Plastic and Reconstructive Surgery • January 2014 5. Swanson E. Prospective outcome study of 225 cases of breast augmentation. Plast Reconstr Surg. 2013;131:1158–1166; discussion 1167–1168. 6. Picavet VA, Prokopakis EP, Gabriëls L, Jorissen M, Hellings PW. High prevalence of body dysmorphic disorder symptoms in patients seeking rhinoplasty. Plast Reconstr Surg. 2011;128:509–517. 7. Sarwer DB, Wadden TA, Pertschuk MJ, Whitaker LA. Body image dissatisfaction and body dysmorphic disorder in 100 cosmetic surgery patients. Plast Reconstr Surg. 1998;101: 1644–1649.
Reply: Preoperative Symptoms of Body Dysmorphic Disorder Determine Postoperative Satisfaction and Quality of Life in Aesthetic Rhinoplasty Sir:
We sincerely thank Dr. Swanson for his vivid interest in our recent large-scale prospective study on the impact of preoperative symptom severity of body dysmorphic disorder on subjective outcomes in aesthetic rhinoplasty. This study highlights for the first time the inverse correlation between the severity of preoperative body dysmorphic disorder symptoms and the postoperative satisfaction of rhinoplasty patients. First, we clearly state that we agree fully with Dr. Swanson’s opinion about the importance of clinical judgment on the risk-to-benefit ratio in the preoperative evaluation of aesthetic rhinoplasty patients, as is the case in any surgical setting. In aesthetic rhinoplasty, the identification of the severe body dysmorphic disorder patient, presenting with delusional thoughts and a perfect nasal shape, is not a challenge. We here deal with the true preoperative challenge, which is the identification of those patients with a “surgically correctable” nasal deformity and discrete body dysmorphic disorder traits, that are at risk of not being satisfied with the postoperative results. In the latter case, clinical judgment is only considered a weak base for evaluating the degree of severity of body dysmorphic disorder symptoms, and objective tools are warranted for research purposes. Most rhinoplasty surgeons agree that the recognition of body dysmorphic disorder symptoms can be challenging, and underdiagnosis of the latter may be a reason for postoperative dissatisfaction. In a previous study by our group, we highlighted the high prevalence of body dysmorphic disorder symptoms in an aesthetic rhinoplasty population using validated questionnaires and confirmed the low prevalence of true body dysmorphic disorder. We want to explicitly point out that some colleagues may draw false conclusions from our results, such as the statement of body dysmorphic disorder symptoms being the result of the nasal deformity. As our data clearly demonstrate the lack of correlation between the objective evaluation of the nasal shape by the surgeon and the body dysmorphic disorder symptom severity, they do not support the argument of body dysmorphic disorder being the consequence of a nasal deformity. Of note, many other authors have already
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demonstrated that the subjective evaluation of the nasal deformity does not correspond to the objective scoring of the deformity by the surgeon. Furthermore, the discrepancy between the low percentage of rhinoplasty patients meeting the criteria for full body dysmorphic disorder and the high percentage of patients with significant body dysmorphic disorder symptoms highlights the difficulties of applying the current diagnostic criteria for body dysmorphic disorder in an aesthetic surgery setting. We recognize that not all patients with moderate to severe obsessive-compulsive symptoms concerning their appearance have body dysmorphic disorder, as explicitly stated in the article. Finally, we would like to comment on the remark concerning the lack of comparison between postoperative results and preoperative baseline scores. Taking into account the wide variety of baseline scoring of the nasal deformity and the variable degree of percentage of improvement of scoring of the nasal deformity by the patient, the authors felt the most interesting approach was to study the correlations between the preoperative body dysmorphic disorder symptom severity and the final appreciation of the nasal shape by the patient. Considered together, we are convinced that our large-scale prospective study on the impact of body dysmorphic disorder symptom severity on the subjective outcomes of rhinoplasty contributes significantly to the field of facial plastic surgery, as it demonstrates for the first time the importance of non–surgery-related reasons for (dis)satisfaction in aesthetic rhinoplasty patients. DOI: 10.1097/01.prs.0000437262.08822.8a
Valerie A. Picavet, M.D. Peter W. Hellings, M.D., Ph.D. Department of Otorhinolaryngology, Head and Neck Surgery University Hospitals Leuven Leuven, Belgium Correspondence to Prof. Dr. Hellings Department of Ear, Nose, and Throat University Hospitals Leuven Herestraat 49 Leuven 3000, Belgium [email protected]
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication.
Are Systemic Antibiotics Indicated in Aesthetic Breast Surgery? A Systematic Review of the Literature Sir:
W
e read with great interest the recent article by Hardwicke et al. entitled: “Are Systemic Antibiotics Indicated in Aesthetic Breast Surgery? A Systematic Review of the Literature.”1 In their work, a systematic
Volume 133, Number 1 • Letters review of the literature concerning the use of systemic antibiotics in aesthetic breast surgery is performed. We congratulate the authors for the proficient analysis of the literature and the interesting findings they reported, and we would like to further discuss some aspects of this common issue. Frequently, surgeons deal with compelled choices, resulting from common sense more than from scientific evidence. For example, many surgeons dip the prosthesis in povidine-iodine, other disinfectants, or antibiotic solutions before breast implantation for the purpose of reducing the incidence of capsular contracture and/or infections. Until now, only a few studies succeeded in assessing the true benefit of such procedures, with contrasting results in the literature.2,3 The same applies to the choice of whether to prescribe postoperative antibiotic therapy or not after dismissal from the hospital.4 In the past decade, the fear of medicolegal lawsuits and claims has become a major reason leading to infection-reducing strategies or so-claimed ones in clinical practice. The surgeons had to protect themselves from further risk5 in a context where a surgical complication, such as a postoperative infection, is very likely to become an accusation by a lawyer, on the chance of procedural errors such as type and timing of antibiotic prophylaxis. As a consequence, the choice of using antibiotic therapy up to the removal of the drain or to limit it to a single dose of preoperative antibiotic is certainly an interesting and meaningful topic in the postsurgery treatment geared to prevent infections. We strongly believe that the procedures performed to reduce the risk of infection should be codified by international protocols. In our opinion, the article by Hardwicke and colleagues1 is an important piece of evidence on this topic. Nevertheless, as long as surgeons will have to answer to a judge regarding any postoperative issue, they will always be conditioned to implement any procedure protecting them from possible legal issues. Official international guidelines are of paramount importance to overcome the need for “defensive medicine.” DOI: 10.1097/01.prs.0000436416.91458.d3
Pierluigi Gigliofiorito, M.D. Luca Piombino, M.D. Stefano Campa, M.D. Francesco Segreto, M.D. Alfonso Luca Pendolino, M.S. Paolo Persichetti, M.D., Ph.D. Plastic and Reconstructive Surgery Unit Università Campus Bio-Medico di Roma Rome, Italy Correspondence to Dr. Gigliofiorito Plastic and Reconstructive Surgery Unit Università Campus Bio-Medico di Roma 00128 Rome, Italy [email protected]
DISCLOSURE The authors have no conflict of interest to declare; they received no funding for this research. REFERENCES 1. Hardwicke JT, Bechar J, Skillman JM. Are systemic antibiotics indicated in aesthetic breast surgery? A systematic review of the literature. Plast Reconstr Surg. 2013;131:1395–1403. 2. 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. Aesthet Surg J. 2013;33:675–680. 3. Gylbert L, Asplund O, Berggren A, Jurell G, Ransjö U, Ostrup L. Preoperative antibiotics and capsular contracture in augmentation mammaplasty. Plast Reconstr Surg. 1990;86: 260–267; discussion 268. 4. Mirzabeigi MN, Mericli AF, Ortlip T, et al. Evaluating the role of postoperative prophylactic antibiotics in primary and secondary breast augmentation: A retrospective review. Aesthet Surg J. 2012;32:61–68. 5. Murray JE. On ethics and the training of the plastic surgeon. Plast Reconstr Surg. 1978;61:270–271.
Reply: Are Systemic Antibiotics Indicated in Aesthetic Breast Surgery? A Systematic Review of the Literature Sir:
I would sincerely like to thank Drs. Gigliofiorito et al. for their considerate letter regarding our article.1 I agree that international agreement for the use of antibiotic prophylaxis in aesthetic breast surgery is key to safer practice. This will allow the provision of the best quality of care to our patients and avoid the need to practice empirical “defensive medicine.” Some of the current national guidance available is limited in its scope and has drawn broad conclusions that could be applied to reduction and augmentation mammaplasty from evidence that has been gleaned from other surgical specialities.2 The American Society of Plastic Surgeons guidelines3 do at the outset provide a disclaimer stating that “…this guideline should not be construed as a rule, nor should it be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed at obtaining the appropriate results,” and although our systematic review did not attempt to provide a clinical guideline, our aim was to present the available evidence, on which the clinician could base their best practice. We attempted to show that the best available evidence was sometimes insufficient for drawing substantial conclusions. Based on this, we cannot refute current U.K. guidelines2 with respect to augmentation mammaplasty and U.S. guidelines3 with respect to reduction mammaplasty for the reduction of surgical-site infection, and would therefore consider these to be current best practice and could be used as a framework for the development of future international protocols/guidelines. I agree that not all decisions in medicine are based on scientific
63e
Reply: Preoperative Symptoms of Body Dysmorphic Disorder Determine Postoperative Satisfaction and Quality of Life in Aesthetic Rhinoplasty Sir:
We sincerely thank Dr. Swanson for his vivid interest in our recent large-scale prospective study on the impact of preoperative symptom severity of body dysmorphic disorder on subjective outcomes in aesthetic rhinoplasty. This study highlights for the first time the inverse correlation between the severity of preoperative body dysmorphic disorder symptoms and the postoperative satisfaction of rhinoplasty patients. First, we clearly state that we agree fully with Dr. Swanson’s opinion about the importance of clinical judgment on the risk-to-benefit ratio in the preoperative evaluation of aesthetic rhinoplasty patients, as is the case in any surgical setting. In aesthetic rhinoplasty, the identification of the severe body dysmorphic disorder patient, presenting with delusional thoughts and a perfect nasal shape, is not a challenge. We here deal with the true preoperative challenge, which is the identification of those patients with a “surgically correctable” nasal deformity and discrete body dysmorphic disorder traits, that are at risk of not being satisfied with the postoperative results. In the latter case, clinical judgment is only considered a weak base for evaluating the degree of severity of body dysmorphic disorder symptoms, and objective tools are warranted for research purposes. Most rhinoplasty surgeons agree that the recognition of body dysmorphic disorder symptoms can be challenging, and underdiagnosis of the latter may be a reason for postoperative dissatisfaction. In a previous study by our group, we highlighted the high prevalence of body dysmorphic disorder symptoms in an aesthetic rhinoplasty population using validated questionnaires and confirmed the low prevalence of true body dysmorphic disorder. We want to explicitly point out that some colleagues may draw false conclusions from our results, such as the statement of body dysmorphic disorder symptoms being the result of the nasal deformity. As our data clearly demonstrate the lack of correlation between the objective evaluation of the nasal shape by the surgeon and the body dysmorphic disorder symptom severity, they do not support the argument of body dysmorphic disorder being the consequence of a nasal deformity. Of note, many other authors have already
62e
demonstrated that the subjective evaluation of the nasal deformity does not correspond to the objective scoring of the deformity by the surgeon. Furthermore, the discrepancy between the low percentage of rhinoplasty patients meeting the criteria for full body dysmorphic disorder and the high percentage of patients with significant body dysmorphic disorder symptoms highlights the difficulties of applying the current diagnostic criteria for body dysmorphic disorder in an aesthetic surgery setting. We recognize that not all patients with moderate to severe obsessive-compulsive symptoms concerning their appearance have body dysmorphic disorder, as explicitly stated in the article. Finally, we would like to comment on the remark concerning the lack of comparison between postoperative results and preoperative baseline scores. Taking into account the wide variety of baseline scoring of the nasal deformity and the variable degree of percentage of improvement of scoring of the nasal deformity by the patient, the authors felt the most interesting approach was to study the correlations between the preoperative body dysmorphic disorder symptom severity and the final appreciation of the nasal shape by the patient. Considered together, we are convinced that our large-scale prospective study on the impact of body dysmorphic disorder symptom severity on the subjective outcomes of rhinoplasty contributes significantly to the field of facial plastic surgery, as it demonstrates for the first time the importance of non–surgery-related reasons for (dis)satisfaction in aesthetic rhinoplasty patients. DOI: 10.1097/01.prs.0000437262.08822.8a
Valerie A. Picavet, M.D. Peter W. Hellings, M.D., Ph.D. Department of Otorhinolaryngology, Head and Neck Surgery University Hospitals Leuven Leuven, Belgium Correspondence to Prof. Dr. Hellings Department of Ear, Nose, and Throat University Hospitals Leuven Herestraat 49 Leuven 3000, Belgium [email protected]
DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication.
Are Systemic Antibiotics Indicated in Aesthetic Breast Surgery? A Systematic Review of the Literature Sir:
W
e read with great interest the recent article by Hardwicke et al. entitled: “Are Systemic Antibiotics Indicated in Aesthetic Breast Surgery? A Systematic Review of the Literature.”1 In their work, a systematic
Volume 133, Number 1 • Letters review of the literature concerning the use of systemic antibiotics in aesthetic breast surgery is performed. We congratulate the authors for the proficient analysis of the literature and the interesting findings they reported, and we would like to further discuss some aspects of this common issue. Frequently, surgeons deal with compelled choices, resulting from common sense more than from scientific evidence. For example, many surgeons dip the prosthesis in povidine-iodine, other disinfectants, or antibiotic solutions before breast implantation for the purpose of reducing the incidence of capsular contracture and/or infections. Until now, only a few studies succeeded in assessing the true benefit of such procedures, with contrasting results in the literature.2,3 The same applies to the choice of whether to prescribe postoperative antibiotic therapy or not after dismissal from the hospital.4 In the past decade, the fear of medicolegal lawsuits and claims has become a major reason leading to infection-reducing strategies or so-claimed ones in clinical practice. The surgeons had to protect themselves from further risk5 in a context where a surgical complication, such as a postoperative infection, is very likely to become an accusation by a lawyer, on the chance of procedural errors such as type and timing of antibiotic prophylaxis. As a consequence, the choice of using antibiotic therapy up to the removal of the drain or to limit it to a single dose of preoperative antibiotic is certainly an interesting and meaningful topic in the postsurgery treatment geared to prevent infections. We strongly believe that the procedures performed to reduce the risk of infection should be codified by international protocols. In our opinion, the article by Hardwicke and colleagues1 is an important piece of evidence on this topic. Nevertheless, as long as surgeons will have to answer to a judge regarding any postoperative issue, they will always be conditioned to implement any procedure protecting them from possible legal issues. Official international guidelines are of paramount importance to overcome the need for “defensive medicine.” DOI: 10.1097/01.prs.0000436416.91458.d3
Pierluigi Gigliofiorito, M.D. Luca Piombino, M.D. Stefano Campa, M.D. Francesco Segreto, M.D. Alfonso Luca Pendolino, M.S. Paolo Persichetti, M.D., Ph.D. Plastic and Reconstructive Surgery Unit Università Campus Bio-Medico di Roma Rome, Italy Correspondence to Dr. Gigliofiorito Plastic and Reconstructive Surgery Unit Università Campus Bio-Medico di Roma 00128 Rome, Italy [email protected]
DISCLOSURE The authors have no conflict of interest to declare; they received no funding for this research. REFERENCES 1. Hardwicke JT, Bechar J, Skillman JM. Are systemic antibiotics indicated in aesthetic breast surgery? A systematic review of the literature. Plast Reconstr Surg. 2013;131:1395–1403. 2. 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. Aesthet Surg J. 2013;33:675–680. 3. Gylbert L, Asplund O, Berggren A, Jurell G, Ransjö U, Ostrup L. Preoperative antibiotics and capsular contracture in augmentation mammaplasty. Plast Reconstr Surg. 1990;86: 260–267; discussion 268. 4. Mirzabeigi MN, Mericli AF, Ortlip T, et al. Evaluating the role of postoperative prophylactic antibiotics in primary and secondary breast augmentation: A retrospective review. Aesthet Surg J. 2012;32:61–68. 5. Murray JE. On ethics and the training of the plastic surgeon. Plast Reconstr Surg. 1978;61:270–271.
Reply: Are Systemic Antibiotics Indicated in Aesthetic Breast Surgery? A Systematic Review of the Literature Sir:
I would sincerely like to thank Drs. Gigliofiorito et al. for their considerate letter regarding our article.1 I agree that international agreement for the use of antibiotic prophylaxis in aesthetic breast surgery is key to safer practice. This will allow the provision of the best quality of care to our patients and avoid the need to practice empirical “defensive medicine.” Some of the current national guidance available is limited in its scope and has drawn broad conclusions that could be applied to reduction and augmentation mammaplasty from evidence that has been gleaned from other surgical specialities.2 The American Society of Plastic Surgeons guidelines3 do at the outset provide a disclaimer stating that “…this guideline should not be construed as a rule, nor should it be deemed inclusive of all proper methods of care or exclusive of other methods of care reasonably directed at obtaining the appropriate results,” and although our systematic review did not attempt to provide a clinical guideline, our aim was to present the available evidence, on which the clinician could base their best practice. We attempted to show that the best available evidence was sometimes insufficient for drawing substantial conclusions. Based on this, we cannot refute current U.K. guidelines2 with respect to augmentation mammaplasty and U.S. guidelines3 with respect to reduction mammaplasty for the reduction of surgical-site infection, and would therefore consider these to be current best practice and could be used as a framework for the development of future international protocols/guidelines. I agree that not all decisions in medicine are based on scientific
63e
