MAMMOPLASTY

Augmentation

Now that the dust of silicone implant Class Action suits has largely settled, it is useful to reflect on the process of establishing Medical Causation.

It is nearly twenty years since the first reports appeared linking Connective Tissue Disorders (CTD) with breast implants. With hindsight, the answer to a simple epidemiological question could have short-circuited the prolonged medicolegal debate that followed: is there an excess of women with breast implants who also have CTD ¹? Since about 1% of US women had implants and about 1% have CTD, 1 in 10,000, or about 10,000 US women, would be expected to have both ².

Side-stepping the relative merits of "democratising" medical evidence as established in Daubert v. Merrel Dow Pharmaceuticals, Inc., 1993, no substantive epidemiological evidence has yet come to light in fulfilment of the standard 8 tests of medical causation.

The remote effects of silicone implants aside, proposed causes of medical malpractice action following augmentation mammoplasty usually fall into one or more of the following categories ³:

Contour and firmness problems arising from encapsulation are not complications but are intrinsic to silicone implants. The medicolegal issue is usually that the client did not have a realistic expectation, whether or not because the surgeon failed to disclose.

Reconstruction

Following mastectomy for breast cancer or its prevention, different options are available for reconstructive mammoplasty. 

Breast prosthesis with prior tissue expansion has many advantages^3a but results in increased rates of complication^3b as a result of a) obesity (proportional to severity), b) current or recent smoking, and c) prior radiotherapy^3c. 

However, prior radiotherapy is not^3d considered an absolute contraindication to the procedure^3e and cosmetic and general satisfaction may not be significantly diminished^3f.  

Tissue expanders are recognised to be prone to technical failure^3g. 

The Transverse Rectus Abdominis Myocutaneous (TRAM) flap uses abdominal muscle and skin for reconstructive mammoplasty.  The procedure is complicated by abdominal hernia in 5^3h-7³ⁱ% of cases, often therefore requiring a further surgical procedure for repair of the hernia. Some researchers recommend^3j the use of synthetic mesh to repair the abdominal wound, and have shown a materially lower rate of abdominal hernia^3k. 

Even though diabetes compromises healing and subsequent scar strength, animal experimental research suggests that diabetics can accept free tissue grafts and diabetes should not be considered a contraindication to such procedures. 

Current or recent cigarette smoking significantly increases^3l the risk of flap necrosis and abdominal hernia^3m. 

Reduction

Most reduction mammoplasties in Canada are undertaken for back and shoulder pain. Nevertheless, a cosmetically pleasing result is important and expected. Certain themes are common in this, the most common cause of plastic surgery malpractice action ⁴ apart from breast implants:

Necrosis of the nipples after reduction mammoplasty⁵ is much more commonly seen in smokers⁶.  Indeed, some plastic surgeons require proof (urine testing) of smoking cessation before undertaking the procedure^3l. 

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