The Role of Patient Education in Managing Postoperative Challenges

Management of postoperative problems and complications begins preoperatively with patient education. When problems occur postoperatively and require reoperations, patients frequently question the causes of the problems and ask “Why me?” and “Whose fault is this?” When patients are thoroughly informed preoperatively of mechanisms and potential problems that neither surgeon nor patient can control, surgeons can address postoperative issues more effectively and efficiently. Patients are less prone to focus on unanswerable questions such as “Why me” and are less prone to assign blame for untoward events.

During the preoperative patient education process, surgeons should provide patients with written information that describes specific areas of wound healing and tissue stretch that are not controllable by surgeon or patient. After reading the written information, patients should receive verbal reinforcement of key concepts and have an opportunity to ask questions about factors that surgeon and patient cannot control. Before surgery, patients should acknowledge their understanding and acceptance of factors that surgeon and patient cannot control, and acknowledge the problems, reoperations, costs, and risks that are associated with these uncontrollable mechanisms in clearly written informed consent documents.

Educating the Patient About Factors the Surgeon Cannot Control

The following content is excerpted from a preoperative patient education DVD and accompanying document entitled “My Preferences and Information I Fully Understand and Accept” that are components from a staged, repetitive, and comprehensive system for augmentation patient education that is peer reviewed and published in the journal Plastic and Reconstructive Surgery.¹ As the DVD presents information in stages, the program pauses at intervals to allow the patient to read the accompanying printed document and document an understanding and acceptance of the information. Video content from the patient education program and the accompanying document are included in the Resources folder on the DVDs that accompany this book.

Document used by the patient while watching the video:

Video: Infection can occur following any surgical procedure, despite all efforts to prevent it using the most state-of-the-art techniques and drugs.

Every woman’s breasts contain bacteria that normally live on the skin and enter the breast through the nipple. In some women, the amounts or types of these bacteria may make them more likely to develop an infection following breast augmentation, but we currently have no tests to identify women who may be at increased risk.

We give every patient intravenous antibiotics immediately prior to starting surgery. These antibiotics are in the blood stream during surgery and in the tissues and tissue fluids following surgery. We do not routinely prescribe antibiotics following surgery because statistics show that they are unnecessary, and because of concern that antibiotics can kill many normal bacteria and encourage the overgrowth of other undesirable bacteria.

If you develop an infection following surgery, the safest and best treatment to avoid prolonged problems and possible permanent deformities is to remove the implants as soon as possible. My experience in trying to salvage infected breast implants is that in the vast majority of cases, the implants ultimately have to be removed, and the longer the delay, the greater the scarring and permanent deformities.

Once implants are removed, infection usually subsides with the help of antibiotics over a 1–3 week period, but the tissues of the breast require at least 3 months to soften and heal. The more aggressive the infection, the greater the risk of internal or external scarring that can leave permanent deformities.

Once the infection is treated, some surgeons attempt to replace implants after waiting 6 months to 1 year. Having tried this several times in patients referred to me with infection, I am convinced that when patients have had a previous infection in their breasts, at least half of them will develop another infection if we try to replace implants. Patients who can get by without recurrent infection, however, almost always develop severe capsular contractures that produce additional deformities and require additional surgery. The bottom line is that if you develop infection, you are at much less risk for future problems if you remove and do not replace your implants, despite your disappointment and mine.

Next, on your paper informed consent document, carefully read and initial item 17. When you have completed this portion of the program, please click on the Next Topic button on the screen.

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Video: After we perform surgery and place implants in your breasts, your body healing mechanisms take over. These mechanisms can vary significantly from patient to patient, and despite our best efforts, we cannot precisely predict or control how you will heal.

When any medical device such as a breast implant is placed inside the body, the body forms a lining around that device. That lining is called a capsule, and it forms in the first few weeks to months following surgery. As the lining forms and matures, it usually tightens or contracts slightly, but in some patients it contracts or tightens excessively, putting pressure on the implant, causing it to feel too firm, or causing other deformities or discomfort.

Every patient who has an augmentation forms capsules around her implants. Unfortunately, there are no tests we can perform on you prior to surgery to predict whether the capsules you form will tighten excessively and cause deformities. If we could predict that you are likely to form an excessively tight capsule, we would advise you not to have an augmentation, but unfortunately we cannot predict or control how your body heals and how much your capsule will tighten.

Your capsules can tighten a small amount or a large amount, and they rarely tighten the same in both breasts. During the first 3–6 months, you may notice slight shape changes or severe shape changes, depending on how your capsule forms and tightens. If a capsule tightens a small amount in the lower portion of the breast, the capsule puts pressure on the lower implant, causing an upper bulge in the breast. If the capsule tightens at the outside of the pocket, it can push the implant inward, causing more bulging toward the middle of the breast. If the capsule tightens more toward the inside of the breast, it can displace the implant outward, widening the gap between your breasts. When the capsule displaces the implant, you may be able to feel or see implant edges.

If the entire capsule tightens excessively, your breasts will feel excessively firm. Some patients who form excessively tight capsules also form heavier scars where the incision is located, since both are part of the normal healing mechanism, and that mechanism seems to be overactive in some patients. If capsular tightening is severe, it can cause discomfort and a feeling of tightening, or in rare cases may cause pain. The tightening may interfere with sensation in any area of the breast, and other aspects of the healing mechanism may cause lymph node enlargement or the formation of small bands near the incision.

The risk of your developing an excessively tight capsule around your implants is at least 3%, or 3 chances in 100. In 1700 reported cases in our practice, capsules requiring reoperations occurred in less than 1% of patients with saline implants, but we think that it is prudent to consider at least a 3% capsule rate for purposes of decision making. Regardless of the rate you consider, if you develop an excessively tight capsule, and there is always that chance, the rate is 100% for you, so if you choose to have an augmentation, understand that problems with capsules are a very real consideration and risk, even though the percentage is relatively low.

Most patients who form excessively tight capsules will do so in the first 3–6 months following surgery. If you don’t form a tight capsule within a year, at least 90% of your risk is over, but a small percentage of patients can form tight capsules at any time following augmentation.

If any of these problems caused by the capsule are mild to moderate, I may not recommend a reoperation. When the problems are mild, your body is sending us a message that your healing mechanisms tend to form tight capsules. If we reoperate, we are not changing your body’s healing mechanisms, and you might form an even worse capsule with worse deformities than you already have. On the other hand, if the deformities are severe, and I have to be the judge of that, we may need to reoperate. Our experience has taught us that regardless of how rapidly a capsule tightens, we should not reoperate on that capsule until at least 6 months following the initial surgery. During that time, the capsule is forming and maturing, and if we interrupt that process, recurrence of the excessively tight capsule is almost certain.

When we reoperate on a capsule, we remove the implant, remove the capsule, and place a new implant into the pocket. Because we cannot control your healing mechanisms, and we already know that you are prone to form excessively tight capsules, our chances of correcting the problem are only about 60% successful, with a 40% chance that you will form another excessively tight capsule. Since the chance for correction is limited, we only recommend reoperations for severe capsular deformities, not mild to moderate ones. If you form another tight capsule after we reoperate one capsule, we will recommend that you live with the capsular tightening if it is mild or moderate, or if it is severe, remove and not replace your implants. What we will not do is continue to reoperate on you when your body has clearly shown that it tends to form recurrent tight capsules, because the risks of problems with additional surgeries far outweigh any chances of success.

Capsules can be very frustrating to you and to me, and it is important that you understand that we cannot control what the capsules do, the capsules will be different on the two sides, they may produce differences in appearance on the two sides, and capsular contractures cannot be controlled and may not be correctable by additional surgery.

Next, on your paper informed consent document, carefully read and initial items 18–24. When you have completed this portion of the program, please click on the Next Topic button on the screen.

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Video: When we place breast implants into your body, your tissues will stretch to accommodate the implants, and then will stretch additionally over time due to the additional weight of the implants in the breasts. The stretch characteristics of patients’ tissues are built into the body genetically from birth, and may vary tremendously from one patient to another.

Obviously, the larger the breast implant we place into the breast, the more stretch and thinning of the overlying tissues we expect to see in the future as your tissues age and stretch under the weight of the implant. But occasionally, in rare instances, a patient’s tissues may stretch excessively with even a small implant.

We cannot test you to predict how your tissues will stretch following augmentation, and we cannot control tissue stretch, except by limiting implant size and weight. If your tissues are thin and very stretchy on examination, you may be more prone to excessive stretching after surgery. This excessive stretching can occur rapidly, in the first 6–12 months following surgery, or it can occur more slowly, over several years. The important thing to remember is that we cannot predict or control it.

If excessive stretch occurs in the lower portion of the breasts, the implants will shift downward, the upper breast will lose fullness, and the nipple will point upward excessively. If excessive stretch occurs at the outside of the breasts, the implants will shift outward and widen the gap between the breasts. When tissues stretch, they become thinner, and you may be able to feel or see the edges or shell of your implant in any area of the breast. The weight of the implant pulling on the capsule and thin overlying tissues can produce visible traction rippling in any area of the breast. In patients who are prone to excess stretch, we are not aware of any bra or support device that will prevent it, regardless of how much it is worn.

If you develop a deformity from unpredictable or excessive stretch of your tissues, surgical correction of those stretch deformities is unpredictable at best, because we are operating on the same tissues that have already demonstrated that they will stretch excessively. We can change to a smaller implant to decrease weight, but the stitches placed internally to close off the excess pocket and reposition the implant may not hold in the thin tissues against the weight of even a smaller implant, and the stretch deformity may recur. If a stretch deformity recurs after a surgery to attempt to correct it, we will usually recommend implant removal without replacement to avoid even further stretch and thinning of your tissues that could cause permanent uncorrectable deformities.

Next, on your paper informed consent document, carefully read and initial items 25–28. When you have completed this portion of the program, please click on the Next Topic button on the screen.

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Video: If problems occur due to your healing mechanisms that form a capsule or due to tissue stretch deformities following your augmentation, you may need additional surgery, and it is important that you understand and accept responsibility for the costs of that additional surgery.

Because we cannot predict which patients may develop problems as the result of their healing mechanisms or their tissue stretch characteristics, you are responsible for all costs for any reoperation that is necessary to attempt to correct a problem caused by the capsules or by tissue stretch. These costs include surgery fees, laboratory fees, surgical facility fees, anesthesia fees, costs of medications, costs of time away from work or other activities, mammogram fees, and electrocardiogram fees for patients over 40 years old.

We do not accept any payments from insurance companies or third parties for costs associated with any additional surgery following your augmentation. We will be happy to provide you with copies of your operative notes and medical records if you choose to pursue any third party payments, but you are responsible for all costs discussed previously, and these costs must be prepaid at least 2 weeks prior to any reoperation surgery.

If you have any type of problem that is not associated with capsules or tissue stretch, such as infection or bleeding, most surgeons do not charge a surgeon’s fee for additional surgery to address those problems. In our practice, if any additional surgery is necessary for any problem whatever that is not associated with capsules or tissue stretch, we do not charge surgeon fees. In addition, for problems not related to capsules or tissue stretch, we will take care of all of the other expenses listed above, with the exception of medications and time off work or normal activities.

Next, on your paper informed consent document, carefully read and initial items 29–33. When you have completed this portion of the program, please click on the Next Topic button on the screen.

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Surgeon Discussion of Wound Healing and Tissue Stretch Factors

During the surgeon consultation, a few minutes of the surgeon’s time to explain the interactions of healing mechanisms and tissue stretch is invaluable. If uncontrollable mechanisms produce postoperative problems, the surgeon can remind the patient: “Remember, we discussed things we can’t control and how those mechanisms can challenge us after surgery. Let’s review our documents that we completed before surgery.”

The following paraphrases the conversation that the author has with patients during the surgeon consultation:

Distinguishing Inferior Pocket Closure from Capsular Contracture

After every breast augmentation, some degree of dead space exists around the implant, regardless of the precision of pocket dissection. Small amounts of serous or serosanguinous fluid accumulate immediately postoperatively, even if a surgeon places drains which are unnecessary in primary augmentation. Wound healing mechanisms attempt to close dead space, but the amount and location of closure varies substantially from one case to another or from one breast to the other in the same patient.

The most common area of fluid accumulation is the inferior pocket sulcus along the inframammary fold. Small amounts of fluid accumulate in this area regardless of whether a surgeon uses a drain. Immediately postoperatively, a triangular dead space exists in the inferior-most portion of the pocket along the inframammary fold (Figure 18-1, A) because the implant does not completely fill the lower pocket due to pressure of overlying soft tissues. The larger or more projecting an implant, the larger the dead space along the inframammary fold, but some dead space exists in this area regardless of implant type, size, or pocket location (Figure 18-1, B).

Figure 18-1 A Dead space exists in the implant pocket inferior to the implant after every breast augmentation.

B The triangular dead space beneath the implant fills with serosanguinous fluid that the body reabsorbs in most cases.

C With more fluid or trauma stimulating inflammation, the dead space can undergo intense capsular thickening and tightening or fibrous replacement, causing inferior pocket closure and upward implant displacement (blue arrows).

D Black lines and red arrows indicate the degree of upward implant displacement that resulted from inferior pocket closure.