Out-to-Dinner Breast Augmentation with 24-Hour Return to Normal Activities -- By John B. Tebbetts, M.D. and Terrye Tebbetts
The Development of Processes and Techniques That Have Redefined the Patient and Surgeon Experience in Breast Augmentation
In 1993, Dr. Tebbetts recognized that the patient experience in breast augmentation had remained largely unchanged for over two decades, with patients requiring 10 days or more to return to normal activities following breast augmentation, and with an average of 18-20% of patients needing a reoperaiton within just 3 years following their augmentation according to United States FDA Premarket Approval Study data. When analyzing the reasons for lack of progress in the patient experience in breast augmentation, Dr. Tebbetts realized that almost every area connected with breast augmentation needed major rethinking and a major overhaul of the processes that determine patient results and recovery. Areas that needed improvement included patient education and informed consent, surgical planning and implant selection, surgical and anesthesia techniques, and patient management after surgery.
In each of these areas, Dr. Tebbetts instituted scientific studies to reassess and refine processes that determine the patient experience, recovery, and patient outcomes. These studies were subjected to rigorous peer review and were subsequently published in the most widely read and respected professional journal in plastic surgery, Plastic and Reconstructive Surgery Journal. From 2000 through 2005, Dr. Tebbetts published studies that detail every aspect of the processes that have enabled patients to predictably be out to dinner the evening of their breast augmentation if they choose, and to return to normal activities within 24 hours. These same studies also confirm that patients who recover more rapidly have low rates of complications and a much lower risk of needing reoperations compared to patients in US FDA PMA studies. Making every aspect of the patient experience better, and making breast augmentation safer and more predictable for patients who choose to have the operation is what this is all about. Rapid recovery is only the tip of the iceberg.
To date, Dr. Tebbetts has performed more than 2000 breast augmentations using the processes that allow patients to be out to dinner and achieve 24-hour return to normal activities. The processes described by Dr. Tebbetts are transferable to other surgeons, and Dr. Tebbetts has lectured extensively in the United States and abroad to share this information with colleagues. Other surgeons in the United States and abroad are learning these processes and are working diligently to deliver this level of recovery and results to their patients. Some of these surgeons include Dr. Steve Teitelbaum (Santa Monica and Beverly Hills, California), Dr. Bill Adams (Dallas, Texas), Dr. Mark Deuber (Dallas, Texas), Dr. Mark Epstein (Long Island, New York), and Dr. Charles Randquist (Stockholm, Sweden).
The Six Critical Keys to Predictably Delivering Out to Dinner and 24 Hour Return to Normal Activities
1) More in depth patient education- patients must be very knowledgeable about how we do what we do, and how it all is possible. Otherwise, they are excessively fearful and hesitant after surgery, slowing their recovery. To change their opinions from having seen their friends require a week to ten days to recover, we rely on thorough education and allowing patients to communicate with our patients who routinely experience out to dinner and 24 hour return to normal activities.
2) Tissue based implant selection using the High FiveTM System- Instead of forcing a patient’s breast tissues to an arbitrary, desired size, use a proved system of measurements of the patient’s tissues and a defined decision process to assure an optimal level of safety and an optimal outcome. This system uses each patient’s tissue measurements to define an implant size that her tissues can safely accept to minimize negative effects on her tissues over time
3) Refining general anesthesia techniques- Total operating time must be 45 minutes or less to minimize drugs the patient receives. Anesthesia requires general endotracheal anesthesia with muscle relaxants per our protocol in our published articles, minimizing doses of narcotics and other drugs during surgery and recovery that delay recovery.
4) Refining surgical instruments, surgical techniques, surgical efficiency-
Instruments- Monopolar, handswitching electrocautery forceps and other specialized instruments described in our publications, when used in specific ways, prevent bleeding before it ever starts, minimizing blood in patients’ tissues that causes inflammation, bruising, and pain.
Surgical techniques- Surgeons must plan more thoroughly before going to the operating room to eliminate unnecessary time wasting maneuvers while maintaining prime quality; surgical efficiency is essential to cut down on operating times and thereby reduce the amounts of drugs the patient receives.
Specific techniques described in our scientific publications include prospective hemostasis (preventing bleeding before it happens), no-touch techniques for the tissues that encase the ribs (periosteum and perichondrium) that are exceedingly sensitive to trauma, and muscle relaxant medications as part of anesthesia to minimize the forces necessary to lift and manipulate the tissues. All of these measures are designed specifically to minimize trauma and bleeding. Trauma (injury to tissues during surgery) and bleeding are the main causes of pain after surgery. When a patient recovers rapidly, it means that the surgeon minimized trauma and bleeding during the operation.
Surgical efficiency- It all starts with the surgeon. By planning more thoroughly before surgery, using proved systems for implant selection, and critically reexamining and refining every step of the surgical process, surgeons can deliver the same or higher level of quality in less time. The less time a patient is in surgery, the fewer drugs she receives, and the less narcotics and drugs she receives, the more rapidly she can recover without nausea, vomiting, or constipation.
5) Eliminate unnecessary surgical adjuncts that detract from recovery- All of the following adjuncts have been proved in published scientific studies to be totally unnecessary, and each of these items increases recovery time and detracts from an optimal patient experience during recovery: bandages, compressive dressings, special bras or straps, drains, pain pumps, narcotic pain medications, muscle relaxant medications, intercostals blocks (local anesthesia injected between ribs), nerve stimulator devices, restricted activities, and pulsed electromagnetic therapy. When a patient experiences a level of discomfort or has to deal with any of these devices following surgery, she unavoidably feels wounded or sick and will never recovery as rapidly. Our peer reviewed and published studies describe processes that make all of these adjuncts totally unnecessary in first time breast augmentation cases.
6) Refining management processes after surgery- All of the previously listed keys work together to put the patient in a position to be able to immediately resume normal activities after surgery. All patients have some degree of fear and reticence to become mobile soon after surgery, so it is critically important that the surgeon and staff support the patient to assure that she becomes mobile within the first few hours following surgery. All of our patients are raising their arms above their heads before they leave the surgical facility. Every patient receives calls at specific timed intervals after returning home to answer questions and assure that together, we are getting moving and out of the house according to our recovery schedule.
Each of these keys is essential for a surgeon to make out to dinner and 24 hour recovery predictable. Surgical techniques alone do not achieve this level of recovery—surgeons must address all of the processes of patient education, surgical planning, tissue based implant selection, surgical techniques, and postoperative management. Failing to optimize even one of these areas reduces a surgeon’s chances of predictably delivering this level of recovery.
More information in:
The Correlation of Rapid Recovery with Patient Outcomes and Reoperation Rates
The results of these processes is confirmed in peer reviewed and published studies in the most respected and widely read Journal in plastic surgery, Plastic and Reconstructive Surgery Journal. Not only can 96% of patients predictably return to normal activities within 24 hours, but the processes that deliver this level of recovery also deliver a predictable 3% risk of needing a reoperation at up to 7 years compared to current FDA studies in the United States in which over 20% of patients needed a reoperation within just 3 year! The same processes, for the first time in history, enabled us to achieve zero percent reoperation rate at three years following augmentation in a consecutive series of patients that were in a US FDA study that was supervised by an independent clinical review organization. These statements are confirmed by data in our peer reviewed scientific publications in Plastic and Reconstructive Surgery Journal that are listed in the References section at the end of this document.
The same key processes listed above not only enable patients to be out to dinner the evening of surgery and return to full, normal activities within 24 hours, but they also lower patients’ risks of complications and dramatically lower reoperation rates. Together, these key processes have redefined the patient experience in breast augmentation.
Confirming Our Credibility
All of the details that allow surgeons to deliver out to dinner augmentation and 24 hour return to normal activities were published in great detail in the attached article in Jan 2002, so all of this information has been available to surgeons for 5 years. I have performed live surgery of this procedure at the largest and most respected live surgical venue in the United States, the Baker-Gordon symposium, and independent videotaping of the patient the evening of surgery showed her shopping, out to dinner, and dancing (not in our instructions). Clips from this video are included in the scientific article that is attached.
It’s important that patients and surgeons understand that improved patient outcomes were the goal of a decade of studies-- not really about a 30 minute breast procedure. While refining the processes that produce better patient recovery and results, one of the by products is that surgery and anesthesia time and the amount of drugs a patient receives have been drastically reduced.
Differences in Our Processes Compared to Conventional Processes
Patients are more thoroughly educated and prepared before the surgery; implants are chosen using a scientifically based system that matches the implant to the patient's individual tissue characteristics; surgical techniques dramatically reduce the degree of trauma and bleeding the patient experiences; the necessity of bandages, drain tubes, pain pumps, and narcotic pain medications have been eliminated; and our management of the patient following surgery is dramatically different.
Surgical Experience, Results, and Impact on Patient Outcomes
Dr. Tebbetts has performed more than 2000 breast augmentations using the processes that allow patients to be out to dinner and achieve 24-hour return to normal activities. Not only can 96% of patients predictably return to normal activities within 24 hours, but the processes that deliver this level of recovery also deliver a predictable 3% risk of needing a reoperation at up to 7 years compared to current FDA studies in the United States in which over 20% of patients needed a reoperation within just 3 year! The same processes, for the first time in history, enabled us to achieve a zero percent reoperation rate at three years following augmentation in a consecutive series of patients that were in a US FDA study that was supervised by an independent clinical review organization. These statements are confirmed by data in our peer reviewed scientific publications in Plastic and Reconstructive Surgery Journal.
Other Frequently Asked Questions
How do you avoid creating visible bruising?
Bruising is caused by internal bleeding that soaks through the tissues. By using surgical techniques that drastically reduce or eliminate bleeding during or after the surgery, patients almost never experience any bruising following routine augmentation, and patients do not need any type of bandages, special bras, drain tubes, or pain pumps following surgery.
Are there any risks associated with the speed of the operation?
The efficiency of the operation is simply a by product of improving and refining every step, instrument, and technique using multiple video cameras, time and motion study analysis, and process engineering analyses. These refinements were achieved using principles of process engineering that optimize products for the world's most successful businesses by eliminating unnecessary and unproductive processes, while combining and refining the processes that assure the best product. Inherent in the studies and analysis is the requirement that no aspect of quality declines as efficiency increases. Much of the increased efficiency comes from using proved processes to more thoroughly and accurately plan the operation and select implants before entering the operating room, minimizing decision making time waste in the operating room, and thereby minimizing the narcotics and drugs the patient receives.
Is the operation painful or uncomfortable, during or afterwards?
The level of pain that our patients experience does not require any narcotic strength pain medications, or any medications other than Ibuprofen which is available over the counter without a prescription in the United States. Certainly patients experience some tightness and discomfort, but the level of discomfort allows the vast majority of patients to be out to dinner the evening of surgery and return to full normal activities within 24 hours.
Doesn’t rapid resumption of activities cause risks of bleeding or other problems?
I, like many other surgeons, was taught during my training that early resumption of activity by patients may cause bleeding or other problems. Through extensive, detailed, and incremental changes in every process we use in breast augmentation, we have shown that bleeding and other problems are not the result of early resumption of normal activities. Instead, bleeding, escessive trauma that causes excessive pain and disability, and the necessity of tubes coming out of a patient’s body are all the direct result of how the patient is educated, the choices the patient and surgeon make, and how the surgeon performs the operation. When these processes are optimized, patient recovery is rapid and dramatic, but more importantly, patient outcomes show dramatic improvement, with lower rates of complications and reoperations as documented in the peer reviewed and published studies I attached.
The best news for patients is that all of the information to deliver this level of result is available to surgeons worldwide and has been available for over 5 years. Most surgeons require 1-2 years minimum to learn and implement all of the processes, not just the surgical techniques. More and more surgeons are now working to offer patients this level of recovery, patient experience, and outcome.
If I can answer other questions or be of further assistance, please contact me or my wife Terrye by e-mail or phone.
John B. Tebbetts, M.D.
More information in:
24 Hour Recovery Papers
(1) Tebbetts, J.B. Achieving a predictable 24-hour return to normal activities after breast augmentation Part I: Refining practices using motion and time study principles. Plast. Reconstr. Surg.109:273-290, January 2002.
(2) Tebbetts, J.B.: Achieving a predictable 24-hour return to normal activities after breast augmentation Part II: Patient preparation, refined surgical techniques and instrumentation Plast. Reconstr. Surg.109:293-305, January, 2002.
Other publications that describe and detail all of the processes that are key to delivering this level of recovery and outcome
(3) Tebbetts, J.B.: An approach that integrates patient education and informed consent in breast augmentation. Plast. Reconstr. Surg. 110 (3): 971-78, September, 2002.
(4) Tebbetts, J.B.: Dual plane (DP) breast augmentation: Optimizing implant-soft tissue relationships in a wide range of breast types”, Plast. Reconstr. Surg.. 107: 1255, April 2001.
(5) Tebbetts, J.B.: A system for breast implant selection based on patient tissue characteristics and implant-soft tissue dynamics. Plast. Reconstr. Surg.109 (4): 1396-1409, April, 2002.
(6) Tebbetts JB and Adams WP. Five critical decisions in breast augmentation using 5 measurements in 5 minutes: The high five system. Plast. Reconstr. Surg.116(7), 2005-16, Dec 2005.
(7) Tebbetts, J.B. Achieving a zero percent reoperation rate at 3 years in a 50 consecutive case augmentation mammaplasty PMA study. Plast. Reconstr. Surg. 118 (6), 1453-57, Dec 2006.
(8) Tebbetts, J.B.: Out points criteria for breast implant removal without replacement and criteria to minimize reoperations following breast augmentation. Plast. Reconstr. Surg.114 (5): 1258-62, October, 2004.
(9) Adams, W. Bengtson, B. Glicksman, C. Gryskiewicz, J. Jewell, M. McGrath, M. Reisman, N. Teitelbaum, S. Tebbetts, J. Tebbetts, T. Decision and management algorithms to address patient and Food and Drug Administration concerns regarding breast augmentation and implants. Plast. Reconstr. Surg.114 (5): 1252-57, October, 2004.
(10) Tebbetts, J.B. Axillary endoscopic breast augmentation: processes derived from a 28-year experience to optimize outcomes. Plast. Reconstr. Surg. 118 (7S), 53S-80S, Dec 2006.
(11) Tebbetts, J.B. Patient acceptance of adequately filled breast implants. Plast. Reconstr. Surg. 106(1):139-47, July 2000.