57-year-old lady who had bilateral breast implant replacement (reduction) and liposuction done in Sept 2023. Long story short, she had bilat nipple necrosis which then caused implant infection/removal.
***PHOTOS and OP NOTE ATTACHED***
Details:
Two days post-op, PC had two episodes of vasovagal syncope. She contacted the office and was was told as it was “normal” post anesthesia. Two days later, PC having redness and swelling and sent photos to office. She was told not to worry and follow up would be in 5 days. First official post-op visit was 10 days after the procedure. Office note reports “well healing with right nipple having a central area of necrosis”. Was told to continue antibiotic ointment and that they would follow closely.
7 days later PC returns for additional follow-up, there are “two areas of delayed healing along right abdominal incision. Left nipple reveals partial necrosis centrally and right nipple non-viable” (??) PC instructed to continue bacitracin on both nipples and that they will continue to monitor them closely. She was instructed to return in 2 weeks.
She returns in 2 weeks with concerns of foul odor from nipples and low-grade fevers. Office note reports right nipple has progressed to an eschar with the left side showing partial necrosis. Was instructed to continue to wash area with soap and water but discontinue antibiotic ointments.
Told the return once again in 2 weeks.
She returned in one week due to continued pain and discomfort along with foul odor from nipples. Office note reports right nipple with separation of the central eschar from surrounding skin. There is fat necrosis drainage from right inferior breasts T-junction site. Also developing abnormal swelling. She had a debridement of both nipples and would begin wet to dry dressing along with oral antibiotics. Was told to return 5 days later for reevaluation.
She returns, office note reports several new areas of right breast skin abnormalities that was likely bacterial infection. This would involve implant removal.
She had multiple episodes of sepsis and required lengthy wound treatment and a few trips to the ER for IV ABX. Eventually, both implants had to be removed by 11/2023 due to significant surgical site infections.
PC still receiving wound care treatment to this day and now has developed L breast deformity. Likely the wound will never fully heal. The photos on file are quite remarkable. Long road ahead.
Our concern is the delay in proper treatment of the infections and the overall plan of care.
We are seeking a plastic surgeon who is well versed with breast implants and reductions. Also familiar with wound care follow up and treatments.
We appreciate your opinions in advance.
**OP NOTE**
The patient was marked in the preoperative holding area with Wise pattem mastopexy markings,abdominoplasty and liposuction markings. She was transported to the operating room and placed in the supine position on the operating table. Sequential compression devices were activated on both lower extremities. She received 2 grams of Ancef for antibiotic prophylaxis. She received an additional 1gram of Ancef4 hours into the operation. General anesthesia was induced and an endotracheal tube was inserted. An underbody warmer was utilized for temperature control. Foley catheter was inserted by the circulating nurse without difficulty. The surgical prep was performed with ChloraPrep solution and sterile drapes were applied. A time-out was called and the procedure, patient's identity, operative sites, and surgical consent were verified by all in the room.
The breast portion of the procedure was performed first. The nipple-areolar complex was marked with a 42 mm nipple marker for resizing. A combined superior and inferior nipple pedicle was utilized for preservation of blood flow to the nipples in both breasts. All planned incision Sites were injected with 0.5% lidocaine with epinephrine,
Skin incisions were made and the nipple pedicles were deepitheliahzed. Dissection of theWise pattern skin flaps was performed medially and laterally through the breast tissue down to the chest wall. The excess lower pole skin was removed according to the mastopexy markings. The implant capsules were encountered during the skin flap dissection. A complete petiprosthetic capsulectomy was performed in each breast carefully dissecting the capsular tissue away from the breast tissue and chest wall. An enbloc resection of theimplants and their affiliated capsules was performed. The capsule was noted to be very thin but contracted in the right breast. The capsule was thicker and also very contracted in the left breast.
The capsules were opened and inspected on the back table. Both implants were marked with a #700. These were smooth, round silicone breast implants. The left implant was ruptured. The right implant was intact. A small amount of extracapsular silicone extrusion had occurred while removing the left implant. This was wiped with sterile laparotomy sponges and all free silicone appeared to have been adequately removed. Both breast wounds were then irrigated with antibiotic solution containing | gram ofAncef and 80 mg of gentamicin and 50 mL of 10% Betadine solution
The nipple pedicles were advanced to their predetermined location which measured 21 cm from the sternal notch. A 400 mL gel implant Sizer was placed into the breast and this was deemed to be an acceptable implant volume. Two Allergan Style $ Rx 400 mL smooth, round, extra high projection silicone breast implants were opened and prepared for implantation. The implants were inserted back into the subglandular implant pocket beneath the nipple pedicles. The Wise pattern skin flaps were rotated around the pedicles and the implants. Hemostasis was confirmed and multilayered closure of all incisions was performed with 3-0 Vicryl and 3-0 Monocryl interrupted sutures in the deep dermis followed by a running 4-0 Monocryl subcuticular closure
Next, attention was turned to the abdomen. Infiltration oftumescent solution was performed into the mons pubis, left, Jeft hip and flank and right hip and flank. A total of 900 mL of rumescent solution was injected into the hips and flanks on each side. 225 mL of tumescent solution was injected into the mons pubis. Suctioning ofthe excess adipose tissue was then carried out with 4 mmand 5 mm liposuction cannulas utilizing standard liposuction technique. A total of 600 mL of liposuction aspirate was removed from the left hip and flank. 600 mLofliposuction aspirate was also removed from the right hip and flank. 125 mL of liposuction aspirate was removed from the mons pubis. The excess lower abdominal skin and adipose tissue was carefully measured and marked for excision. The planned abdominoplasty incision sites were then injected with 0.5% lidocaine with epinephrine. The lower abdominoplasty incision was made with a 10-blade scalpel. Dissection of the skin flaps was performed down to the level of the rectus fascia in the midline and Scarpa's fascia laterally.
The abdominal flap dissection was then carried up to the umbilical stalk. The umbilicus was carefully separated from the surrounding abdominal tissue. A cuff of periumbilical fat was preserved to optimize blood flow to the umbilicus. The abdominal flap dissection then continued up to the xiphoid process in the midline and the costal margins laterally. The patient was noted to have a 1.5 cm rectus diastasis. This was repaired in one layer with a #1 running PDO Quill suture from the xiphoid to the pubis. This nicely approximated the medial borders ofthe rectus abdominis muscles in the midline. The patient was then placed in the upright position on the operating table to determine the optimal amount of lower abdominal tissue for removal while sull be able to obtain wound closure. This was determined to be just above the level ofthe umbilicus. She was then retumed supine and the excess tissue was excised. All breast and abdominal tissue was then weighed. The abdominal tissue weighed 1153 grams. The right breast tissue weighed 153 grams. The left breast tissue weighed 147 grams.
20 mL of Exparel liposomal Marcaine were diluted in 30 mL ofinjectable saline and 30 mL of 9.25% plain Marcaine. Under ultrasound guidance, a
tansversus abdominis plane block was performed with 30 mL ofthe dilute Exparel mixture on each side, injecting between the intemal
oblique and transversus abdominis muscles. A posterior rectus sheath block was also performed with 10 mL ofthe dilute Exparel mixture on each side under ultrasound guidance. The abdomen was then irrigated with antibiotic solution and hemostasis was achieved. Two 15-French round, fully fluted Blake Channel drains were placed in the upper and lower abdomen and secured laterally with 2-0 silk sutures. The patient was then placed in the beach chair position on the
operating table to allow for advancement of the abdominal flap and closure ofthe transverse abdominoplasty incision. The umbilical stalk was delivered through a new opening in the anterior abdominal wall and inset with 3-0 Monocryl deep dermal sutures and a running 5-0 Monocryl subcuticular closure.
The umbilical stalk had been shortened with 3-0 Vicryl sutures at 3 o'clock, 6 o'clock, 9 o'clock, and 12 o'clock suturing the mid umbilical stalk to the underlying rectus fascia. Closure ofthe transverse abdominoplasty incision was then carried out with 2-0 PDS suture in Scarpa’s fascia followed by 3-0 Monocry] interrupted sutures in the deep dermis followed by running 4-0 Monocry! subcuticular closure.
At the end ofthe operation, benzoin and Steri-Strips were applied to all incisions. A small piece ofXeroform gauze was placed in the umbilical stalk. The patient was placed in a surgical bra and an abdominal binder with dry sterile dressings. A small amount of Nitro paste was applied to each nipple to help optimize mpple perfusion. Chlorhexidine Biopatches were placed at both drain exit sites and secured with a Tegaderm. The Foley catheter was discontinued with 500 mL.
Files:
No questions yet!
Do you believe there might have been medical error?
Would need to review operative report and medical history for contraindications to performing procedure(s) Potential delay in diagnosis and treatment: When it was noted at two days post-operatively that patient had redness and swelling, patient should have been brought in for evaluation. To allow potential ischemic tissue and/or infection to progress without diagnosis and treatment for 5 additional days (and ended up being 8 additional days since first post-op visit was not until 10 days post-op), denied patient opportunity to attempt to salvage tissue and implants with early diagnosis and treatment (e.g., hyperbaric oxygen, nitropaste, antibiotics if not prescribed).
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Infection, necrosis, tissue loss, loss of implants were all directly related to complications of the procedures performed and delay in diagnosis and treatment.
What makes you a good expert for this case?
Board certified in plastic surgery (Diplomat, American Board of Plastic Surgery) Fellowship-trained in breast plastic surgery Over 13 years of experience Previously testified as expert
How often do you encounter cases similar to this one in your practice?
Perform breast plastic surgery almost every week
Do you believe there might have been medical error?
Not enough information provided to make any reasonable determination. Detailed past surgical history vital. Preop photos vital. Complete operative reports vital. This complication can occur with or without surgical error. Post op care not comfortable for me but not outside of acceptable, depends on documentation. More to this procedure than originally described. Essentially a bilateral bipedicled Mastopexy, complete capsulectomies en bloc with old implants from subglandular plane, implant replacement with smaller size THEN flank liposuction followed by full abdominoplasty. Big operation and risks of complications are increased. Where the procedure was done is not specified.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Cannot be determined without full case review. Poor technique can cause the injury but so can good technique and bad luck. It depends on the detailed documentation to make reasonable difference.
What makes you a good expert for this case?
I have had a long career, done many cases of this type and have seen complications of this type before, both from my community and personally
How often do you encounter cases similar to this one in your practice?
Less than one annually over a forty year career. Clarification: I have seen hundreds of breast implant problems, hundreds of abdominoplasties, hundreds of liposuctions. Complications of each are infrequent.
Do you believe there might have been medical error?
Difficult to ascertain if the patient had a previous mastopexy or breast reduction. Based on the information provided, the choice of implant size and the tightness of the skin envelope most likely contributed to compromised vascular flow to the nipples. As soon as the patient has the vasovagal episode and described redness, the surgeon should have seen the patient immediately. Did the patient have a hematoma which contributed to additional tension of the breast envelope? Not clear if oral antibiotics were used in this case but should have been initiated when cellulitis first occurred. Because an implant was placed, the ischemic nipple should have been debrided sooner and area primary closed to avoid infection to the implant. If the necrosis was due to infection and not surgical technique, then cultures taken with sensitivities, referral to infectious disease for further care. None of these actions were taken with the information provided.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The lack of in person follow-up within a timely manner could have averted or at least minimized the extent of the infection of the breasts. However once the breast become infected with implants,removal is almost always the definitive treatment.. Based on bilateral nipple necrosis, the error is more than likely a technical issue related to the surgeon and the etiology is choosing an implant size larger than the breast envelope, or creating a tight breast envelope surrounding the implant.
What makes you a good expert for this case?
I am a board certified breast surgeon who specializes in breast reconstruction for the past 15 years.
How often do you encounter cases similar to this one in your practice?
I have not encountered bilateral nipple necrosis in my practice.
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