Archive March 2000 I, No. 3

How to Streamline Breast Augmentation Procedures

Christopher DeBacker, MD

BIO

Aesthetic breast augmentation patients want more from their surgeons than acceptable results - like all elective surgery patients, they expect to be treated with extra attention and concern in private and pleasant surroundings. If you want to make these procedures profitable for your facility, however, it's crucial to perform them as efficiently as possible while still giving patients the attention they deserve. We perform about seven of these procedures a month in our ASC, and we've formed what we think is a good protocol for producing happy patients and keeping our surgical team running at peak efficiency. In this article, we'll describe how you can do the same.

Pre-op Preparation
Perform a comprehensive consultation: Every patient undergoes a thorough consultation and exam in our office, which is adjacent to our ASC. During this office visit, we talk about the patient's aesthetic preferences, perform a breast exam, discuss all the risks of the procedure, and obtain informed consent. By giving the patient ample time to air her concerns and ask questions, we alleviate anxiety and lay the groundwork for a smooth surgical day. We also require the patient to have a physical and a series of tests with her primary physician, who can alert us to any problems well ahead of time.

Allow for size changes: A patient may be unsure about what size she wants to be, and this can lead to doubts and second thoughts on the day of surgery. To help her visualize her new look, we have her wear a brassiere of her desired cup size filled out with plastic baggies containing birdseed; this also helps us estimate the volume of the implant. We also have her hold and manipulate various implants to help her decide what kind she would like.

Even if the patient seems to be completely certain of her desired size during the consultation, there's every possibility that she will change her mind on the day of surgery. Sometimes, patients opt for a size smaller at the last minute, but they end up disappointed a few weeks later, when post-surgical swelling subsides and they lose volume. We're careful to explain this during the initial consultation, but we keep extra implants in smaller and larger sizes at the ASC in case we have to make a last-minute switch. We've also found that it's a good idea to have at least two of each implant, just in case one ruptures or breaks.

Warn the patient about post-op pain: Often, patients don't expect to be in much pain, and if they are surprised by their discomfort, they tend to spend more time in the PACU. Therefore, we're sure to warn them that they will be quite sore, run down, and perhaps slightly nauseous immediately post-op. Patients who know what to expect are much better able to handle the side effects and go home earlier.

The Surgical Procedure
On the day of surgery, we make sure the operating staff is fully informed and prepared, having reviewed the patient's medical history, noted any potential problems, and talked with her on the phone. The patient arrives an hour before the scheduled procedure; the doctors arrive at least a half-hour ahead of time. It's important to start on schedule; tardiness on the staff's or surgeon's part increases the patient's anxiety and adds to the overall time.

Here are some of the things we do to streamline the surgical process and ensure an excellent outcome:

- It's important to have an anesthesiologist familiar with aesthetic procedures as part of the surgical team. An anesthesiologist who usually does other kinds of cases may tend to overmedicate, leading to a longer recovery time. Our anesthesiologists use laryngeal mask anesthesia or endotracheal intubation for general anesthesia; they give just enough medication to keep the patient asleep for about 45 minutes. We normally use inhalational agents or nitrous oxide, combined with propofol as a hypnotic, fenatanyl as an analgesic, and Versed as an amnestic.
- Our OR technicians are well familiarized with breast augmentation instrumentation and technique, which greatly adds to the surgeon's efficiency. The technicians know how to recognize and troubleshoot all aspects of the procedure, and they also have a sense of the aesthetic endpoints of the case.
- To allow maximum access to the surgical field, we place all EKG leads on the patient's back or legs, and we place a blood pressure cuff on the calf instead of the upper arm, where it might get in the way. We also use a fitted chest drape that defines the surgical field and helps maintain sterility.

- We use a table with arm boards that incline simultaneously with the table, which allows us to easily sit the patient upright during surgery to judge the adequacy of the augmentation. The patient's arms are secured to the arm boards to prevent movement during surgery.

We recently realized how much of a difference these small steps make when we performed a few of these procedures at a different facility. The staff had less technical experience, we didn't have a well-fitting chest drape or inclining table, and the patient wasn't prepped exactly right (with the blood pressure cuff on the leg and EKG leads away from the surgical field). These factors all served to double our normal procedure time to more than two hours.

Post-Op Care
The patient wakes up soon after the surgery and is usually ready to go home about 45 minutes to an hour post-op. During the recovery period, we review post-op instructions with her and her family, give her printed instruction sheets, and administer antibiotics and pain medication (we prefer Oxycontin, because we find that it provides a smooth and sustained level of pain control). A member of the surgical staff calls the patient on the evening of the surgery to provide an added sense of comfort and security and let her know that we wish to do everything possible to aid her recovery. We also see the patient the day after surgery and one week post-op.

By giving your patients the attention they need before surgery and preparing them well in advance, you'll ensure that they are pleased with their results - and you'll increase the chance that they'll refer other patients to you. By using our tips to streamline your procedures, you'll ensure that your facility can handle an ever-increasing caseload with ease.

Dr. DeBacker is currently a fellow in general cosmetic surgery and has been performing eye and facial plastic surgery for the past five years. He is on the clinical staff at the University of Arizona School of Medicine.

Dr. Dryden built the Arizona Centre Plastic Surgery, which specializes in cosmetic surgery management, in 1988. He is fellowship trained in facial, eye, and cosmetic plastic surgery and is a clinical professor at the University of Arizona School of Medicine.

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