Telemedicine: Risks, Benefits, and Pitfalls in the Postoperative Care of Plastic Surgery Patients and Review of the Literature

Background

As a practice grows in volume and reputation, a plastic surgeon may be asked to perform surgical procedures on patients from neighboring states, other areas of the country, and even other countries.  Postoperative follow-up in these situations is anything but routine, and, until recently, these patients of medical tourism had no direct way to follow-up with their surgeons without both great expense and time expenditure.  Digital image transmission has been studied in the plastic surgery literature as a means to evaluate wounds, skin malignancies, digital injuries, and free flap viability.

However, there remains little information regarding the use of patient-submitted digital images and their role in post-operative follow-up in the plastic surgery patient.  With the advent of digital imaging and, more specifically, the global, mass-market spread of high resolution, automatic point-and-shoot cameras, the authors sought to evaluate the utility of patient-taken digital photographs as a means of follow-up after plastic surgery procedures. 

Methods

This study reviewed 25 patients in two surgeons’ practices over a 3 year period, focusing specifically on those patients who were unable to return for follow-up and experienced a complication or a concern about healing.  Detailed instructions were given to patients to facilitate acquiring standardized views of the surgical area.  The images were transmitted to the surgeon for review by email.

Results

All 25 patients were able to take accurate digital photographs with standard views of the areas involved.  Follow-up ranged from 2 months to 3 years, with an average follow-up of 4 months. The most common postoperative complications were incision breakdown or dehiscence (6), breast cellulitis (5), and breast bruising, without hematoma (2).  The largest subgroup (10) included normally healing wounds in the postoperative patient.

Conclusions

These patient-submitted images proved invaluable in determining the need for additional intervention, while initial trepidation about poor image quality proved unfounded.  The authors offer this postoperative management paradigm as a novel way to meet an ever expanding, ever more diverse patient population who scours the globe for plastic surgical expertise.

There are significant legal risks due to privileging and credentialing rules for providers who use telemedicine.  Telemedicine creates the possibility for a provider to be sued for medical malpractice in remote states or even countries; therefore, it must be used judiciously.  Providers must be certain that their malpractice covers the provision of telemedicine services, especially in areas of obtaining proper informed consent and maintenance of medical records.

Introduction

Prior to the development of technology within the last several years, patients from remote geographical locales could not follow-up with their plastic surgeon without great commitment of time and expense; routine follow-up was difficult in most cases. Using telemedicine to follow the postoperative course of this subset of plastic surgical patients provides a solution.  PubMed searches performed for “telemedicine and plastic” revealed a total of 44 publications of which the more relevant will be reviewed in the following paragraphs.  One should note that the majority of these studies involve trained, hospital affiliated personnel with proper camera equipment and not patients using cellular phone cameras.

A review of the literature of reveals that the majority of publications on the topic of telemedicine in plastic surgery has taken place over the last eight years, yet we as a group are far from taking advantage of the full array of its benefits.  Pap et al. reviewed a  a multi-institutional study utilizing plastic surgery residents taking digital images of radiographs and complex wounds of the hand and face following trauma and transmit them electronically to the attending physicians on call.   The authors evaluated 20 patients, 12 of whom had hand injuries.  This method of review proved reliable for triaging and discerning additional operative management.  1   Study limitations were defined by the current technology: picture resolution of the two megapixel camera as well as the storage size of the file (picture size of 400 × 320 pixels, 100 dots per inch) and electronic transmission speed available at that time.  The study highlighted patient privacy and the need for encryption – 128-bit encryption was employed in this study. 1

Jones et al. in 2004 published an extensive study of 150 images after trauma and burns that were taken by trained personnel in the emergency room setting.  They also involved an IT staff to develop software to enable faster transmission, encryption, and storage.  Even with these advantages, they had to compress the images to 800 x 600 pixels in JPEG format.  Additionally, only 82 of the 150 images were able to be evaluated due to data gathering loss or inadequate image capture.  They cited recurrent technical difficulties and significant capital outlay was significant.  2

A case report published in 2004 demonstrated an early account of the use of images taken by a patient’s cellular phone to document a finger wound over an eight day period. 3   The authors pointed out the low cost and easy manipulation with such a technique. 3   However, resolution was limited with technology of cellular phone cameras at this time.3        

The first large study utilizing a mobile camera phone was published later in 2004 by Hsieh et al.  45 patients with 81 digital injuries were evaluated by 110,000 pixel digital camera images taken by surgical residents in the emergency room.  These camera phone images were transferred to another camera phone as 132 × 176 JPEG files to be viewed by the consulting surgeon. In 25 percent of the cases, there was significant discordance in triaging.  Camera phones at this time were not capable of generating high-quality images suitable for surgical interpretation in a reliable fashion.  Also, 3G and 4G networks did not exist and significantly compromised the image transmission quality. 4

Tsai et al. evaluated extremity wounds in 60 patients with camera phones of residents and transmitted images to consulting surgeons. In this study, surgeons had similar difficulty triaging due to image quality, reporting 68% to 90% concordance among surgeon evaluators.  5

Another study published a few months later evaluated potential for replantation in amputated fingers.  This study utilized images from camera phones taken by emergency room personnel that were transmitted to consulting plastic surgeons.  35 patients with a total of 60 digital injures were evaluated in this manner, and the sensitivity and specificity of recognizing digital replantation potential was determined to be 90% and 83%, respectively. 6 

Wright, et al. evaluated 151 cases after preoperative image procurement and showed that 68.9 percent of those patients in this see-and-treat protocol for plastic surgery were not able to be treated that same day.  The authors cautioned that patient and surgeon alike must be prepared for cancellation on the day of surgery if cases are incorrectly designated. 7 

Murphy, et al. compared the evaluation of wounds of by a vascular surgeon, a surgical resident, and later by a plastic surgeon.   This study utilized a 3.3 megapixel camera and agreement among study personnel was largely uniform.  8 

Wilkins, et al. completed a nine month pilot study to evaluate largely lower extremity chronic wounds in 56 patients by remote means.   Surveys showed 98.2% patient satisfaction and similar satisfaction on the part of the referring physician.   This study was one of the first to focus on the satisfaction of patient and physician alike with the telemedicine consult system. 9 

Rees, et al. investigated the financial repercussions of telemedicine consultation in homebound patients with chronic wounds. 19 patients were followed in a prospective fashion for two years, and the authors showed fewer emergency department visits, hospitalizations, and, as expected, lower cost. 10 

Varkey, et al. analyzed 67 cases and five reexplorations after a diagnosis of venous congestion was made.  This evaluation was all done remotely and highlights how the improved resolution in images and improvement in image transmission capabilities allowed the authors the ability to diagnose what can be a subtle pathological entity. 11

Diver, et al. studied twenty patients in triage setting before transferring traumas for plastic surgical evaluation.  Management was only altered in one instance after the consultation by the plastic surgeon.  They alluded to the reduced costs with such a system in place. 12

Tadros, et al.  examined a series of 300 patients after digital image capture for skin malignancy and other cutaneous lesions.  They reported diagnostic accuracy in a random sample of 30 patients to be comparable to face to face consultations. 13 

However, there is no question that store-and-forward technology and televideo have been underutilized and underdeveloped. 14   Knobloch, et al. theorized that a cell phone-based multimedia service allows for transmission of high-resolution photographs and short videos that would be useful in free flap surveillance.  15 

What should be demonstrated at this juncture in the evolution of telemedicine is whether or not patient taken images can be useful in preoperative diagnosis, postoperative diagnosis, or surveillance.  A six month study evaluating patient taken images has gotten underway at George Washington University.  They have been evaluating emergency room patients with wounds, infections, and rashes.  The preliminary results of the study look promising, with a reported 90% accuracy.  16 

In this same manner, the goal of this study is to follow the postoperative course of plastic surgical patients with patient-taken images and determine the feasibility of this method as a postoperative management paradigm for those patients who are separated from their surgeons by issues of geography.

Methods/Results

After being granted Institutional Review Board approval at Beth Israel Deaconess Medical Center, information was collected from the charts of 25 patients who took digital photographs of their operative sites during their postoperative course.  Follow-up ranged from 2 months to 3 years, with an average follow-up of 4 months.  The most common postoperative complications were incision breakdown or dehiscence (6), breast cellulitis (5), and breast bruising, without hematoma (2).   The largest subgroup (10) included normally healing wounds in the postoperative patient.

Table 1 shows the entire list of patients involved.  Neither specific ages nor specific locations of individual patients are presented to maintain patient confidentiality.  However, to give an idea of the geographical span, these patients were separated by as little as a state ( New York) to overseas ( France).

1) normal healing following secondary breast augmentation

2) dehiscence of donor site after latissimus flaps with implants for breast reconstruction

3) normal healing following eyelid lesion removal

4) erythema after symmastia repair with Strattice

5-8) wound breakdown of breast following breast reduction (3), DIEP (1)

9) dehiscence after thigh lift

10-14) breast cellulitis after breast reduction (2), DIEP (1), tissue expander placement (2)

15-16) bruising after breast reductions (2)

17) seroma after abdominoplasty

18-19) normal healing after skin grafting

20) normal healing after DIEP flap

21) normal healing of subciliary incision after facial fracture repair

22) residual swelling after lower bleph

23) partial thickness burn after breast reconstruction

24) normal healing after medial canthal basal cell carcinoma removal

25) normal healing after latissimus flap with implant for breast reconstruction

Review of Select Cases

The first case was a young female who presented after primary breast augmentation with a double bubble deformity.  She had a periareolar revision with correction of the deformity.  She took standardized views of the breast postoperatively, which are provided in Figure 1, and had an uneventful postoperative course. 

The second case was an elderly lady who presented to clinic with bilateral breast implant rupture.  She had undergone implant-based breast reconstruction 20 years prior to presentation.  She underwent breast revision surgery with placement of new implants.  She had concerns about her left breast postoperatively, but subsequent image procurement allowed the surgeon to reassure the patient (see Figure 2).

The third case is a middle-aged old female who underwent breast reduction surgery.  She developed an area of wound breakdown, which was managed conservatively (see Figure 3).  The area healed without additional problems.

The fourth patient underwent skin-sparing simple mastectomy and immediate DIEP flap reconstruction.   Two of her postoperative images are presented in Figure 4.

The fifth patient was a young male who underwent open reduction and internal fixation of a right orbital floor fracture with titanium mesh plate.  Postoperatively, the patient became concerned about the reddened nature of his subciliary incision after about 1 week (see Figure 5).  Pt had a full return to function without visual disturbance, enophthalmos, or lid malposition.

The sixth patient was a delayed breast reconstruction s/p mastectomy and radiation who was reconstructed with a latissimus flap and implant after repeated failures with implant-based reconstruction alone at an outside institution.  She expressed concern that her flap had changed colors over the course of the week (Figure 6).  There was no cause for concern, and she has healed uneventfully.

Discussion

Escalating Technology and Patient Instruction

While very little has been published in regard to amateur procurement of images in plastic surgery,  the global availability of affordable, user-friendly, wireless internet capable cellular phones with higher resolution point-and-shoot cameras allow an individual to create high quality images with little instruction.  Most of these cameras have built in automatic zoom lenses and a series of automatic settings, which adjust light capture and promote better image quality.  The technical aspects of creating a high quality image have been increasingly simplified. 

Virtually any make or model of cellular phone made after 2008 contains at least a 2 or 3 megapixel camera and 8 megapixel cameras are commonplace on phones of today.  From a resolution of image standpoint, patient taken photographs are already more than adequate and they will only get better with each passing year.

What compromises photo quality more from the surgeon’s perspective is the inability to create standardized or useful images by the patient photographer.   However, with a few instructions to the patient, reasonable views can be obtained.  Most frequently, we ask patients to get two lateral views and an AP view, although other views are sometimes obtained   We also emphasize that the distance from the subject is kept constant and that the height of the camera is kept constant as well.  This study along with several others in development is demonstrating the efficacy of patient taken photographs in managing patient expectations and outcomes. 

Legal Ramifications of Telemedicine

Informed consent as always is important in telemedicine as it is in all areas of medicine.  The patient must be made aware of the transmission of images as well as any further storage or reproduction of those images. 17 Even though database encryption has become the standard to protect these transmissions, the patient should be aware of the limitations of the technology and its security. 18   The patient must voice consent and written consent should be obtained.  

Plastic surgeons should familiarize themselves with the risks inherent in the practice of telemedicine.  Telemedicine is a rapidly evolving technology, and technological snafus intrinsic to its practice provide a liability concern.  A technical glitch may result in transmission of inaccurate medical advice due to deletions or corruptions of data. 18

In addition, there is a great deal of variation across the state medical boards in terms of requirements for providing telemedicine services regarding licensure and credentials.  17 This practice of medicine across state lines can open the plastic surgeon up to lawsuits from patients in other states or countries.  In addition, state laws for bringing lawsuits against physicians can vary in statute of limitations as well as the types of claims and the damages that may be recovered. 17   Also, the surgeon must know if his malpractice insurance applies to telemedicine services rendered.  Otherwise, the physician can suffer large personal losses during a lawsuit without malpractice coverage. 17 

To help avoid the legal pitfalls at present, a plastic surgeon should probably evaluate only those patients from states in which the physician is licensed.  In our study, patients were evaluated initially in one of our local offices and were only followed in the postoperative course with the aid of telemedicine, after a doctor-patient relationship had been established.

Conclusions

For managing patients who cannot follow-up with their plastic surgeons due to geographic constraints or undue expense, telemedicine provides an avenue of follow-up, which did not exist just a few years ago.  Unlike previously published studies, which involved trained photographers, this study only evaluated patient-taken images.  The image quality and the perspectives obtained proved adequate for interpretation.  Ultimately, these images helped usher in a new postoperative management paradigm to the practices studied, and we offer this as a useful adjunct to any practice that delivers healthcare to patients from diverse locales.  However, plastic surgeons must be familiar with privileging and credentialing rules in telemedicine as well as medical malpractice and legal statutes of the areas in which the telemedicine is practiced.   

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