Filed under: breast augmentation
By Terrye Tebbetts
Often times, an implant is simply not the best way to fix what a women sees in her breasts. But how do you know? Employing the High Five Measurement System is the key to determining implant size, or whether the patient really needs a Mastopexy. Below is a very common question and answer about Mastopexy and Breast Implants…..
Question….
Hi Terrye,
I just bought your book, it should arrive today, I’m so excited to read it. My surgery is scheduled for March. I’m getting a lift and implants, on the smaller side. I’m a Mom of three who nursed, and I’m trying to stay natural looking.
I noticed you had posted on implantinfo about having an information sheet on the types of lifts that you mentioned you could email. Can you email it to me? I want to make sure I’m informed about the life and asking the right questions.
Answer….
I am happy to send you the information we give out on Mastopexy! I know you are scheduled and set – but I think you should know this and think about it and talk with your ps.
An interesting wrinkle, that you probably won’t like to hear, is that Dr. Tebbetts will not perform a lift and an implant at the same time. We stopped 15 years ago, because it was the only procedure that had unpredictable results. You see, if you need a lift, it is because your tissue did not hold your own weight well through out the pregnancies. You can lift that tissue, but in the end, it is the SAME tissue (tissue that is prone to excessive stretch). So then factor in that the two operations are diametrically opposed (Augmentation makes the breast bigger, Mastopexy makes the breast envelope smaller) and you have to shake your head a little and wonder if this is really the right thing to do…….we ask our patients to have the lift and wait 6 months, if the tissue has not stretched more than 20% under the weight of their own tissue, then it is reasonable to put an implant in that breast. Some patients (about 40%) can be happy with simply a firmer, perkier breast, the others will want to come back for an implant.
It is just something to keep in mind. I read so many posts from women on the forum and they have all had multiple lifts and implants and are wondering why they can’t keep upper pole fullness or the look they want (having had lifts and 400 plus cc implants) – it all boils back down to realizing and understanding the tissue you were given – then make the best surgical choices you can make given that tissue – because I don’t care how many times you operate on it – it is still the same tissue.
Having jumped off my soap box, I will say, there are many women who chose to do this at the same time and are completely happy, and if you are using a conservative size implant – that is half the battle. I truly wish you the best with your surgery – I just wanted you to be aware of all the options, choices and think through all of the issues. There is no magic here – we all have to work with what we bring to the OR table – both patients and surgeons.
Filed under: breast augmentation
By Terrye Tebbetts
I was answering questions on www.implantinfo.com yesterday when I ran across this one. Since I know this is something that many of you struggle with, I thought you might like to see my answer and then one more helpful answer from another forum contributor that has been through multiple reoperations due to excessively large implants.
Question ~
My doctor is reccomending that I get silicone unders with a maximum of 380 cc’s which he says will make me approximatly a full c. I want to be a full D or DD. He is saying that due to my skin envelope I would be at an increased risk for bottoming out. I’m wondering if anyone else was told this and went against the doctors reccomendation and how it worked out for them. I’m 5′6″ 125 pounds and have a base diameter of 13.1
My Answer ~
It sounds like your surgeon is trying to keep you and your implants out of trouble – which is good! There are limits to what your skin envelope can hold safely and age with over time.
Dr. Tebbetts uses the High Five System of measurement to determine what the breast will hold – It is so easy – you can do it yourself! Email me at TTebbetts@plastic-surgery.com and I will email it right back to you (as I know we are pressed for time!). This system takes more into account than simply your base width – when you respect the amount of tissue you are bringing to the table, I promise, longterm, you will be a much happier camper because you will have done all you can do to avoid problems like bottoming out, edge visability and traction rippling.
You can read the How to Determine size article on our book website, www.thebestbreast.com on the home page under articles – this will help you SO much!
Please remember, you only have so much to work with and if you choose to ignore it’s limits, you can end up with irreversable tissue deformities. I know it is tempting for us all to want to SUPER SIZE things in life – but here, it just doesn’t make sense. I would trust your surgeon and rely on his judgements – a fuller, firmer, bigger, yet pretty breast that will last a long time is a heck of a lot more attractive than multiple re-operations. Also, please remember, there is NO medical definition for cup size – nor is there a “full” C or D or whatever – - so please don’t base your satisfaction with your result purely on the first bra you buy as the size may be different when you buy your next bra.
Please let me know if I can help you – and most importantly, if you still have questions, call your ps office, I am sure they will be happy to work you through the issues.
Second contributor’s answer and experience with implants that were TOO BIG…let us all learn from her experience…….
I am now a C cup with the proper sized implants in “my” breasts sitting on my chest wall. It is much better to have years of beautiful ,problem free breasts, a little smaller than having larger ones that “could”….. not saying they would, require one surgery after another…
I had 4 full surgeries in a 2 year span to finally have normal looking and feeling breasts and the size I wanted for me.. I personally did not like the larger breast size on me, even if I had had no problems at all with them . I would have downsized. They were way to large on me, to heavy feeling and none of my cloths fit. I wear a small top and a 4 in jeans , no tops would fit me, if they did I had to go up a size or two to get them to button, zip or pull over my very large breasts and then they fell over at my shouder to far , as they were to wide across my shoulders to fit my small frame. ( I am 5′6 , 119 lbs) No size 4 dresses I had and use to wear would even come close to zipping up.. I had to buy a size 8 dress for a special ocassion and have the “rest” of the dress altered to fit me.
I am not saying a woman should not have the sized breasts she would like to have , she should… but IF the womans breasts are not able to accomidate and support the implants that is not a good idea, at all… some Ps’s will place whatever a woman wants…that is not what you want nor need from a PS… for if they are too large for your chest and your breasts then you could be just asking for trouble…. and if so it can be a living nightmare. Physcially, mentally and in your pocket book. Many, many thousnads of dollars, later….. (I have paid well over $26,000 for surgeries )to “correct my breasts” and get them to the right size for myself and my body ….with no bottoming out and all the many surgical problems corrected.
I have friends with D , DD cups I have one that is an E cup, they have all done great, love their breast size and I am very happy for them.. They look very beautiful.. But for “ME personally” that is much too large busted on MY body and for my personal liking and also “no doubt” much too large of implants for what fit “my” breasts correctly.
My best to you with your surgery tomorrow , if you want larger breasts you can have them placed… but if me and my PS said I am afraid that could cause you some problems…( which that old PS of mine just placed what he wanted) I would listen.. ok.. ( My new PS placed what I had in mind I wanted with with my breast size and placed the implants that worked best and safest in “my” breasts.
Just my long journey with too large of implants placed in my breasts. I love my C cups , the size is perfect for ME.. and the best part of all ” no problems”.
Filed under: Uncategorized
Chapter 2- Looking at breast augmentation surgery in new ways, and the first hidden prize
by John B. Tebbetts, M.D.
Back to the pig (if you don’t get it, check out my previous post, Chapter 1 of the 24 hour recovery story). I wasn’t at all confident that acorns (pig prizes) were to be found, but I figured (again, in case you missed it the first time, “figured” is Texican lingo for “I thought”) that at worst, I could get some good video footage of breast augmentation surgery. Three inexpensive video cameras later (one over my shoulder, one looking at the folks around the operating table, and a third viewing the entire room), and we had a setup that could record the movements of everyone in the surgical suite as I performed a breast augmentation.
My surgical team thought I had lost it (nothing new to my group). Most later admitted feeling a bit threatened by my intent to micro analyze every move each of us made. But I’m blessed with a committed group who’ll do anything to make things better for patients…and for me. Several operations later, we had piles of videotape that documented every move. Frank Gilbreth would have been proud. Now the fun (translated….butt busting hard work) began.
I never imagined the time required to analyze every motion in a breast augmentation. I love visual images, video, and if I could choose another life, I’d come back as a clone of Speilberg. But this isn’t creative imaging. This is stuff I’ve seen thousands of times, thought I could do with my eyes closed (just kidding) and I’m supposed to look at it in a different way? It was incredibly boring at first. Uncomfortable. Repetitive. Where is the prize?
More than 300 working hours into analyzing the video, I still didn’t get the picture (no pun intended). I felt like a donkey trying to climb Mt. Everest. Three minutes of video required more than 90 minutes to just document the motions, much less try to figure out what it all meant, and I had 20 hours of video. It wasn’t fun…..until suddenly it became incredibly fun.
One day…long into the day when dead tired usually means not very productive or observant, I was looking at a video segment and dutifully logging motions. BAM! Damn. Look what I just did on that video! I cut that blood vessel, and it was clearly visible an instant before I cut it–but I cut it anyway. WHY? If there was one turning point in the story, this is it. You never see what you don’t look for. Sometimes, because of how surgeons are trained, your eyes work a programmed way, yada, yada, yada…all lame excuses…you just didn’t see. It happened because I was thinking the same way I’d always been thinking…seeing what I’d always been seeing….no surprise. Even Einstein recognized that insanity is doing the same thing over and over again and expecting different results (sorry if I paraphrased you Al, we still buds?). I needed to change.
Back to the blood vessel spewing on the video. Worst thing, it’s zoomed video. That tiny blood vessel looked like Mt. Vesuvius when the blood erupted. In reality, it was only a few drops of blood, something no surgeon blinks at…do what you need to do, let it bleed, and then stop the bleeding. But zoomed and magnified, that small blood vessel’s eruption spilling a couple of drops of blood onto adjacent tissues looked like bloody diarrhea hitting a sponge (yes, I know, not pleasant). The tissues adjacent to that tiny blood vessel were soaked…red..yuck…compared to the beauty of human tissue that’s not stained by blood (I know most of you don’t really want to go there either). I wouldn’t go there if it were not important to the story. The visual image hit me, and it changed the way I think about the most basic of my surgical techniques. Tiny areas of bleeding, never even noticed by most surgeons, become huge when they soak into millions of cells in adjacent tissues. Blood cells, outside of a normal blood vessel, are like white phosphorus (that’s some seriously burnin’ stuff) to normal tissues. Blood soaked into tissues, even a little bit, promotes unbelievable inflammation and pain. Stay tuned for later pictures of the differences between a blood stained implant pocket and a “bloodless” one (for some that may be a reason to exit now).
Because I was looking at a hugely magnified view of what I see every day, I say something I see every day from a different perspective. Not until much later did I understand the significance of what I saw (remember the pig….), but finally I did recognize that.. Small things make big differences. Small amounts of blood soaked into tissues can cause big time discomfort. I was taught during my surgical training that blood is no big deal. Cut what you need to cut to do what you need to do, and then stop the bleeding. I can tell you right now, that ain’t so if you want to get the prize.
So Prize 1 was recognizing that it was possible to recognize small blood vessels before cutting them, and if I could control those small blood vessels before they bled into adjacent tissue, that could reduce pain. Bingo- while trying to become more efficient, I found the first prize of reducing bleeding to reduce pain. Small thing, everyone said…until later when they saw how it impacts patient comfort and recovery.
Then the rib thing happened. While I was working on this project, I took a little time off and made one of my twice a year pilgrimages to Moab, Utah to ride dirt bikes (yes, I admit that I’ve always loved throttles and air). Poison Spider got me. Poison Spider is a 23 mile ride, and if you start from the south end, you ascend from a canyon to the top of the mesa very rapidly, straight up a series of very large boulder jump-ups (steps 2-4 feet high each). I wheelied successfully to the last jump up, and relaxed just for an instant as the front wheel came down on a small rock less than a foot in diameter that should have been nothing. It wasn’t nothing. Flipped the bike, I’m on the ground, and the bike with hot pipes and muffler comes down directly on top of my chest, creating a bike-Bubba-red rock club sandwich.
Didn’t notice the popping sounds very much, but after getting up, found it a bit hard to breathe as I kicked and kicked on the bike starter to get going. Five miles further on, I tried to walk 1/2 mile to an overlook to photograph, but had to stop because I couldn’t get enough air (and I don’t mean air in the jumping a dirt bike sense). I couldn’t breathe worth a damn, but being a doctor and not wanting to whine around my studly buddies, I ignored it. Rode the rest of the 23 miles out, but every time I tried to inhale, it felt like some bad dude jabbing knives into my chest…and the bumps, rock jumps, and descents didn’t help a bit. Life sucked, and the last thing I was thinking about was efficiency.
Five broken ribs, a punctured lung, and two separations of the ribs from the breastbone (sternum)- oh well. Not fun. Ended the riding, despite highly technical treatment of lots of Motrin and adult beverages at night. Got back to Dallas, and for about 3 months, the bad dude with the jabbing knife stayed around. But what in the world does the rib thing have to do with 24 hour recovery?
Back at the video workstations, I was logging steps and motions, now inside the pocket for the implant. The back wall of the pocket is the rib cage. A retractor is an instrument that lifts the overlying tissues to allow the surgeon to see between the tissue planes and develop a pocket for the implant. As I was inserting a retractor on the video, I noticed that the tip of the retractor and the tip of the attached fiber optic bundle used to light the inside of the pocket….struck a rib (picture below). Just a tap, but instantly, the white, glistening surface of the rib began to develop a red splotch that was spreading beneath a clear layer of tissue that covers the rib–the periosteum. Another light went on. The periosteum is a very sensitive layer of tissue, and blood beneath the periosteum (periosteal hematoma) causes significant pain. What blew my mind was the thought that earlier in my career, I was taught to create the pocket for the implant with a blunt instrument that banged on every rib over the entire chest wall and ripped tissues to create a pocket. No wonder patients have pain after augmentation when surgeons create the pocket for the implant using blunt dissection . Well meaning surgeons ripping tissue to create a pocket, blunt instruments banging on ribs, and blood soaking into tissues and beneath rib periosteum. Take a look.
This is a picture inside the implant pocket that shows a close up of a rib with tiny blood vessels coursing over the rib. The yellow arrow shows the tip of a retractor just barely touching the rib, and beneath the retractor, the broken blood vessel and blood flowing under the rib lining (periosteum). This small, but very significant detail can cause significant pain for patients. It’s called a subperiosteal hematoma (throw that term around at your next cocktail party).
Now I could imagine how the usual breast augmentation patient felt after surgery- that bad dude that got me after the dirt bike rib thing not only was sticking a knife in various places, but he was lighting that fire of inflammation inside the tissues as the blood that soaked in created inflammation. While looking to improve efficiency, I had stumbled onto a couple of very simple but significant pearls–problems recognized–blunt trauma to ribs and blood soaked into tissues. Like the pig, just by continuing to look, and look, and look, good things were beginning to happen.
Recognizing problems is a key first step. Developing solutions is usually more difficult. But not this time. The initial solutions were straightforward: 1) Find a way to create the pocket for the implant that stopped bleeding before it started, preventing blood soaking into tissues, and 2) change my surgical techniques and instruments to develop a strict no-touch technique for ribs and rib periosteum.
Enter the electrocautery. An electrocautery is an electrical generator (sophisticated) that sends a programmable electric current to a surgical instrument. When the instrument is activated, the current can do two things: a) cut through tissue and seal small blood vessels in the process to prevent bleeding, and b) when encountering larger blood vessels, applying current using pinch forceps can seal the ends of vessels and stop bleeding. For surgeons, an electrocautery is not magic. But how a surgeon uses electrocautery instruments can be magic. We hear from surgeons routinely that “I use the electrocautery, but I don’t get the results you get.” My reply is always the same, “It’s not that you use it, it’s how you use it. I used electrocautery instruments for 15 years before I realized specific ways to use them more effectively.”
Surgeons use two basic types of electrocautery instruments routinely- a handswitching electrocautery pencil, and various types of electocautery forceps (see pics below). Traditionally, surgeons are taught to use the pencil instrument to cut tissue and control smaller blood vessels, and taught to use the forceps type instrument to coagulate (close and seal) blood vessels after cutting the vessel–to stop the bleeding. The problem with that approach is that it allows blood to soak into tissues before the bleeding is stopped. Blood in tissues…fire….inflammation.
Another problem was apparent on the videos’ analysis. In slow motion, I noticed that when the electrocautery pencil cut through a larger blood vessel that was unseen, the pencil was not capable of quickly and predictably stopping the bleeding. Follow this sequence: I cut the unseen vessel with the electrocautery pencil…bleeding starts….I turn, put down the pencil instrument….the instrument nurse places electrocautery forceps in my hand…I look down to find the foot switch to activate the forceps…I look back into the pocket–more blood….I take a gauze sponge on another instrument to soak up the blood…and then switch instruments again, back to the electrocautery forceps…and control the bleeding. Eight steps….five miles of unnecessary motions (well, not quite, but on analysis it appears that way), and by the time the vessel is controlled, the tissues lining the pocket look like the Red Sea (except redder) with blood soaked into every adjacent tissue (I decided not to reiterate the sponge analogy).
Now the Gilbreth principles really kick in, and I begin to realize how dramatically different all this could be if I could do a couple of things. What if I could develop a very sharp tipped electrocautery forcep that could cut tissue as effectively as the pencil instrument, and use the same instrument to stop bleeding either before it starts (prospective hemostasis)? If I cut a blood vessel that I simply couldn’t see, I’d have the forceps already in hand and could stop the bleeding before blood soaked into adjacent tissues. And if I designed an instrument with a hand switch on the forceps that activated the current, I’d never have to look down to find a foot switch. Eight motions would be reduced to one–now we’re talking efficiency! And in the process, I’ve addressed one of the main causes of pain….blood soaked into tissues.
Tools are great, but remember, I mentioned that it’s all about how you use them. To optimize the concept of prospective hemostasis, I needed to stop bleeding before it starts. That meant relearning surgical anatomy on a new level–by mapping the locations of much smaller blood vessels that are not illustrated in any anatomy text, and by sequencing my thoughts during surgery to prioritize searching for those smaller vessels as I dissect a pocket and using the electrocautery forceps to seal at least two spots along the vessel before cutting between the sealed locations.
The photograph below shows the locations of the larger blood vessels that surgeons must control before cutting in order to prevent tissue staining and minimize inflammation and pain for the patient. In addition to these major vessels, surgeons must also know and anticipate the locations of many smaller blood vessels throughout the pocket. I had always focused on the fancy dials and current settings on the electrocautery, but while going through video, I noticed that despite all the fancy settings, the speed at which I moved the tip of the electrocautery instrument made a huge difference. Different pace in different tissue types…way too much detail…but it was just another acorn.
The ribs solution (avoiding touching ribs with any instrument) was a simpler problem, but more difficult to address. Changing habits is tough for anyone. For a surgeon, it’s near impossible. It sounds incredibly simple to just keep the tissues elevated off the ribs at all times, and never touch the ribs when inserting or removing a retractor. The concepts are primitive. Implementing them 100% of the time requires constant attention to detail–the old habits of ignoring the ribs don’t ever go away. Some retractor design changes and other instrument changes helped, but end of the day, I was learning that I was having to change how I think and focus on details I’d never focused on before.
Visual proof. The three pictures above show (left) inside a pocket dissected by blunt instrument dissection (note the red staining), (center) a pocket dissected on the right with blunt techniques and on the left using our electrocautery instruments; and (right) a pocket dissected entirely using electrocautery instruments and avoiding all contact with the ribs seen on the right. The absence of blood staining in the pocket in the right picture is dramatic, and means that the patient will have a much more rapid recovery with much less pain.
Several very simple observations, a modification of instrument designs, a checklist of steps to locate and control even the smallest blood vessels before blood could soak into tissue, and changing longstanding habits to prevent instruments from ever touching the ribs–over a few months it all happened, and surgery started to change dramatically.
The pig had found a couple of prizes–in unexpected places. Simple things that I had always believed were routine and not important became very important. Things I thought I was good at, I realized that I was strictly average, and that’s why I was seeing average efficiency in surgery and average recovery with my patients. But as the pig would have it, as I was focusing on improving efficiency, I stumbled onto small surgical details that were beginning to dramatically change our surgery and our patient’s experience.
How we put it all together and the prize for us and our patients is the subject of Chapter 3 of the 24-hour recovery story. Stay tuned for the rest of the story–and what happened to the pig.
Filed under: breast augmentation
By John B. Tebbetts, M.D.
Subplots: 1) Blind pigs and acorns, 2) Looking in what might appear to be unlikely places, and 3) overcoming preconceptions, learning from data, and finding the prize for patients
It’s an incredible experience to be part of something that continues to amaze you while offering breast augmentation patients a redefined experience. A “good piece” down the road, it’s really cool on every surgery day to talk with patients who are out shopping, at dinner or a movie a few hours after their breast augmentation. My response is always the same: “Damn, that’s amazing.”
Some wise soul once said, “Even a blind pig occasionally finds an acorn.” May be true, but that wise soul didn’t know much about pigs- their intelligence, persistence and olfactory (that would be smell) senses. What do pigs have to do with augmentation recovery? If you’ve ever watched pigs, especially wild ones, it’s amazing how diligently they dig (wrecks beautiful pastures), seemingly finding nothing, and then all of a sudden, they’re chewing on a prize. It’s not totally surprising that sometimes when they are diligently looking for something, they find something even better. Another thing about wild pigs–if they don’t find the acorn/prize in one place, you can bet that they will keep moving and look around in other places–often unlikely places. And one more thing–because they can’t see worth a damn, pigs sometimes don’t recognize things until the thing hits them in the face. That’s how the story of 24 hour recovery begins, and in this post and two more that will follow, the story unfolds.
Chapter 1- Moving off point zero, asking “why not”, and learning from others
When we began operating in our own surgery center almost a decade and a half ago, several things became apparent: 1) nausea and vomiting were fairly common, 2) like most hospital settings, patients required an hour or more in the recovery room before spending another hour or two before going home, 3) and we were having to charge patients for all that recovery time and staffing following an augmentation.
Those observations prompted obvious questions: 1) how can we cut down on nausea and vomiting, 2) how can we help patients to awaken quicker while still keeping them comfortable, 3) how can we cut surgical facility costs to patients while improving every aspect of their care? We chose to begin with anesthesia, because drugs and anesthesia are the first determinant of a patient’s perioperative experience.
Nausea, vomiting, and postoperative constipation (just ruins the positives of an augmentation) are caused by narcotics, so the first logical question was “why not decrease total doses of narcotics?” Problems are, a) the longer an operation takes, the more narcotics are required to keep the patient optimally anesthetized, and b) I’d always been taught that narcotics are absolutely necessary to manage patients’ pain following augmentation. Those issues meant that first, we had to find ways to reduce unnecessary operation times. It’s very difficult for any surgeon to hear, much less admit, that he wastes time in the operating room. Being a surgeon, I’d love to blame something else, but truth is, it all starts with the surgeon. But how could I get more efficient without compromising the quality of my surgery–that was the real question–and it challenged every preconception I’d been taught during my general and plastic surgery residencies.
I figured (that’s Texican for “I thought”) that if surgeons who taught me really knew how to be more efficient, most of them would have, because surgeons get paid for their time (most think it’s their expertise, but it’s really their time, like every other professional). But most surgeons who were my mentors during my residency were really not very efficient compared to a surgeon I had the opportunity of observing during an elective period in medical school–Denton Cooley, M.D. Rewind 18 years back to 1972, because the story really began in 1972 when I was exposed to Dr. Cooley.
Dr. Cooley, a legendary cardiothoracic surgeon in Houston, performed the first human heart transplant in 1968 and implanted the first artificial heart in a human in 1969. Read more about Dr. Cooley here and here. While those feats and his countless others (being a superb basketball and racketball player as well) are impressive, the single thing that impressed me most about Dr. Cooley as a surgeon was his technical skill and efficiency. Dr. Cooley is unquestionably one of the most technically gifted, if not the most technically gifted surgeon who has ever lived. The speed with which he carried out massive cardiac and vascular operations in very high risk patients was astounding. Most astounding was that his moves were never fast. He never appeared to hurry. But not a single move was ever wasted. And the level of his assessment and planning before entering the operating room meant that I never saw him waste time with thinking and unnecessary moves that could have been avoided by better planning.
While other surgeons who were jealous of Dr. Cooley often opined that it was impossible to perform a quality operation at a speed that was routine to Dr. Cooley, any objective observer could readily see that Dr. Cooley’s patients, no matter how high risk, survived more often and recovered more rapidly than any other cardiothoracic surgeon of his era. From that early experience, I carried away lifelong lessons I’ve never forgotten: 1) I am no Denton Cooley; 2) it is unquestionably possible to deliver a level of surgical efficiency that is unimaginable to many surgeons, 3) improving efficiency, instead of detracting from quality as many surgeons might like to believe, does just the opposite–it improves the patient experience and outcomes in ways that most surgeons never dream of.
But I was challenged (many who know me would guarantee that I still am, and I don’t mean in a positive way). First, despite constant efforts to increase my planning and technical skills, during seven years of surgical residency and the first decade of my clinical practice, I couldn’t begin to approach a Cooley level of efficiency. Recognizing that I didn’t have the innate talent and skills of Dr. Cooley, I knew I had to try harder and look outside my surgical training realm (remember the pig?) for other ways to improve my efficiency.
Enter bricklaying. Yep, bricklaying. While visiting with a friend of my father who was a process engineer (I had no clue at the time what a process engineer did), I was venting my frustrations about not being able to take my surgical efficiency to another level. The year was 1986, 8 years into my clinical practice. I had just left a professorship and academic practice for a full time private practice, and was working at 7 different hospitals. My father’s friend commented, “You’re wasting a ton of your time. You need to learn bricklaying. I’m going to send you a book.” The book was authored by Frank and Lillian Gilbreth.
Frank Gilbreth (read a bio here) began as a bricklayer and building contractor. Working with his wife Lillian, Frank was interested in making his bricklaying faster and easier. Long story short, Frank pioneered concepts of motion and time studies that focus on making manufacturing processes more efficient by diagramming and timing all of the motions required to complete a task. Kind of cool aside…Frank’s son, Frank Jr. is the author of Cheaper By the Dozen, a book that inspired two subsequent movies–a story inspired by events that occurred in the Gilbreth family.
Gilbreath’s concepts were not totally manufacturing oriented. He is purported to be the first to advocate that a surgical nurse (Gilbreth called the nurse a “caddy”) hand surgical instruments to a surgeon. At the time, I had no clue of a medical relationship. I was much more interested in how Gilbreth drastically refined what appeared to be simple bricklaying, and how he used a camera to study motion and efficiency. Another book by Fred Meyers further tweaked my interests and provided more insight into motion and time study.
A light went on. What if I used Gilbreth’s bricklaying/ motion study principles to try to improve our surgical efficiency? If we could deliver the same quality breast augmentation more efficiently, the patient would require less drugs, especially narcotics that cause nausea and vomiting and prolong patient recovery. But using principles of motion and time study borrowed from manufacturing and process engineering–applied to surgery? That had to be nuts. Oh well, not the first time I’ve gone there, and won’t be the last. I’ve never been more excited about working on something, because I’d learned from Cooley that extraordinary is possible, and I learned from Gilbreth and Meyers some new tricks for looking at the issues and improving efficiency. Better bricklaying might lead to better surgery. Why not try?
The simple methods (and countless hours of analyzing video) that led to giant improvements in surgical efficiency, and the first blind pig prize of what we stumbled onto are the subject of Chapter 2 of the 24-hour recovery story (the other “pig prizes” are in Chapter 3).
