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
Plastic and Reconstructive Surgery • January 2014 fact, and the role of personal experience and common sense in practicing the art of medicine, tailored uniquely to the patient’s requirements, is an important skill to learn and master. Although systematic reviews of randomized and blinded patient cohorts are considered to be the best evidence available, we always need to recognize the needs of the individual patient under our duty of care, and weigh the risks associated with extended antibiotic administration. DOI: 10.1097/01.prs.0000436829.88570.68
Joseph Hardwicke, Ph.D.
University Hospitals of Birmingham Queen Elizabeth Hospital Mindelsohn Way, Egbaston Birmingham B15 2WB, United Kingdom [email protected]
DISCLOSURE The author has no financial interest to declare in relation to the content of this communication. 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. National Collaborating Centre for Women’s and Children’s Health. Surgical Site Infection: Prevention and Treatment of Surgical Site Infection. Clinical Guideline, October 2008. London: Royal College of Obstetricians and Gynaecologists; 2008. Available at: http://www.nice.org.uk/nicemedia/ live/11743/42378/42378.pdf. Accessed May 11, 2012. 3. Kalliainen LK; ASPS Health Policy Committee. ASPS clinical practice guideline summary on reduction mammaplasty. Plast Reconstr Surg. 2012;130:785–789.
Defining Nipple Displacement, and the Prevention and Treatment of the High-Riding Nipple Sir:
D
rs. Spear et al. propose a new classification to evaluate the postoperative high-riding nipple.1 This ratio uses as its landmarks the nipple level, the inframammary fold, and the superior breast margin, based on a method reported previously by Mallucci and Branford.2 The method is not compared to existing classifications that measure the nipple level (as opposed to a treatment algorithm).3,4 The authors use the term “nipple displacement” synonymously with nipple malposition. Nipple displacement, however, is defined more precisely as the vertical distance between the nipple level and the level of maximum breast projection (Fig. 1).4 By consensus, the nipple is correctly positioned at the apex (i.e., the most projecting point) of the breast mound.4 Therefore, this level is the most appropriate vertical landmark for evaluation of nipple position.
64e
Measurements that do not relate the nipple level to this plane are bound to fall short. Some traditional measurements are not helpful. The distance to the sternal notch varies with torso length. The level of the inframammary crease is often hidden in photographs and is known to drop after breast augmentation and rise after vertical mastopexy, undermining its usefulness as a landmark.4 Because the correct nipple position is in relation to the breast mound only, further classification as relative, absolute, or complex is unnecessary. The superior border of the breast (where the breast starts and the chest wall stops) is usually not a welldefined landmark and is therefore subject to interpretation, undermining the reliability of any ratios based on it. This limitation is apparent in the authors’ Figures 4 and 5.1 In these patients, the horizontal reference line appears to intersect the upper pole of the breast lower than its takeoff on the chest wall, unlike Figures 6 and 7. The authors do not illustrate any patients with breast ptosis, in whom the inframammary fold is hidden in photographs. Presumably, the lower pole level is substituted for the inframammary fold in these patients. The authors indicate that upper-to-lower ratios greater than 45 percent are normal.1 However, values close to 100 percent would likely be abnormal, indicating that the nipples are too low. Ideally, a nipple-level classification would be applicable to both high- and low-riding nipples. These deficiencies point to the greater practicality and simplicity of using nipple displacement4 as a guide. A “skyward” nipple inclination of 20 degrees, advocated by Mallucci and Branford,2 and repeated here,1 is an unnatural appearance; the correct nipple inclination is neutral.4 The ideal upper pole contour is not concave. Women prefer upper pole convexity5; the breast parenchymal ratio should be greater than 1:1, not less.4 Like Mallucci and Branford,2 the authors use oblique photographs. These views are difficult to standardize because of differences in rotation. Lateral photographs are preferred. Lateral images can also be used to evaluate breast projection and upper pole projection, which are other important parameters related to breast shape.4 Frontal views need to be standardized. Dropping a shoulder can affect the appearance of n ipple asymmetry (authors’ Fig. 4).1 Spear et al. report using secondary augmentations and mastopexies, combinations, and human acellular dermal matrix as remedies for nipple overelevation but do not show any examples and provide little description.1 The single example of surgical treatment shows a reconstruction patient treated with a nipple-areola transposition flap, followed by another operation to inject fat and substitute a shaped implant, with some improvement but at the cost of upper pole scarring. The authors report 100 percent patient satisfaction and there is no mention of complications. Because this is a retrospective chart review, the frequency of this complication remains unknown. Only patients who complained of the problem underwent treatment. In fact, nipple overelevation is so prevalent,
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
Plastic and Reconstructive Surgery • January 2014 fact, and the role of personal experience and common sense in practicing the art of medicine, tailored uniquely to the patient’s requirements, is an important skill to learn and master. Although systematic reviews of randomized and blinded patient cohorts are considered to be the best evidence available, we always need to recognize the needs of the individual patient under our duty of care, and weigh the risks associated with extended antibiotic administration. DOI: 10.1097/01.prs.0000436829.88570.68
Joseph Hardwicke, Ph.D.
University Hospitals of Birmingham Queen Elizabeth Hospital Mindelsohn Way, Egbaston Birmingham B15 2WB, United Kingdom [email protected]
DISCLOSURE The author has no financial interest to declare in relation to the content of this communication. 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. National Collaborating Centre for Women’s and Children’s Health. Surgical Site Infection: Prevention and Treatment of Surgical Site Infection. Clinical Guideline, October 2008. London: Royal College of Obstetricians and Gynaecologists; 2008. Available at: http://www.nice.org.uk/nicemedia/ live/11743/42378/42378.pdf. Accessed May 11, 2012. 3. Kalliainen LK; ASPS Health Policy Committee. ASPS clinical practice guideline summary on reduction mammaplasty. Plast Reconstr Surg. 2012;130:785–789.
Defining Nipple Displacement, and the Prevention and Treatment of the High-Riding Nipple Sir:
D
rs. Spear et al. propose a new classification to evaluate the postoperative high-riding nipple.1 This ratio uses as its landmarks the nipple level, the inframammary fold, and the superior breast margin, based on a method reported previously by Mallucci and Branford.2 The method is not compared to existing classifications that measure the nipple level (as opposed to a treatment algorithm).3,4 The authors use the term “nipple displacement” synonymously with nipple malposition. Nipple displacement, however, is defined more precisely as the vertical distance between the nipple level and the level of maximum breast projection (Fig. 1).4 By consensus, the nipple is correctly positioned at the apex (i.e., the most projecting point) of the breast mound.4 Therefore, this level is the most appropriate vertical landmark for evaluation of nipple position.
64e
Measurements that do not relate the nipple level to this plane are bound to fall short. Some traditional measurements are not helpful. The distance to the sternal notch varies with torso length. The level of the inframammary crease is often hidden in photographs and is known to drop after breast augmentation and rise after vertical mastopexy, undermining its usefulness as a landmark.4 Because the correct nipple position is in relation to the breast mound only, further classification as relative, absolute, or complex is unnecessary. The superior border of the breast (where the breast starts and the chest wall stops) is usually not a welldefined landmark and is therefore subject to interpretation, undermining the reliability of any ratios based on it. This limitation is apparent in the authors’ Figures 4 and 5.1 In these patients, the horizontal reference line appears to intersect the upper pole of the breast lower than its takeoff on the chest wall, unlike Figures 6 and 7. The authors do not illustrate any patients with breast ptosis, in whom the inframammary fold is hidden in photographs. Presumably, the lower pole level is substituted for the inframammary fold in these patients. The authors indicate that upper-to-lower ratios greater than 45 percent are normal.1 However, values close to 100 percent would likely be abnormal, indicating that the nipples are too low. Ideally, a nipple-level classification would be applicable to both high- and low-riding nipples. These deficiencies point to the greater practicality and simplicity of using nipple displacement4 as a guide. A “skyward” nipple inclination of 20 degrees, advocated by Mallucci and Branford,2 and repeated here,1 is an unnatural appearance; the correct nipple inclination is neutral.4 The ideal upper pole contour is not concave. Women prefer upper pole convexity5; the breast parenchymal ratio should be greater than 1:1, not less.4 Like Mallucci and Branford,2 the authors use oblique photographs. These views are difficult to standardize because of differences in rotation. Lateral photographs are preferred. Lateral images can also be used to evaluate breast projection and upper pole projection, which are other important parameters related to breast shape.4 Frontal views need to be standardized. Dropping a shoulder can affect the appearance of n ipple asymmetry (authors’ Fig. 4).1 Spear et al. report using secondary augmentations and mastopexies, combinations, and human acellular dermal matrix as remedies for nipple overelevation but do not show any examples and provide little description.1 The single example of surgical treatment shows a reconstruction patient treated with a nipple-areola transposition flap, followed by another operation to inject fat and substitute a shaped implant, with some improvement but at the cost of upper pole scarring. The authors report 100 percent patient satisfaction and there is no mention of complications. Because this is a retrospective chart review, the frequency of this complication remains unknown. Only patients who complained of the problem underwent treatment. In fact, nipple overelevation is so prevalent,
