Complications with scar treatment

by Emma Louise, Risk Management Representative

Presentation

In November 2014, a 53-year-old woman came to a dermatologist for treatment of a mastectomy scar. Her history included right-side breast cancer and right breast reconstruction surgery a year earlier. The reconstruction surgery included an implant and acellular dermal matrix graft of the inferior pole. She had been a patient of the dermatologist for two years.

Physician action

At the appointment, she was evaluated by a physician assistant who advised that her scarring would become less noticeable over time, but corticosteroid injections were a treatment option. The patient was told to follow up in a year. 

On March 13, 2015, the patient returned and expressed interest in corticosteroid injections to treat the right-side breast mastectomy scar. The scar had a raised appearance, measuring 13 x 0.8 centimeters, and was described as feeling tender. 

The dermatologist identified seven lesions on the right breast and injected each with 40mg/cc of corticosteroid. It was noted in the medical record that the patient was aware of the risks including atrophy and hypopigmentation.

On June 5, 2015, the patient met with her primary care physician after finding bruises and increased rippling of her skin due to the implant. The physician also noticed some deflation of the implant and darkening skin at the bottom of the breast.

Over the next month, the patient’s right breast incision had completely thinned out and the inframammary fold had lost its structure causing the implant to droop down below the inframammary fold. 

On August 21, 2015, the patient returned to the dermatologist. She explained that a few weeks after the injection, the scarred area began to flatten and the skin around the scar became a reddish-purple color. After another few weeks, the discoloration expanded and rippling and thinning of the skin occurred. 

The dermatologist expressed his belief that the corticosteroid injections migrated outside the scar area causing significant atrophy to the right breast. The scar and atrophy measured 10 x 6 x 0.5 centimeters. 

The patient told the dermatologist she consulted with two plastic surgeons, and both recommended a right breast reconstruction. The dermatologist apologized for the complications and agreed that surgical repair would achieve a proper cosmetic result. 

They discussed which surgeons had experience with similar complications and subsequent repairs. After the appointment, the patient requested a copy of her medical records and did not return for follow-up.

The patient underwent right breast reconstruction revision on October 25, 2015. A month later, the thin skin area had improved and the mastectomy was adhered to the modified Ryan flap. 

A year later, the patient wanted to increase the right-side breast implant due to it being smaller than the left side, but she was advised against it due to concerns with skin quality.

Allegations

A lawsuit was filed against the dermatologist alleging:

• the steroid injection caused healthy breast tissue to atrophy;
• failure to obtain informed consent;
• improper steroid dosage;
• failure to assess patient response; and
• failure to consult with the treating surgeon prior to administering corticosteroid injections.

Additionally, complications from the steroid injections resulted in a second breast reconstruction and possibly a future third. The time off from work for surgery resulted in lost wages and future lost wages if a third reconstruction is needed.

Legal Implications

There were differing opinions among consultants about the appropriate course of treatment in this case. The disagreements mostly centered on questions about the standard of care for scar treatment on a reconstructed breast of a former breast cancer patient, and whether the dermatologist should have consulted the treating plastic surgeon.

The dermatologist documented that the patient was informed about the risks of atrophy and hypopigmentation. However, the patient disputed this. Dermatology consultants said oral consent is standard for this treatment, and patients are only instructed to follow up if problems occur. The patient did not return to the dermatologist for re-evaluation until five months after the corticosteroid injections. If she had returned sooner, it is likely something could have been done before the skin began to atrophy.

Experts for the plaintiff argued that the dermatologist should have consulted with the plastic surgeon and done a smaller test dose first. They expressed that it is common knowledge that mastectomy flaps are thin and vulnerable to corticosteroid injections. Consulting the patient’s treating surgeon would ensure that complicating factors, such as the implant, were identified and addressed before proceeding.

The defense was unable to find supportive medical literature for the dosage the dermatologist used as a starting dose for an intralesional injection. In addition, the manufacturer recommendations were 10mg per 2cc for intralesional injections and 2.5 and 5mg per 2cc for treatment of dermal lesions.

During the case review, it was discovered the patient had a breast revision surgery scheduled before receiving the steroid injection, due to breast asymmetry and some loss of the inframammary fold. However, the revision surgery would not have been as extensive as the revised reconstruction.

Disposition

This case was settled on behalf of the dermatologist.
‍

More about improper performance.

‍