A few weekends ago, a patient of mine - who had an explant about 3 1/2 weeks prior to that - contacted me with concerns on a Sunday (alas, being contactable and sometimes giving up your weekends is part of the deal when you operate on people).

I saw her in the rooms that day and had to arrange an admission to hospital for antibiotics because she had developed an infection.

Now, post-op complications are uncommon in my practice. But they do happen, and when they happen, I tend to get a little introspective and engage in some naval gazing whilst trying to work out how I could have prevented it (which, to be fair, may not always be possible).

It is probably a good time to discuss this as I have just submitted a research paper looking at the technique I use for explant surgery, and in particular, the focus of the paper was the very low incidence of complications associated with the muscle repair that I bang on about endlessly. We had just looked at the last 140 capsulectomy procedures I had done for ladies with under-the-muscle implants, and there had been NO seromas, NO haematomas and NO infections requiring admission to hospital.

So I guess it was the universe laughing at me when this lady popped up with a small collection and an infection in her breast. Whilst that makes her the first patient of mine to experience this complication after this sort of explant surgery, and it can be problematic to draw too many conclusions from an isolated event (inductive reasoning is ever a flawed concept, right?), I think it is important to consider how these things happen and how they can be prevented. And we can also consider how we manage the issue when it occurs.

The most likely cause of this particular issue was a small area of fluid which then becomes secondarily infected. Which poses another question: why was there fluid? All fluid collections are most likely an inflammatory response to excess movement, a suture, or even a bit of loose fat tissue. I have written another article on this previously, which you can read here. Often that may pose no issue and resolve spontaneously, but for some patients, a bug can get into that fluid pocket and start to multiply. That bug may be from the skin surface or other sources, but it is something we have to factor into any operation. Remember, the breast is a "colonised" part of the body and therefore the bugs may already be living in the breast tissue. This is why all of my patients do receive antibiotics after surgery (that is contentious, I know), but obviously at 3 1/2 weeks after surgery, those antibiotics are long since finished.  

In any case, this patient ended up in hospital on a drip. She needed IV antibiotics for 2 days, before going home on a stronger tablet form. Fortunately, this patient didn't need more surgery, and ultrasound scans have confirmed that there is no more fluid build up.

The issue here is two-fold. Firstly, a complication like this sets a patient's recovery back. Instead of being at the tail end of recovery and starting to return to normal, this lady is now at the start of a new recovery process, because a complication is like pressing reset on the recovery clock. We go back to square one, we tell the patient they need to treat this like they are immediately post-op (throw the last 3 weeks away, slow it all down, we're starting again!), and we have to accept that the scars may be uncontrollably altered by things like infection. And of course the prolonged/altered recovery process gets in the way of work, family, life and so on. Secondly, this lady is fortunate in that she has private insurance which covered her readmission to hospital. In some respects, the true value of insurance in the context of procedures like this is that in the event of complications, readmission and even re-operation is covered by insurance (for my patients). If this lady had been uninsured, then admission to a private hospital would have been at great expense. The alternative is admission through a public hospital, the problem with that being that the patient would no longer be under my direct care, which can make things tricky.

So, to go back to the start: what could I have done differently?

Honestly, not sure. This collection developed around the 3 week mark, which may just be bad luck, but unfortunately is more commonly related to too much activity too soon. That isn't necessarily to say that a complication like this is a patient's fault...but it is at least worth considering that as a patient, you can substantially modify your own risk post-operatively based on what your level of activity.

What is too much activity? There is no good "science" here, and every surgeon has their own ideas. Personally, I tell my patients that they cannot engage in any repetitive arm movements, and they cannot bounce, and ideally we want the breast to remain as still as possible for the first 6 weeks. I also tell people that they shouldn't do any one thing for more than 15 minutes at a time. So, whilst walking (strolling!) a bit is good, an hour long walk (not matter how gentle) is too much.

I really stress the importance of the recovery period both before and after surgery. Should I be more strict with my patients? I suspect most would tell you that I already am quite direct in telling them what to do. We talk about avoiding excessive activity in conversation, in consent, in our instructions, and at every post-op visit.

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Ultimately, this is a good example of the reality of surgery. No matter what I do, I can only control so much. I can reduce risk substantially with my techniques and protocols, but I can never reduce the risk of surgery to zero.

Worth keeping in mind.