“Without standards, there can be no improvement”—Taiichi Ohno
Editorial Commentary

“Without standards, there can be no improvement”—Taiichi Ohno

Shafreena Kühn1, Robert Sader2, Ulrich M. Rieger1

1Department of Plastic and Aesthetic, Reconstructive and Hand Surgery, AGAPLESION Markus Hospital, Academic Teaching Hospital of the Goethe University, Frankfurt am Main, Germany; 2Department of Oral, Cranio-Maxillofacial, and Facial Plastic Surgery, Goethe-University Frankfurt, Frankfurt am Main, Germany

Correspondence to: Shafreena Kühn, MD. Department of Plastic and Aesthetic, Reconstructive and Hand Surgery, AGAPLESION Markus Hospital, Wilhelm-Epstein-Strasse 4, 60431 Frankfurt am Main, Germany. Email: sha.kuehn@gmail.com.

Provenance: This is an invited article commissioned by the Editorial Office of Gland Surgery.

Comment on: Spronk PER, Becherer BE, Hommes J, et al. How to improve patient safety and quality of care in breast implant surgery? First outcomes from the Dutch Breast Implant Registry (2015-2017). J Plast Reconstr Aesthet Surg 2019;72:1607-15.

Submitted Nov 12, 2019. Accepted for publication Nov 24, 2019.

doi: 10.21037/gs.2019.11.23

After introducing silicon filled breast implants over half a century ago in 1963 (1), studies concerning all aspects of heterologous breast augmentation have been conducted. These range from different aspects of why? how? and where? through to thorough investigations on social, psychological and physical complications, ranging from short to long term, as well as complication assessment and management and means of complication reduction. The introduction of different means of complication control, for example those evaluated by the Dutch Breast Implant Registry (DBIR) such as implant immersion in antiseptic solution or administration of intravenous antibiotic or the placement of drainages (2) have led to significant changes in surgical practices and thus furthered the evolution of breast implant surgery. Spronk et al. (2) have analysed the DBIR, first established in 2015 and have found high participation rates for hospitals and private clinics. The DBIR enabled a minimum estimate of implant incidence rate for Dutch women, an understanding for indication, as well as for patient, device and surgery characteristics. Furthermore different infection control measures were analysed. The results emphazise the benefit of further developments regarding national data base and ultimately breast implant surgery (2).

Improvement is at the heart of each and every study conducted; this is true for breast surgery but nonetheless for every aspect of medical research. The aim of standardization is the improvement of outcome and hence perfection of treatment processes. Large-scale registries lead to well found standardization.

In times of rapid progression of worldwide digitalization and in the midst of peaking globalization processes, health professionals make it a main goal to use opportunities in terms of data digitalization and immediate data recall, in order to optimize and learn from established national and international treatments and processes from past and present.

In order to use our daily produced data effectively, an international system of data management should urgently be implemented as to make the great amount of collective and arranged data readily usable for every physician, and hence improve knowledge and quality of treatment for every patient.

According to the International Society of Aesthetic Plastic Surgery 1.540.289 heterologous breast augmentations were performed worldwide in 2017 (3). If the aim is to create standards by which surgeons can base their decisions and therapeutic plans on, these standards need to be established, at best through a multinational database, thereby learning from one another’s experiences in a transparent and non-judgmental fashion. The Dutch Ministry of Health, Welfare and Sport have been one of the pioneers in taking this important step forward and have set an example for other nations to follow.

Through effective analysis of the DBIR, Spronk et al. have shown readers an overview of current conduction in breast implant surgery in the Netherlands (2), whilst allowing an insight in different patient, device and surgical characteristics. The objective outlay and analysis of national code of practices allow surgeons to compare and improve their treatments.

Continuing the gathering and processing of information through the DBIR will allow conclusions to be drawn from these data in future, hence allowing for large-scale evidence-based treatments and standards to be established.

We commend Spronk et al. for their efforts in meticulous data evaluation as well as their endeavor in data presentation. In our opinion, the establishment of the DBIR leading to the presented data, as well as the analysis of the DBIR data will effectively help practitioners in their daily performance, simplifying decision making based on evidence and finally lead to further understanding and standardization of treatment, ultimately making breast implant surgery safer for women.

Furthermore, we commend the Dutch Health and Youth Care Inspectorate for establishing the DBIR, as well as the increasing number of Dutch health professionals participating in the registry, hence supporting further improvement in the medical field and women’s lives in particular.




Conflicts of Interest: The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.


  1. Cronin TD, Brauer RO. Augmentation mammaplasty. Surg Clin North Am 1971;51:441-52. [Crossref] [PubMed]
  2. Spronk PER, Becherer BE, Hommes J, et al. How to improve patient safety and quality of care in breast implant surgery? First outcomes from the Dutch Breast Implant Registry (2015-2017). J Plast Reconstr Aesthet Surg 2019;72:1607-15. [Crossref] [PubMed]
  3. Available online: https://www.isaps.org/medical-professionals/isaps-global-statistics
Cite this article as: Kühn S, Sader R, Rieger UM. “Without standards, there can be no improvement”—Taiichi Ohno. Gland Surg 2019;8(6):591-592. doi: 10.21037/gs.2019.11.23