Sometimes It’s Not Your Fault

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As physicians, and particularly as surgeons, we are ultimately responsible for what befalls patients as a result of our care. We take full ownership of postoperative problems, for example, and labor to resolve them as expeditiously as possible. Hematomas are a case in point. Most occur early postoperatively, and are not totally avoidable. Meticulous hemostasis in a normotensive setting is the best prevention but no guarantee. We accept this risk, explain the possibility to our patients, and act regardless of the time of day or night when one occurs. Fortunately, timely evacuation of hematomas neither prolongs recovery nor negatively impacts long-term results.
What about late hematomas? Decades of practice have revealed to me that hematomas do occur during the second week postoperatively, although less commonly, and are virtually nonexistent further out than that. The cause for late hematomas may be attributable in part to the natural progression of wound healing where the balance between clot formation and fibrinolysis has tilted in favor of the latter. In addition, “clot lysis is affected by mechanical factors; in particular, high shear stresses can rupture the clot.”1,2 This would aptly describe sudden or vigorous muscle activity involving the surgical site.
Subpectoral breast augmentation is a cardinal example of a procedure prone to hematomas during the second week of recovery. Over the years, our practice has witnessed late hematomas resulting from such varied activities as fly swatting, playing ping pong, opening stuck refrigerator doors, and of course, the premature resumption of intimate activities. Breast augmentation patients typically feel nearly normal at 1 week, and most are eager to get back to exercise or resume care of their young children. It seems logical therefore that enhanced patient awareness could help prevent late hematomas.
In a quest to reduce this risk, we distribute an information letter (conveniently kept in an examination room folder) to selected patients at their 1-week postoperative visit (Fig. 1). Although our breast augmentation patients are the primary target, we also give it to our rhytidectomy, abdominoplasty, and breast reduction patients. Fortunately, rhytidectomy and abdominoplasty patients typically have enough surgical-site awareness at 1 week that caution usually endures, and the risk is inherently lower in reduction patients where musculature is not exposed during the procedure. Body lift patients would seem another appropriate group to consider for this practice.
Hematomas, besides creating sudden psychic stress for all involved, incur labor and facility costs. These costs are overlooked with early hematomas as a courtesy, as is the norm in our specialty. However, additional fees are mentioned in our letter so that patients still at risk have some “skin in the game,” at least theoretically, and will possibly be more motivated to follow recovery guidelines.
We have come to realize that although we are responsible for the welfare of our patients, there are times when patients cause a problem that is not our fault. The additional effort at patient education described will pay dividends in a busy practice, preventing as much as one untoward event per quarter, as it has in ours. More importantly, patients are the ultimate beneficiary of this proactive effort.
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