A Botched Surgery?

DR. GREGORY LAURENCE EXPLORES BOTCHED SURGERY AND EXPLAINS WHY PHYSICIANS MUST BE VIGILANT TO PROTECT THE CONSUMER FROM INACCURATE INFORMATION.

A Texas plastic surgeon has accused a colleague of a botched surgery and needlessly started a firestorm. This chain of events began when he removed the breast implants from a patient who had suffered the complication of excessive scar formation around her breast implants (capsular contracture). It is forgivable that this revision surgeon did not recognize the removed breast implant as an acceptable quality device. Either the patient or this revision surgeon initiated a story with a local news broadcaster alerting Texas residents to a “serious breast implant situation”. It is understandable that the news broadcaster would make an attempt to alert the public concerning the apparent serious situation – http://abc13.com/health/patients-treated-by-former-houston-plastic-surgeon-urged-to-get-checkup/228134/#gallery-2. What is very troubling is the fact that a national surgical association disseminated the news coverage and the associated misinformation nationwide through an electronic re-publication. The reconstructive plastic surgeon who removed the implant did not have the experience to make the correct diagnosis. Unfortunately, many implanted women will be emotionally unsettled and some may undergo the needless risk associated with unneeded revision surgery. The patient was selfless and willing to forego her privacy as she decided to “go public”. However, she should have been informed by her surgeon that her adverse event was common and could be fixed without the drama and confusion.

Removed Intact ImplantWhat made this story explode was the fact that the original surgeon – Dr. Billy Ringer of Houston – was deceased and therefore unable to clarify the record. Since Dr. Ringer was known to have engaged in civil misconduct with multiple patients and even his own staff, the story “had legs.” Add to this the media’s description of “black oily tar” substance in the implant and the public was certain to be concerned. Is there a legitimate cause for fear for this doctor’s other patients? NOT AT ALL!

In the last ten years, I have seen over a dozen similar situations in my cosmetic breast practice. I have seen every imaginable variation of implant shape, size, shell thickness and viscosity. A large proportion of these older implants are NOT stamped with a visible serial Removed Ruptured Implantnumber. The assumption and suggestion that the implant “likely came from another country” had no validity and was not confirmed. This was a normal surgical finding. What about the black substance? It was common for surgeons to take measures to minimize the risk of sub-clinical infection using steroids, antibiotics, or Betadine. In previous decades, these agents were used in the surgical pocket and/or in the saline-filled component of the implant. Certainly the surgeon who provided implant photographs (see photo) to the media knew that this substance was a Betadine-like iodine solution? The patient who came forward can take comfort in the fact that her previous doctor, no matter how otherwise flawed, was attempting to minimize risks for her. Iodine solution is frequently used in surgical wounds even to this day.

The implant is a silicone-inside-saline-outside double lumen implant distributed by Santa Barbara-based Cox-Uphoff (see figure). The original surgeon placed Betadine solution in the outside saline compartment in an attempt to minimize the risk of scar formation. Although this technique is not commonly employed today, it probably neither helped nor hurt this patient. Hardly a “shocking” finding as reported by the media. It should be noted that the original surgeon accurately diagnosed the ruptured implant in the patient. His dismissive attitude concerning the ruptured implant was inappropriate. But…”Botched” surgery? Maybe, but keep in mind that I see a dozen patients a year who have firm scar tissue and implants that are ruptured. I also routinely see older unmarked implants which were placed by surgeons with excellent reputations.

Perhaps the most common adverse event regarding breast augmentation is the formation of (capsular) scar tissue around the implant. The public should be reassured that universally American surgeons are diligent in doing everything possible to minimize this adverse event. And everything about cosmetic breast surgery is getting better. I published on this in a cosmetic surgery textbook to be published in 2014 where I catalog the continued development of more minimally invasive surgical techniques and continued refinement of the breast device implant.

As reporter John Stossel indicates in his recent segment called “Let Us Experiment” – innovation depends on smart people with new ideas DOING NEW THINGS. Every surgeon is thoughtful about how he/she can ensure a better result. In the case of breast implant capsular contracture, many changes have been made with regard to surgical techniques and the devices themselves in order to improve the surgical result. All surgeons participate in this process. Four decades ago capsular contraction rates were absolutely horrible and it was only through innovation that patients have been able to benefit.

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Questions and answers:

Which is better, silicone gel breast implants or Saline-filled implants?
Saline might be preferred for patients who desire small incisions and patients who have excellent tissue thickness. Silicone gel has been found to be the most effective non-saline material to fill the breast implants. In many patients, silicone gel implants may perform better.

Are silicone gel implants safe?
We are now confident that non-coated silicone gel implants (like the ones used in this case) from all companies used in the U.S. have been found generally to be safe and effective. The newer devices significantly outperform the older implants.

What is the likelihood that silicone breast implants will become overly firm?
No single silicone gel implant manufacturer has been able to prevent capsular contracture (scar tissue formation around the implant) for all cases. While the rates of serious capsular contracture were greater than 50% at one time, improvements in surgical techniques and device characteristics have decreased that rate to less than 10%.

Is it true that breast implants will wear out in 10 years?
Any patient who is happy with the position and softness of her implants may potentially continue with those implants indefinitely. When revisions occur around 10 years, the reason is more commonly related to aging changes or desire for size change, rather than device failure.

Should I follow the FDA recommendations regarding periodic MRI imaging after silicone breast implantation?
Ruptured silicone gel implants have a higher risk for capsular contracture, but the data does not suggest that the rupture poses any risk to the patient. Patients have wide latitude with how they monitor the integrity of their breast implants, and what they do in the event of a suspected implant shell failure.

How is it best to monitor the integrity of my silicone breast implants?
All patients with any breast implant should consider annual examination by a surgeon or OB/GYN. Any symptomatic breast demands clinical evaluation.

How can I maximize the chance that I will be happy with my decision for breast augmentation?
The best surgical results and highest patient satisfaction are in the context of excellent communication. Adequate surgeon training, education, experience and proven ability must be verified. Patients should not feel shy about asking about credentials and certifications.