Surgical site infections in cosmetic surgery: evidence from meta-analyses and systematic reviews

Evidence selection criteria and PubMed search strategy

For this review, a targeted PubMed search was conducted, including only systematic reviews and meta-analyses related to surgical site infections in plastic surgery, cosmetic surgery and related procedures. Studies providing quantitative data and systematic analyses on the incidence of postoperative infections, the main factors associated with infection risk, the effectiveness of preventive strategies and the role of antibiotic prophylaxis in reducing complications were included. Surgical variables and individual patient characteristics potentially associated with clinical outcomes were also evaluated.

The final body of evidence consists of meta-analyses focusing on the safety of plastic surgery procedures, the mechanisms influencing infection risk and the most effective interventions for preventing surgical site infections.

Incidence of surgical site infections in cosmetic surgery

The available evidence indicates that surgical site infections (SSIs) are relatively uncommon complications following cosmetic surgery procedures, but they may have clinically significant consequences when they occur. Meta-analyses in plastic surgery demonstrate overall low SSI rates in elective procedures, although the risk may vary according to several factors, including:

• Type of procedure performed;
• Duration of surgery;
• Presence of implants or foreign materials;
• Patient clinical characteristics;
• Surgical technique used.

Even superficial or localized infections may negatively affect wound healing, the final aesthetic outcome and, in more complex cases, require additional treatment or revision surgery.

Cosmetic procedures associated with a higher risk of infection

The risk of infection is not uniform across cosmetic procedures and tends to increase in operations involving prosthetic materials, foreign bodies or more extensive tissue manipulation. Procedures most commonly associated with a higher risk of infection include:

• Breast surgery involving prosthetic implants;
• Procedures using synthetic materials;
• Combined or prolonged surgical procedures;
• Operations involving more extensive tissue dissection.

In aesthetic breast surgery in particular, even infrequent infections may have important clinical consequences because they can compromise the surgical outcome and require additional treatment, such as prolonged antibiotic therapy, drainage or, in more complex cases, implant removal.

Factors influencing the risk of postoperative infection

Systematic reviews show that the risk of surgical site infection (SSI) following cosmetic surgery is influenced by a combination of individual patient factors and variables related to surgical technique. Assessing these factors is essential for identifying patients at higher risk and implementing targeted preventive strategies.

Patient-related factors

Individual clinical conditions may affect tissue healing and immune response, increasing susceptibility to postoperative infections. The main risk factors include:

• Diabetes mellitus;
• Obesity;
• Immunosuppression;
• Smoking;
• Systemic conditions associated with impaired wound healing.

Appropriate preoperative patient selection and optimization of clinical conditions are therefore fundamental steps in reducing the risk of infection.

Technical and surgical factors

Technical aspects of the procedure also play a crucial role in the development of surgical site infections. The main associated variables include:

• Duration of the surgical procedure;
• Adherence to sterilization protocols;
• Atraumatic tissue handling;
• Hemostasis control;
• Proper wound closure and postoperative wound management.

The available evidence supports the role of standardized and meticulous surgical technique in reducing infectious complications and improving the overall safety of cosmetic procedures.

Role of antibiotic prophylaxis in infection prevention

The use of antibiotic prophylaxis in cosmetic surgery remains a topic of debate, particularly for elective procedures associated with a low risk of infection. Meta-analytic evidence suggests that the appropriate use of antibiotics may help reduce infection rates in specific clinical situations, especially when risk factors such as the following are present:

• Use of prosthetic implants or foreign materials;
• More invasive or prolonged surgical procedures;
• Increased risk of contamination.

However, the routine or non-selective use of antibiotics is not supported by the available evidence, given the potential for increased bacterial resistance, adverse effects and disruption of the microbiota. Current practice therefore favors an individualized approach to antibiotic prophylaxis based on the type of procedure, the patient’s risk profile and the specific characteristics of the operation.

Preventive strategies to reduce surgical site infections

Systematic evidence indicates that the prevention of surgical site infections (SSIs) in cosmetic surgery requires a multimodal approach based on the integration of preoperative, intraoperative and postoperative measures. The main preventive strategies include:

• Appropriate skin preparation before surgery;
• Strict implementation of sterilization and surgical safety protocols;
• Optimization of the patient’s clinical condition before the procedure;
• Appropriate use of antibiotic prophylaxis in selected patients;
• Proper management of postoperative drains and dressings;
• Early postoperative monitoring to identify signs of infection promptly.

The combined application of these measures helps reduce the overall risk of SSIs, improve perioperative management and enhance the safety of cosmetic surgery procedures.

Clinical implications in aesthetic practice

The management of surgical site infections in cosmetic surgery requires an approach based on prevention, appropriate risk stratification and the implementation of standardized perioperative protocols. Although SSIs are relatively uncommon in elective cosmetic procedures, they may compromise wound healing, aesthetic outcomes and, in more complex cases, require additional treatment. The available evidence indicates that reducing the risk of infection depends primarily on:

• Careful preoperative patient selection and optimization;
• The application of standardized surgical techniques and rigorous safety protocols;
• Appropriate use of antibiotic prophylaxis when indicated;
• Early identification and management of complications.

Overall, the prevention of SSIs in cosmetic surgery requires an integrated approach that considers both individual patient factors and the characteristics of the surgical procedure.

Summary of the main evidence on the risk and prevention of surgical site infections

The available meta-analyses and systematic reviews show that the risk of infection is influenced by multiple procedural and patient-related factors:

• Surgical site infections (SSIs) following cosmetic surgery are relatively uncommon events but may compromise wound healing, aesthetic outcomes and require additional treatment in more complex cases.
• Infection risk varies according to the procedure performed, with greater attention required for operations involving implants, foreign materials or more extensive tissue manipulation.
• Patient characteristics significantly influence the risk of complications, particularly in the presence of conditions such as diabetes, obesity, smoking or impaired wound healing.
• Surgical technique and perioperative management play a fundamental role in prevention through standardized protocols, contamination control and appropriate tissue handling.
• Antibiotic prophylaxis should be used selectively, based on the type of procedure and the individual patient’s risk profile, avoiding unnecessary use.
• Early postoperative monitoring allows prompt identification of signs of infection, reducing the risk of major complications and improving surgical outcomes.

Bibliography: PubMed meta-analyses and systematic reviews considered

ElHawary H, Hintermayer MA, Alam P, Brunetti VC, Janis JE. Decreasing Surgical Site Infections in Plastic Surgery: A Systematic Review and Meta-analysis of Level 1 Evidence. Aesthetic Surgery Journal. 2021;41(7):NP948-NP958. PMID: 33693462.

Schlager JG, Hartmann D, Wallmichrath J, et al. Patient-dependent risk factors for wound infection after skin surgery: A systematic review and meta-analysis. International Wound Journal. 2022;19(7):1748-1757. PMID: 35229471.

Zhang Y, Dong J, Qiao Y, et al. Efficacy and safety profile of antibiotic prophylaxis usage in clean and clean-contaminated plastic and reconstructive surgery: a meta-analysis of randomized controlled trials. PMID: 24343320.

Saco M, Howe N, Nathoo R, Cherpelis B. Topical antibiotic prophylaxis for prevention of surgical wound infections from dermatologic procedures: a systematic review and meta-analysis. Journal of Dermatological Treatment. PMID: 24646178.

Hardwicke JT, Bechar J, Skillman JM. Are systemic antibiotics indicated in aesthetic breast surgery? A systematic review of the literature. Plastic and Reconstructive Surgery. PMID: 23416440.