I just finished updating my ‘MOC’ = maintainance of Certification for the American Board of Plastic Surgery. This annual process is required to ‘maintain’ a plastic surgeon’s board certification status. Its debatable whether the MOC process is truly effective or even important, but it is required – so I’ve done it. Anyway, this post outlines what I learned from an article I was required to read for the MOC.
Best Practices in Breast Augmentation – What I’ve Learned and What I’m Going to Continue to Do.
Looking back at my case list from the past 4 years, primary breast augmentation using implants is the number one cosmetic surgical procedure that I’ve done. I think I’ve got the operation down to a ‘science’, but after reviewing the recent article of breast augmentation ‘best practices’ by Dr. Charles Thorne, I picked up a couple of pointers.
In our field, there is a push toward ‘evidence based medicine’, in hopes of eradicating much of the anecdotal practices that we surgeons have clung to for years. So here is a review of my ‘best practices’ for BBA surgery.
1. The use of a single peri-operative dose of antibiotics – I’ve been doing that for years. No changes here.
2. The use of a pre-incision dose of methylprednisolone, which both diminishes post op nausea and reduced post-op narcotic use. I’ve been using corticosteroids pre-op for facial surgery, and for patients that have has past issues with post-op nausea. But I was not aware that there was a reduction in post-op narcotic use. So I plan to do for this for all patients from now on.
3. Incidentally, I’ve always done breast augmentation using ‘twilight sleep’ anesthesia – which is a IV based anesthetic, under the care of a anesthesia provider (MD or CRNA). I think there is less post-op nausea with ‘twilight sleep’ than a general anesthetic.
4. The use of local anesthetic (Bupivicaine) in the implant pocket – I’ve been doing this since the beginning, and believe it really helps patients. I have also been ‘pre localizing’ patients with local anesthetic prior to prepping the skin. Glad to see that my clinical suspicion that the in-pocket local anesthetic is effective has been confirmed with a clinical trial.
5. For a couple of years, I was using Lyrica (pregabalin) as an adjunct to the post-op pain medication. There appears to be evidence that post-op gabapentin reduced the need for post op narcotics. This confirms my suspicion that the Lyrica was actually helping, so I’m going to return to using it for 5 days post-op. Will use Gabapentin for patients that don’t have access to Lyrica through their insurance approved pharmacy medication list.
6. Lastly, I plan to resume the use of Celocoxib (Celebrex) in my practice. When I was a general surgeon years ago doing hernia repairs and gall bladder surgery, I had patients take a dose in the pre-op area. I stopped when there were news reports about cardiac events in patients using Celebrex long-term (not the case for my patients, but our of caution, I ditched the practice) – but I think a dose of the anti-inflammatory drug Celecoxib prior to breast augmentation surgery will add additional level of post-op pain control.
Anyway, that’s my ‘take away’ from my recent MOC experience – look me up in Seattle WA if you’d like to schedule a breast augmentation procedure implementing these state-of-the-art ‘best practices’.