Available via license: CC BY 4.0
Content may be subject to copyright.
39
patient outcomes and recovery from surgery by
reducing scar burden, pain and surgical errors
caused by poor visualisation. In aesthetic and
reconstructive breast surgery the most common
type of lighted retractor is the Tebbetts retractor
Prevention of thermal injury from lighted retractors in
breast surgery: a comparative study of optical cable calibre
Danielle Nizzero MBBS,PGDipSurgAnat,FRACS(Plast) 0000-0002-0175-0124 1,a Roland Deek
MD 0000-0001-5027-3101 2 Nicola Dean MBChB,PhD,FRACS(Plast) 0000-0001-7084-2359 3
1 Royal Children’s Hospital, Parkville, Victoria, AUSTRALIA. 2 Flinders University, Bedford Park, South Australia, AUSTRALIA.
3 Flinders University, Bedford Park, South Australia, AUSTRALIA; Flinders Medical Centre, Bedford Park, South Australia,
AUSTRALIA; Section Editor, Australasian Journal of Plastic Surgery, St Leonards, New South Wales, AUSTRALIA.
Keywords: Iatrogenic, burns, optical fibres, mammoplasty, breast implants
Submitted: 2021 January 14 AEST Revised: 2021 January 25; February 18 AEST Accepted: 2021 January 29 AEST Published:
2022 March 31 AESST
DOI: https://doi.org/10.34239/ajops.v5n1.289
Australasian Journal of Plastic Surgery
Vol 5, Issue 1, 2022 | March 31 2022 AEST
BREAST
Nizzero D, Deek R, Dean NR. Prevention of thermal injury from
lighted retractors in breast surgery—a comparative study of optical
cable calibre. Australas J Plast Surg. 2022;5(1):39–42. https://doi.
org/10.34239/ajops.v5n1.289
Objective
Iatrogenic thermal injury can result from the use of lighted retractors during
breast surgery due to the generation of heat at the connection between the
optical cable and the lighted retractor. This study aims to determine whether
a smaller calibre optical cable generates less heat at its connection with a
Tebbetts lighted retractor.
Methods
We measured the heat generated at the connection between an optical cable
and a Tebbetts lighted retractor for a 3.0 mm optical cable and a 5.5 mm optical
cable.
Results
Both optical cables showed temperature rises. The 3.0 mm optical cable
reached a peak temperature of 33.29 °C after 44 minutes and 47 seconds. The
5.5 mm optical cable reached a peak temperature of 49.23 °C after 53 minutes
and 19 seconds. Light intensity was similar between the two cable types.
Conclusion
A 3.0 mm optical cable generates less heat than a 5.5 mm cable at the connection
between the cable and the retractor. We recommend using the smaller calibre
optical cable to reduce the risk of thermal injury to patients from the use of
Tebbetts lighted retractors during breast surgery.
a Corresponding author: Danielle Nizzero MBBS,PGDipSurgAnat; daniellenizzero@gmail.com
Introduction
Lighted retractors are used in a wide variety of
surgical elds. They allow illumination of surgical
elds that would otherwise require more extensive
access incisions and dissection. Their use enhances
40
Prevention of thermal injury from lighted retractors in breast surgery: a comparative study of optical cable calibre
Australasian Journal of Plastic Surgery | ISSN: 2209–170X
with bre optic illumination. However, both
anecdotally and in the literature, a recurring
issue has occurred with bre optic illumination—
latrogenic burn injury. The heat generated at the tip
of the optical cable at its connection to the retractor
may cause a thermal injury if it comes into contact
with the patient, either directly or through the
drapes. Prompted by a recent case in our unit we
sought to conrm if our current set-up generated
temperatures sucient to cause thermal injury
and, if so, whether changing to a smaller calibre of
optical cable would minimise this risk.
Methods
In this study we compared two dierent calibre
Stryker® (2825 Airview Boulevard Kalamazoo,
MI 49002. USA) optical cables, 3.0 mm and 5.5
mm. Each cable connected a Stryker® L9000 light-
emitting diode (LED) light source to a Snowden-
Pencer™ (5175 S Royal Atlanta Dr Tucker, GA,
30084-3053 USA) 88-1088 Tebbetts lighted retractor
with 3.5 mm light port. The same light source and
retractor were used for each cable.
Temperature measurements were recorded at
multiple points along the connection between each
optical cable and the lighted retractor using Philips
21091A (65 Epping Rd, North Ryde NSW 2113,
Australia) small bead type temperature sensing
probes connected to an Omega (800 Connecticut
Avenue Suite 5N01, Norwalk, CT 06854,USA) OM-
DAQPRO-5300 Datalogger (Figure 1). Ambient
temperature was also measured. For each cable, we
measured the change in temperature at each point
for 120 minutes after the light source was turned
on. After 120 minutes the light source was turned
o and the temperature continued to be recorded
until it returned to baseline. In order to determine
if the size of the optical cable aected the quality of
the light produced, we also measured light intensity
using a YEW 3281 Lux Meter (Yokogowa Australia
Pty Ltd, Level 3, 66 Waterloo Road Macquarie Park,
NSW 2113 Australia).
Results
Both optical cables showed temperature rises. The
3.0 mm optical cable reached a peak temperature
of 33.29 °C after 44 minutes and 47 seconds
(Figure 2). It took 14 minutes and 28 seconds to
return to baseline temperature (dened as less
than 25 °C). The 5.5 mm optical cable reached a
peak temperature of 49.23 °C after 53 minutes and
19 seconds (Figure 3). It took 35 minutes and six
seconds to return to baseline temperature. Light
intensity for the 3 mm optical cable was 2500 lux
(adjusted for background light). Adjusted light
intensity for the 5.5 mm optic cable was 2450 lux.
This demonstrates that the 3.0 mm optical cable
generates less heat at the connection between the
cable and the retractor without compromising the
quality of light emitted.
Fig 1. Experimental setup. An Omega OM-DAQPRO-5300 Datalogger with
temperature probes (A–G) attached to various points connecting the 5.5
mm optical cable to the Tebbetts lighted retractor, with an additional
ambient temperature probe.
Fig 3. Temperature measurements, in degrees Celsius, of a Tebbetts
lighted retractor with a 5.5 mm optical cable attached. Seven points (A–G)
along the set-up are measured over time, in minutes, with an additional
ambient temperature sensor (Amb).
Fig 2. Temperature measurements, in degrees Celsius, of a Tebbetts lighted
retractor with a 3 mm optical cable attached. Six points (A–F) along the
set-up are measured over time, in minutes, with an additional ambient
temperature sensor (Amb).
Lighted retractor with a 3.0 mm flexible light fibre Lighted retractor with a 5.0 mm flexible light fibre
41
Prevention of thermal injury from lighted retractors in breast surgery: a comparative study of optical cable calibre
Australasian Journal of Plastic Surgery | ISSN: 2209–170X
CC-BY-4. This is an open access article distributed under the Creative Commons Attribution 4.0 International
License (CC-BY-4) which permits unrestricted use, distribution and reproduction in any medium, provided the
original work is properly cited. View this license’s legal deed at http://creativecommons.org/licenses/by/4.0 and
legal code at http://creativecommons.org/licenses/by/4.0/legalcode for more information.
Discussion
Our study was prompted by a recent case in our
unit of a patient who sustained a partial thickness
burn to the right breast from the use of a lighted
retractor during alloplastic reconstructive breast
surgery. We reviewed the literature and found
several case reports of iatrogenic full thickness
burns from the use of cold light sources and optical
cables during orthopaedic arthroscopic surgery.1–3
A review of the US Food and Drug Administration
(FDA) adverse event report database also conrmed
that our case was not an isolated incident. The FDA
database has logged greater than 30 occasions
where a patient undergoing breast surgery
sustained a burn from the heat generated at the
connection between an optical cable and a lighted
retractor.4 In 2012, in response to reports of these
injuries, the manufacturer of Snowden-Pencer™
Tebbetts lighted retractors issued an urgent safety
notice to all of its distributors advising them not to
use an optical cable with a calibre greater than 3.5
mm with their retractor due to the risk of thermal
injury.5 Unfortunately, this warning has not
prevented thermal injuries from the use of lighted
retractors in breast surgery, as reected in the FDA
database and our recent case.4
The calibre of optical cable contributes to the
risk of thermal injury due to the size mismatch
between the cable and the retractor connector.
When the optical cable is of greater calibre than
the connector, light is lost as heat when it passes
from the cable to the lighted retractor.6 This risk
is greatest when optical cables are new as the
bres in older cables become damaged over time,
reducing the amount of light that is transmitted at
the connector.6
The degree of thermal injury depends on the
temperature generated and duration of exposure.
In a porcine model Moritz and colleagues
demonstrated that partial or full thickness burns
from hot water can occur at temperatures as low as
44 °C with prolonged exposure (6 hours). Every 1 °C
increase in temperature reduces the time to cause
thermal injury by approximately half.7
Prompted by our patient’s injury and our
review of the literature we sought advice from
our hospital’s biomedical engineering department
regarding the safest calibre of optical cable for
our retractor that would still provide adequate
illumination. They recommended the use of a 3.0
mm optical cable. Given the risk is greatest with
a new cable we chose to compare our current,
older, 5.5 mm optical cable with a new 3.0 mm
cable in order to investigate our hypotheses that
our current cable could generate sucient heat to
cause thermal injury and that the use of a 3.0 mm
cable would prevent this from occurring.
Our study conrmed that a 3.0 mm optical
cable prevents the connection between the cable
and the Snowden-Pencer™ Tebbetts lighted
retractor from reaching temperatures that can
cause thermal injury. We used an LED light source
as previous studies have conrmed the superior
safety prole of LED light sources to Xenon high
intensity discharge light sources in terms of heat
generated.8 By avoiding Xenon light sources, and
using an appropriately sized optical cable for the
lighted retractor, we avoid our reliance on human
factors to prevent injury to our patients. Since this
study our unit has converted to using only 3.0 mm
optical cables and has found no disadvantages
to this change in practice. However, our analysis
was limited to a single cable of each size. Further
testing of dierent brands, calibres and ages of
optical cables as well as dierent brands and types
of lighted retractors would add further weight to
these results.
Conclusion
Despite the documentation of the risks in the
literature, and recommendations by manufacturers
to avoid large calibre optical cables, many plastic
surgery units continue to expose their patients to
the risk of thermal injury by using inappropriately
sized optical cables with Tebbetts lighted retractors.
We recommend that hospitals have a range
of optical cables available for use with lighted
retractors and endoscopes, and use a 3.0 mm
optical cable with the Tebbetts lighted retractor
in order to reduce the risk of thermal injury from
this instrument. Alternatives such as headlights or,
if available, cordless lighted retractors should also
be used where appropriate to further minimise the
risk to patients from the use of cold light sources
and optical cables.
42
Prevention of thermal injury from lighted retractors in breast surgery: a comparative study of optical cable calibre
Australasian Journal of Plastic Surgery | ISSN: 2209–170X
Acknowledgements
Tony Carlisle, Biomedical Engineer, Flinders
Medical Centre.
Disclosure
The authors have no conicts of interest to disclose.
Funding declaration
The authors received no nancial support for the
research, authorship, and/or publication of this
article.
References
1 Kwon D, Kim B-G, Yang C, Won J, Kim Y. Inadvertent
thermal injury following knee arthroscopic surgery in a
pediatric patient. Korean J Anesthesiol. 2018;71(2):157–60.
https://doi.org/10.4097/kjae.2018.71.2.157 PMid:29619789
PMCid:PMC5903108
2 Lau YJ, Dao Q. Cutaneous burns from a beroptic cable tip
during arthroscopy of the knee. Knee. 2008;15(4):333–35.
https://doi.org/10.1016/j.knee.2008.02.007 PMid:18514527
3 Chitnavis J. Silent burn: the hidden danger and eects of
bright light from bre-optic cables in arthroscopic knee
surgery. J Surg Case Rep. 2020;2020(4):rjaa068. https://
doi.org/10.1093/jscr/rjaa068 PMid:32280444 PMCid:P-
MC7136709
4 Maude Alerts. Reports for product code FDG [web page].
Texas: Innolitics. [Updated 31 December 2020; cited 24 Jan-
uary 2021]. Available from: https://maude.innolitics.com/
productcodes/FDG.
5 Carefusion. Urgent eld safety notice [PDF on Internet].
France: Snowden-Pencer Tebbetts Fiber Optic Retractors.
[Updated 16 October 2012; cited 24 January 2021]. Avail-
able from: https://www.bfarm.de/SharedDocs/Kundeninfos/
EN/14/2012/06788-12_kundeninfo_en.pdf?__blob=publica-
tionFile&v=5.
6 DePuySynthes. Instructions for use, 03.612.031 bre optic
cable for light clip/light strip [PDF on Internet]. Swit-
zerland: Synthes GmbH. [Updated 5 May 2020; cited 25
January 2021]. Available from: https://ifu.depuysynthes.
com/binary/org/DPY_SYN_EMEA/ifu_documents/Spine/
SE_236814_AD_eng.pdf.
7 Moritz AR, Henriques FC. Studies of thermal injury: II. The
relative importance of time and surface temperature in the
causation of cutaneous burns. Am J Pathol. 1947;23(5):695–
720. PMID: 19970955 PMCID: PMC1934304
8 Tomazic PV, Hammer GP, Gerstenberger C, Koele W,
Stammberger H. Heat development at nasal endoscopes’
tips: danger of tissue damage? A laboratory study. Laryn-
goscope. 2012;122(8):1670–673. https://doi.org/10.1002/
lary.23339 PMid:22555994
