Revision & Complications

By Dr. Howard Silverman

Let’s talk about nobody’s favourite topic, complications and revisions.  What happens when a surgery does not go as planned or hoped, and how do we avoid this issue?

While our complication and revision rates are very low at Ottawa Plastic Surgery, surgery is not an exact science and sometimes things don’t work out as was intended.  Breast implants can get infected or slip, scars can heal poorly, wounds can open, and on and on.  Sometimes even after extensive pre-operative consultation, patient/surgeon interactions are not exact and our understanding of what the patient desires and what the patient actually wanted are not aligned, leading to disappointment.  It’s important to know that all surgeries, even cosmetic surgeries, have an element of risk, and that while all efforts are made to minimize these risks, they still can happen, despite well performed and well-planned surgery. 

I think that the most important factor in this topic is trust.  The prospective patient must choose their surgeon and procedure carefully and then place their trust in their surgeon.  On our end, the surgeon must accept and be worthy of that trust.  Anyone can accept a perfect result, but what happens when the result is not perfect? Then our doctor-patient relationship is really important.  The patient must trust that the surgeon has done, and will do, their best to achieve the desired shared end goal, and the surgeon must do their best to achieve the best possible resolution to the complication. Although uncommon, this may unfortunately mean that with a severe complication, we may have to accept a lesser result than was initially sought.  Fortunately these situations are very unusual, but I have found that most patients can understand and accept this, as long as they know that their surgeon went to the wall for them both before and after the surgery.

Your surgeon should operate at a safe, clean, spacious and provincially accredited facility  with rigorous infection control and staffing policies, and 24 hour backup for any unexpected eventuality.  Your surgeon should hold admitting privileges at an accredited hospital that can also deal with any adverse outcome with access to other affiliated health care providers, so that you are not left searching for help on your own, especially after typical office hours.  This is especially important to understand if you are considering having surgery in another country, or even another province.

So how to avoid the dreaded complication?  First of all, what is a complication?  An adverse or unexpected outcome in the relatively early post-operative period, like a breast implant infection or a wound separation or infection, would certainly be one.  Ruptured breast implants 20 years out, or looseness of a tummy tuck after significant weight fluctuations and pregnancies after the surgery, are disappointing, but would be more considered as the natural progression of the operation.  This doesn’t mean that they can’t be revised or repaired but shouldn’t be considered as a complication.  The most important factor to avoiding a complication is in the choice of your surgeon, and the conversation you have during consultation.  Your surgeon should have significant experience and reputation in the procedure that you desire and should be up front about his or her familiarity with what you seek, and their ability and confidence to reach that goal for you.  They should describe a carefully thought-out plan for the surgery as well.  As mentioned, you need to be able to build a bond of trust with your surgeon before surgery.  This means that you understand your surgeon and what they can realistically accomplish for you, and that if things do go sideways, they will do their best to get you to your desired outcome.  This also means that they have taken the time to patiently draw out what you expect, and that they give you an honest reality check with what can be achieved surgically.  

Like all relationships, the conversation goes both ways!   Sometimes I will meet with a patient, and for whatever reason, it’s not a match for me, and I don’t feel that I can meet the patient’s needs, or that they have an unrealistic expectation of what I can achieve.   In that case I will politely suggest that they seek consultation elsewhere, and that I’m not the surgeon for them.  I would advise that if you were getting this type of feedback from consultations, I would heed this very carefully, as an honest and caring surgeon will refuse a patient whose goals they believe they cannot meet, and maybe the operation you desire is unsafe or impossible to achieve.  If you see enough surgeons, eventually someone will do the surgery, possibly leading to disastrous consequences.  However, not all surgeons are the same, and we all have different abilities, personalities, areas of expertise and comfort levels, hopefully born from extensive experience.  

At OPS, I see many patients for secondary, or revision breast surgeries from all over Canada, and internationally from medical tourism.  This probably is a factor of having done breast surgery for over 25 years, as I’ve seen a lot!  The best way to avoid a revision is to choose wisely for the initial surgery and to allow your surgeon to make a safe plan for you, so that the operation goes well from the get-go.  Secondary surgeries are always more difficult than primary surgeries, especially when being done by a different surgeon.  Unexpected intra-operative findings requiring complex intra-operative decision making are the norm, and one must rely on the surgeon’s skill and experience to achieve the desired correction.  Sometimes correction may even require a series of operations rather than just one and will often involve more expense than the initial operation.  As such, when considering a revision, choose your surgeon very carefully and make sure that you each understand the plan, and what the expectation of a successful outcome will look like.  

To sum up a difficult topic, your job is to choose a surgeon that you trust and to whom you relate well, and who has the capabilities and experience to achieve the stated outcome.  Your surgeon should spend a good amount of time talking to you about this, and should also present a list of possible outcomes, complications, and their remedies, as well as their policy for managing revisions.  This will allow you to build a relationship with your surgeon, so that you can move forward with confidence in your surgery.  We at OPS have the greatest collection of expertise and surgical depth in cosmetic plastic surgery in the region, practice in an extraordinary surgical facility, and all hold privileges at the Ottawa Hospital, ensuring that we have the expertise both to minimize and hopefully avoid complications, and to thoroughly manage the unexpected, should it occur.