ASPS Participates in the ABIM Foundation’s Choosing Wisely® Campaign
To Promote Healthy Patient/Surgeon Communication, the American Society of Plastic Surgeons Announces “Five Things Physicians and Patients Should Question” in Participation in the ABIM Foundation’s Choosing Wisely® Campaign

Arlington Heights, Illinois. -- The American Society of Plastic Surgeons (ASPS) is pleased to participate in the ABIM Foundation's Choosing Wisely® Campaign. ChoosingWisely aims to promote conversations between providers and patients by helping patients choose care that is:

• Supported by evidence
• Not duplicative of other tests or procedures already received
• Free from harm
• Truly necessary

In response to this challenge, national organizations representing medical specialists to identified tests or procedures commonly used in their field, whose necessity should be questioned and discussed. The resulting lists of "Things Providers and Patients Should Question" will spark conversations about the necessity of frequently ordered tests or treatments.

The Choosing Wisely campaign is consistent with ASPS's commitment to providing quality care to plastic surgery patients and assisting them in making 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.

The list below was compiled by the American Society of Plastic Surgeon's Health Policy, Patient Safety, and Quality and Performance Measurement Committees.

Five Things Physicians and Patients Should Question

Avoid performing routine mammogram 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 on physical exam which would suggest the need for further investigation.

Avoiding 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.

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.

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 are helpful in instances of dental and/or isolated mandibular injury or trauma.

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.

Sources

1. • American College of Radiology. ACR Practice Guideline for the Performance of Screening and Diagnostic Radiology. Reston, Va: American College of Radiology, 2013. Accessed September 20, 2013.
   • 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. Revised 10/24/2013. Accessed November 4, 2013.
2. • American Society of Plastic Surgeons. Evidence-based clinical practice guideline: reduction mammaplasty. Arlington Heights (IL): American Society of Plastic Surgeons; 2011 May.
   • Stojkovic CA, Smeulders MJC, Van der Horst CM, Khan SM. Wound drainage after plastic and reconstructive surgery of the breast. Cochrane Database of Systematic Reviews 2013, Issue 3. Art. No.: CD007258. DOI: 10.1002/ 14651858.CD007258.pub2.
   • 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. 132: 443, 2013.
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.
   • American College of Radiology. ACR Practice Guideline for the Performance of Screening and Diagnostic Mammography. Reston, Va: American College of Radiology, 2013. Accessed September 20, 2013.
   • National Comprehensive Cancer Network (NCCN). Clinical Practice Guidelines in Oncology: Breast Cancer Screening and Diagnosis. Version2.2013.
4. • 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. 127:1270,2011.
   • Stacey DH, Doyle JF, Mount DL, Snyder MC, Gutowski KA. Management of Mandible Fractures. Plast. Reconstr. Surg. 117:48e, 2006.
5. • Bratzler DW, Dellinger EP, Olsen KM et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health-Syst Pharm. 2013; 70:195-283.
   • Bratzler DW, Houck PM. Antimicrobial Prophylaxis for Surgery: An Advisory Statement from the National Surgical Infection Prevention Project. Clinical Infectious Diseases, 2004; 38:1706-15.