Doc suspended after multiple patient complaints, including breast implant mixup

Manitoba’s physician watchdog suspended a Winnipeg plastic surgeon who admitted to professional misconduct after three patients complained of post-operative complications from breast augmentations and other surgeries.

A disciplinary report, released by the College of Physicians and Surgeons of Manitoba on May 25, found Dr. Manfred Ziesmann displayed a “lack of skill, knowledge, and judgment in the practice of medicine” while dealing with the women.

Ziesmann was suspended for six weeks on March 24 and ordered to pay about $34,000 in costs.

It is the latest example of punitive action taken against the doctor, who has a history of complaints against him.

The 15-page report outlined a college investigation, launched after the patients accused Ziesmann of poor communication, record keeping and aftercare.

The doctor appeared before an inquiry panel on March 11 and pleaded guilty to the allegations.

According to the report, one case involved a patient who suffered “necrosis of the nipple and areola” after surgery in April 2022.

The woman met with Ziesmann to correct asymmetry with her breasts (caused by a different operation and doctor). She signed a consent form allowing him to insert a larger implant in her right breast and a smaller implant on the left, the report said.

“During the course of surgery, Dr. Ziesmann inserted the larger implant into the left breast and the smaller implant into the right breast, contrary to the consent form,” it said.

The patient experienced serious issues after the operation, requiring numerous return visits to Ziesmann, urgent care clinics and hospitals. She was eventually referred to another surgeon, who removed the implants and other damaged tissue, it said.

Ziesmann admitted he did not collect the patient’s full medical history; failed to adequately inform her about the surgery risks; and inserted implants into opposing breasts without her consent, the document said.

He also admitted to “failing to address symptoms of necrosis in a timely and appropriate manner while displaying a lack of empathy and compassion in communicating,” it said.

The patient provided an impact statement to the college’s inquiry panel during the March hearing. Her name was redacted from the report and was referred to as Patient 2.

“The panel was particularly struck by how the actions of Dr. Ziesmann have had such a negative impact on the health and well-being of Patient 2. She has suffered significantly over the last few years and there is little doubt that she will continue to be impacted for years to come,” the document said.

In another case, a woman who Ziesmann operated on five times between 2012 and 2022 repeatedly suffered issues with wound healing and scarring.

Ziesmann admitted to not keeping detailed and accurate patient records, including information about how he explained surgery risks to the woman, the report said.

In April 2023, Ziesmann failed to remove a cancerous skin lesion from a patient referred to him by her dermatologist. The dermatologist immediately flagged the error in a pathology report and sent it to Ziesmann, who had to redo the surgery that August.

When Ziesmann again failed to remove the cancerous lesion, the dermatologist referred the patient to a different surgeon.

Ziesmann acknowledged he did not appropriately address the pathology report, and did not document the steps he took to identify the lesion during the second surgery.

In addition to the suspension, the college also imposed certain limitations on his ability to practise, although those are not detailed in the disciplinary decision.

Ziesmann, who has been registered with the college since 1981 and been licensed as a plastic surgeon since 1987, has been subject to six prior complaints, the documents said.

Those previous complaints related to: obtaining informed consent from patients; his level of vigilance and attentiveness in following patients and monitoring for post-operative complications; and/or the accuracy and completeness of clinical documentation, the report said.

Twice, in 2017 and 2020, Ziesmann was ordered to complete additional record keeping and communication training.

He is required to meet monthly with a practice monitor who will review his care and report to the college, the discipline report said.

In an unrelated civil lawsuit settled in March 2023, the Court of King’s Bench of Manitoba ruled in favour of a patient who claimed Ziesmann ripped a drain from her breast after surgery in 2010, breaking a piece of it off in her body.

According to the court ruling, the fragment remained inside the woman — causing pain and making her unable to wear regular bras — until it was located and surgically removed in 2017.

Justice Brenda Keyser found Ziesmann breached his standard of care to the patient.

The college’s physician directory, which is updated daily, shows Ziesmann works from his private clinic on Portage Avenue. His six-week suspension ended at the beginning of May.

tyler.searle@freepress.mb.ca