When Things Aren’t Perfect:  Problematic Wounds after Elective Surgery

When Things Aren’t Perfect: Problematic Wounds after Elective Surgery

In the world of elective plastic surgery, one expects and hopes for a perfect result. This is the goal of every surgeon when starting a case, and the patient should have a reasonable expectation of a good surgical outcome. This essay is not about the perfect expected result. Sometimes things don’t go perfectly in the recovery process. How do we manage an imperfect result? In all areas of cosmetic surgery there are chances that the incision won’t heal perfectly. I am restricting this discussion to one area, breast reduction and breast lift. This is an area in which I have a large volume of experience, and I have seen results that range from perfect to disaster.  It is well known in the field of Plastic Surgery that breast reduction has a higher than average rate of wound healing problems.  I think it is important that the patient go into the procedure armed with the knowledge of what may transpire and have a good handle on things they can do to alter the balance in their favor.

What are the wound issues of which I speak? The number one area of concern is the intersection in the infra-mammary fold at the junction of the vertical and horizontal scars. This area is under high tension and has a poor blood supply. The combination of these factors has the potential to cause the skin to ulcerate and ooze yellowish fluid. It is important to note that this is not an infection; the area will heal with some TLC in the form of gentle hygiene in the form of soap and water twice daily and the application of petroleum jelly.  Depending on the size of the area, this may take weeks or months to heal.  Studies show that the 30 day surgical morbidity after breast reduction is 3.98%. According to the research sited below, the risk factors for a poor outcome are resident participation, obesity, smoking, steroid use, and operating in the third quarter of the year. According to the Baltodano Breast Reduction Score, depending on the number of risk factors included, the predicted risk of complications ranges from 1.9% for those who are perfectly optimized, to 44.3% for those at greatest risk.

Based on this information, it is up to the surgeon to instruct patients on how best to prepare themselves for the surgery, and it is the surgeon’s responsibility to determine as to who is an acceptable candidate for the procedure. Based on this data, I do not operate on patients who smoke or are carrying too many pounds. Even after patient selection, there is a risk of adverse outcomes.

Good wound healing is a team effort; the surgeon works hard to do a great job, and the rest is up to the individual’s tissues to complete the process. Take care of the incision and optimize your healing potential by consuming adequate protein and avoid stress on the healing area. It can be easy to sabotage your outcome by resuming your habits of daily life. One thing I have come to warn people of is to not sleep with their pets. Early in my practice I had a couple of patients who developed wound infections that were hard to explain, until I found out that they were cuddling with dog or cat in bed as soon as they got home!  This is now part of my pre-operative discussion, and I am sure I will learn of other activities to avoid in the years to come. If despite your best efforts you have a problem area, make sure you have it checked by your surgeon and follow his or her instructions. With time these areas do heal, and the results are surprisingly good.

The Baltodano Breast Reduction Score: A Nationwide, Multi-Institutional, Validated Approach to Reducing Surgical-Site Morbidity

Baltodano, Pablo A. M.D.; Reinhardt, Myrna Eliann B.A., B.M.; Ata, Ashar Ph.D.; Simjee, Usamah F. B.S.; Roth, Malcolm Z. M.D.; Patel, Ashit M.B.Ch.B.

Plastic and Reconstructive Surgery: August 2017 - Volume 140 - Issue 2 - p 258e–264e

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