In plastic surgery, clean, elective operations such as breast reductions are anticipated to have low risk factors for infections (1.1-2.1%). To further lower or prevent surgical site infections (SSI), the efficacy of a prophylactic administration of anti-microbacterials remains a current controversial issue in plastic surgery. We report here the findings of a retrospective study in which we examined two groups of patients with breast reductions, one of which received a single-shot antimicrobacterial prophylaxis with cefuroxime preoperatively and the other who were given no anti-microbacterials. The aims were to determine the early SSI incidence of both groups, to classify breast reductions with respect to their inherent SSI risk by two widespread, combined risk scores, i.e., the National Nosocomial Infection Surveillance (NNIS) score and the Study on the Efficacy of Nosocomial Infection Control (SENIC) score, and to compare the actual SSI incidence to the predicted risk of the scores. In the divisions of plastic surgery at two hospitals, 153 patients (group I) and 136 patients (group II) could be included in the study in the 4-year period April 1997 to December 2001. Excluded were all patients with unilateral breast reduction or breast reconstruction and patients who were followed up less than 30 days postoperatively. The two groups were comparable with respect to demographic and clinical features such as age and risk factors, and there were no detectable significant intergroup differences in the general perioperative data. According to the NNIS and the SENIC scores, all operations were "clean," and the American Society of Anesthesiologists (ASA) score was < 3 in all patients. Although the mean duration of the operation was significantly different in the two groups (190 min in group I, 160 min in group II; p < 0.001, Mann-Whitney test; 75th percentile at and 4 and 3 h, respectively), it was longer than 2 h in both groups. The incidence of early infections was 3.9% in the first group, compared with 3.6% in the second group (p = 1.0, odds ratio = 1.07, 95% CI = 0.32-3.6). All infections were local and superficial; no general symptoms were noticed. Three patients had to be readmitted and two of these were reoperated. The rate of infections for both groups was higher than generally anticipated for this kind of clean operations and higher than predicted by the NNIS score for medium risk (predicted risk of 2.9%). The reason for this discrepancy is that the NNIS score is an inpatient risk score which does not include a postdischarge SSI surveillance. Using the NNIS definition of SSI we would have had an infection rate of 0% in both groups in our study. According to the SENIC score, breast reductions can be classified also as medium risk of SSI with a predicted risk of 3.9%, which showed a nearly perfect correspondence with the actual SSI incidence in both study groups. The reason for this increased, medium risk is the factor "operation time > 2 h," which is obviously an inherent risk factor in breast reductions. Among t...

Our retrospective review thus showed that with an arbitrary 500 g breast resection-rule all women beyond the mean values for weight and height were clearly put at a disadvantage. Also not completely solving this problem are the already available, more objective guidelines for graded minimum resection weight recommendations, which have relied on the body weight or the body surface area, parameters that both had a much lower correlation to the resected breast tissue in the patient group than the BMI. We therefore suggest using the BMI as the basis for a graded, more-level weight resection standard for reconstructive breast reductions. This algorithm is related solely to objectifying data and thus avoids biases from empirically derived data or hardly quantifiable breast (or obesity)-related pain syndromes, and respects all the different body builds of women.

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Breast reduction is a highly emotional topic, involving three conflicting interests: (a) women suffering from symptomatic macromastia, (b) health insurance companies, and (c) surgeons. Many insurance companies, including those in Austria, cover (if at all) only breast reductions with a minimum resection weight of 500 g per breast, irrespective of the physical build of the woman involved. We retrospectively reviewed 136 patients' charts from both cosmetic and reconstructive breast reduction operations and compared the breast resection weight to various parameters of body proportions such as height, weight, body mass index (BMI), and body surface area to determine the parameter best correlated to the weight of breast tissue resected. From this we developed a graded scale for guiding future operations irrespective of a woman's body build. The resection weight ranged from 55 to 1530 g (mean 450±266, median 406); mean BMI was 25.1. The arbitrary 500 g breast resection rule discriminates against women of nonaverage weight or height: of 24 patients (18%) with a cosmetic indication 4 had more than 500 g breast tissue resected bilaterally, while in 62 reconstructive patients (46%) less than the arbitrary 500 g breast tissue was resected. The parameter best correlated to the mean weight of breast tissue resected (sum of both breasts) was BMI. We therefore suggest using the BMI as the basis for a graded weight resection guideline for reconstructive breast reductions. The BMI-based scale treats equally women of all types of body build. In women with a BMI greater than 30 (classified as adiposity) we recommend that breast reduction be postponed, and a general body weight reduction program be undertaken for the sake of a higher impact on general well-being.