Review| Volume 75, ISSUE 11, P4180-4190, November 2022

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Patient Safety Initiatives in Cosmetic Breast Surgery: A Systematic Review



      Improved patient safety (PS) in cosmetic breast surgery relies upon high-quality evidence. The objective of this study was to systematically review the existing evidence for PS and quality improvement (QI) in cosmetic breast surgery.


      A systematic review of published plastic surgery literature from 1965 to 2021 was undertaken through a computerized search following PRISMA guidelines. Publication descriptors, methodological details, and overall results were extracted. Articles were assessed for methodological quality using either the MINORS, Cochrane ROB2, or AMSTAR 2 instrument depending on the type of study.


      Sixty studies were included. Most studies were retrospective, and 43.3 percent were from the 3rd level of evidence. Overall, the scientific quality was moderate, with randomized controlled trials and non-comparative non-randomized studies generally being rated of higher quality. Studies investigating approaches to antisepsis (38.3 percent) in cosmetic breast surgery indicated conflicting opinions on prophylactic antibiotics. Studies focusing on risk factor assessment tools (8.3 percent) held possible utility in identifying high-risk patients for cosmetic surgery. Studies assessing anesthesia in cosmetic breast surgery (5 percent) demonstrated a significant benefit to tumescent local anesthesia. Drains for decreasing hematoma and seroma (8.3 percent) largely showed no benefit.


      Overall, PS and QI studies were of moderate quality and investigated numerous interventions. Our review identified a need for additional studies to decrease infection and other breast implant morbidities, specifically breast implant-associated anaplastic large cell lymphoma and capsular contracture.


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      1. American Society of Plastic Surgeons. 2019 Plastic Surgery Statistics Report. Published 2019. Accessed September 8, 2020.

        • Kim YJ
        • Kelley BP
        • Nasser JS
        • Chung KC.
        Implementing precision medicine and artificial intelligence in plastic surgery: Concepts and future prospects.
        Plast Recon Surg - Glob Open. 2019; 7
        • Hensel JM
        • Lehman JA
        • Tantri MP
        • Parker MG
        • Wagner DS
        • Topham NS.
        An outcomes analysis and satisfaction survey of 199 consecutive abdominoplasties.
        Ann Plast Surg. 2001; 46: 357-363
        • Abdel-Rehim S
        • Morritt A
        • Perks G.
        WHO surgical checklist and its practical application in plastic surgery.
        Plast Surg Int. 2011; 2011: 1-5
        • Yoho RA
        • Romaine JJ
        • OʼNeil D.
        Review of the liposuction, abdominoplasty, and face-lift mortality and morbidity risk literature.
        Dermatol Surg. 2005; 31: 733-743
        • Wilson SC
        • Levine S
        • Sinno S
        • Rothwax J
        • Dillon A
        • Saadeh PB.
        Use of the morbidity and mortality conference to analyze patient death in plastic surgery.
        Plast Recon Surg. 2014; 134: 48
        • Liberati A
        • Altman DG
        • Tetzlaff J
        • et al.
        The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: Explanation and elaboration.
        PLOS Med. 2009; 6e1000100
        • Slim K
        • Nini E
        • Forestier D
        • et al.
        Methodological index for non-randomized studies (MINORS): Development and validation of a new instrument.
        ANZ J Surg. 2003; 73: 712-716
        • Higgins JPT
        • Altman DG
        • Gotzsche PC
        • et al.
        The Cochrane Collaboration's tool for assessing risk of bias in randomized trials.
        BMJ. 2011; 343: d5928
        • Shea BJ
        • Reeves BC
        • Wells G
        • et al.
        AMSTAR 2: A critical appraisal tool for systematic reviews that include both randomized or non randomized studies of healthcare interventions, or both.
        BMJ. 2017; 358: j4008
        • Nguyen A
        • Mahabir R.
        An update on the level of evidence for plastic surgery research published in Plastic and Reconstructive Surgery.
        Plast Recon Surg. Glob Open. 2011; 4: 798
        • Adams WP
        • Rios JL
        • Smith SJ.
        Enhancing patient outcomes in aesthetic and reconstructive breast surgery using triple antibiotic breast irrigation: Six-year prospective clinical study.
        Plast Reconstr Surg. 2006; 117: 30-36
        • Ahmadi AH
        • Cohen BE
        • Shayani P.
        A prospective study of antibiotic efficacy in preventing infection in reduction mammaplasty.
        Plast Reconstr Surg. 2005; 116: 126-131
        • Anker AM
        • Miranda BH
        • Prantl L
        • et al.
        50 Shades of Red: The Predictive Value of Closed Suction Drains for the Detection of Postoperative Bleeding in Breast Surgery.
        Aesthetic Plast Surg. 2019; : 608-615
        • Asplund O
        • Gylbert L
        • Jurell G
        • Ward C.
        Textured or Smooth Implants for Submuscular Breast Augmentation: A Controlled Study.
        Plast Reconstr Surg. 1995; 97: 1200-1206
        • Ausen K
        • Fossmark R
        • Spigset O
        • Pleym H.
        Randomized clinical trial of topical tranexamic acid after reduction mammoplasty.
        Br J Surg. 2015; 102: 1348-1353
        • Baltodano PA
        • Reinhardt ME
        • Ata A
        • Simjee UF
        • Roth MZ
        • Patel A.
        The baltodano breast reduction score: A nationwide, multi-institutional, validated approach to reducing surgical-site morbidity.
        Plast Reconstr Surg. 2017; 140: 258e-264e
        • Basile FV
        • Basile AR.
        Reoperative transaxillary breast surgery: Using the axillary incision to treat augmentation-related complications.
        Aesthetic Plast Surg. 2012; 36: 323-330
        • Becherer BE
        • De Boer M
        • Spronk PER
        • et al.
        The Dutch Breast Implant Registry: Registration of Breast Implant-Associated Anaplastic Large Cell Lymphoma-A Proof of Concept.
        Plast Reconstr Surg. 2019; 143: 1298-1306
        • Burkhardt BR
        • Demas CP.
        The Effect of Siltex Texturing and Povidone-Iodine Irrigation on Capsular Contracture Around Saline Inflatable Breast Implants.
        Plast Reconstr Surg. 1994; 93: 123-128
        • Burkhardt BR
        • Eades E.
        The Effect of Biocell Texturing and Povidone-Iodine Irrigation on Capsular Contracture Around Saline-Inflatable Breast Implants.
        Plast Reconstr Surg. 1994; 96: 1317-1325
        • Burkhardt B
        • Dempsey P
        • PL S
        • JJ T
        Capsular Contracture: A Prospective Study of the Effect of Local Antibacterial Agents.
        Plast Reconstr Surg. 1986; 77: 919-930
      2. Carlesimo B, Cigna E, Fino P, Rusciani A, Tariciotti F, Staccioli S. Antibiotic Therapy of Transaxillary Augmentation Mammoplasty. 2009;23:357-362.

        • Carvajal J
        • Carvajal M
        • Hernández G.
        Back to Basics: Could the Preoperative Skin Antiseptic Agent Help Prevent Biofilm-Related Capsular Contracture?.
        Aesthetic Surg J. 2019; 39: 848-859
        • Chao JW
        • Raveendran JA
        • Maly C
        • Rogers G
        • Boyajian M
        • Oh AK.
        Closed-Suction Drains After Subcutaneous Mastectomy for Gynecomastia: Do They Reduce Complications?.
        Aesthetic Plast Surg. 2017; 41: 1291-1294
        • Collis N
        • McGuiness CM
        • Batchelor AG.
        Drainage in breast reduction surgery: A prospective randomised intra-patient trail.
        Br J Plast Surg. 2005; 58: 286-289
        • Garcia ES
        • Veiga DF
        • Veiga-Filho J
        • et al.
        Postoperative Antibiotic Prophylaxis in Reduction Mammaplasty: A Randomized Controlled Trial.
        Plast Reconstr Surg. 2020; 145: 1022e-1028e
        • Giordano S
        • Peltoniemi H
        • Lilius P
        • Salmi A.
        Povidone-iodine combined with antibiotic topical irrigation to reduce capsular contracture in cosmetic breast augmentation: A comparative study.
        Aesthetic Surg J. 2013; 33: 675-680
        • Gylbert L
        • Asplund O
        • Berggren A
        • Jurell G
        • Ransja U
        • Ostrup L.
        Preoperative Antibiotics and Capsular COntracture in Augmentation Mammoplasty.
        Plast Reconstr Surg. 1989; 86: 260-267
        • Hall JC
        • Willsher PC
        • Hall JL.
        Randomized clinical trial of single-dose antibiotic prophylaxis for non-reconstructive breast surgery.
        Br J Surg. 2006; 93: 1342-1346
        • Hersant B
        • SidAhmed-Mezi M
        • Lapadula S
        • Niddam J
        • Bouhassira J
        • Meningaud JP.
        Efficacy of autologous platelet-rich plasma glue in weight loss sequelae surgery and breast reduction: A prospective study.
        Plast Reconstr Surg - Glob Open. 2016; 4: 1-6
        • Hester TR
        • Ghazi BH
        • Moyer HR
        • Nahai FR
        • Wilton M
        • Stokes L.
        Use of dermal matrix to prevent capsular contracture in aesthetic breast surgery.
        Plast Reconstr Surg. 2012; 130: 126-136
        • Hever P
        • Cavale N
        • Pasha T.
        A retrospective comparison of 3MTM MicroporeTM with other common dressings in cosmetic breast surgery.
        J Plast Reconstr Aesthetic Surg. 2019; 72: 424-426
        • Huang CK
        • Handel N.
        Effects of Singulair (montelukast) treatment for capsular contracture.
        Aesthetic Surg J. 2010; 30: 404-408
        • Jacobson JM
        • Gatti ME
        • Schaffner AD
        • Hill LM
        • Spear SL.
        Effect of incision choice on outcomes in primary breast augmentation.
        Aesthetic Surg J. 2012; 32: 456-462
        • Keramidas E
        • Lymperopoulos NS
        • Rodopoulou S.
        Is antibiotic prophylaxis in breast augmentation necessary? A prospective study.
        Can J Plast Surg. 2016; 24: 195-198
        • Khoo LS
        • Radwanski HN
        • Senna-Fernandes V
        • Antônio NN
        • Fellet LLF
        • Pitanguy I.
        Does the Use of Intraoperative Breast Sizers Increase Complication Rates in Primary Breast Augmentation? A Retrospective Analysis of 416 Consecutive Cases in a Single Institution.
        Plast Surg Int. 2016; 2016: 1-8
        • Kornstein A.
        Porcine-derived acellular dermal matrix in primary augmentation mammoplasty to minimize implant-related complications and achieve an internal mastopexy: A case series.
        J Med Case Rep. 2013; 7: 1-8
        • Lapid O
        • Pietersen L
        • van der Horst CM.
        Safety of Pre and Post-Operative Administration of LMWH, Assessment in 720 Breast Reductions.
        Plast Reconstr Surg. 2012; 130: 66
        • Leroy J
        • Given KS.
        Wound Infection in Breast Augmentation: The Role of Prophylactic Perioperative Antibiotics.
        Aesthetic Plast Surg. 1991; 15: 303-305
        • Lynch MP
        • Chung MT
        • Rinker BD.
        Dermal autografts as a substitute for acellular dermal matrices (ADM) in tissue expander breast reconstruction: A prospective comparative study.
        J Plast Reconstr Aesthetic Surg. 2013; 66: 1534-1542
        • Lynch MP
        • Chung MT
        • Rinker BD.
        A comparison of dermal autograft and acellular dermal matrix in tissue expander breast reconstruction: Long-term aesthetic outcomes and capsular contracture.
        Ann Plast Surg. 2015; 74: S214-S217
        • Matarasso A
        • Wallach SG
        • Rankin M.
        Reevaluating the Need for Routine Drainage in Reduction Mammaplasty.
        Plast Reconstr Surg. 1997; 102: 1917-1921
        • Maxwell GP
        • Gabriel A.
        Efficacy of acellular dermal matrices in revisionary aesthetic breast surgery: A 6-year experience.
        Aesthetic Surg J. 2013; 33: 389-399
        • McCarthy CM
        • Loyo-Berríos N
        • Qureshi AA
        • et al.
        Patient Registry and Outcomes for Breast Implants and Anaplastic Large Cell Lymphoma Etiology and Epidemiology (PROFILE): Initial Report of Findings, 2012-2018.
        Plast Reconstr Surg. 2019; 143 (3 A Review of Breast ImplantAssociated Anaplastic Large Cell Lymphoma):65S-73S
        • McCarthy CM
        • Pusic AL
        • Hidalgo DA.
        Efficacy of pocket irrigation with bupivacaine and ketorolac in breast augmentation: A randomized controlled trial.
        Ann Plast Surg. 2009; 62: 15-17
        • Mendes DA
        • Veiga DF
        • Veiga-Filho J
        • et al.
        Influence of dressing application time after breast augmentation on cutaneous colonization: A randomized clinical trial.
        J Plast Reconstr Aesthet Surg. 2018; 71: 906-912
        • Mirzabeigi MN
        • Mericli AF
        • Ortlip T
        • et al.
        Evaluating the role of postoperative prophylactic antibiotics in primary and secondary breast augmentation: A retrospective review.
        Aesthetic Surg J. 2012; 32: 61-68
        • Monsivais SE
        • Roehl KR
        • Mahabir RC.
        Does preoperative heparin increase the postoperative bleeding risk in women undergoing prosthetic breast implant surgery? A review of the data from a single institution.
        Can J Plast Surg. 2015; 23: 165-166
        • Nathan B
        • Singh S.
        Postoperative compression after breast augmentation.
        Aesthetic Plast Surg. 2001; 25: 290-291
        • Pfeiffer P
        • Jørgensen S
        • Kristiansen TB
        • Jørgensen A
        • Hölmich LR.
        Protective effect of topical antibiotics in breast augmentation.
        Plast Reconstr Surg. 2009; 124: 629-634
      3. Rivera M, Moon W, Ozturk C, Ozturk CN.Breast Implant Infection Can Be Successfully Treated with Nonsurgical Therapy.; 2017.

        • Roberts JM
        • Carr LW
        • Jones A
        • Schilling A
        • MacKay DR
        • Potochny JD.
        A Prospective Approach to Inform and Treat 1340 Patients at Risk for BIA-ALCL.
        Plast Reconstr Surg. 2019; 144: 46-54
        • Rusciani A
        • Pietramaggiori G
        • Troccola A
        • Santoprete S
        • Rotondo A
        • Curinga G.
        The Outcome of Primary Subglandular Breast Augmentation Using Tumescent Local Anesthesia.
        Ann Plast Surg. 2016; 76: 13-17
        • Scott GR
        • Carson CL
        • Borah GL.
        Dermabond skin closures for bilateral reduction mammaplasties: A review of 255 consecutive cases.
        Plast Reconstr Surg. 2007; 120: 1460-1465
        • Scuderi N
        • Mazzocchi M
        • Rubino C.
        Effects of zafirlukast on capsular contracture: controlled study measuring the mammary compliance.
        Int J Immunopathol Pharmacol. 2007; 20: 577-584
        • Serletti JM
        • Davenport MS
        • Herrera HR
        • Caldwell EH.
        Efficacy of prophylactic antibiotics in reduction mammoplasty.
        Ann Plast Surg. 1994; 33: 476-480
        • Setälä L
        • Papp A
        • Joukainen S
        • et al.
        Obesity and complications in breast reduction surgery: are restrictions justified?.
        J Plast Reconstr Aesthetic Surg. 2009; 62: 195-199
        • Simpson AM
        • Donato DP
        • Kwok AC
        • Agarwal JP.
        Predictors of complications following breast reduction surgery: A National Surgical Quality Improvement Program study of 16,812 cases.
        J Plast Reconstr Aesthetic Surg. 2019; 72: 43-51
        • Stevens WG
        • Cohen R
        • Schantz SA
        • et al.
        Laser-assisted breast reduction: A safe and effective alternative. A study of 367 patients.
        Aesthetic Surg J. 2006; 26: 432-439
        • Stutman RL
        • Codner M
        • Mahoney A
        • Amei A.
        Comparison of breast augmentation incisions and common complications.
        Aesthetic Plast Surg. 2012; 36: 1096-1104
        • Thomas SS
        • Srivastava S
        • Nancarrow JD
        • Mohmand MH.
        Dilute Adrenaline Infiltration and Reduced Blood Loss in Reduction Mammaplasty.
        Ann Plast Surg. 1999; 43: 127-131
        • Vandeweyer E.
        Breast reduction mammaplasty shall we drain?.
        Acta Chir Belg. 2003; 103: 596-598
        • Veiga-Filho J
        • Veiga DF
        • Neto MS
        • Amorim MC
        • Novo NF
        • Ferreira LM.
        The role of antibiotics in reduction mammaplasty.
        Ann Plast Surg. 2010; 65: 144-146
        • Vieira LFDF
        • De Melo Neto AF
        • Schio MR
        • De Oliveira JAV
        • Almeida CLA
        • Ferraz AAB.
        Controversies in Reduction Mammoplasty: Being A “clean” Operation, Does It Mandate Antibiotic Prophylaxis?.
        Surg Infect (Larchmt). 2016; 17: 596-600
        • Wiener TC.
        The role of betadine irrigation in breast augmentation.
        Plast Reconstr Surg. 2007; 119: 12-15
        • Wirthmann AE
        • Welsch L
        • Wellenbrock S V
        • et al.
        Reduction mammoplasty in adolescents and elderly: A ten year case series analyzing age related outcome with focus on safety and complications.
        J Plast Reconstr Aesthetic Surg. 2018; 71: 377-383
        • Young ZT
        • Close M
        • Herrera FA.
        National Surgical Quality Improvement Program Analysis of 9110 Reduction Mammaplasty Patients: Identifying Risk Factors Associated With Complications in Patients Older Than 60 Years.
        Ann Plast Surg. 2019; 82: S446-S449
        • Zhang Y
        • Hong W
        • Chen Y
        • Zeng L
        • Luo S.
        Proper Skin Management in Breast Augmentation with a Periareolar Incision Prevents Implant Contamination and Biofilm-Related Capsular Contracture.
        Aesthetic Plast Surg. 2021; 45: 1451-1457
        • Kalaria SS
        • Boonipat T
        • Michael Smith J
        • Cole EL
        Antibiotic prophylaxis: current recommendations in plastic surgery.
        Eur J Plast Surg. 2019; 42: 481-488
        • Shah Z
        • Lehman JA
        • Tan J.
        Does infection play a role in breast capsular contracture?.
        Plast Reconstr Surg. 1981; 68: 34-38
        • Piscatelli SJ
        • Partington M
        • Hobar C
        • Gregory P
        • Siebert JW.
        Breast capsule contracture: Is fibroblast activity associated with severity?.
        Aesthetic Plast Surg. 1994; 18: 75-79
        • Cole NM.
        Consequences of the U.S. Food and Drug Administration-Directed Moratorium on Silicone Gel Breast Implants: 1992 to 2006.
        Plast Reconstr Surg. 2018; 141: 1137-1141
        • Cordeiro PG
        • Ghione P
        • Ni A
        • et al.
        Risk of breast implant associated anaplastic large cell lymphoma (BIA-ALCL) in a cohort of 3546 women prospectively followed long term after reconstruction with textured breast implants.
        J Plast Reconstr Aesthetic Surg. 2020; 73: 841-846
        • Barnsley GP
        • Sigurdson LJ
        • Barnsley SE.
        Textured surface breast implants in the prevention of capsular contracture among breast augmentation patients: A meta-analysis of randomized controlled trials.
        Plast Reconstr Surg. 2006; 117: 2182-2190
        • Ngan PG
        • Iqbal HJ
        • Jayagopal S
        • Sillitoe AT
        • Dhital SK
        • Juma A.
        When to use drains in breast reduction surgery?.
        Ann Plast Surg. 2009; 63: 135-137
        • Stelfox HT
        • Palmisani S
        • Scurlock C
        • Orav EJ
        • Bates DW.
        The “To Err is Human” report and the patient safety literature.
        BMJ Qual Saf. 2006; 15 (145-145)