Key points

Introduction

The discovery of antibiotics marked one of the greatest milestones in human history. The advances that followed have saved countless millions of lives around the globe. These advances have contributed to the evolution of surgery from a practice that was used only when necessary, carrying great risk of death and morbidity, to what we know today. Cosmetic surgery may never have become as mainstream as it currently is if not for advances in prevention and treatment of infections.

Antibiotic use, however, is not without risk. Allergic reactions, side effects, opportunistic infections, increased health care costs, and most importantly the emergence of drug resistance have led many to question whether we are overusing antibiotics. The National Action Plan for Combating Antibiotic-resistant Bacteria developed in response to Executive Order 13,676 by President Barack Obama highlights the importance of this matter.

In 1999 the Centers for Disease Control and Prevention issued the “Guideline for prevention of surgical site infection.” In their report, they advocate for the use of an antimicrobial prophylaxis agent for all operations or classes of operations in which its use has been shown to reduce surgical site infection (SSI) rates based on evidence from clinical trials or for those operations after which an SSI would represent a catastrophe. In the following sections the authors discuss the most commonly performed procedures in facial plastic surgery with one question in mind: Is antimicrobial prophylaxis indicated for these procedures based on the available literature?

Preoperative antibiotic administration is defined as any dose given before surgery; perioperative antibiotics are those given within 1 hour of incision and continuing less than 24 hours after the procedure, and postoperative antibiotics are administered 24 hours or more after surgery.

Introduction

The discovery of antibiotics marked one of the greatest milestones in human history. The advances that followed have saved countless millions of lives around the globe. These advances have contributed to the evolution of surgery from a practice that was used only when necessary, carrying great risk of death and morbidity, to what we know today. Cosmetic surgery may never have become as mainstream as it currently is if not for advances in prevention and treatment of infections.

Antibiotic use, however, is not without risk. Allergic reactions, side effects, opportunistic infections, increased health care costs, and most importantly the emergence of drug resistance have led many to question whether we are overusing antibiotics. The National Action Plan for Combating Antibiotic-resistant Bacteria developed in response to Executive Order 13,676 by President Barack Obama highlights the importance of this matter.

In 1999 the Centers for Disease Control and Prevention issued the “Guideline for prevention of surgical site infection.” In their report, they advocate for the use of an antimicrobial prophylaxis agent for all operations or classes of operations in which its use has been shown to reduce surgical site infection (SSI) rates based on evidence from clinical trials or for those operations after which an SSI would represent a catastrophe. In the following sections the authors discuss the most commonly performed procedures in facial plastic surgery with one question in mind: Is antimicrobial prophylaxis indicated for these procedures based on the available literature?

Preoperative antibiotic administration is defined as any dose given before surgery; perioperative antibiotics are those given within 1 hour of incision and continuing less than 24 hours after the procedure, and postoperative antibiotics are administered 24 hours or more after surgery.

Septoplasty/rhinoplasty

The nasal cavity comes into contact with everything we breathe and is well known to harbor bacterial pathogens. Studies have demonstrated a clear correlation between nasal bacterial colonization and SSI in general. But is the same true for nasal surgery; is antibiotic prophylaxis indicated for these cases?

The incidence of postseptoplasty/rhinoplasty infection found in current literature fluctuates significantly between 0% and 18%, but in general 2% is considered acceptable. Although indications are still a topic of debate, various survey studies have shown that, in practice, prophylactic antibiotic use is favored by most physicians performing rhinoplasty. Lyle and colleagues found a 200% increase in antibiotic prophylaxis use between 1985 and 2000. Despite their limitation of survey studies with relatively low response rates, these studies demonstrate that prescribing prophylactic antibiotics is becoming more common in today’s rhinoplasty practice.

Table 1 shows studies that evaluated patients who did not receive any antibiotics. The complication rate for this group fluctuated between 0% and 0.6%. If one looks at these data in isolation, one could make a compelling argument that risk of infection is so low that there is no need for antibiotics. However, 2 studies had well less than 100 patients, which limits their reliability and reproducibility. Cabouli and colleagues had larger numbers but were limited by recall bias; of the 12 patients who developed infections, only 5 were well documented. Interestingly, Yoder and Weimart reported a 0.48% (5 of 1040) infection rate without the use of antibiotics or surgical preparation solution.

Table 2 shows studies that prospectively compared patients who received antibiotics with those who received either placebo or nothing at all. All had low sample sizes, which limited their power. Three of the studies show no difference between groups, which would support the argument that antibiotic prophylaxis is not helpful. Conversely, Schäfer and Pirsig found a significant difference between groups, whereby the placebo group had a 27% (14 of 52) infection rate, whereas the antibiotic group had an 8% (4 of 48) infection rate. If evaluated in isolation one could say that this study makes a compelling argument favoring antibiotic prophylaxis. However, it is important to note the high infection rate relative to that published in the literature. The investigators attribute the high infection rate to the fact that all cases were complex revisions, but this could also be an effect of the broad definition of infection used in this study.

Table 3 compared groups whereby all patients received antibiotics of some sort. Interestingly, Andrews and colleagues commented that they did not include a placebo arm because they thought it would be “unethical to do so given the high infection rates in published literature.” Two of these articles found no added benefit in using postoperative antibiotics in addition to the perioperative therapy, but all investigators think that antibiotic prophylaxis is indicated in rhinoplasty surgery.

Although available literature does not support routine antibiotic prophylaxis, it is not sufficient to make a legitimate argument against their use either. Furthermore, the national tendency to routinely give antibiotics highlights the fact that further data are required in order to draw any significant conclusions.

Blepharoplasty

The periocular region is considered a clean area. Rich vascularity and ease of preoperative surgical site preparation makes the need for antibiotic prophylaxis questionable. The incidence of infection following blepharoplasty is less than 1%. However, several case reports have described severe postblepharoplasty infections that result in significant morbidity even when treated early.

In 2003 Lyle and colleagues found a greater than 200% increase in antibiotic use from 1985 to 2000 in patients undergoing blepharoplasty. In the 1985 survey 11% of respondents admitted to using antibiotic prophylaxis in more than 50.0% of their cases, whereas 46.9% did so in the survey done in 2000. Interestingly this increase came about without any literature to support such an increase. Hauck and Nogan published a similar survey in 2013 whereby they found that 64% of respondents used antibiotics greater than 50% of the time, 51% of respondents always used antibiotic prophylaxis, and 21% never used them. It is important to note that these studies referred to systemic antibiotics not topical. In 2015, Fay and colleagues published their multinational survey directed specifically to members of the oculoplastic societies worldwide. They found that topical antibiotic use was common in all regions (85.2%), whereas perioperative systemic antibiotic was uncommon in all regions (13.5%).

In 2003 Carter and colleagues published a retrospective review of 1627 patients who underwent blepharoplasty. All received topical antibiotics, but only 11 patients received an oral course prophylactically because of prosthetic joints or heart valves. The infection rate was 0.2% (4 of 1627), all of which resolved with a course of antibiotics. They, therefore, concluded that topical postoperative antibiotic prophylaxis alone is sufficient for routine blepharoplasty.

With the evidence available, it is difficult to show that use of antibiotics can decrease an already low complication rate in blepharoplasty. It is the authors’ impression that systemic antibiotics are not advantageous in blepharoplasty, but high-quality evidence would be beneficial in order to draw a definitive conclusion and convince physicians to change their practice patterns.