American Society of Plastic Surgeons

Five Things Physicians and Patients Should Question

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1

Avoid performing routine mammograms before breast surgery.

Mammograms should be ordered based on existing clinical practice guideline recommendations, for patients undergoing breast surgery, including non-complicated breast augmentation, mastopexy, and breast reduction. Existing clinical practice guidelines recommend annual screening mammograms for patients of specific age groups. There are no recommendations for patients undergoing elective breast surgery to undergo 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.

Although wound drains can minimize the amount of fluid at the surgical site, there is no evidence to support the use of drains. 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 that have liposuction as an adjunctive technique to the breast reduction, the decision to use drains is left to the surgeon’s discretion.

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. Current clinical practice guidelines recommend regular clinical exams for detection of breast cancer and imaging studies are not recommended as a part of routine surveillance. However, 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.

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, in instances of facial trauma. Evidence also indicates that the use of plain X-rays does not improve quality of care, causes unnecessary radiation exposure and leads to substantial increase in costs.

Use of plain X-rays for diagnosis and treatment is helpful in instances of dental and/or isolated mandibular injury or trauma.

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. Prolonged use of antibiotics may increase the occurrence of antibiotic resistant bacteria and increase the risk of other infections. This recommendation is also supported by the Surgical Care Improvement Project, which is a national quality partnership of organizations interested in improving surgical care by significantly improving surgical complications. In cases where 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 therefore the decision is left to the surgeon’s discretion.

This recommendation does not apply to cardiothoracic surgical procedures.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

The American Society of Plastic Surgeons (ASPS) is composed of more than 94% of all board-certified plastic surgeons in the United States and Canada who perform aesthetic and reconstructive surgery. Representing more than 7,000 member surgeons, the Society is recognized as a leading voice for advancing quality care to plastic surgery patients by encouraging high standards of training, ethics and physician practice and research.

The Choosing Wisely® campaign dovetails with our own commitment to providing quality care to plastic surgery patients and helping them make the most informed decisions about procedures. The Society continuously works to improve evidence-based clinical guidelines, quality measures and quality improvement programs in order to better serve patients and to ensure their surgical goals are met. Our Symbol of Excellence is a promise that an ASPS member surgeon will be board certified in plastic surgery and meets strict requirements for training and ethics, including pre- and post-operative relationships with patients; procedures will be carried out only in accredited medical facilities; surgeons adhere to a strict code of ethics; and fulfills ongoing continuing education requirements, including patient safety techniques. For more information, find us at PlasticSurgery.org or on Facebook, Twitter and YouTube.

For more information or questions, please visit PlasticSurgery.org.

How this list was created: The Choosing Wisely® initiative was initially reviewed by the American Society of Plastic Surgeons (ASPS) Quality and Performance Measurement Committee and the Executive Committee. Once ASPS signed on to participate in the initiative, ASPS Quality staff solicited potential topic suggestions from the ASPS Health Policy, Patient Safety and Quality and Performance Measurement Committees. All topic suggestions were collected and collated with topics that were suggested by multiple committees or committee members being prioritized. A final list of prioritized topics was developed and compared to those currently included on lists that have been published by other specialty societies, to minimize any overlap. ASPS Quality staff then conducted a review of supporting evidence, including evidence-based clinical practice guidelines and systematic reviews. The draft topics/statements for the ASPS list were then narrowed down further, based on supporting evidence and a final review by the Quality and Performance Measurement Committee. The final suggested list was then shared with the active ASPS membership and approved by the ASPS Executive Committee.

The American Society of Plastic Surgeons’ disclosure and conflict of interest policy can be found at PlasticSurgery.org.

Sources

1.

American College of Radiology. ACR Practice Guideline for the performance of screening and diagnostic mammography [Internet]. Reston (VA): American College of Radiology; 2013 [cited 2013 Sep 20]. Available from: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Screening_Mammography.pdf.

American Society of Breast Surgeons. Position statement on screening mammography. Columbia (MD): American Society of Breast Surgeons; 2011 Aug 15.

American College of Obstetricians and Gynecologists (ACOG). Breast cancer screening. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2011 Aug 11.

U.S. Preventive Services Task Force. Screening for breast cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2009 Nov 17;151(10):716–26, W–236.

American Cancer Society. Breast cancer: early detection [Internet]. Atlanta (GA): American Cancer Society; 2013 [updated 2013 Oct 24; cited 2013 Nov 4].Available from: http://www.cancer.org/cancer/breastcancer/moreinformation/breastcancerearlydetection/breast-cancer-early-detection-toc.

2.

American Society of Plastic Surgeons. Evidence-based clinical practice guideline: reduction mammaplasty. Arlington Heights (IL): American Society of Plastic Surgeons; 2011 May. 16 p.

Stojkovic CA, Smeulders MJC, Van der Horst CM, Khan SM. Wound drainage after plastic and reconstructive surgery of the breast. Cochrane Database Syst Rev. 2013 Mar 28;3:CD007258.

Kosins AM, Scholz T, Cetinkaya M, Evans GRD. Evidence-based value of subcutaneous surgical wound drainage: the largest systematic review and meta-analysis. Plast Reconstr Surg. 2013 Aug;132(2):443–50.

3.

American Society of Plastic Surgeons. Evidence-based clinical practice guideline: breast reconstruction with expanders and implants. Arlington Heights (IL): American Society of Plastic Surgeons; 2013 March. 23 p.

American College of Radiology. ACR Practice Guideline for the performance of screening and diagnostic mammmography. Reston (VA): American College of Radiology; 2013 [cited 2013 Sep 20]. Available from: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Screening_Mammography.pdf.

National Comprehensive Cancer Network (NCCN). Clinical practice guidelines in oncology: breast cancer screening and diagnosis [Internet]. National Comprehensive Cancer Network (NCCN); Version2.2013 [cited 2013 Sep 20]. Available from: http://www.nccn.org/professionals/physician_gls/pdf/breast-screening.pdf.

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Sitzman TJ, Hanson SE, Alsheik NH, Gentry LR, Doyle JF, Gutowski KA. Clinical criteria for obtaining maxillofacial computed tomographic scans in trauma patients. Plast Reconstr Surg. 2011 Mar;127(3):1270–8.

Stacey DH, Doyle JF, Mount DL, Snyder MC, Gutowski KA. Management of mandible fractures. Plast Reconstr Surg. 2006 Mar;117(3):48e–60e.

5.

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Bratzler DW, Houck PM. Antimicrobial prophylaxis for surgery: an advisory statement from the National Surgical Infection Prevention Project. Clin Infect Dis. 2004 Jun 15;38(12):1706–15.