Evidence-Based Perioperative Incisional Care in Plastic Surgery: A Narrative Review

INTRODUCTION: Perioperative incisional care is essential in plastic surgery for minimizing complications and optimizing outcomes, yet conflicting guidelines from major health organizations, such as the World Health Organization (WHO) [1], the Centers for Disease Control and Prevention (CDC) [2], and the Society for Healthcare Epidemiology of America (SHEA) [3], create variability in clinical practice. A survey of American Society of Plastic Surgeons (ASPS) members highlights this variability, revealing a lack of consensus on best practices incisional care techniques [4]. Further complicating surgical protocols, the FDA’s removal of bacitracin in 2020 due to nephrotoxicity concerns has altered the use of triple antibiotic solution, leading to a shift toward alternative irrigation strategies [5]. Given these ongoing changes and practice inconsistencies, an evidence-based approach to perioperative incisional care in plastic surgery is critical for improving patient safety and surgical outcomes.

METHODS: A comprehensive literature search of PubMed, MEDLINE, and Embase (2000–2025) was performed using defined terms (“clean surgical wounds,” “plastic surgery,” “incisional care”). Randomized controlled trials, systematic reviews, and meta-analyses focusing on six key areas-antiseptic preparation, wound irrigation, suture materials, wound closure devices, dressings, and topical agents-were prioritized. Studies pertaining to non-English publications, contaminated wounds, chronic wounds, and animal models were excluded. References were further compared with guidelines from health organizations, including the NIH, WHO, CDC, and ASPS. A narrative review was chosen over a systematic or scoping review to provide a structured synthesis of diverse evidence, integrating various study designs, expert consensus, and clinical guidelines to better inform clinical decision-making in plastic surgery.

RESULTS: Six evidence-based recommendations emerged. First, 4–5% alcohol-based CHG is preferred for preoperative antisepsis. Second, antiseptic solutions (e.g., CHG or PVP-I) are recommended for irrigation over normal saline, and routine antibiotic irrigation is discouraged to mitigate antimicrobial resistance. Third, standard sutures are generally favored over barbed or antimicrobial-coated sutures. Fourth, 2-octyl-cyanoacrylate adhesives pose a high risk of hypersensitivity reactions, while silk fibroin strips offer improved biocompatibility and paper tapes remain useful for low-tension incisions. Fifth, traditional dressings remain adequate for most clean wounds, while closed-incision negative pressure wound therapy (ciNPWT) and silver dressings may benefit chronic wounds. Sixth, plain petrolatum is a safe topical agent, as antibiotic ointments confer no additional benefit and increase antibiotic resistance risks.

CONCLUSION: This narrative review synthesizes current evidence to offer six actionable, perioperative recommendations tailored to Class 1 clean incisions in plastic surgery. By synthesizing current evidence, this review serves as a comprehensive resource to guide clinical decision-making and optimize surgical outcomes for plastic surgeons.