan a minimum incision length of 5.0–5.5 cm for Style 410 implants less than 300 grams, and 6.0–6.5 cm for implants larger than 300 grams. These guidelines afforded a level of patient satisfaction and device safety that defined a zero percent reoperation rate in a consecutive premarket approval (PMA) series.

Surgical Instrumentation

Inframammary and periareolar approaches for breast augmentation are optimized by specific instrumentation that can improve efficiency and accuracy while decreasing tissue trauma. The author’s breast instrument set (Figure 10-1) includes instruments for augmentation and all other types of breast surgery. Instruments in the set are listed in Table 10-1. Instruments in the set are designed or modified from other designs to optimize efficiency and accuracy. A limited number of these instruments are required to perform augmentation via the three main incision approaches, and the specific use of each instrument is detailed in respective chapters that address each incision approach.