Wednesday, October 13, 2010

The "No Down-time Breast Augmentation"

I was visiting another plastic surgery colleague in another state recently, and after learning where I had trained, he told me he had visited one of the surgeons who trained me during my residency. It turns out, the surgeon has been in practice longer than me and does a fair number of breast surgeries, but had always told his patients that they would need significant time off work and daily activities, and that they would require a lot of pain medication during their recovery period. He mentioned this "no-touch technique" and how it so drastically reduces recovery periods to mere days, and I guess I got a pretty quizzical look on my face - I usually try to be more subtle - and he then asked me if I use that technique (especially important when placing the implant under the chest muscle, or pectoralis). I said, "well, yes!" (Again, Ms. Subtle). I put that information away to think about later, as more and more surgeons are using their new-found information about this technique as a marketing tool, and it wasn't until today, when one of my own happy breast augmentation patients said the following (she was here for some October "Boo-tox" and happily telling me of a friend she is referring to me for breast augmentation), "When was the last time one of your breast augmentation patients went to Red Lobster the night of her surgery - you know I did!" I decided right then and there that although I am happy to learn that knowledge of the technique is spreading, because patients will be the huge beneficiaries if their surgeons use this technique, I decided that I must be guilty of not emphasizing the difference this technique can make to my very own patients enough. We do tell patients that we will give them pain meds and muscle relaxants, but most tell us they didn't need them, they take Tylenol and go to back to work in 2 to 3 days. There is virtually no bruising or swelling, and this is true even when we place the implant under the muscle.

The "no-touch technique" is really the use of a very light general anesthetic, so that the chest muscle can be fully relaxed while a pocket is made under it to hold the implant. Traditionally, most surgeons are taught to fairly bluntly pull the muscle up, and although this is moments faster, it allows too much oozing into the submuscular pocket. This blood will usually be absorbed by the body slowly, but leads to much more discomfort, which is the most common cause of post-operative nausea and vomiting. The leftover blood can also stimulate a higher risk of capsular contracture (scar tissue), or if it is enough bleeding, can cause an unexpected trip back to the OR for evacuation of the hematoma. Additionally, post-op asymmetries are more common when more bleeding is allowed to occur.

Instead of this rather brutane method of pocket creation, advocates of the "no-touch" technique utilize a special hand-held cautery device that works much like a laser to control bleeding before it starts. Therefore, the pocket for the implant is very dry and controlled, minimizing down-time, helping to "control" the symmetry of the result, reducing the risk of hematoma or capsular contracture, and most importantly...reducing the risks of revisionary surgery, which I believe is the true "hidden cost" of all surgical procedures...ie, how many times does the surgeon have to operate to get it right? Additional nuances of the technique involve irrigating the pocket once it is made with antibiotic solutions, changing gloves after making the pocket, using talc-free gloves before touching the implant, opening it only when ready for insertion into the pocket, and limiting touching of the implant to the surgeon only. I am also a big believer in offering selected patients intra-operative sizing with temporary, single use sizers if there is asymmetry or uncertainty about ultimate size desired, and sitting all patients up in surgery to assess the final result before leaving the OR. All of these manuevers add seconds to the actual surgery time (still only a little over an hour or 80 minutes if sizing is performed), but drastically reduce the risk of revision or the "post-operative surprise"!

The use of the "no-touch technique" is even more important when I am using the investigational "Gummi bear" device, because this device mandates a tight seal between the implant and the capsule which forms arouond all implants. This device is currently investigational for certain patient indications (revision patients right now), and I am happy to be one of only a very limited surgeons in the U.S. invited to finish the clinical trials for Allergan. It's advantages are a tear-drop anatomic shape, very soft feel, no liquid nature to the filler (fully cohesive silicone gel), low risk of capsular contracture, and low risk of spread of silicone if the device should rupture.

26 comments:

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