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The “Chain of Reliance” in Plastic Surgery

Prado, Arturo S., M.D.; Parada, Francisco, M.D.

Plastic and Reconstructive Surgery: December 2009 - Volume 124 - Issue 6 - p 462e-463e
doi: 10.1097/PRS.0b013e3181bf7ff5

Plastic Surgery Division, Department of Surgery, Jose Joaquin Aguirre Clinical Hospital, University of Chile School of Medicine, Santiago, Chile

Correspondence to Dr. Prado

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Plastic surgeons must be able to be trusted to act in the way expected. This means that we must trust “responsible” people that act as shackles of a complicated system of control (chain of confidence) and are indispensable for suitable outcomes.

We give credit to Mauricio Parada, M.D., our mentor and professor of surgery who always gave us this information during surgery residency.1

In the “team work,” the surgeon is only one part of this chain. To trust each one of the links of the chain is a precondition for good performance of any enterprise. A failure of any part of the chain is recipe for disaster.

Plastic surgeons travel often, and the best example of a chain of confidence is a commercial airline flight. A disaster is always possible: a pilot under stress and possibly under the influence of drugs, flight assistants who fail to close the door of the airplane firmly, and so on. After some time working in a university hospital, we give six examples that clarify this idea in plastic surgery:

  1. A bone graft was delivered from the hip for a case of nasal reconstruction. The scrub nurse received the implant and the team continued to finish the reconstruction. The surgeon asked for the bone, but the nurse answered that it was discarded as “she thought it was only traumatologic debris.”
  2. An abdominoplasty case finished without incident. The patient was moved from the operating room table to her bed, but the resident had “stepped on top of the recipient of the Foley catheter”; forced traction produced extrusion of the bladder (mucosa) that needed further urologic surgery.
  3. In another abdominoplasty case, during transfer of the patient from the operating room table to the bed, “the drains were left underneath the mattress” and were pulled out of the wound. The patient underwent reoperation and the drains were reinstalled with the aid of endoscopy.2
  4. A liposuction case was recovering in the postanesthesia room, where the nurse confused the urine recipient with a water trap recipient used in lung surgery and connected the system to the wall suction. The patient suffered shock and intense pain that needed treatment with morphine and stabilization in the intensive care unit.
  5. An upper blepharoplasty case was performed under sedation and local anesthesia and controlled by an anesthesiologist that refused to use a mask to deliver oxygen. The result: fire in the operating room.3
  6. After a transverse rectus abdominis musculocutaneous flap, the patient was recovering in a sitting position. The nurse measured the debits of the drains, putting the bed in the horizontal position with the consequence of a dehiscence and bleeding of the abdominal wound.

The plastic surgery team operates with a sequence of events and multiple personnel—including the anesthesiologist, operating room assistants, recovery room nurses, and others—until the patient is back in his or her room and discharged from the hospital.

Faith and truth are synonyms of confidence when they are used in the sense of a chain of reliance that starts with the patient and his or her safety. The analogy of “perfect teamwork” is the truth and “bad teamwork” the lie; the truth is constructed as a tower of cards that will resist the final destruction if the cards are put in the correct order; the lie is constructed with failure of a part of the chain, and the missing card determines the final collapse of the tower.

When a chain of confidence (plastic surgery team) works in both ways, the organization is internally competitive and even more competitive to the sector and subsectors. Reliance is a “top-10 concept” during the surgeon-patient communication. Allegiance of plastic surgery patients is based in sound principles, objectives, results, and expectations.

Organizations such as the International Society of Aesthetic Plastic Surgery and the American Society of Plastic Surgeons have worked in constant support on behalf of safety and play an important role as mediators between the shackles of the chain of reliances. Finally, protecting a chain of confidence will make any enterprise more competitive and recommendable.

Arturo S. Prado, M.D.

Francisco Parada, M.D.

Plastic Surgery Division

Department of Surgery

Jose Joaquin Aguirre Clinical Hospital

University of Chile School of Medicine

Santiago, Chile

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The authors have no conflicts of interest to disclose.

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1.Parada M. Personal communication, 1999.
2.Prado A, Parada F. Accidental “pull-out” of drains after abdominoplasty: Outpatient endoscopic control of an expanding hematoma and re-installation of drains under direct vision without opening the wound. Plast Reconstr Surg. 2009;123:79e–120e.
3.Prado A, Andrades P, Fuentes P. Fire in the operating room after reading a CME. Plast Reconstr Surg. 2007;119:770–773.

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©2009American Society of Plastic Surgeons