37 year old female one year post placement of silicone implants presents to dermatologist for evaluation and treatment of keloid scars from implants. Dermatologist’s assessment Hypertrophic scar and performed Intralesional Kenalog injection. Two months later, dermatologist performed second Intralesional Kenalog injection.
Patient started to notice a change in her left breast. Three months later, patient returned to her plastic surgeon who ordered MRI for suspected rupture. MRI confirmed the rupture. Plastic surgeon operative report notes: “The patient states she noticed a change in her left breast shape following an injection by a dermatologist”
Patient had a bilateral implant exchange with capsulectomy. She developed seroma and had exploration one week later.
The scars that she initially saw the dermatologist for have greatly worsened due to the need for the additional surgeries all within 1 ½ years. The patient has pain and loss of sensation in the breast.
Was it malpractice for the dermatologist to perform intralesional Kenalog injections to the area surrounding the implants? If it is proper to perform the injection in this area, was it malpractice to rupture the implant with the needle? The patient was not informed of a risk of rupture to the implant from the procedure. Should the dermatologist have referred the patient back to her plastic surgeon rather than treat the keloid scars?
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Do you believe there might have been medical error?
I believe that the error here has to do with the way the physician dermatologist performed the injections (too deep), considering that the need for scar improvement was superficial.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
A plastic surgeon would be able to better speak to this, as I am not familiar with the possible causes of breast implant rupture. The mitigating circumstances in this case would be the other possible causes / explanations for patient's breast implant rupture.
What makes you a good expert for this case?
I have been consistently doing dermatology medical expert witness work since 2014, while maintaining an excellent, top-of-the-line reputation.
How often do you encounter cases similar to this one in your practice?
This would be a first ... but not the first time I've been an expert on a case that's "a first."
Do you believe there might have been medical error?
I would prefer to review the entire case before commenting, but it is possible that my opinion will be that the dermatologist should have referred the patient back to her plastic surgeon to treat her, as it is very well known that plastic surgeons treat scars and can offer kenalog injections if appropriate. Also, her plastic surgeon would have potentially been better to treat her knowing where exactly the implant had been placed (do what depth). It is also likely that my opinion may be that the dermatologist should have informed the patient of the risk of rupture of the implant.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
same as above, if the kenalog needle reached the implant it would have likely ruptured it.
What makes you a good expert for this case?
I am a cosmetic laser surgeon, trained in general surgery with multiple plastic surgery rotations. In my current practice I specialize in cosmetic laser procedures and injections and specialize in many forms of treatments of scars, including kenalog injections. I am not a board certified dermatologist however.
How often do you encounter cases similar to this one in your practice?
This type of case is relatively rare (rupture of an implant after steroid injection) but I am comfortable opining on the case once I have been given the opportunity to review all of the material.
Do you believe there might have been medical error?
The kenalog injections are intradermal and do not go below the scar tissue. If the implant was that close to the surface, it could have been patient's healing mechanism that caused the scar rupture or surgeon's method placing the implant too close to the surface. Please review the original scar photos if possible.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Steroid Injections are administered intradermaly into hypertrophic scar tissue which lies above the sub cutaneous layer. Breast implant lays normally in subcutaneous plane or submuscular plane. The amount of steroid administered is very small and needle is very small gauge and short making such injury very unlikely.
What makes you a good expert for this case?
I am a Board Certified Dermatologist with knowledge of scar remodeling and procedures to treat scars such as kenalog injections. I also understand basic anatomy of skin and breast tissue.
How often do you encounter cases similar to this one in your practice?
I see a lot of Keloid Scarring, however, I do not usually see post op Keloids after breast implant surgery.
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Comments from similar speciality or otherwise pertinent to the case may also be accepted.