A plastic surgeon has been reprimanded after he dropped a chin implant on a theatre floor before picking it up and placing it in a bath of Betadine and continuing with the mentoplasty.
He apologised for the mishap, which occurred approximately 30-40 minutes into the cosmetic operation at Sydney’s Hunters Hill Private Hospital in 2021, saying his decision was spontaneous but made without sufficient consideration.
“After I had just opened up the patient’s chin, the nurse assisting, passed me the sterile implant to be inserted in the chin,” the surgeon said.
“Unfortunately, I dropped the sterile implant onto the floor. The implant was on the floor for less than five seconds.
“I instinctively picked it up and placed it immediately into a dish filled with Betadine.
“I then changed my gloves and continued to wash the implant thoroughly with Betadine.”
The doctor described “shelling” the outer layers of the implant that were in contact with the floor, washing the remaining implant with new sterile Betadine, and then washing the cavity and changing his gloves.
The NSW Health Care Complaints Commission (HCCC) investigated the incident after receiving an anonymous complaint about the surgery from one of his colleagues.
The commission claimed the surgeon had acted “recklessly” and should have been aware of the possible risk of long-term infection.
It also pointed to omissions about the accident in the report of the operation which also involved a septorhinoplasty.
The surgeon acknowledged the omissions but denied there was any attempt or intention by him to hide the incident.
He said he told the patient and her parents about what had happened during her postoperative appointment four days later.
“In hindsight, I acknowledge that it was not appropriate to re-use the implant. I have apologised to both the patient and the hospital management for this error of judgement,” the surgeon said.
He added: “The decision to re-use the implant was inappropriate and made with insufficient consideration.
“At the time I thought it would be acceptable to re-use the implant as I discarded the non-sterile outer part of the solid silicone, implant, thoroughly re-sterilised the remaining part of the implant, maintained full, sterile surgical field, and I did not have a spare implant available to use.
“On reflection, I completely accept that the appropriate course would have been to perform the septorhinoplasty while waiting for a new implant to arrive.”
But he said he “strongly refuted that I am a reckless surgeon”.
“I have learnt from this incident and now always order spare implants for all procedures to avoid a similar future incident.”
The tribunal heard from the anaesthetist in the operating room, who recalled hearing the words, “Oh dear,” before noting the implant in the kidney dish.
“The anaesthetist heard the [surgeon] make comments to the room like, ‘It will be alright’ and ‘I am happy to proceed.’
A scrub nurse said she had passed the implant to the surgeon, who was cutting and shaping it, and checking the fit in the pocket created in the patient.
She said on one of the occasions, while the surgeon was attempting to fit the implant, the implant “flung out of the chin and landed on the floor”.
One of the other nursing staff present during the procedure tried to complete a RiskMan Report but was unable to do so because of technical computer problems.
The surgeon said he sees, treats and operates on around 3000 patients each year, yet received few complaints.
The HCCC’s expert witness Assistant Professor Harvey Stern said: “If there was no backup prosthesis, that component of the patient’s surgery should have been abandoned unless a new prosthesis could be delivered from the supply company within a reasonably short time frame.”
He said the surgeon’s conduct was significantly below standard.
The tribunal found the surgeon guilty of unsatisfactory professional conduct and reprimanded him.
“His action led to the requirement to have the implant removed and replaced with a sterile version in order to be sure that the initial implant was not contaminated when it was inserted into the patient’s chin.”
It added: “The issue as to whether another implant could have been delivered to the operating theatre, following the mishap of dropping the original implant, is really clouded by the debate as to how long it would have taken to obtain a replacement.
“The matter which stands out in this case to condemn the respondent is that he did not stop to enquire how long that wait might have been. He did not cause an inquiry to be made to the supplier.
“He did not consider that information, and then determine what action to take.”
More information: NSW Civil and Administrative Tribunal; 13 October 2023