The History of 24 Hour Recovery®
- [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.
- 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.]
From the first breast augmentation with silicone gel implants in 1962, breast augmentation patients experienced a recovery and return to full normal activities interval of 10 days to several weeks, depending on the techniques and processes used by surgeons. For four decades, the norm for patients was prolonged recovery with restrictive bandaging, special bras, drain tubes, pain pumps, nerve blocks, narcotic pain medications, and other burdensome adjuncts.
In 2002, after more than a decade of work refining virtually all of the processes and techniques of breast augmentation, Dr. Tebbetts published two landmark papers in the most respected professional journal in plastic surgery, Plastic and Reconstructive Surgery Journal. These publications represented the first peer reviewed, scientifically confirmed methodologies that for the first time in history, enabled 96% of 627 consecutive patients to resume full, normal activities within 24 hours of their breast augmentation. Anticipating the understandable skepticism of surgeons who believed that 24 Hour Recovery® was impossible, Dr. Tebbetts invited the editor of the Journal, Dr. Robert Goldwyn, and his representatives, to personally visit and review all of the data and speak with patients from the study.
The studies began with an effort to reduce the amount of drugs that patients received by reducing operation times. Dr. Tebbetts used principles derived from process engineering and motion and time studies, videotaping with multiple cameras and then documenting and evaluation every move or action that occurred during an augmentation. During hundreds of hours of video analysis, actions that were unnecessary were eliminated and other actions refined or combined to make them more efficient. Instruments were developed to facilitate surgeon visualization and control. Surgical techniques were refined to dramatically reduce trauma to tissues and ribs, and to virtually eliminate bleeding and blood soaking into tissues, causing pain and inflammation and increasing risks of capsular contracture.
Dr. Tebbetts had already demonstrated that 24 Hour Recovery® was not only possible, but predictable by applying specific processes and surgical techniques. Surgeons often believe only when they can directly observe, so in 2000, Dr. Tebbetts performed a breast augmentation surgery in a live surgery setting at the largest and most respected live surgery symposium in the world, the Baker-Gordon Symposium in Miami. Over 800 surgeons in attendance were able to observe the live surgery via a video feed and were able to question Dr. Tebbetts during the surgery. The surgery required less than a half hour, and the patient returned to her hotel room less than two hours after the surgery began. She took a short nap, and then showered, washed and dried her hair, dressed to go out, went out to dinner in Coconut Grove in Miami (and ate raw oysters), and then (against previous medical advice) went dancing at a Grove disco. All of her recovery from the time she returned to her hotel until she left Miami the next day to return home to Texas and back to work a day later was documented on video that was shown to surgeons who attended the symposium the next year. Excerpt images from the video of her recovery are published in the scientific articles in PRS Journal.
More than a decade later, no other surgeon has demonstrated equivalent surgery and recovery in a live surgery setting as large and respected as the Baker Gordon Symposium. Many surgeons claim to deliver “rapid recovery”, but none have documented their cases with the level of accountability, predictability, and independent monitoring and surgeon observation that Dr. Tebbetts has established. Patients frequently ask why, if all of the processes are published for surgeons to read and implement, that more surgeons have not adopted the techniques and delivered similar results. A more thorough understanding of what is required to achieve this level of recovery will help answer the question.
Predictably delivering 24 Hour Recovery® requires that surgeons read, practice, and implement all of the processes, not just some of the processes that have been defined by Dr. Tebbetts. Many surgeons read and adopt some of the processes, but for various reasons, choose not to follow the recipe to the letter and implement all of the processes exactly as described. Evidence over the past decade clearly shows that failure to implement ALL of the proved processes that deliver 24 Hour Recovery® results in a failure to predictably and consistently deliver this level of recovery. The fact that no surgeon, in more than a decade, has proved as conclusively as Dr. Tebbetts that they can predictably and consistently deliver a 96% level of 24 Hour Recovery® speaks for itself. A few surgeons in the United States have implemented a majority of the processes and deliver 24 Hour Recovery® for a majority of their patients, but even those surgeons have not documented an equivalent level in peer reviewed and published scientific studies and in live surgery venues as respected as the Baker Gordon Symposium.
So what is the recipe? What are the processes that are absolutely essential to deliver 24 Hour Recovery®? The following is a summary of the processes that are required. More information is detailed in Dr. Tebbetts’ published articles in PRS and in his book for surgeons.
- Comprehensive and detailed patient education materials and content - patients must thoroughly understand how and why 24 Hour Recovery® occurs, and what their role and responsibilities are toward making it happen. Education allays many normal patient concerns, and enables patients to optimally comply with their postoperative care instructions.
- The surgeon must control the surgical environment – It all begins with the surgeon. The surgeon must operate in a facility where the surgeon is assured that he can consistently expect to work with the same personnel, and that all personnel including anesthesia and recovery personnel, will strictly follow prescribed protocols. The surgeon must be willing to pay the personnel to train above and beyond what is routinely expected. And most of all, the surgeon must commit to self-training and practice as well as train with his personnel. Absent those controls and commitment, 24 Hour Recovery® rarely, if ever, predictably happens.
- Objective, not subjective, clinical evaluation and tissue assessment – taking the grays out of the equation, using objective measurements instead of subjective, indefinable terms like cup size, to characterize each individual patients tissue characteristics; getting rid of terms like “tight skin”, “loose skin”, “stretched”, “tight”, “full”, “empty” , and substituting objective measurements that can then be used with a proved, scientifically validated system that defines the optimal amount of fill for each patient’s breast to deliver optimal aesthetic results and the lowest risks of reoperations and uncorrectable deformities, the High Five System®.
- Strict adherence to a tissue based, objective and scientifically validated system for decision processes and implant selection, the High Five System® - this system prioritizes decisions and provides a scientifically proved framework for surgeons to assure maximum soft tissue coverage for a patient’s lifetime, and recommends a specific volume of fill for each patient’s breasts based on the width, tissue stretch, and amount of existing breast tissue fill in the breast. This system has proved it’s predictability, accuracy, and effectiveness for more than a decade, producing results and reoperation rates that are unmatched in the medical literature. When surgeons or patients “cheat” on the recommendations of this system, data from FDA PMA studies suggest that patients experience reoperation rates of up to 30% at 7 years (up to 20% in just 3 years) instead of the exceedingly low reoperation rates of less than 5% documented by surgeons who rigidly apply the system.
- Strict adherence to defined anesthesia and post-anesthesia recovery (PACU) protocols that minimize the amount of narcotics and other drugs a patient receives – these protocols, defined in Dr. Tebbetts’ papers in PRS and in his book, require that surgeons insist that their anesthesia colleagues follow the protocols, and require that surgeons be able to refine their skills to be able to perform breast augmentation in 45 minutes or less.
- Following detailed surgical scripts published by Dr. Tebbetts that eliminate unnecessary and unproductive, time-wasting maneuvers and decision making in the operating room, and practicing these scripts with OR personnel to assure optimal training – these detailed scripts are derived from the hundreds of hours of video analysis, and specify the most efficient moves and processes for each of the personnel in the operating room.
- Implementing detailed surgical processes and surgical instrumentation to assure prospective hemostasis – these techniques and instruments allow the surgeon to create the implant pocket while preventing over 95% of bleeding that would normally occur with older techniques. By preventing bleeding before it ever occurs using specially designed electrocautery forceps to create the pocket, blood does not soak into adjacent tissues and cause pain, inflammation, and increased rates of capsular contracture that are common with older techniques that cause much more bleeding.
- Implementing detailed surgical techniques and instrumentation that dramatically reduce trauma to tissues and dramatically reduce pain and swelling that result from tissue trauma – Dr. Tebbetts designed surgical instruments that allow surgeons to create optimal visualization while minimizing pressure and trauma to adjacent tissues, and to create the pocket for the implant with much less trauma compared to blunt dissection techniques used by many surgeons that rip and tear tissues with a finger or a blunt instrument and cause much more bleeding.
Following strict protocols for patient recovery in the surgery facility and after returning home- the dramatic reduction in tissue trauma and bleeding using the techniques and instruments developed by Dr. Tebbetts results in patients having much less pain, and being able to be out to dinner the evening of surgery and return to full, normal activities within 24 hours. More importantly, patients do not have to tolerate the discomfort and inconvenience of many commonly used postoperative devices including narcotic pain medications, drain tubes, pain pumps, nerve blocks between the ribs, special bras or compressive bandages, and instructions to remain immobile and restrict activities—all of which have been conclusively shown to be totally unnecessary if surgeons implement the scientifically proved processes.
Dramatic improvements in recovery, reoperation rates, and the entire patient experience are not magic, but they do not predictably occur without substantial commitment and effort by the surgeon and all personnel. Delivering this redefined level of patient experience requires that surgeons read peer reviewed and published literature, but more importantly, follow the processes and techniques exactly before modifying or ignoring them, and commit the time and effort required to learn and practice the processes with their personnel. So in answer to why more surgeons don’t predictably deliver 24 Hour Recovery®, the answer seems evident—because the surgeon has made choices to not do the things that are required to make it happen. All of the things to make it happen are peer reviewed and published, and are readily available to surgeons.
Is 24 Hour Recovery® guaranteed if a patient has surgery by Dr. Tebbetts? The answer is a definitive “No.” 3-5% of patients, regardless of the commitment and processes used by any surgeon, either are not able to comply or choose not to comply with what is required of them to make it happen. And in 1-2% of cases, complications or issues can arise that prevent a patient from fully complying. But over the decade since Dr. Tebbetts first published the techniques for 24 Hour Recovery®, over 95% of his patients consistently and predictably experience it.