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 DR. CARRAWAY |
In public education, the No Child Left Behind Act is another way to say that we have zero tolerance for letting any child slip through the cracks and not get the best education that they are capable of receiving. The labor union SACOP (State Associations of Chiefs of Police) has a "safe shield" project that espouses zero tolerance to workplace injuries. Britain's largest labor union demands the same level of attention to injuries in the workplace and the term zero tolerance is commonplace and well understood by all. It is also obvious to all of us that the greater the risk for injuries in a workplace, the more the possibility for them exists.
PATIENT PERSPECTIVE In the past week, i have seen some interesting consultations regarding eyelid problems from around the country. one patient (a physician) has bilateral upper lid entropion with his lashes constantly brushing against his cornea, secondary to a bilateral upper eyelid ptosis repair that was not successful, which his doctor did not know how to correct with follow-up surgery. this physician is dealing with this very troublesome problem all day long every day and even when he sleeps at night. this could have been prevented by a simple addition to the operation that is known to at least some people who do this type of surgery.
I also consulted with a male patient who had unusual placement of facial prostheses and facial fat that now gives him an appearance totally different from his original and, actually, handsome appearance. Another patient has had too much fat removed from her upper and lower lids, giving her an extremely hollow look with lower lid retraction and incomplete closure. Yet another patient had a facelift that lasted seven to eight hours (!) and resulted in wide scars around her ears and postauricular area and a neck that was still "hanging" down. Granted, as one of the older plastic surgeons in the field, I do see my share of unhappy patient referrals simply because there is often no place else for them to go. However, each one of these patients has told me that we as a specialty need a policy that espouses zero tolerance for negative outcomes just like the industrial and educational fields have.RISK LEVELS When we look at patients and evaluate them for surgical procedures, we should think in terms of a "graded risk level" so that we can predict the percentage level of negative outcomes for a procedure. for example, subcutaneous versus deep plane facelifts have different risks. there is a certain small but definite risk of facial nerve injury in even the best executed deep plane facelifts. if even no gross facial nerve branch damage occurs, some of the smaller nerve filaments can be injured causing problems with blinking or post-operative twitching of the facial muscles. in this instance, these risks should be explained to patients so that they can choose between having nearly zero complications with a subcutaneous facelift or a higher level of potential injury to delicate structures with a deep plane lift. in the case of a subcutaneous facelift, the extent of undermining and the degree of tightening of the skin determines whether the patients will heal their wounds perfectly or whether they will have some level of poor wound healing, including bad scars or necrosis of skin. as a conservative surgeon, i like the idea of perfect scars, perfect healing and, obviously, getting as good a result as i can. like all of you, i "walk the tightrope" every day in dealing with risk versus benefit and constantly strive for zero tolerance to complications.
In every procedure that we perform, particularly around the facial area, we should be able to anticipate possible complications and keep our rate of complications approaching zero. We also need to explain to patients in advance what their risk levels are. If they wish to seek a higher risk level with a different or more invasive procedure and we are capable of delivering this for them, it may be a reasonable pathway in some instances.
