European Journal of Plastic Surgery

, Volume 42, Issue 2, pp 155–160 | Cite as

Quality auditing in breast reconstruction using funnel plots and indicators: a semi-anonymous and practical method for your practice

  • Inge Smits
  • Nikki Beudeker
  • Byrthe J. P. R. VosEmail author
  • Narda Hendriks-Brouwer
  • Ute Schmidbauer
  • Yvonne C. M. M. Smulders
  • Oliver T. Zöphel
  • Hinne A. Rakhorst
Original Paper



In recent years, there is an increasing focus on the delivery of high-quality care in a cost-efficient fashion. A key strategy in improving practice is gaining insight in outcome differences. We present a simple and quick method of quality auditing in a local practice, aiming to start a discussion between surgeons and reduce complication rates by improving protocols.


Patients who underwent breast reconstruction with implants were evaluated on explantation rate within 60 days of insertion. Patients were traced using administrative data. Results were compared during yearly audits between 2014 and 2017. Each year, a meeting was held in which the data of all surgeons were compared using funnel plots in a semi-anonymous manner.


At baseline, 6.1% (15/244) of all implants and 9.9% (9/91) of all tissue expanders had to be explanted, mainly due to infection (60.0% and 77.8%, resp.). Discussion at the audit led to the implementation of an anti-infection protocol. In the following years, explantation rates decreased to 3.8% (8/208) and 7.8% (8/102) in 2015 (infection 55.6% and 63%), and 3.4% (6/176) and 3.1% (2/64) in 2017 (infection 50% and 100%) and in 2016.


Audit feedback and the subsequent discussion about the causes of inter-surgeon differences led to a change in practice protocols for breast implant surgery and a reduction of breast implant explantation in our center.

Level of Evidence: Level III, risk / prognostic study


Funnel plot Quality indicator Complication Breast reconstruction Plastic surgery 



The authors would like to thank Corry van Zuuren for assisting in the registration of the explantations of prosthesis.


This work was not supported by grants.

Compliance with ethical standards

Conflict of interest

Inge Smits, Nikki Beudeker, Byrthe J.P.R. Vos, Narda Hendriks-Brouwer, Ute Schmidbauer, Yvonne C.M.M. Smulders, Oliver T. Zöphel, and Hinne A. Rakhorst declare that they have no conflict of interest.

Ethical approval

The local medical ethics committee deemed that official medical ethical approval was not required.

Informed consent

All medical files were analyzed by treating physicians; therefore, informed consent for insight in patient data was not required.


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Inge Smits
    • 1
  • Nikki Beudeker
    • 2
  • Byrthe J. P. R. Vos
    • 1
    Email author
  • Narda Hendriks-Brouwer
    • 1
    • 2
  • Ute Schmidbauer
    • 2
  • Yvonne C. M. M. Smulders
    • 2
  • Oliver T. Zöphel
    • 2
  • Hinne A. Rakhorst
    • 1
    • 2
  1. 1.Department of Plastic, Reconstructive, and HandsurgeryMedisch Spectrum TwenteEnschedeThe Netherlands
  2. 2.Department of Plastic, Reconstructive, and HandsurgeryZiekenhuisgroep TwenteHengeloThe Netherlands

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