In many respects, quality breast surgery is as much a product of intelligent preoperative preparation and planning as it is sound technical skill. In fact, much of the most useful information that hopefully will come from this book will be contained in this chapter. As I have built my breast practice over the years, a pattern for success has emerged that has improved my personal results in both aesthetic and reconstructive breast surgery. This approach has made these results more consistent and helped tremendously in holding complications to a minimum. This approach can be divided into preoperative and intraoperative considerations.

The specifics of the standard preoperative consultation for each aesthetic breast procedure covered in this book will be addressed in the appropriate chapters. However, for all breast procedures, a preoperative office appointment 1–3 days before the actual procedure is performed is highly recommended. For a Monday surgery, this appointment takes place either Thursday or preferably Friday. At this appointment, the procedure is reviewed in detail and the goals and expectations of the patient are once again confirmed. If there was any question as to the exact nature of the procedure to be performed, these uncertainties are eliminated as much as possible and final decisions concerning breast implant size, bra cup size, incision location or implant position are determined. If there are variables or unknowns related to a specific portion of the procedure, these are once again reviewed and how these unknowns will be handled at the time of surgery are decided upon. One example of this relates to the inframammary fold. After total capsulectomy, the fold sometimes drops, which necessitates suture plication to provide symmetry with the opposite breast. This is notoriously an unpredictable and difficult undertaking and a certain percentage of patients will require a revisionary procedure to obtain the best result. While covered during the initial consult, these limitations are best stressed again at this preoperative visit to remind the patient of what the important considerations are for a specific procedure and how problems will be managed. If, in fact, complications do occur, the patient will be better educated and have a greater understanding of her condition if the case is managed in this proactive fashion. Attempting to explain complications after the fact is tolerated only by the most realistic of patients and can result in great medicolegal risk for the treating physician, even in cases where true malpractice is not even remotely an issue.

In addition to issues which fall into the category of appropriate informed consent, basic procedural matters are efficiently and easily managed at this visit. All required paperwork can be completed at this time, including history and physical completion, writing of the operative note and postoperative orders, reviewing the appropriate procedure-related preprinted discharge instruction sheets and filling out prescriptions for anti­biotics and analgesics as indicated. Arrangements for postoperative follow-up can also be made, understanding that specific times and dates may change. Such an organized approach, while somewhat labor intensive on the front end, pays significant dividends later on. Most importantly, many potential postoperative problems are eliminated because they will have been managed ahead of time. Issues such as antibiotic allergies or analgesic intolerances can be addressed at this time rather than later over the phone with nurses or pharmacists. On-call responsibilities are greatly minimized, which eliminates over-the-phone decision making. Perhaps most importantly, patient confidence in the entire process is greatly facilitated,which creates the best environment for postoperative management. All of the above enhance overall patient safety and reduce the potential for complications.

The second major goal of the preoperative visit is technical and relates to patient marking. As opposed to the often harried environment which is present in the hospital or surgical center, marking in the office allows the surgeon to apply all his or her energies to the task at hand in a quiet, controlled environment without interruption by anesthesia staff or nurses. All marking supplies will be readily available and experienced nursing staff assistance is assured. Marking done in conjunction with the administrative functions described previously assures that all issues will be addressed and greatly minimizes the potential for either significant or insignificant errors. Standard ‘permanent ink’ skin markers are used to identify pertinent landmarks as the patient stands upright in a relaxed position. Various multicolored packs of markers are available, with my personal preference being the ‘Sharpie’ brand, which offers up to 24 different colors (Figure 2.1). Bedsides the standard black and red, various other colors can be used to signify the particular surgical steps to be undertaken. For instance, areas of skin to be resected can be designated one color and areas where undermining is to be performed can be outlined in another. Any color scheme is appropriate and when this scheme is applied uniformly from patient to patient, the accuracy of the preoperative plan becomes enhanced. Essentially, the entire operative sequence is performed in the surgeon’s mind’s eye during the marking procedure with the marks documenting the surgical steps. In my opinion, the more detailed the marking pattern, the better the likelihood the proposed surgical procedure will be successful (Figure 2.2 A,B). One additional device which is quite useful is a standard laser leveler, which is available at most hardware stores. By dimming the lights and using the red laser light to reveal the true horizontal plane across the chest, accurate placement of important breast landmarks such as the top of the areola can be assured. Using this device can be very helpful, particularly in patients with preoperative asymmetries, where landmarks can be sometimes difficult to identify correctly and symmetrically (Figure 2.3 A,B).

Figure 2.1 Multicolored ‘Sharpie’ markers allow versatility and accuracy in designing and documenting a preoperative surgical plan.

Figure 2.2 (A,B) Using the multicolored markers, a detailed and visually descriptive surgical plan can be instantly appreciated. Such detailed markings are helpful not only at the time of surgery, but also later on after full healing has occurred. By referring back to the marking photographs, the accuracy and success of the overall surgical strategy can be assessed. In this way, the maximum amount of information and learning can be obtained from each patient experience.

Figure 2.3 (A) A standard laser leveler which emits a straight line laser beam can assist in evaluating symmetry from side to side in a patient. (B) By turning down the lights, the laser beam can assist in drawing patterns which are symmetric. In this case, the beam is confirming symmetry in the top of the periareolar pattern on each side.

At this point, it is very important to note the patient’s natural shoulder position. Many patients will have an asymmetry in their shoulder level, which affects the position of the breast when the shoulder is artificially raised or lowered (Figure 2.4