Four plastic surgeons reveal problems they’ve encountered during surgery—and how they addressed them
Despite everyone’s best efforts, there are times when problems occur before, during, or after surgery. They can be related to the procedure itself, personnel, equipment, patients, or other reasons. Often, these problems can be avoided with the proper preventive steps.
Plastic Surgery Products asked four plastic surgeons to discuss things that have gone wrong during surgery—or could have—as well as what they did to resolve those situations. We also solicited any advice they could give others to avoid the problems themselves. Most responses dealt with breast surgeries and equipment-related issues, but there was an assortment of other problems as well.
Loren S. Schechter, MD, FACS: The day before a planned breast augmentation, my office contacted the operating room (OR) supervisor to confirm that the appropriate breast implants were in stock, which the supervisor did. The following day, the patient was placed under general anesthesia, prepped, and draped. Prior to making the skin incision, I asked to see the implants.
When the nurse brought the implant boxes into the OR, it was clear that they were the wrong ones—the implants were actually for a reconstructive breast case later that week. The size and shape were not appropriate for the breast-augmentation patient.
Before proceeding with the surgery, the OR staff contacted the implant salesperson, who fortunately happened to have the correct implant in stock and readily available. The salesperson was able to deliver the appropriate implant to the hospital within 45 minutes, and the procedure progressed uneventfully.
We now keep a consignment of implants at the hospital. In addition, for cases requiring an implant size or shape not on consignment, my office purchases the implants directly from the vendor. My physician assistant delivers the implants herself to the OR.
It is also helpful to have a good working relationship with the sales representatives, because occasionally instruments or devices are required on short notice. Also, the reps may be helpful intraoperatively in assisting and in-servicing the OR staff with new products.
Anthony Youn, MD: At the end of a combined breast augmentation–mastopexy, closing the incisions can be difficult if too much breast skin is excised. In this situation, the implants are put into the breasts, and the skin is excised for the mastopexy. When the flaps are redraped and stapled into place for suturing, they do not close because of excess tension. This tension would likely cause devascularization of the flaps and dehiscence of the closure postoperatively.
This has happened to me in my earlier augmentation–mastopexy surgeries. I have found that the best way to avoid it is to be conservative with the skin excision. As the old barbershop saying goes, “You can always take off more, but you can’t put it back on.”
If it is too late, and the skin has already been removed, one solution is to deflate the implants, if possible, or replace the implants with smaller ones. If this is not possible, it may be necessary to remove some breast tissue to decrease the volume of the breast and allow the incisions to close with less tension.
Also, when performing a combined breast augmentation–mastopexy, it can happen that the nipple does not transpose into the new location due to tethering to its surrounding tissues. In this situation, the excess skin is excised from the breasts, and when the nipple is mobilized to its new position higher on the breast, it will not mobilize far enough due to tethering to the surrounding tissues.
I had this happen to me when performing a combined augmentation–mastopexy on a patient with grade III breast ptosis. Her nipples needed to be transposed 11 cm superiorly. After excising the necessary breast skin, I attempted to relocate the nipple to its new position, but it would not mobilize far enough due to tethering to the surrounding tissues.
I solved the problem by leaving the nipple attached to an inferior pedicle and releasing its attachments superiorly, medially, and laterally. This allowed it enough mobility to transpose it to the new position. If an inferior periareolar incision is used for implant placement, then a superiorly based pedicle can be used.
In breast-reduction surgeries, the development of dusky nipples intraoperatively is a possibility. This is most common in the reduction of excessively large or long breasts. All of my breast-reduction patients are counseled on the possibility of free nipple grafts, although none of them have had free nipple grafts in their initial surgery plans.
I had one patient who developed dusky nipples intraoperatively—she had very large and long breasts, and more than 2 kg of tissue was removed—after the flaps and nipple–areola complex were tacked into place after an inferior-pedicle Wise reduction mammaplasty. My first action was to release the incisions in an attempt to relieve torsion on the pedicle.
When this did not clear up the duskiness, nitroglycerin ointment was applied. In the end, free nipple grafting was performed due to arterial insufficiency.
If the problem is venous in nature, then serial punctures with a fine needle or leech therapy may be effective in relieving venous congestion. It is important to give proper antibiotic prophylaxis with leech therapy, because leeches carry the potentially hazardous bacterium Aeromonas hydrophilia.
Dusky mastectomy flaps can pose a problem during breast-reconstruction surgery. Although this is not usually the fault of the plastic surgeon, we are often left having to reconstruct and treat breasts that have undergone an overly aggressive mastectomy that resulted in thin, dusky mastectomy flaps—the product of an overzealous oncologic surgeon.
I have always made sure to closely examine the mastectomy defect prior to beginning any flap harvesting or reconstruction. If the patient has mastectomy flaps that are nonviable, this tissue will have to be removed and the skin portion possibly replaced with skin from a flap, such as the latissimus or transverse rectus abdominis myocutaneous (TRAM) flap.
One way to determine whether the mastectomy flaps are viable is to inject intravenous fluorescein and inspect the flaps with a Woods lamp. Tissue that does not light up must be considered for excision. By examining the flap before harvest, the surgeon can better determine the size of skin paddle to harvest so as not to burn any bridges.
Marguerite Aitken, MD: Venous congestion of the nipple following breast reduction is a potential problem. If it is dark-colored and has dark blood oozing from the incisions, and does not respond to typical measures such as removing the sutures, a trick borrowed from hand surgeons who work on fingernails is to puncture the areola with an 18-gauge needle in multiple sites—ideally, the most congested areas—and abrade the margins of the areola with a dilute heparin-soaked gauze hourly to encourage ongoing drainage of the venous blood. This is labor-intensive, but it can preserve portions that might otherwise be lost.
Another potential problem is irregularly shaped nipples following reduction or mastopexy. Occasionally, following the inset of the nipple–areola complex, the areolar shape is not round. To prevent this, first inset the areola at the 90° positions (3, 6, 9, and 12 o’clock). Also, avoid too much tension on the vertical closure, particularly in a vertical-style reduction.
Finally, if the abnormal shape persists, simply reapply the nipple marker over the abnormal shape and mark the breast skin that intrudes into the shape of the circular nipple. The area can be de-epithelialized and the skin suture secured for a new circular areola.
We sometimes have difficulty identifying the location of the expander port following breast reconstruction with tissue expanders because of the thickness of the patient’s chest wall or transferred latissimus flap. Removing the magnet from the port locator and affixing it to a string can rapidly locate the port as the magnet draws itself immediately to the skin overlying the port. This also works for thin patients to verify the center of the port, when it is more palpable.
Michelle Ehrlich, MD: During my training, I experienced a citywide power failure that interrupted electricity to our hospital. The hospital had backup generators, but they provided power only to the electrical sources that were deemed “critical,” which did not include much of our lighting. I was able to finish a small case with the help of a headlamp and flashlights, but it did take several minutes for my assistant to locate these items in the dark. I now make sure that all of my surgical areas have emergency lighting devices that turn on automatically in the event of power interruption.
From time to time, equipment may break, fail, be dropped on the floor, or otherwise become “unsterile” or unusable. I try to have backup equipment sterile and ready to go as much as possible. I also have a second backup autoclave in the office, in case I need to sterilize an additional item after the larger autoclave has already started a cycle or, of course, in case the main autoclave breaks.
Schechter: During a circumferential liposuction and excisional body-contouring procedure, the liposuction machine malfunctioned, preventing the completion of the liposuction portion of the operation. The procedure started with the patient in the prone position, and the back and flanks had been treated with liposuction.
The patient was then turned supine for the planned abdominoplasty and completion of the anterior liposuction. At this time, the liposuction machine malfunctioned, preventing the liposuction of the anterior abdomen. The hospital biomedical engineers were unable to fix the liposuction machine intraoperatively. The abdominoplasty was completed without anterior liposuction.
The professional fee corresponding to the liposuction was refunded, and the hospital waived the facility fee for the entire procedure. The findings were discussed with the patient, who was taken back to surgery several months later for the liposuction procedure.
Unforeseen equipment problems may arise. Remain calm, and address the situation in as level-headed a manner as possible. If the equipment is not repairable, proceed with the remainder of the operation, if it is safe to do so. Postoperatively, explain the situation to the patient. Consider speaking with the facility and arrange to complete the procedure in as convenient a manner for the patient as possible.
During a microvascular breast reconstruction, the microscope was suddenly unavailable prior to the anastamosis. The neurosurgeon operating next door needed the microscope, and unknown to me, the nurses had moved it to the other OR. When I asked the nurses to “drape the scope,” I learned that it was not available.
I have two sets of operating loupes in my locker—X2.5 and X4.5. Rather than waiting an additional hour while the patient was under general anesthesia, I divided the flap and performed the anastamosis under loupe magnification.
Always be prepared with a “plan B.” It is important not to be overly reliant on technology. For example, in addition to keeping a second pair of operating loupes in my OR locker, I also keep a spare set of eyeglasses. It is important to remain up to date with technology, but it is also important to know how to troubleshoot.
Once, early in the week, my office scheduled a pedicled, fasciocutaneous flap for covering a hand wound later the same week. When the case was scheduled, several days prior to the proposed date of surgery, a sterile tourniquet was requested. On the day of surgery, the patient was placed under general anesthesia, prepped, and draped. When I asked for the sterile tourniquet, there was none.
Before commencing with the procedure, the OR staff contacted a neighboring hospital that had an available sterile tourniquet. An OR assistant drove to the neighboring hospital and borrowed the tourniquet, and the procedure progressed uneventfully.
It seems as though hospitals now rely more on “visiting” or “traveling” nurses who are unfamiliar with individual surgeons’ preferences. Therefore, communication with staff is important. Periodically reviewing and updating preference cards is helpful.
Aitken: This seems obvious, but avoid the risk of fire and possible explosions and facial burns in the OR. During typical sedation cases for repair of small defects on the face, such as Mohs defects or small excisions, drapes are commonly tented over the patient’s airway. This provides an opportunity for oxygen to accumulate and form a potential source of combustion that could result in burns to the patient’s face.
Solutions to this problem are to completely drape off the airway from the surgical site, turn off the oxygen during use of the electrocautery, or cut a nasal cannula and slide it down the nasal passageway to the oropharynx for more direct delivery of the oxygen and decreased risk of fire.
Ehrlich: One of my patients who was scheduled for deep full-facial laser resurfacing decided to substitute an over-the-counter “cold-sore ointment” for the herpes simplex virus (HSV) prophylaxis that I had prescribed for her. Given the questionable efficacy of the ointment was using, the patient developed an HSV outbreak 2 days before her scheduled procedure.
When she arrived at the surgery center with a full-blown cold sore on her lip, we realized that she had not been taking her prophylaxis medications as prescribed. If my patient had not developed the outbreak prior to her scheduled surgery, we might not have recognized the problem with the medication substitution.
Following this experience, I now have my assistants contact surgical patients 1 or 2 days prior to their scheduled surgeries to review all of their preoperative instructions, including the names and dosing schedules of all of their medications.
I also had a patient who was having her lips injected with hyaluronic acid for the first time, and she became very anxious and fainted. While she was having this vasovagal response, she experienced convulsive syncope-type symptoms with myoclonic jerks and a foamy mouth. We followed general seizure safety precautions and cleared her immediate area from any dangerous objects.
The episode ended very quickly, and her blood sugar and vital signs returned to normal. The patient felt well afterward and wanted to go home, but I was not comfortable letting her drive following this episode. We monitored her in the office with the crash cart on hand until her husband picked her up and drove her to the emergency department for evaluation.
On another occasion, a patient arrived at the surgical center for liposuction surgery appearing drowsy and slightly confused. Apparently she had taken an anti-anxiety medication at home that morning. We could not accept her consent forms signed while under the influence of medication, so we had to cancel her surgery.
Our policy is now to have patients read their consent forms at the time of their preoperative visit, and we explain to them at that time that they must not take anything on their own prior to the procedure. We also reassure patients that if they feel anxious on the day of their surgery we will give them something in the office—after they have signed their consent forms.
Schechter: I was instructing a surgical resident in the harvesting of a skin graft when I asked the nurse to prepare the dermatome. She loaded the blade, set the depth, and handed the instrument to the resident. Prior to proceeding with the graft harvest, I asked to see the dermatome to verify the settings.
The wrong blade was loaded—a Padgett blade had been forced into a Zimmer dermatome by a scrub technician unfamiliar with the instrument. This caused the depth of the dermatome to be set significantly deeper than requested, and would have resulted in a significantly thicker skin graft than required. Fortunately, I routinely check the instrument prior to use, and the problem was corrected.
It is easier to prevent a problem than to treat one, so always check power tools prior to use. Whether it is a drill, a saw, or a dermatome, it is important to ensure that bits, blades, and other incision devices are loaded properly. Also, remember the carpenter’s rule: Measure twice, cut once.
Youn: When performing a standard lower-eyelid blepharoplasty using a subciliary incision, I have on rare occasion excised too much intraorbital fat from one eyelid, resulting in what would be an unsightly depression. When this occurs, I have found that the most reasonable course of action would be to replace the fat as pearl fat grafts, as rediscovered by Ellenbogen in 1986.1 As a result of using this technique, none of my patients have developed this depression from excessive fat removal during lower blepharoplasty.
Aitken: To simplify the marking of large abdominoplasty patients as they stand in front of you and you attempt to mark the pubic region, ask them to hold their often heavy excess abdominal skin upward to expose their lower abdomen, upper thigh, and pubic area. They have the best angle and typically have nothing else to do with their hands. They will be glad to assist you and feel like they are helping with the procedure. PSP
Danielle Cohen is a contributing writer for Plastic Surgery Products.
1. Ellenbogen R. Free autogenous pearl fat grafts in the face—A preliminary report of a rediscovered technique. Ann Plast Surg. 1986;16: 179–194.