The American Society of Plastic Surgeons (ASPS) has teamed up with the ABIM Foundation’s Choosing Wisely campaign. As part of this campaign, organizations such as ASPS create lists of “Things Providers and Patients Should Question.”
“The days are gone where we took at face value that we should just keep doing what we were taught to do. In many cases in medicine, we instinctively do things as we were taught even though there was never any data to support it,” says M. Mark Mofid, MD, FACS, a board-certified plastic surgeon in La Jolla, Calif and a PSP editorial advisory board member. “We are just catching up to evidence-based medicine in plastic surgery.” Mofid and several other plastic surgeons reviewed the ASPS list for Plastic Surgery Practice.
According to the ASPS list, physicians should:
1) Avoid performing routine mammograms before elective breast surgery.
The ASPS states that there are no recommendations for patients undergoing elective breast surgery to have additional screening unless there are concerning aspects of the patient’s history or findings during a physical exam which would suggest the need for further investigation.
2) Avoid using drains in breast reduction mammaplasty.
There is no evidence to support the use of drains, ASPS points out. Evidence also indicates that the use of drains neither increases nor decreases postoperative complications, causes greater patient discomfort, and possibly increases the length of the hospital stay. In patients who have liposuction as an adjunctive technique to breast reduction, the decision to use drains is left to the surgeon’s discretion. Mofid agrees that drains following breast reduction mammaplasty are, in large part, “unnecessary.” San Francisco-based plastic surgeon Gabriel M. Kind, MD, is on the fence about this recommendation. “You don’t always needs drains, but this list should not supercede clinical judgment. There will be times when drains are warranted,” Kind says.
“The impetus for these published guidelines comes from the increasing emphasis on evidence-based medicine, and in terms of developing clinical guidelines for hospital-based procedures and reconstructive surgery they are generally useful. But outcomes in the aesthetic surgery arena must include subjective judgments and longer term issues that are not as easily measured and standardized.” —Richard A. Baxter, MD
3) Avoid performing routine and follow-up mammograms of reconstructed breasts after mastectomies.
Evidence indicates that clinical examination is sufficient to detect local cancer recurrence in patients undergoing breast reconstruction after complete mastectomy. Diagnostic imaging is indicated if there are clinical findings and/or clinical concern for recurrence. In cases of breast reconstruction after partial mastectomy or lumpectomy, mammography is still recommended. It is also important to continue mammography of the opposite breast in women who had a unilateral mastectomy.
Kind says this is sound counsel.
4) Avoid performing plain x-rays in instances of facial trauma.
Evidence currently indicates that maxillofacial computed tomography (CT) is available in most trauma centers and is the most sensitive method for detecting fractures caused by facial trauma. Use of plain x-rays for diagnosis and treatment are helpful in instances of dental and/or isolated mandibular injury or trauma, the ASPS states.
5) Avoid continuing prophylactic antibiotics for greater than 24 hours after a surgical procedure.
Current evidence suggests that discontinuing antibiotic prophylaxis within 24 hours or less after surgery is sufficient in preventing surgical-site infection compared to continuing antibiotic prophylaxis beyond 24 hours after surgery. In addition, this practice could also increase the risk for antibiotic resistance. If a surgical drain is placed next to a prosthetic device (breast implant or tissue expander), there is not enough evidence to recommend discontinuing antibiotics, and the decision is left to the surgeon’s discretion. “If the only measured endpoint is postop infection, then it is valid,” says Seattle plastic surgeon Richard A. Baxter, MD. But, he adds, “the potential effects on prevention of capsular contracture would not be captured by this methodology.”
Baxter adds that aesthetic plastic surgery doesn’t always adhere to these evidence-based recommendations quite as firmly as reconstructive procedures. “The impetus for these published guidelines comes from the increasing emphasis on evidence-based medicine, and in terms of developing clinical guidelines for hospital-based procedures and reconstructive surgery they are generally useful,” he says. “But outcomes in the aesthetic surgery arena must include subjective judgments and longer-term issues that are not as easily measured and standardized.”