Title: Maximizing Outcomes in Breast Reduction Surgery: An ...



Title: Maximizing Outcomes in Breast Reduction Surgery: An Analysis of 518 Consecutive Patients

Authors: Gregory Robert Scott, MD, Cynthia L. Carson, PA-C, and Gregory L. Borah, MD

Economic constraints and diminished health care resources mandate increased efficiency in labor intensive surgical procedures such as reduction mammaplasty. The evolution to our current approach over a nine-year period was analyzed to identify those factors that maximize patient satisfaction outcomes while reducing physician resources for this frequent surgical procedure.

Methods: From 1992 to 2001 a total of 518 patients underwent bilateral reduction mammaplasty (1,036 breast resections) by a single plastic surgeon. Information was obtained from the patients’ medical records. Since 1992 we have used a bilateral simultaneous approach to reduction mammaplasty, with the primary surgeon making the preoperative markings and determining the final resections. An inferior pedicle, “inverted T” technique using a Wise pattern was used for all cases. The initial two years (113 consecutive patients; 1992-1994) were compared to the most recent two year period (103 patients; 1999-2001). Select information was also obtained for the intervening time period (1995-1998; 302 patients). Variables which increased patient satisfaction while decreasing operative times and resources were identified.

Results: Length of stay (admission to discharge was initially 27 hours (overnight stay). This decreased to 9 hours (hospital-based outpatient surgery) and to 5 hours (outpatient surgery center ) in the most recent group. Drains were used in 100% of the earlier series but since 1995 were used selectively and in only 7% in the recent series. Major complications occurred in 3% of the entire series (518 patients). The only case of complete bilateral nipple loss occurred in 1993 in a patient who was a cigarette smoker. There have been no postoperative hematomas in the past 5 years. A total of 3 unilateral hematomas occurred earlier and required operative evacuation. No patient required a blood transfusion. Minor wound separations occurred in 10% of patients. In the recent series 97% of patients expressed satisfaction with their results. There were also no reports of complete loss of nipple sensation; unilateral diminished nipple sensation was reported in 13% of patients in the recent series. Three patients in the entire series (0.58%) were found to have incidental breast carcinomas within the resected specimens. Operative times (incision to closure) decreased to 102 minutes. “Dermabond” skin adhesive was used for skin closure in all of the patients in the most recent series.

Discussion: Surgical efficiency and optimal patient outcomes begin with appropriate preoperative patient education, preparation and selection. All patients presenting for evaluation are shown an informational video with Kaiser Permanente Plastic surgeons and former breast reduction patients discussing the surgical approach to and results from reduction mammaplasty. Obese patients (BMI>35) are strongly urged to lose weight prior to surgery. Cigarette smokers are required to discontinue smoking and the use of nicotine replacements for 3 months prior to surgery. Patients are offered Physical Therapy evaluation as an alternative or adjunct to surgery. The possible complications of breast reduction surgery are reviewed with the patients so that they can obtain a realistic expectation from surgery.

Appropriate mammographic evaluation is required of all patients scheduled for reduction mammaplasty. Patients who have begun screening mamographic exams should have a current exam in force. “First ever’ mammograms are recommended for all patients >40 years of age. Mammograms for patients between 35-40 years is recommended if the patient has risk factors for breast cancer.

Standardization of surgical technique helps to maximize efficient use of the operating room. Surgical draping and instrumentation is kept to a minimum. The operative team consists of the primary surgeon, an assistant surgeon and 2 surgical assistants. Controlled operative hypotension is utilized during the first half of the case to minimize blood loss during the resection. Blood pressure is normalized to preoperative levels while hemostasis is obtained. The patient is fitted for a surgical bra preoperatively which is placed beneath the patient on the OR table to facilitate placement after surgery, securing the dressings in place.

Conclusion: an evolutionary approach to bilateral reduction with low complication rates and high patient satisfaction is presented. Optimization of technique and patient preparation leads to decreased operative times, shortened lengths of stay, and contributes to efficient use of surgeon and operating room resources.

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download