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Achieving a Predictable 24-Hour Return toNormal Activities after Breast Augmentation:Part I. Refining Practices by Using Motionand Time Study PrinciplesJohn B. Tebbetts, M.D.Dallas, Texas

The purpose of this study was to develop techniques topredictably return patients receiving inframammary andaxillary, subpectoral breast augmentation to full normalactivities within 24 hours of their primary breast augmen-tation. This 5-year study applies motion and time studyprinciples to refine practices in augmentation mamma-plasty to reduce perioperative morbidity and shorten pa-tient recovery. Retrospective data for operative times,medications administered, recovery times, times to dis-charge, and time to return to normal activities were col-lected from patient chart reviews and patient contactsfrom 1982 to 1984 (group 1, n � 16, axillary partial ret-ropectoral augmentations) and 1990 (group 2, n � 16,inframammary partial retropectoral augmentations). Vid-eotapes from operative procedures of groups 1 and 2 wereanalyzed with macromotion and micromotion study prin-ciples, and tables of events were formulated for all oper-ating room personnel, detailing every step of each func-tion they performed. The events tables were then refinedinto detailed scripts by using motion and time study prin-ciples. Scripts were used for surgeon and personnel train-ing and for reference during operative procedures. Ex-tensive changes in all aspects of patient care, includingpatient education, preparation, operative planning, im-plant selection, anesthesia techniques, surgical tech-niques, instrumentation, and postoperative care derivedfrom data and videotape studies of patients in groups 1and 2 were then applied to a third group of patients(group 3), collecting prospective data over a 3-year period(1998 to 2000). Group 3 (n � 627) data included timedevents, medications, and time to return to normal activ-ities. Patients in group 3 had substantially shorter anes-thesia, operation, and postanesthesia care unit times andtime to discharge and time to return to normal activitiescompared with groups 1 and 2. Of the patients in group3, 96 percent were able to return to normal activities, lifttheir arms above their heads, lift normal-weight objects,and drive their car without any narcotic medications,drains, bandages, special bras, or other adjunctive treat-ments within 24 hours after their partial retropectoral

breast augmentation. Applying motion and time studyprinciples to analysis and refinement of surgeon and per-sonnel actions and surgical techniques resulted in a sub-stantial reduction in perioperative morbidity and a sim-pler, shorter 24-hour return to normal activities withoutintercostal blocks, narcotic pain medications, drains, ban-dages, or other adjunctive devices in 96 percent of 627augmentation patients. (Plast. Reconstr. Surg. 109: 273,2002.)

Perioperative morbidity, recovery time, andtime to return to normal activity or work areimportant factors for elective cosmetic surgerypatients. During the past two decades, no stud-ies have documented methods to dramaticallyand consistently reduce morbidity and shortenrecovery in augmentation mammaplasty pa-tients. Methods and techniques to reducemorbidity and speed return to normal activ-ity could benefit a wide range of patientshaving cosmetic and noncosmetic surgicalprocedures.

Eliminating time waste in the operatingroom shortens operation and anesthesia timesand reduces drug requirements. Reducing tis-sue trauma, bleeding, and inflammation de-creases postoperative pain and complicationsand results in a more uneventful, faster recov-ery with a faster return to normal activity orwork. Considering the numbers of breast aug-mentations that are performed annually world-wide, the potential medical and financial im-plications of these factors are great for

Received for publication February 9, 2001; revised November 1, 2001.Dr. Tebbetts is a consultant to McGhan Medical Corporation and Genzyme Snowden Pencer. He receives financial benefits from these

companies. Breast implant products and surgical instruments distributed by these and other companies are mentioned in this article.

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patients, surgeons, and surgical facilities. Mo-tion and time study principles1 have been ap-plied previously to improve medical and surgi-cal efficiency.2–5 These principles, adapted forsurgical procedures, can potentially increaseefficiency in the operating room, decreaseperioperative morbidity, and speed patient re-covery in breast augmentation and other cos-metic surgical procedures.

Perioperative morbidity and patient recoveryinvolve many factors, some of which the sur-geon can control and others that the surgeoncannot control. This study focuses on specific,surgeon-controlled factors that affect perioper-ative morbidity and recovery in breast augmen-tation. The following hypotheses are the basisof the study:

1. Reduction of the time required to performall optimal actions during an operation willresult in a decrease in anesthesia time, drugrequirements, drug side effects, and periop-erative recovery times.

2. Reduction in surgical trauma can producesignificant decreases in postoperative in-flammation and pain, analgesic require-ments, necessity of drains, bandages, orother devices that complicate recovery, andpotential incidence of complications.

3. Patients who experience reduced operationtimes and surgical trauma will experience asimpler, less complicated, and faster recov-ery and return to normal activity.

4. Alteration of preoperative patient educa-tion, surgical techniques, perioperativemanagement, and postoperative manage-ment based on hypotheses 1 through 3 cansignificantly alter perioperative morbidityand recovery in augmentation mamma-plasty to shorten recovery time.

5. Addressing all pertinent factors (nonsurgi-cal and surgical) simultaneously rather thanisolated factors is likely to produce largerincremental improvements in perioperativemorbidity and recovery.

6. If surgical trauma, operative times, and peri-operative morbidity can be substantially re-duced, a majority of patients undergoinginframammary or axillary, subpectoralbreast augmentation can return to full, nor-mal activities (lifting their arms above theirheads, lifting normal-weight objects, anddriving their car) within 24 hours aftersurgery.

7. Optimal patient education, breast evalua-

tion, operative planning, and surgical tech-niques make narcotic pain medications, in-tercostal blocks, drains, bandages, specialbras, and other adjunctive devices unneces-sary in primary breast augmentation.

8. In addition to all of the potential benefits topatients listed previously, increased effi-ciency, precision, and reduced time wastecan reduce patient costs, surgery facilitycosts, and produce substantial savings of sur-geon time.

9. Dramatic improvements in patient outcomeare possible by detailed reassessment ofpractices and techniques, even by surgeonswith 15 years of experience. Best practicesmodels derived from detailed reassessmentsby experienced surgeons provide useful in-formation for resident education and sur-geon continuing education and skillsbuilding.

Each hypothesis involves basic principlesknown to every plastic surgeon. This studyquestions whether these principles can be ex-tended, refined, and applied in a large numberof patients to produce significant, consistent,and predictable improvement in perioperativemorbidity and recovery following augmenta-tion mammaplasty. The principles involved inthis study are applicable to every operation inelective, cosmetic surgery. Part I of this studyaddresses methodologies and findings of themotion and time studies and their impact onperioperative and postoperative parameters.Part II addresses the details of surgical tech-nique modifications that resulted from motionand time study findings to produce the resultsreported.

PATIENTS AND METHODS

Duration of Study

This study was initiated in January of 1995and concluded in December 2000. The first 3years of the study focused on developing themethodologies, integrating the technologies,and initiating motion and time study data col-lection and analysis1 to generate refined prac-tice protocols for clinical integration. In late1996 and throughout 1997, refined protocolswere integrated and personnel were retrained.Retrospective data were collected for twogroups of 16 patients each (groups 1 and 2) ofpatients at 10-year intervals before implemen-tation of motion and time study findings for

274 PLASTIC AND RECONSTRUCTIVE SURGERY, January 2002

comparison to group 3 prospective data. Pro-spective timed events data and recovery datawere collected for 627 patients in group 3 whowere operated on after implementation of mo-tion and time study findings and surgical tech-nique modifications from January 1998through December 2000.

Study Parameters

Figure 1 lists parameters, methods, and tech-nologies addressed in the study. Surgicaltrauma and surgical efficiency are two major

categories of variables that affect perioperativemorbidity and recovery. The degree of surgicaltrauma is largely determined by surgeonskills—analysis and planning, implant selec-tion, operative technique, perioperative man-agement, and postoperative managementskills. Each of these skills categories impactsurgical efficiency and tissue trauma. Surgicalinstrumentation and anesthesia-related func-tions (muscle relaxation, blood pressure man-agement, and limiting intraoperative medica-tions and dosages) indirectly affect surgical

FIG. 1. Study parameters flowchart. Surgical trauma and surgical efficiency factors that have an impact onpatient recovery, methods used to refine each factor, and methodologies and technologies used in the study toincorporate refinements into patient care and surgery center management.

Vol. 109, No. 1 / MOTION AND TIME STUDY PRINCIPLES 275

trauma. Increased surgical efficiency is re-quired to reduce operative times without sacri-ficing precision and quality. Additional factorsaffecting surgical efficiency include surgeonoperative planning, time management (elimi-nation or reduction of time-wasting activities),operating room personnel training, and man-agement of the surgical environment. Each ofthese parameters potentially affects patientoutcome.

Patient Groups

Two groups of 16 patients each (groups 1and 2) were studied retrospectively for compar-ison to a third group of 627 patients (group 3)studied prospectively after implementing thisstudy. Patients in group 1 had transaxillary par-tial retropectoral breast augmentations in1982–1983, using dissociative anesthesia, bluntinstrument implant pocket dissection, andDow Corning, double-lumen implants contain-ing 20 mg of methylprednisolone and 20 cc ofsaline in the outer lumen of the implants. Pa-tients in group 2 (1990) had inframammary,retromammary augmentations by a combina-tion of blunt and electrocautery dissection,Surgitek Replicon polyurethane-covered, sili-cone gel–filled anatomic implants, and generalendotracheal anesthesia. In group 3 (627 pa-tients), 533 patients had inframammary, partialretropectoral augmentations, 35 patients hadinframammary retromammary augmentations,and 59 patients had axillary, partial retropec-toral augmentations by using only electrocau-tery pocket dissection. All patients in group 3had general, endotracheal anesthesia and sa-line-filled implants: 1220 McGhan Style 468textured anatomic implants (97 percent), 26Mentor Siltex textured round implants (2 per-cent), and eight Mentor smooth round im-plants (1 percent).

Methodologies

To evaluate and refine each factor identifiedfor surgical trauma and operative efficiency, auniform set of methods was developed. Basedon principles of motion and time studiesadapted and simplified from industrial engi-neering principles,1 the sequence of methodsis graphically depicted in Figure 1. Each factorwas analyzed in extensive detail, listing everycurrent practice event (motion or group ofmotions) and breaking each practice into de-tailed subroutines. Essential steps were identi-fied and nonessential steps eliminated. Essen-

tial steps were then analyzed, alternativesstructured for greater efficiency, and a refinedlist of steps for each practice or factor wasgenerated. The refined list was then used as achecklist to define new practices. The goal ofmotion and time studies is to eliminate muda, aJapanese word for waste, by working smarterand harder. Inherent in motion and time studyprinciples and applied throughout this study isthe tenant that no refinement in method everoccurs at the expense of quality.

Technologies were identified to facilitateanalysis and data collection and were inte-grated with refined practices. Surgeon and per-sonnel were retrained on the basis of improvedpractices, new or refined instrumentation wasintegrated into surgical procedures, and intra-operative management was altered to optimizerefined practices for group 3.

Data Collection

Retrospective data were compiled from chartreviews of two different groups of patients, 16consecutive axillary augmentation mamma-plasties from a previously reported series6 bythis author (group 1) and 16 consecutive infra-mammary augmentations performed beforeinitiation of this study (group 2). Medicalrecords personnel selected the retrospectivecases at random from a specified time period.Retrospective data were collected for the fol-lowing parameters for each case: anesthesiatime; operative time; implant type; implantsizer use; anesthetic drugs and total dosagesadministered for each; time in a postanesthesiacare unit; use of drains; use of postoperativebandages, bras, or devices; time after dischargefrom postanesthesia care unit to dischargehome; drugs and dosages administered beforedischarge (postanesthesia medications); post-discharge medications; and time to return tonormal activity. Time to return to normal ac-tivity was defined as (1) lifting the arms abovethe head three times in sequence four times aday, (2) lifting all normal-weight objects (up to20 pounds) or young children, (3) driving per-sonal car, (4) going out of house for shoppingor entertainment, (5) returning to work or fullnormal activities, (6) being able to lie prone onbreasts for at least 15 minutes, and (7) beingtotally free of all postoperative adjunctive de-vices or narcotic medications. Postdischargedata were obtained from telephone callrecords (all patients were called daily for 3 dayspostoperatively), prescription records, and


postoperative visit notes from patients’ officecharts. Prospective data were collected for 627primary augmentation patients (group 3) overa 3-year period from January 1998 throughDecember 2000 by using all of the same param-eters of collection for retrospective cases. Allprospective data were collected by using pre-defined events that were translated into barcodes (Fig. 2, above) and recorded by bar-codewands that contained a clock to define exacttimes for each patient event and time interval.All drugs and dosages administered were alsorecorded by using similar technology. Bar-codedata for each case were downloaded at the timeof patient discharge (Fig. 2, below) to a surgerycenter management database for subsequenttabulation and analysis.

Data for retrospective motion and time studyanalysis were collected from unedited video-tapes of axillary and inframammary augmenta-tions recorded during the same time intervalsas the retrospective patient samples. Thesedata were used to identify time-specific catego-

ries of activity and details of subroutines duringthe operation for comparison to group 3 afterintegrating refined practices. Data for prospec-tive motion and time study analysis and surgi-cal technique analysis were collected by usingthree video cameras simultaneously in the op-erating room. One camera was set to view theentire operating room throughout the opera-tion, a second camera was set to view the scrubnurse, instrument stand, assistant, and sur-geon, and the third camera was set over thesurgeon’s shoulder or a surgeon head-mountcamera was used to view the surgeon’s field ofvision. Videotapes were then digitized by usinga nonlinear digital video editing system withAdobe Premiere software in a two-screen con-figuration (Fig. 3) with a simultaneous wordprocessing program, Microsoft Word. Opera-tions were analyzed by breaking each video-taped operation into segments of 3 to 5 min-utes, listing large groups of motions(macromotion studies), then breaking each ofthe larger groups into smaller groups of mo-tions or individual motions (micromotion stud-ies), listing each in a table of events in the wordprocessing program. A table of events was cre-ated for each person in the operating room,listing all motions or groups of motions frompreparation of the operating room to comple-tion of the operation. These tables were thenanalyzed to identify all essential motions orgroups of motions, using principles that askedfive questions: (1) Can I eliminate this step?(2) Can I combine this step with another stepor steps? (3) Can I rearrange the steps to makethe flow shorter or smoother or both? (4) CanI simplify the step? and (5) Can the changes bemade without any sacrifice of quality? Eachdetail of surgical technique, instrumentation,and event was analyzed by asking the followingquestions: (1) Is this technique or event causingsurgical trauma? If so, how, and can it be modi-fied to reduce surgical trauma? and (2) Is thistechnique, instrument, or event causing anybleeding whatever? If so, how, and can it bemodified to prevent bleeding from ever occur-ring and, if it occurs, to minimize residual bloodin tissues surrounding the implant pocket?

Nonessential motions were eliminated fromeach table incrementally in stages, and motionswere combined, rearranged, simplified, and re-grouped to improve efficiency. Refined tableswere then converted to script checklists for eachpersonnel position that were used for retrainingand were available on computer screens in the

FIG. 2. (Above) Bar codes for predefined events in thepatient care sequence were scanned with a bar-code scannercontaining a clock that recorded timed events data. (Below)At the time of patient discharge, bar-code scanners weredocked and timed events data were downloaded to a databasefor subsequent analysis.


operating room for use during operations. Aminimum of four and maximum of 13 reanalysesand revisions were made to each table of eventsfor each of the following personnel: certified reg-istered nurse anesthetist, surgeon, surgical tech-nician assistant, instrument (scrub) technician,and circulating nurse. Details of analysis, modifi-cations, and results of surgical techniques arepresented in part II of this study.7

Postanesthesia Recovery

All patients in group 3 were treated accord-ing to a strict postanesthesia recovery unit pro-tocol following guidelines of the AmericanSociety of PeriAnesthesia Nurses.8 After admis-sion to the postanesthesia care unit, patientsreceived 12.5 mg of Phenergan intravenously,followed by 25 mg of Demerol intravenously,followed by stimulation, sitting up, and deepbreathing. Immediately before discharge fromthe postanesthesia care unit to step down, 12.5mg of Phenergan and 25 mg of Demerol weregiven intramuscularly. No other medicationswere given. Three milligrams of morphine wassubstituted for Demerol in patients who had ahistory of adverse reaction to Demerol. In stepdown, patients were stimulated and ambulateduntil they achieved American Society of Peri-Anesthesia Nurses scores of 10 and met dis-charge criteria.

Postoperative Medications, Drains, and Bandages

Patients in groups 1 and 2 received postop-erative pain medication prescriptions for

Phenaphen 3 and Tylenol 3, respectively, 35doses for 1 week. All patients in group 3 re-ceived 800 mg of ibuprofen (Motrin 20) for 5days and 50 mg of diphenhydramine(Benadryl) for sleep for 3 days. No patient ingroup 3 received any intercostal blocks. No pa-tient in group 3 received any other prescriptionmedication. Patients in group 1 were bandagedwith gauze sponges over the incision sites andelastic wraps around the chest for 4 days. Patientswith inframammary augmentation in groups 2and 3 were discharged postoperatively withoutany bandages, except the patients with the axil-lary procedure in group 3 who had a single gauzesponge in the axilla that was removed the firstpostoperative morning. No drains were placed inany patient in any of the three groups, and nopatient had any type of bra, strap, or other posi-tioning device postoperatively.

Clinical Experience and Results

Tables of events. For each of the personnel inthe operating room, Table I presents the numberof motion events or groups of motions that werelisted initially, the number that existed after finalrefinement, and the percentage of reduction intotal events. Details of these lists and scripts areprohibitively extensive for publication in this for-mat. A compiled summary excerpt of one seg-ment of the table for incision through pocketdissection for the surgeon and assisting person-nel is presented in Table II. Complete surgicalscripts for inframammary and axillary augmenta-

FIG. 3. Digitized intraoperative video from each of three cameras was analyzed foreach motion and combination of motions by using digital video editing software (leftscreen), simultaneously listing each motion to derive a table of events in a word pro-cessing program (right screen).


tion are available for download at the Journal’sWeb site at http://www.plasreconsurg.org.

Excerpts of the anesthesia table of events forinframammary subpectoral augmentation arepresented in Table III. The specific time inter-vals listed in Table III are adjusted as surgeonskills and efficiency require. Complete surgeontable of event scripts for inframammary andaxillary partial retropectoral augmentation areavailable for download on the Journal’s Website at http://www.plasreconsurg.org.

Time Parameters Results

Table IV lists a summary of results for each ofthe timed intervals studied and compares group1 axillary, partial retropectoral patients togroup 3 axillary partial retropectoral patientsand group 2 inframammary, retromammary pa-tients to group 3 inframammary, partial retropec-toral patients.

Perioperative and Postoperative Medications

Table V lists perioperative medications dataand Table VI lists postdischarge medicationsand average dose per patient for groups 1through 3. Average dose per patient is the totaldosage of medication administered to all pa-tients in the group divided by the number ofpatients in the group.

Procedures and Implants

Table VII details the types of procedures byincision and pocket location that were per-formed in patients in group 3. Table VIII listsimplant types, size ranges, and average size inpatients in group 3.

All patients in group 1 received Dow Corn-ing, low profile, double lumen implants con-taining 20 cc of saline with 20 mg of methyl-prednisolone in the outer lumen of theimplant, in sizes ranging from 220 to 350 cc,with an average of 256 cc. All patients in group

2 received Surgitek Replicon, silicone gel-filled, anatomic implants in sizes ranging from325 to 500 g, with an average of 393 g.

Implant Sizers

Implant sizers were used in 11 of 16 cases ingroup 1 and in 7 of 16 cases in group 2. Nosizers were used in any patient in group 3.

Return to Normal Activities

Table IX presents times required for returnto normal activities for group 3. Patients wererequired to meet all seven criteria listed previ-ously by the evening of the first postoperativeday to be included in the 24-hour return tonormal activities.

Ten Categories of Surgical Refinement

Ten specific areas evolved from the studiesthat directly impacted intraoperative times andtechniques. Details of the refined surgical tech-niques developed from this study are extensiveand will be presented in part II of this report.7Needs for surgical technique refinement wereinitially identified from detailed analysis of dig-itized videotape segments during motion andtime study analyses.

Complications

Patients in group 3 (n � 627 patients, 1254breasts) were followed up for up to 36 months.Table X lists complications requiring reopera-tions in patients from group 3. Of the 627patients in group 3, no patient experienced ananesthetic complication or anesthesia-relatedcomplication after discharge other than minorthroat irritation from the endotracheal tube.This required no treatment and uniformly sub-sided in less than 24 hours.

Recovery and Discharge Criteria

Every patient in group 3 met all dischargeassessment criteria for phase I and phase IIrecovery established by the American Societyof PeriAnesthesia Nurses,8 and each was dis-charged from the postanesthesia care unit witha recovery score of 9 or 10 and a final phase IIdischarge score of 10.

Time Savings in Group 3

Table XI lists pro forma time savings andsurgical facility cost savings for timed intervalsin patients from group 3 with the inframam-mary, partial retropectoral augmentation com-

TABLE ISterile Field Personnel Motion and Time Events for

Inframammary Augmentation Subroutine fromIncision to Closure

Operating Room Personnel

No. ofEvents beforeRefinement

No. ofEvents afterRefinement

Reduction inEvents (%)

Surgeon 326 114 65Surgical technician assistant 66 26 61Instrument technician 143 51 64Certified registered nurse

anesthetist 22 7 68


TABLE IISurgeon, Assistant, and Scrub Table of Events Script Subroutine for Inframammary Subpectoral Pocket

Dissection, Excerpted*

Tasks Surgeon Assistant Scrub

Entering subpectoral spaceCautery forceps to surgeon XSuction to assistant XEnsure long forceps and sponges ready XAim for medial border areola XLift retractor to tent lower pectoralis major, think about “no touch” perichondrium and location of first

infraareolar perforatorX

Look for intramuscular perforators, divide pec origins in small increments XCoagulate pinch intramuscular vessels XEnter subpectoral space medial to areola XLook ahead for large perforator before advancing retractor, lift tissues with forceps and think “no touch”

perichondrium before advancing retractor tipX

Insert forceps and lift soft tissues XChange to long blade of double-ended retractor without touching periosteum/perichondrium XIdentify and coagulate first large perforator inferior to areola X

Inferomedial pocket developmentEnlarge lower medial pocket inferiorly, aim toward sternum 4 cm superior to junction with IMF, think about

location of second inferomedial perforatorX

Begin division pec origins along IMF 1 cm above proposed new fold from undersurface, divide in small increments XExpose lower muscle incision line 1 cm above proposed new IMF XLook medially for second large perforator, pinch coagulate proximal and distal, divide XIncrementally incise/divide pec across IMF XCheck skin markings and topography during muscle divisionWhen muscle division is complete inferiorly and medially to junction of IMF with sternum, look for vessels in

muscle stumps and subQ tissue along muscle division line as retractor is withdrawnX

With index finger, palpate line of muscle division along IMF from medial to lateral to ensure complete release XCentral pocket dissection

Sweep long blade of double-ended retractor from medial to lateral in midpocket, at all times keep tissues pulledonto retractor blade with nondominant hand’s ring and small fingers

X

Dissect from medial to lateral with electrocautery forceps XLook ahead for small perforators before advancing retractor blade XIdentify plane between pectoralis major and minor, dissect medial to lateral XStop dissection at lateral border of pectoralis minor to avoid excessive lateral pocket dissection initially, sweep

retractor inferiorly to assure complete division of pec origins laterally along the IMFX

Look back at cut muscle edge and previously dissected pocket for bleeders XAssistant brings longer fiberoptic retractor to field XInsert longer fiberoptic retractor beneath long blade of double-ended retractor without touching perichondrium

with fiberoptic bundle on retractor, then remove double-ended retractorX

Upper pocket dissectionPull tissue onto blade of retractor with ring and small fingers—ensure retractor is advanced to the most distal

portion of the pocket at all times, reposition frequentlyX

Dissect superiorly until thoracoacromial pedicle is visible XDissect laterally over the edge of the upper pectoralis major, stop at the posterior edge of the muscle X

Medial pocket dissectionMove retractor tip superomedially in the upper pocket and open the most superomedial portion of the pocket;

think about looking for medial perforatorsX

Check medial topographical skin marks frequently as superior to inferior dissection proceeds medially XDissect from superior to inferior along the medial pocket border, keeping retractor tip advanced medially at all

times and pulling overlying tissues onto retractor blade with small and ring fingers of nondominant handX

Pinch all structures to be divided medially with forceps instead of using closed forceps-tip dissection XScrub brings irrigation and syringe to field XAssistant brings suction to field XDivide only the medial origins of pectoralis that are white (tendinous) or that are clearly lateral to the main body

of the muscle medially. Pinch divide with forceps, look for medial perforators at all times. Never completelydivide any medial pectoralis origins along the sternum.

X

Stop dissection at medial IMF where medial pocket dissection joins the IMF XRecheck inferomedial pocket borders where medial dissection joined IMF XRecheck medial pocket relative to topographical skin markings XRecheck cut muscle edges superiorly and inferiorly as retractor is withdrawn, check remainder of pocket for minor

bleeding, coagulate as necessaryX

Scrub brings double-ended retractor to field XBefore removing fiberoptic retractor, insert long blade of double ended retractor, avoiding perichondrium,

remove fiberoptic retractor, leaving double-ended retractor in pocketX

Scrub brings irrigation basin to field X

* IMF, inframammary fold; pec, pectoralis; subQ, subcutaneous. Complete versions of surgical events scripts for inframammary and axillary augmentation areavailable for download at the Journal’s Web site at http://www.plasreconsurg.org.


pared with patients in group 2 with the infra-mammary, retromammary augmentation.

DISCUSSION

A bricklayer, Frank Gilbreth (1868 to 1924),and his wife, Lillian (1878 to 1972), are recog-nized as the pioneers of motion study.2 Theirbasic methods formed the basis of lean manu-facturing popularized by Toyota and widelyadapted to many types of businesses. Principlesof motion and time study are helpful in evalu-

ating and revising surgical practices and focuson changes that ultimately benefit the patient,the surgeon, and the surgical facility. Surgeons,like bricklayers, are trained as apprentices. Spe-cific techniques or beliefs ingrained from train-ing become sacrosanct when, in fact, they maybe unproductive, unnecessary, and actuallycontribute to morbidity by wasting time or in-creasing trauma to tissues. These habits canpersist for years (in the author’s case, 15 years)until detailed reassessment identifies areas for

TABLE IIIAnesthesia Table of Events Script (Excerpted)*

Time (min) Event Medication Dosage Notes

Premed Versed 2 mg IV After surgeon has marked patientEndotracheal tube for all patients

1 Induction Reglan 10 mg, 2 cc Forehead strip—no esophageal temp probeInapsine 0.6 mg, 2 cc Tape head in place—table moves side to sideRobinul 0.2 mg, 1 ccFentanyl 50 �g/cc, 2 cc

5 LidocainePropofol 1–2.5 mg/kgNimbex

20 mg IV, 2 cc20 cc4–6 cc

If incision is made within 10 minutes, will usually notrequire reversal

Timing is critical for optimal pectoralis relaxation and toobviate reversal

Decadron 4 ccForane 2% Connect upper operative-field suction to anesthesia

suctionOxygen Hook up fill tube from field to bag of saline for implant

fillingConnect surgeon’s fiberoptic light source

10 Incision

Prepare to roll table toward surgeon

15 Right pocket dissectioncomplete

ROLL TABLE

When assistant begins filling right implant, ROLLTABLE AS FAR AS POSSIBLE TOWARD SURGEON

Assistant fills right implant,surgeon begins left pocket

Keep running total of right implant fill on Post-It Noteduring filling, attach to Clin Eval Sheet for surgeondictation

If difficulty or delay prolongs right pocket dissection,repeat dose of 1–2 mg of Nimbex when surgeonmakes left incision, may require reversal

20 Prepare to roll table level

Left pocket dissectioncomplete

Forane 1.5 or 1% Reduce Forane concentrationAssistant fills left implant Keep running total on Post-It Note–label as “left breast”

25 Surgeon closes right fasciaLEVEL TABLESIT PATIENT UP

LEVEL TABLE, SIT PATIENT UPRIGHT

Elevate to as near true sitting as possible

RETURN TO SUPINE,ROLL

Off ventilator, reduceforane

0.5–0.75% ROLL TABLE TOWARD SURGEON for closure of leftincision

30 CLOSURE BEGINS If pocket adjustments necessary, surgeon may ask toreposition table as needed

Closure left fasciaClosure left skinROLL TABLE

ROLL TABLE TO LEFT for closure of right incision

Closure right skinCLOSURE COMPLETECOMPLETE

35 SURGERY ENDS Reverse Nimbec prn, extubate, to PACU.

* IV, intravenous; prn, as needed; PACU, postanesthesia care unit.


improvement. Wasted time intraoperativelyprolongs anesthesia, increases medication dos-ages, increases medication side effects, andprolongs recovery. Surgical techniques thatincrease tissue trauma or bleeding produceunnecessary morbidity. This study suggeststhat major improvements can result from de-tailed refinements and extensions of existingprinciples, practices, techniques, andinstrumentation.

The micromotion analyses in this study werevaluable because they: (1) pointed out largenumbers of time-wasting practices that did notaffect quality, (2) encouraged the surgeon toview a totally different perspective that ques-tioned the necessity and productivity of themost minute details, (3) subjected time-honored surgical practices to scrutiny that sug-gest that many are unnecessary, wasteful, orineffective, (4) identified details of surgicaltechnique that dramatically affected patient re-covery, and (5) resulted in changes that dra-matically affected the patient, the surgeon, andoperating room personnel.

When the study entered the implementationand integration phase with patients fromgroup 3, benefits were immediately apparentby evaluating timed events data. Time saved atevery operation prompted scheduling changesthat left large blocks of time that were rein-vested in surgeon and personnel training. Thepractice had essentially no cost basis in thisadditional study and training because it wasaccomplished using “saved” time. The result-

ing increased surgeon and personnel skills in-creased the quality and productivity of surgicalprocedures to positively impact patient out-comes. Intraoperatively, fewer interruptions,distractions, and the elimination of unneces-sary decisions that could have been made pre-operatively provided a much more relaxed at-mosphere for the surgeon that allowed morefocus on the artistic details of the surgery. Elim-ination of delays and time waste also promptedchanges in the configuration of the surgerycenter, its management model, and the sur-gery-scheduling model. These additionalchanges further increased efficiency and im-proved patient recovery.

The efficacy of applying motion and timestudy principles to analysis of a routine cos-metic surgical procedure are evidenced by thedramatic change in patient outcome that waspossible over a 3-year period in the practice ofa surgeon with an extensive 15-year experiencewith augmentation.

The Surgeon’s Role

All potential improvements in morbidity andrecovery begin with the skill of the surgeon. Ifthe surgeon does not continually increaseskills, efficiency does not increase, anesthesiaand operation times do not decrease, medica-tion requirements and side effects do not de-crease, surgical trauma does not decrease, andpatient morbidity and recovery times do notdecrease. In addition to surgical skills, develop-

TABLE IVTimed Events Comparison for Groups 1 through 3*

Events Anesthesia Operation PACUBeginning of Operation to

DischargeReturn to Normal

Activities

(75–150) (60–120) (55–100) (95–515) 5.7 daysGroup 1 AXPRP 99 min 78 min 70 min 325 min 136.8 hr

(57–183) (37–85) (22–73) (54–123) 26.8 hrGroup 3 AXPRP 85 min 51 min 43 min 78 min

Time decrease 14% 35% 39% 76% 80.4%

(85–165) (60–120) (30–60) (120–475) 4.9 daysGroup 2 IMRM 126 min 89 min 45 min 351 min 117.6 hr

(30–74) (18–40) (19–83) (48–124) 24.2 hrGroup 3 IMRM 62 min 31 min 40 min 74 min

Time decrease 51% 66% 11% 79% 79.4%

(85–165) (60–120) (30–60) (120–475) 4.9 daysGroup 2 IMRM 126 min 89 min 45 min 351 min 117.6 hr

(35–88) (15–40) (17–82) (40–120) 25.7 hrGroup 3 IMPRP 52 min 24 min 41 min 75 min

Time decrease 58% 73% 11% 79% 78.1%

AXPRP, axillary partial retropectoral; IMRM, inframammary, retromammary; IMPRP, inframammary, partial retropectoral.* Values expressed as averages; parenthetical values indicate range.


ment of better skills in analysis and planning,technology utilization, and management bene-fits surgeons and their patients. Most impor-tantly, the surgeon must avoid the premise thatany current skill, technique, adjunctive ther-apy, or result is sacrosanct or adequate.

The Surgery Facility

Productivity is the key to business success forany surgery facility. Productivity begins withthe surgeon. Little or no incentive exists foroperating room personnel and surgery centermanagement to invest in change unless theyare motivated or forced by surgeon perfor-mance. The largest single overhead expensefor any surgical facility is personnel. The mas-sive savings in personnel costs to a surgeryfacility listed in the pro forma (Table XI) de-rive initially from increased surgeon skills. Asproductivity increases, personnel time costs de-

crease incrementally, and personnel can becompensated more for performance while si-multaneously reducing overall personnel coststo the facility. Surgeons who can increase skills,improve productivity, and reduce facility per-sonnel costs have substantial leverage with sur-gical facility management to effect changes inscheduling and operating room availability.

Time Results

All time intervals listed in Table IV weredecreased in patients in group 3 comparedwith groups 1 and 2. A combination of factorscontributed to the improved times, all relatedto implementation of the motion studies find-ings and increased surgeon and personnelskills from training. Times savings were imme-diately apparent over a 2-month period afterthe implementation phase began and contin-ued over the entire 3 years after implementa-

TABLE VPerioperative Medications by Group

Time Interval Medication

Average Dose Per Patient Over Entire Group(mg unless otherwise noted)

Group 1 Group 2 Group 3

Preoperative Valium 0.6Versed 3.4 2.0Inapsine 0.2 0.6Demerol 6.3Morphine 0.6Phenergan 1.6RobinulMandol 1000Monocid 1000Claforan 1000Erythromycin 0.1*

Intraoperative Ketamine 140.4Diprivan 139.4 176Valium 17.7Inapsine 1.3 0.7Fentanyl 3.8 cc 6.5 cc 2.0 ccXylocaine 1% with epinephrine 200 169 20Robinul 0.1 0.5 0.2Gallamine 1.2Anectine 5.9Atropine 0.1Regonol 1.2Reglan 0.1 10Pavulon 0.2Tracrium 37.9Scopolamine 0.1Zofran 0.6Decadron 2.0Nimbex 12.8Zemuron 1.1

Postoperative, predischarge Demerol 2.9 64.3 47.8Phenergan 11.7 24.3Phenaphen 3 1 capsule 0.1 capsulesTalwin 3.1Morphine 0.4†

* For patients allergic to cephalosporins or penicillin.† For patients allergic to Demerol.


tion. The bar-coded events data entry systemand the accompanying database provided ac-cess to all data in real time, shortening deci-sion-making and implementation times whendata evaluation demanded changes.

When comparing group 1 to group 3 axil-lary, partial retropectoral augmentations, theimprovements in anesthesia time (14 percent),operation times (35 percent), and postanesthe-sia care unit times (39 percent) can be attrib-uted to increased efficiency in performing theaxillary augmentations in group 3. This in-crease in efficiency was accomplished whilecompletely eliminating all blunt dissection andperforming all pocket dissection under directvision with endoscopic assistance and electro-cautery instrumentation. The most impressiveimprovements in group 3 compared withgroup 1 axillary partial retropectoral augmen-tations, however, occurred in times from endof operation to discharge (76 percent) andreturn to normal activities postoperatively (80percent). Times to discharge were likely re-lated to two factors: (1) use of high doses ofValium associated with dissociative anesthetictechniques in group 1 and (2) procedures per-formed in an outpatient surgical center settingthat did not stimulate patients immediatelypostoperatively and did not encourage patientsto ambulate and raise their arms immediately.The marked improvement (80.4 percent) in

return to normal activity is likely the result ofreduced surgical trauma by eliminating allblunt dissection, markedly reducing bleedingand blood in tissues, and using muscle relax-ants to reduce retractor pressure and traumato the pectoralis.

When comparing group 2 inframammary,retromammary cases to group 3 inframam-mary, retromammary cases, reduction of anes-thesia times (51 percent), operation times (66percent), and postanesthesia care unit times(11 percent), are likely the result of increasedefficiency and reduced operation times result-ing from changes implemented after the timeand motion study evaluations. Marked reduc-tions in the end of operation to dischargetimes (79 percent) were likely affected by de-creased drug dosages resulting from shorteroperation times in patients in group 3. Theimpressive shortening of time to return to nor-mal activities (79.4 percent) is likely the resultof significantly decreased surgical trauma bymodifications of surgical techniques, includingelimination of all blunt dissection, a strict “no-touch” approach to periosteum and perichon-drium, and dramatic reductions in the amountof intraoperative bleeding and blood remain-ing in tissues adjacent to the pocket.

A comparison of group 2 inframammary, ret-romammary cases to group 3 inframammary,partial retropectoral cases was most impressiveand contradicted information we had given

TABLE VIPostdischarge Medications

Medication

Dosage Range/Duration Average Dosage

Group 1 Group 2 Group 3 Group 1 Group 2 Group 3

Phenaphen 3 (acetaminophen withcodeine)

Codeine 480–1440 mg for

4–12 days

NA* NA Codeine756 mg for

6.3 days

NA NA

Tylenol 3 (acetaminophen withcodeine)

NA Codeine 480–1200 mg for

4–10 days

NA NA Codeine672 mg for

5.6 days

NA

Motrin (ibuprofen) 800 mg NA NA 2400–12,000 mgfor 1–5 days

NA NA 7680 mgfor 3.2 days

* NA, not applicable.

TABLE VIIGroup 3 Procedures by Type and Date (n � 627)*

Year IMPRP AXPRP IMRM

1998 107 26 201999 184 18 112000 242 15 4Total 533 59 35Percentage 85 9 6

* IMPRP, inframammary, partial retropectoral; AXPRP, axillary partial ret-ropectoral; IMRM, inframammary, retromammary.

TABLE VIIIImplant Types and Sizes in Group 3 Patients (n � 1254)

Total Implants of TypeMcGhan

468MentorSiltex

MentorSmooth

Total implants of type 1220 26 8Type as % of total 97% 2% 1%Implant size range (cc) 205–450 270–425 200–300Average implant size (cc) 273 321 263


patients. In the information materials providedall patients in this study, we advised patients toexpect a longer, more difficult recovery if theirimplants were placed retropectoral comparedwith retromammary. Patients in Group 3 withretropectoral augmentation experienced a 58percent decrease in anesthesia times, a 73 per-cent decrease in operation times, an 11 per-cent decrease in postanesthesia care unit times,and most significantly, a 78.1 percent reduc-tion in time to return to normal activities com-pared with the patients with retromammaryaugmentation in group 2. In patients in group3, we could identify no difference in times toreturn to normal activities in retromammarycompared with retropectoral augmentation.

Preoperative Medications

Preoperative medications were progressivelydecreased in patients in group 3 comparedwith groups 1 and 2 (Table V). Patients ingroup 3 received 1 to 2 mg of Versed intrave-nously preoperatively as their only premedica-tion, primarily for its amnesic effects. In theoperating room, potential side effects of anyother medications administered are easier tomonitor and treat compared with administer-ing them as a premedication in a patient-readyroom.

Anesthesia

In patients in group 1, a dissociative (Va-lium-ketamine) anesthetic technique was uti-

lized, whereas all patients in groups 2 and 3received general endotracheal anesthesia withForane augmented with Versed and fentanyl.Anesthesia times were shorter for group 1 (n �16; average, 99 min) compared with group 2(n � 16; average, 126 min), but postanesthesiacare unit times were longer for group 1 (aver-age, 70 min) compared with group 2 (average,45 min). Emergence from the effects of thelarger doses of Valium administered to patientsin group 1 for dissociative anesthesia (average,17.7 mg of Valium in group 1; average, 3.4 mgof Versed in group 2) likely contributed to theprolonged postanesthesia care unit times ingroup 1 compared with group 2, even thoughthe patients in group 2 received more narcotics(average, 6.5 cc of Fentanyl) compared withgroup 1 (average, 3.8 cc of Fentanyl). Patientsin group 3 received an average of only 2 mg ofVersed and 2.0 cc of Fentanyl perioperatively, asubstantial reduction in narcotic and sedativemedications compared with groups 1 and 2,that almost certainly contributed to themarked reduction in time from entering thepostanesthesia care unit to discharge home inpatients in group 3 (average 76 minutes) com-pared with group 1 (320 minutes) or group 2(351 minutes).

As operation times decreased, anesthesiatimes decreased proportionately. Anesthesiatime has a predictable effect on recovery. Thelonger the anesthetic times, the more medica-

TABLE IXTime to Return to Normal Activities for Group 3*

Year

24 hr 48 hr 72 hr 7 daysProcedure

TypeAverage hrto RTNAn % n % n % n %

1998 (n � 153) 149 97 2 1 2 1 0 0 IMRM 24.21999 (n � 213) 206 97 4 2 2 1 1 0 IMPRP 25.72000 (n � 261) 245 94 10 4 6 2 0 0 AXPRP 26.8Total (n � 627) 600 96 16 3 10 2 1 0 Average 25.6

* RTNA, return to normal activity; IMRM, inframammary, retromammary; IMPRP, inframammary, partial retropectoral; AXPRP, axillary partial retropectoral.

TABLE XComplications Requiring Reoperations in Group 3 Patients*

Period

III–IVCapsules

Pts/BreastsFold

Revisions Deflations Infections Hematoma

ImplantSize

ChangeMalposition

(Pts/Breasts)

Jan ’98–Jan ’99 1/1 0 0 0 0 1 0Jan ’99–Jan ’00 1 /2 2 1 1 0 1 0Jan ’00–Jan ’01 1/2 3 3 1 2 0 2/3Total Group 3 3/5 5 (4 pts) 4 2 2 2 2/3

% Pts 0.5% 0.6% 0.6% 0.3% 0.3% 0.3% 0.3%% Breasts 0.4% 0.40% 0.3% 0.2% 0.2% 0.2% 0.2%

* n � 627 patients, 1254 breasts.


tions are required, the more side effects arepossible, and the more time required for thepatient to metabolize the medications, contrib-uting to a longer and more difficult recovery.Reducing operative trauma likely contributedto decreased narcotic requirements in group 3compared with groups 1 and 2. Reduced nar-cotic requirements dramatically decreased theincidence of postoperative nausea and vomit-ing, necessitating fewer antiemetics, reducingemergence from anesthesia, and shorteningrecovery room to discharge times. Optimal ad-ministration of muscle relaxants is extremelyimportant to reduce the amount of retractorforce required for exposure in the subpectoralpocket and to reduce blunt trauma to the pec-toralis major muscle. The shorter acting themuscle relaxant and the lower the dose, theless necessity of using reversing agents that canpotentiate narcotic side effects. When surgicalefficiency improved enough to allow the ad-ministration of a single, short-acting musclerelaxant dose (Nimbex, average 5.0 cc, 10 mg,in patients in group 3 ) for dissection of bothpockets, exposure was optimal, repeated dosesof relaxant unnecessary, reversal agents wereunnecessary, and recovery rates improvedmarkedly.

Although this study does not specificallycompare local to general anesthesia, the au-thor’s personal experience with both alterna-tives indicates that no technique of local anes-thesia can compare with the general anesthesiaregimen in group 3 with respect to protectionof the patient’s airway, maintaining surgicalcontrol, reduction of trauma, total anesthesiaand operative times, total dosages of medica-tions administered, and patient recovery times.Although the dissociative anesthesia in group 1

provided a satisfactory operative environment,it required more medication and time for re-peated dosage and effect, allowed less controlof the airway and blood pressure, prohibiteduse of muscle relaxants (requiring more forcefor subpectoral retraction and manipulation),and prolonged postoperative recovery room todischarge time.

Surgery

Patient individuality and the artistry of plas-tic surgery preclude total standardization ofany plastic surgery operation. Acknowledgingthat fact, almost all plastic surgery operationscould benefit from detailed reassessment andrefined protocols that reduce time waste, im-prove efficiency, and provide the surgeon withmore time for artistry and attention to detailintraoperatively without increasing morbidityor prolonging recovery. One of the greatestbenefits of this study was the overall improve-ment in the operating room atmosphere andthe resulting effect on the surgeon. Increasedpersonnel competence and confidence de-rived from training and reference materialsincreased their performance. Consistency inthe surgery (from preoperative planning andperforming the operation to a checklist) al-lowed personnel to dramatically increase effi-ciency by reducing surgeon time delays fordecision making and personnel delays for re-trieval of additional supplies or instruments.The result was a highly efficient, relaxed atmo-sphere that reduced distracting, stressful, time-wasting activities, and encouraged more cre-ative thinking and attention to detail from thesurgeon. The degree of control that a surgeoncan exert over specific operating room prac-tices and personnel varies among different

TABLE XIPro Forma Operation Time and Personnel Cost Savings in 533 Patients in Group 3*

Timed Interval

AverageTime

Group 2IMRM(min)

AverageTime

Group 3IMPRP(min)

Time Saved inGroup 3 versusGroup 2 (min)

Number ofOperationsPerformedin Group 3

IMPRP

TimeSaved(hr)

Cost perHour ofSurgeryFacility

Personnel

Cost Savingsin

PersonnelTime

SurgeonTime

Savings(hr)

SurgeonTime

Savings(8-hr

operatingdays)

Anesthesia 126 52 74 533 657 $737 $ 484,479Operation 89 24 65 533 577 $737 $ 425,556 577 72PACU 45 41 4 533 36 $377 $ 13,396End operation to

discharge351 75 276 533 2452 $ 77 $ 188,789

Total $1,112,220

* Hourly costs of surgery center personnel: supervisor RN, $42; surgical assistant, $20; scrub technician, $18; circulating RN, $23; recovery RN, $21; 2 CRNA, $300;orderly, $14; total, $737/hr operating time; PACU, postanesthesia care unit; IMRM, inframammary, retromammary; IMPRP, inframammary, partial retropectoral;AXPRP, axillary partial retropectoral.


practices, but improvement in any aspect of thesurgeon environment rarely occurs without thesurgeon initiating and persistently pursuingimprovement. Whether improving practices ina hospital-based outpatient surgery facility orin a surgeon-controlled outpatient facility, im-provement, and the degree of improvement,begin with the surgeon.

Many surgical technical refinements weremade from observations early in the motionstudies videotape analyses. Despite 15 years ofsurgical experience, the author did not recog-nize the importance of these details and theirpotential effect on recovery outcomes. A de-tailed description of extensively modified sur-gical techniques is presented in part II of thisstudy.

Some increase in surgical skills and effi-ciency are attributable to the predictable in-crease that occurs as a surgeon gains experi-ence. This study does not distinguish thosegains from benefits derived from the motionstudies, except that the time changes and pa-tient recovery outcomes changed dramaticallyover a 2-year period when findings of this studywere implemented. It is the author’s opinionthat even the most experienced surgeon canachieve dramatic improvements in any cos-metic surgical procedure by applying the meth-odologies in this study. Regardless of the oper-ation or the combination of techniquesselected by a surgeon, deriving best practicesmodels (even though the models might differfor the same operation by different surgeons)could be invaluable to resident education andsurgeon continuing education.

Perioperative Recovery and Medications

The total number of medications and doseof each medication administered during anes-thesia and postoperatively decreased signifi-cantly in patients in group 3 compared withgroups 1 and 2 (Table VI). Similar to the meth-ods used for anesthetic drugs, postoperativemedications were changed one at a time andrecovery times and events tracked and evalu-ated by using timed events data. Some newer,more expensive medications were eliminatedbecause lower doses of more traditional drugswere more effective, with fewer side effects anda lower cost. The most recent regimen for pa-tients in group 3 relies on medications thathave been used for decades, with lower dosesmade possible by changes in planning and sur-

gical techniques that reduced trauma and im-proved efficiency.

Patients in group 3 experienced an exceed-ingly low incidence of postoperative nauseaand vomiting most likely related to the lowdoses of intraoperative narcotics and adminis-tration of Phenergan intravenously or intra-muscularly before each low dose of Demerolpostoperatively. A combination of decreasedoperating times, decreased operative trauma,and minimal muscle relaxant reversing agentsallowed patients in group 3 to receive muchlower total doses of narcotics compared withgroups 1 and 2 and experience a much morerapid emergence and perioperative recovery.The average time from beginning of the oper-ative procedure to patient discharge home av-eraged 7.8 hours in group 1, 8.0 hours ingroup 2, and 80 minutes in group 3 in the first2 years, eventually decreasing to 67 minutes inthe final year of group 3. Patients in groups 1and 2 were treated in an outpatient surgerysetting in hospital-based surgery centers. Afterdischarge from the postanesthesia care unit,patients in groups 1 and 2 received more nar-cotic medications compared with group 3 andwere placed in step-down rooms where theywere not systematically stimulated and ambu-lated. Patients in group 3, treated in a private,accredited, outpatient surgery center setting,received fewer medications and were stimu-lated constantly, dressed, and ambulated.Group 3 patients met the same or more strin-gent criteria for discharge from postanesthesiacare unit (phase I) and for discharge home(phase II) compared with groups 1 and 2,while experiencing dramatically shorter staysin the surgery center. The total absence ofanesthesia-related complications in patients ingroup 3 indicates the skills of the certifiedregistered nurse anesthetists who administeredthe anesthesia and the efficacy of the protocoldeveloped from the study.

As surgical trauma decreased, patient’s needfor postoperative analgesia decreased. Com-plaints from patients in groups 1 and 2 aboutexcessive sedation and nausea from analgesicscontaining codeine prompted a marked de-crease in these medications for patients ingroup 3. Patients in group 3 described muchless discomfort and were able to mobilize andresume normal activities very rapidly. All aug-mentation patients in group 3 received 800 mgof ibuprofen as their only medication for post-operative analgesia. Although ibuprofen has


anti-platelet activity, it had no adverse bleedingeffects in patients in group 3 when used withstrict prospective hemostasis and electrocau-tery dissection techniques, and it delivered pre-dictable and highly effective antiinflammatoryand analgesic effects with lack of sedative andnausea side effects. Most patients in group 3required no analgesics whatever after the thirdpostoperative day.

Patients

The patient is the ultimate benefactor fromincreased efficiency and decreased morbidity.One of the greatest difficulties encounteredduring the study was countering many patients’conviction based on experiences of theirfriends, comments from other surgeons, or in-formation obtained from the media or Inter-net that a 24-hour return to normal activities isimpossible. Patient compliance with postoper-ative instructions to resume normal activity isessential. Supporting the patient by repeatedtelephone calls for clarification of instructionsand encouragement is also essential. Compre-hensive preoperative patient education, pre-paring the patient for what will happen, anddelivering on the promise builds patient con-

fidence that undoubtedly aids and motivatesduring recovery. Every chart of patients ingroup 3 contains telephone records of postop-erative calls and detailed checklists of times toreturn to normal activities. Patient complianceis undoubtedly affected by instructions to care-givers and by reinforcing and encouraging tele-phone calls in the first 24 to 48 hours. Of thepatients in group 3, 96 percent were able toperform all normal activities the evening ofsurgery or the day after surgery. Patients whowere unwilling or unable to raise their arms,pick up normal-weight objects, and drive theircars in the first 48 hours consistently hadlonger recoveries. Even those patients in group3 with less than optimal compliance postoper-atively had much shorter perioperative recov-ery times, fewer medications, and a more un-eventful recovery compared with the shortestrecoveries in groups 1 and 2.

Recovery and Times to Return to Normal Activities

The most important finding of this study isthat 96 percent of patients can return to fullnormal activities within 24 hours after a partialretropectoral augmentation mammaplasty.Based on the data presented in Table IX, by

FIG. 4. Preoperative and 6-month postoperative photographs of the patient operated on atthe 2000 Baker-Gordon Symposium, demonstrating postoperative results, a natural appearancein the supine position, inconspicuous inframammary scars, mobile breasts with good medialdisplacement, and softness demonstrated by pinch.


using the methodologies and techniques de-scribed in this study and the surgical tech-niques in part II of this study, there is nosignificant difference in recovery in retromam-mary compared with retropectoral augmenta-tions, with over 95 percent of both groups ofpatients returning to full normal activitieswithin 24 hours after their operations.

A Case Example from a Live Surgery Symposium

With any new approach or advancement,surgeons must question whether the techniqueis demonstrable or reproducible in an environ-ment other than the surgeon’s own facility.Can it be observed by peers to determinewhether surgeons in a variety of environmentsmight be able to reproduce the techniques?Most importantly, documentation of a randompatient recovery experience in an observed en-vironment is invaluable in assessing patientoutcome.

Using the principles and techniques de-scribed in this article, the author performed aninframammary, partial retropectoral augmen-tation mammaplasty on a 26-year-old gravida 2,para 2 patient at the Baker Gordon CosmeticSurgery Symposium in Miami, Fla., on Febru-ary 5, 2000. Videotapes of the surgery docu-ment the operation that was simulcast to theauditorium for over 600 registered surgeons.In a remote operative environment, using twoof the surgeon’s own personnel, two MercyHospital Miami personnel (anesthesiologist

and circulating nurse), and anesthesia and cir-culating nurse protocols derived from thisstudy, operative time was less than 30 minutes.Figure 4 shows the patient’s preoperative and6-month postoperative appearance. As the lastoperation of the day at the symposium, theoperation concluded at approximately 6:00 PM.Despite the hospital’s mandatory 2-hour stay inrecovery and step down, the patient had din-ner and shopped in Coconut Grove theevening of surgery. She had repeatedly liftedher arms over her head before discharge fromthe hospital and was lifting normal-weight ob-jects the evening of surgery. The patient hadno Marcaine or intercostal blocks and receivedno pain medications after discharge from thehospital until well after midnight when sheretired for the evening (and then only on in-struction). Figure 5 shows frame prints fromvideotape taken of the patient preparing herhair before going out to dinner, dining on rawoysters, shopping, and dancing. Times im-printed on each image are derived from timerecordings on the videotape and representtimes from the completion of the operation tothe activity pictured. The patient drove her carthe next day and returned to work as a medicaltechnician on the morning of the third post-operative day.

CONCLUSIONS

1. Reduction in surgical trauma produced signif-icant decreases in postoperative inflamma-tion, pain, analgesic requirements, and neces-sity of drains or other devices that complicaterecovery and the potential incidence ofcomplications.

2. Reduction of the time required to performthe operation resulted in a decrease in anes-thesia time, drug requirements, drug side ef-fects, and perioperative recovery times.

3. Patients who experienced less surgical trauma,reduced operative times, and the combinedbenefits of all factors related to both experi-enced a simpler, less complicated, and fasterrecovery and return to normal activity.

4. Alteration of preoperative patient education,surgical techniques, perioperative manage-ment, and postoperative management basedon hypotheses 1 through 3 significantly al-tered perioperative morbidity and recovery inaugmentation mammaplasty to shorten recov-ery time.

5. Addressing all pertinent factors rather than

FIG. 5. Frame prints from videotape of the patient oper-ated on at the 2000 Baker Gordon Symposium taken byfriends on the evening of surgery, with arms over her headcurling her hair, having dinner, shopping, and dancing.Times imprinted on each frame print are total times from thecompletion of the operation to the activity pictured, verifiedby times imprinted on the original videotape.


isolated factors produced incremental im-provements in perioperative morbidity andrecovery.

6. If surgical trauma, operative times, and peri-operative morbidity can be substantially re-duced, 96 percent of patients with inframam-mary or axillary, subpectoral breastaugmentation can return to full, normal activ-ities (lifting their arms above their heads, lift-ing normal-weight objects, performing all nor-mal activities, and driving their car) within 24hours after surgery.

7. Using patient education, breast evaluation,preoperative planning, and surgical tech-niques described in this study, no narcoticpain medications, no intercostal blocks,drains, bandages, special bras, or other de-vices are necessary to achieve a 24-hour returnto normal activities in 96 percent of patients.

8. Refining practices and establishing refinedprotocols derived initially from motion andtime study analyses produced a dramatic im-provement in patient recovery outcome in thepractice of a surgeon with a 15-year previousexperience with breast augmentation.

9. Using the methods and techniques describedfor Group 3 patients in this study, there was nosignificant difference in recovery times in ret-romammary compared to retropectoral aug-mentation patients.

John B. Tebbetts, M.D.2801 Lemmon Avenue West, Suite 300Dallas, Texas [email protected]

REFERENCES

1. Meyers, F. E. Motion and Time Study for Lean Manufac-turing, 2nd Ed. Columbus, Ohio: Prentice Hall. Pp.1–334.

2. Rubin, G. D., Armerding, M. D., Dake, M. D., and Napel,S. Cost identification of abdominal aortic aneurysmimaging by using time and motion analyses. Radiology215: 63, 2000.

3. Den Boer, K. T., Straatsburg, I. H., Schellinger, A. V., DeWit, L. T., Dankelman, J., and Gouma, D. J. Quan-titative analysis of the functionality and efficiency ofthree surgical dissection techniques: A time-motionanalysis. J. Laparoendosc. Adv. Surg. Tech. A. 9: 389,1999.

4. Den Boer, K. T., De Wit, L. T., Dankelman, J., andGouma, D. J. Peroperative time-motion analysis ofdiagnostic laparoscopy with laparoscopic ultrasonog-raphy. Br. J. Surg. 86: 951, 1999.

5. Grossman, M. D., Schwab, C. W., Chu-Rodgers, S., andKestner, M. Time and motion: A study of traumasurgeons’ work at the bedside during the first 254hours of blunt trauma care. J. Trauma 46: 757, 1999.

6. Tebbetts, J. B. Transaxillary subpectoral augmentationmammaplasty: Long-term follow-up and refinements.Plast. Reconstr. Surg. 74: 636, 1984.

7. Tebbetts, J. B. Achieving a predictable 24-hour returnto normal activities after breast augmentation: Part II.Patient preparation, refined surgical techniques, andinstrumentation. Plast. Reconstr. Surg. 109: 2002.

8. Miller, K., Sullivan, E., Saufl, N., et al. Standards of Peri-Anesthesia Nursing Practice. Cherry Hill, N.J.: AmericanSociety of PeriAnesthesia Nurses, 1999. Pp. 32–35.


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