Aesthetic mammoplasty: common surgical complications

Shkolnaya Olga Sergeevna , plastic surgeon at Patlazhan Clinic, member of the International Society of Aesthetic Plastic Surgeons ISAPS, member of the Ukrainian Society of Aesthetic Plastic Surgeons USAPS

Aesthetic mammoplasty is one of the most popular operations in plastic surgery. Over the past three years alone, the number of surgical interventions in this area has increased by almost 1 million; in 2018, 2 million 191504 operations were performed, and in 2021 – 3 million 190235 [1].

Any type of mammoplasty, be it breast augmentation, breast reduction or mastopexy, carries not only an excellent desired result that improves the quality of life of patients, but also a high risk of various complications. The risk of complications depends on many factors: the technique and conditions of the operation, the patient’s compliance with recommendations, the characteristics of the rehabilitation period and the patient’s body’s reaction to surgery.

All complications that arise during the above surgical interventions can be divided into two groups: general surgical and specific.
General surgical complications include: bleeding, thromboembolism of the pulmonary artery seroma, hematoma, wound suppuration, formation of pathological scars, allergic reaction, trophic disorders, suture failure, ligature fistula.

Specific complications include: fibrous capsular contracture, secondary ptosis of the mammary glands, asymmetry of the mammary glands, dystopia and deflation of the prosthesis, irregular shape (double fold, waves), impaired sensitivity of the nipple skin, lactation disorders, plexopathy, pneumothorax and subcutaneous emphysema.

Also, complications of mammoplasty can be divided according to the time of occurrence into three groups: intraoperative, early postoperative, and late [2].

Bleeding

Occurs, as a rule, in the next few hours after surgery.

Signs of postoperative bleeding are:

1. Edema;
2. Seal;
3. Change in skin color.

Effective hemostasis during surgery is ensured both by technical means from the arsenal of surgeons - surgical intervention taking into account the anatomical features of the operation area, the use of power tools, and by means affecting the blood coagulation system [3].

The blood supply to the mammary gland is carried out by three large arterial vessels:

• intrathoracic artery (60%) – gives off perforating arteries, emerging in the 3-5 intercostal spaces (medial zone of circulation), the pressure corresponds to the aorta;
• lateral thoracic artery (from the axillary artery 30%) – superolateral zone of blood circulation;
• 3-5 posterior intercostal arteries, as well as branches of the subscapular artery - giving off perforators, inferolateral circulation zone 10% [4].

From the arsenal of agents affecting the blood coagulation system, the following can be distinguished:

Etamzilat

• Stimulates platelet formation by affecting tissue thromboplastin.
• Increases the rate of blood clot formation, reduces capillary fragility.
• It acts in 5-10 minutes, 1 ampoule – 250 mg, maximum – 750 mg IM, IV [5].

Aminocaproic acid (fibrinolysis inhibitor) 5%, 100 ml

• The drug is administered intravenously, up to 100 ml.
• If necessary, repeat infusions at intervals of 4 hours, topically.
• The bleeding surface is irrigated with a cooled 5% solution (50-200 ml each) or 1-2 layers of moistened wipes are applied to the bleeding surface in compliance with the rules of asepsis.
• It works within 15-20 minutes [6].

Tranexam (fibrinolysis inhibitor)

• Solution for intravenous administration.
• Indications for use: bleeding or risk of bleeding due to increased fibrinolysis (bleeding during operations and in the postoperative period).
• If there is a high risk of bleeding due to a systemic inflammatory reaction - at a dose of 10-11 mg/kg 20-30 minutes before the intervention.
• For local fibrinolysis, it is recommended to administer the drug at a dose of 250-500 mg 2-3 times a day. Release form: 5 ml ampoule, 50 mg/ml [7].

Vikasol

• A water-soluble analogue of vitamin K, promotes the synthesis of prothrombin and proconvertin, increases blood clotting by enhancing the synthesis of coagulation factors. The onset of the effect is 8-24 hours (after intramuscular administration).
• A single dose for adults is 10-15 mg, a daily dose is 30 mg.
• The duration of treatment is 3-4 days, after a four-day break the course is repeated.
• For surgical interventions with possible severe parenchymal bleeding, it is prescribed for 2-3 days before surgery [8].

Pulmonary embolism - PE

Blockage of the pulmonary artery or its branches by blood clots , which form more often (sources) in the large veins of the lower extremities or pelvis ( embolism ).

Thromboembolism, starting with deep vein thrombosis (DVT), can be asymptomatic, only manifesting clinically in 33% of patients.

Thus, it is easier and more correct to try to prevent the transformation of DVT into PE than to treat the consequences of a severe, life-threatening complication.

For individuals who have any of the risk factors or two or more low-risk factors, it is advisable to conduct a laboratory test for a specific marker D-dimer .

A low level of D-dimer in the blood plasma excludes the presence of deep vein thrombosis. A positive test (more than 0.5 ng/l) can be considered an indication for ultrasound examination and venography.
Deep vein thrombosis or a high risk of its development requires the perioperative use of a set of measures to prevent further development of thromboembolism. Mechanical prevention includes the use of compression stockings and early mobilization of patients.

Pharmacological prophylaxis has many plastic surgeons concerned that it will increase the risk of bleeding. According to Hsu et al., patients over 40 years of age with an intervention duration of more than 30 minutes should be included in the highest risk group for the development of pulmonary embolism. Additional risk factors are the presence of malignant processes, immobilization, obesity and hypercoagulable status. For such patients, prophylactic use of low molecular weight heparins is indicated primarily.

When used correctly, LMWHs increase the incidence of complications associated with increased bleeding!

Plastic surgeons from Yekaterinburg presented their experience in the use of LMWH (low molecular weight heparins) in aesthetic surgeries on the face: a retrospective analysis of 496 operations was carried out for the period from January 2007 to December 2012. The thromboprophylaxis system proposed by the authors included:

• elastic compression of the lower extremities;
• intermittent pneumatic compression of the lower extremities;
• early activation of patients;
• prescription of LMWH (in the group of high and moderate risk of thrombosis and thromboembolism, it is recommended to prescribe Clexane 40 mg and 20 mg, respectively, 12 hours before surgery, then once a day for 2-7 days) [9-12].

Infection, hematoma, seroma

Prevention of infectious complications includes strict adherence to asepsis, careful stopping of bleeding, washing of formed cavities with an antiseptic and antibiotic solution (with augmentation mammoplasty), as well as a single preoperative administration of a broad-spectrum antibiotic in prophylactic doses [13].

The risk of hematoma formation can be reduced by careful hemostasis. Small hematomas can be evacuated through the wound without reoperation; however, large hematomas require repeated surgery with their emptying and careful hemostasis and drainage.

The criterion for drainage removal is the amount of aspirate per day less than 50 ml, a change in the color of the discharge (with a predominance of the serous component). On average, the duration of the drainage period is two days.

Performing an ultrasound examination of the mammary glands before removing drainage additionally allows one to determine the optimal period of drainage [14].

The incidence of seromas can be reduced by proper incision technique. Some surgeons believe that the use of power instruments increases the likelihood of seroma formation and for this reason recommend acute excision using coagulation only to control bleeding [15].

There is an opinion that hematomas and seromas are provoked by the textured membrane rubbing against the capsule. Seroma leads to the sedimentation of cells onto the membrane, forming a pseudobursa, which turns the textured implant into a smooth one, and this, in turn, increases the risk of capsular contracture. Seromas are eliminated using punctures and aspiration of the contents [16].

An increase in the exudative reaction in the wound may be a consequence of the patient’s violation of the postoperative regimen, early physical activity, refusal of sufficiently long (up to 6 weeks) bandaging with an elastic bandage and wearing a bra [17].

Bibliography:

1. International Society of Aesthetic Plastic Surgery. National plastic surgery statistics. Available at.- . Isaps.org
2. Timerbulatov V.M., Popov O.S., Plechev V.V., Popova O.V. Mammoplasty for disorders of the volume and shape of the mammary gland: monograph / Timerbulatov V.M., Popov O.S., Plechev V.V., Popova O.V. –Moscow 2002.- p.36
3. Petlakh V.I. The role of local hemostatic agents in the provision of surgical care to the sick and injured // Chief Doctor of the South of Russia. - 2014. - No. 5. - P. 12-13.
4. Pshenisnov K.P. - Plastic surgery course. In two volumes./ Pshenisnov K.P. – Yaroslavl 2010- p. 759
5. Encyclopedia of medicines and pharmaceutical products: Etamzilat http:// www rslnet.ru
6. Encyclopedia of drugs and pharmaceutical products: Aminocaproic acid. http:// www rslnet.ru
7. Encyclopedia of drugs and pharmaceutical products: Tranexam. http:// www rslnet.ru
8. Encyclopedia of medicines and pharmaceutical products: Vikasol. http:// www rslnet.ru
9. Lemeneva N. Anesthetic aid in aesthetic surgery. Part 1. Preparation for anesthesia and surgery as a prevention of possible complications of the perioperative period./ Lemeneva N. // Aesthetic Medicine 3(2014) p.467-473
10. Vardanyan A.V., Mumladze R.B., Melkonyan G.G. Prediction and prevention of postoperative venous thromboembolic complications. Method. developer – M., 2009.
11. AHA. Management of Massive and Submassive Pulmonary Embolism, Iliofemoral Deep Vein Thrombosis, and Chronic Thromboembolic Pulmonary Hypertension // Circulation. – 2011. – Vol. 123.
12. Diagnosis and treatment of allergic diseases: educational manual / I.P. Koryukina, A.V. Tuev, V.Yu. Mishlanov, E.S. Horowitz, S.L. Mishlanova. - Perm, 2008. - 135 p.
13. Belousov A.E. Plastic reconstructive and aesthetic surgery. St. Petersburg, 1998. 669-670 p.
14. Shumakova, T. A. Possibilities of ultrasound in assessing the condition of the mammary glands and implants after augmentation mammoplasty with silicone gel endoprostheses / T. A. Shumakova, V. E. Savello. - P.23-33
15. Mustafa Hamdi, Denis Hammond, Foad Nhai. Vertical mammoplasty./Mustafa Hamdi, Denis Hammond, Foad Nhai. - Moscow, 2012 p. 128
16. Collis N., Coleman DJ, Foo IT, Sharpe DT Ten-year review of a prospective randomized controlled trial of textured versus smooth subglandular silicone gel breast implants. Plast Reconstr Surg. 106, 3, 786-791, 2000.
17. Belousov, A. E. Plastic, reconstructive and aesthetic surgery / A. E. Belousov. St. Petersburg: Hippocrates, 1998.-668 p.

Expect more about the possible risks of mammoplasty in the following articles from the author on Pro Cosmetology.