Implants in the News

Breast Augmentation Roundtable

Adams:If people believe that reoperations are not a problem, I'd say to them that they either don't know the data or they are disregarding the data. In the data that we have, that has been alluded to before, there are PMA studies and multiple ones over time, and they all show the same things. Anybody who feels that reoperations are not a problem is just disregarding that or choosing to disregard that. I also think that some comments were made earlier that nobody seems to think they have a high reoperation rate; very few people have it. I think, again, I would echo some of the earlier comments: that's just a fallacy. In the transparent studies, the reoperation rates are 20 percent, so there have to be surgeons with 20 percent reoperation rates. I should mention, in fairness, that for the reoperation rates we are quoting, some of these are for other procedures, such as breast biopsy, but get counted as a reoperation. Nevertheless, when one accounts for these subgroups, the overall reoperation rate is still excessive.

Tebbetts: I think, in fairness, we are throwing around the number 20 percent. It could be 15 to 20 percent. In different studies it's ranged, really, between 15 percent and 20 percent, and what we are talking about here are data from PMA studies over the past 2½ decades. In my opinion, data from a PMA study are the best data, period, available in any aspect of plastic surgery with respect to scientific methodology and peer review.

Teitelbaum: Dr. Bengtson, earlier you mentioned that your opinion changed after you started looking at your data carefully and realized what your true rate of successes was and was not. So when you meet a surgeon who says that reoperations are not a problem, what is it that you would say to that surgeon?

Bengtson: Well, my comment would be that you haven't asked the question, or you haven't asked the right question, and/or you are not being honest with yourself. I am continuously surprised, particularly at national meetings, that there is an inherent lack of follow-up and documentation of actual complication rates and problems and those sorts of things. To me, it took me a long time to figure it out, but a half-truth is a lie. I think we each need to be extremely honest and, as John said, transparent. Otherwise, you can't learn. You don't learn from your successes; that's a great result. You learn from the problems and complications that you have. It's kind of human nature to not want to deal with those things, or not really recognize those things, but you don't excel or get better without that.

The second thing I would say to them is that, and it's a question that we may deal with a little bit later but, if they are going to blast through some of the basic principles at the first operation and they really don't feel reoperations are a problem, then I really would like for these surgeons to have patients sign additional consents that they will stay with that surgeon for life, so that I don't have to deal with them in my office and their problems and baggage. People have talked about in the past in the journals that we need to deal with patients with large implants, because I don't. If they are going to do those things and intentionally blast through what the breast and the body can take, then they should stick with that patient for life, so that maybe they will see that reoperations may be a problem then.

Jewell: I agree pretty much with everything that has been said so far, in terms of many surgeons lacking the insight to ask the question of what was not done to make this process optimal. I also think there is the issue of patient selection, where high-risk scenarios are willfully operated on time and time again. I am talking about patients with augmentations, mastopexies, tubular breasts, small breast diameters that will produce a double-bubble deformity, and so on. In other words, there are a lot of scenarios where you can see a reoperation coming. In that case, it may be better to say to the patient, You don't meet my criteria for this operation, versus saying, Well, it's going to take multiple operations to get you where you need to go, and that may not be the case.

Spear: In regard to surgeons who might say the reoperations are not a problem, most likely they are saying that, in their hands, reoperations are not a problem. It is possible that for some surgeons, their reoperation rate or their perception of their reoperation rate is low and, therefore, they believe it is not a problem for them. I would return to some of my earlier comments, where I said that reoperations that are, in fact, revisions for true postoperative problems are an issue if the rate is high. Reoperations for insignificant events, such as a breast biopsy or a planned mastopexy, are really not a problem in terms of the original surgery. Obviously, one way to avoid having a high reoperation rate is simply to refuse to reoperate on your patients. In other words, to say to patients, for mild capsular contracture, malposition, or size dissatisfaction, that you refuse to reoperate on them. Refusing to reoperate on those patients might reduce your reoperation rate, but it does not necessarily make for a better surgical outcome or a happier patient. So I would simply say that the goal is to provide high-quality surgery by doing the best possible operation that is appropriate for the patient, with the fewest complications or need for medically necessary reoperations. Again, all of the emphasis on reoperations over the last several years has made me look at my own data and to make the effort to keep that number as low as possible while still providing responsive and high-quality surgical care. I did find it interesting in my own data that my reoperation rate for primary breast augmentation over the last 3 years is 1 percent, and that was in a patient who sought a change from saline to silicone implants. My reoperation rate for revision augmentation mastopexy was more like 15 percent, where I was dealing with more complex problems. So we do need to be careful when we look at reoperations in terms of looking at what the patient's initial problem was before surgery.

QUESTION 4

Teitelbaum: Any other comments on this topic? Okay, then I'll move to the next one. Dr. Adams, reoperations: how do you address the problem and, specifically, what is the single most important factor to be addressed?

Continue reading about this breast augmentation roundtable.

More Information about Cohesive Gel Implants