Surgical Mask Fit and Fogging: Why Small Disruptions Matter in the Operating Room

During a lengthy surgical procedure, a shifting mask, moisture buildup, or fogged eyewear can repeatedly pull a clinician’s attention away from the operating field. Addressing these frustrations is a practical concern for infection prevention and perioperative leaders working to support consistent masking practices.

In this Q&A with Infection Control Today® (ICT®), Dana Weaver Storm, MHA, BSN, RN, senior clinical consultant at Cardinal Health, shares insights from her experience in surgical services. She discusses challenges that arise during prolonged mask use, the importance of matching mask selection to procedural needs, and how staff education and frontline feedback can help organizations address barriers to adherence.

ICT: In your experience, what feedback/input have you heard from clinicians, especially surgeons, about how surgical masks perform for them during long-term use in difficult environments?

Dana Weaver Storm, MHA, BSN, RN: With 38 years of experience in an operating room setting, I have consistently heard similar feedback from surgeons and clinicians regarding surgical masks, particularly during prolonged, high-intensity procedures. These cases often last several hours and are performed under warm surgical lights while wearing extensive personal protective equipment (PPE).  

Surgical mask fit remains a frequently reported challenge in the surgical setting. Many surgeons describe masks that initially feel secure but gradually lose their seal or shift during procedures. As the fit changes, surgeons/clinicians may become distracted by the need for repeated adjustments, potentially impacting concentration during critical tasks. A secure and stable mask fit is essential to support uninterrupted focus throughout the procedure.

The seal across the bridge of the nose presents an additional concern. Nosepieces that do not adequately conform to the face or that lose their shape over time can create gaps that allow airflow to escape upward. This may lead clinicians to repeatedly adjust the mask to restore the seal. In addition to interrupting workflow, these adjustments can increase unnecessary face touching, which should be minimized in the perioperative environment.

Another common issue is moisture buildup. Surgeons, clinicians, and anesthesia providers often report masks becoming heavy, damp, or restrictive after prolonged wear. Once moisture builds up, airflow can feel reduced, and the mask may stick uncomfortably to the face. A clinician may slightly pull the mask away from their face to get air, or consider changing it midcase if moisture persists. Pausing during a procedure to change a mask requires scrubbing out and back in, increasing procedure time and disrupting workflow.

Fogging of eyewear and face shields is a universally frustrating issue, one that many people shared while masking in public during the COVID-19 pandemic. A successful surgical procedure depends on a clear field of view, and even brief fogging can disrupt precise, delicate work. Many clinicians instinctively adjust their eyewear or mask to clear the fog, again introducing distractions and unnecessary contact with the mask or their faces.

When a surgical mask performs well, a clinician stops thinking about it. When it doesn’t, it becomes another issue to manage in an already high-stakes environment.

ICT: In your experience, where and when do you most often see adherence to masking, best practices break down? What are the real consequences of infection control and safety when that happens?

DWS: In my experience, adherence to masking best practices most commonly breaks down during longer procedures, high-intensity moments, and transitional phases of surgery. While clinicians generally begin procedures with strong adherence, factors such as fatigue, communication demands, physical discomfort, and increased movement can gradually impact consistency.

During surgeries lasting several hours, clinicians may unintentionally begin adjusting masks more frequently due to heat, moisture buildup, pressure discomfort, or difficulty communicating. This is especially noticeable after the first 1 to 2 hours of a case, when fatigue and cognitive overload can increase. In prolonged or complex procedures, staff may become more task-focused on the surgical challenge itself, making masking practices and hand-to-mask awareness secondary concerns.

High-intensity or complex operations also create situations in which adherence to masking may be compromised. During emergencies, unexpected bleeding, rapid equipment changes, or moments requiring urgent communication, clinicians may instinctively touch or reposition their masks while concentrating on the patient or coordinating with the surgical team. These moments increase the risk of contamination because staff are often moving quickly, speaking more forcefully, and working under elevated stress levels.

There are several transitional points during procedures where masking adherence is more vulnerable, including:

• Positioning or repositioning the patient
• Specimen handling or documentation tasks
• Staff relief breaks or shift changes
• Communication exchanges requiring repeated verbal clarification

• Moving between sterile and nonsterile areas

In surgical settings, where patients are particularly vulnerable, even small lapses matter. Consistent masking practices are an important component of broader infection prevention protocols. These practices are essential for patient safety and supporting overall procedural integrity.

ICT: Surgical mask-related fogging is often treated as a comfort or nuisance issue, but how does impaired visibility from fogged eyewear or face shields become a real safety concern in the clinical setting?

DWS: A clear field of view is imperative for a surgeon or any clinician performing a procedure. From a safety perspective, fogged eyewear or impaired visibility can cause discomfort that may divert attention from patient care.

Many procedures require sustained precision and uninterrupted visualization, including microsurgery, neurosurgery, cardiovascular surgery, ophthalmic procedures, robotic-assisted surgery, and complex orthopedic or vascular cases. These procedures often last several hours and involve highly delicate structures, where even brief visual impairment caused by fogged eyewear or face shields can compromise depth perception, fine motor accuracy, and situational awareness.

For example, in neurosurgery or ophthalmic surgery, surgeons may be working within millimeters of critical anatomy, making continuous visual clarity essential. In robotic-assisted procedures, surgeons rely on enhanced visualization and precise instrumentation, so any interruption due to fogging can disrupt concentration and procedural flow. Similarly, during cardiovascular or vascular procedures, impaired visibility during delicate suturing or vessel repair could increase procedural risk and prolong operative time.

In these high-precision, time-sensitive cases, persistent fogging is more than a comfort issue; it becomes a patient and staff safety concern that can affect efficiency, focus, communication, and overall procedural integrity.

When eye protection fogs, surgeons may pause to adjust their mask or eyewear or ask to step back to wipe their eyewear clean. Such pauses can add incremental time to a procedure, disrupt surgical flow, and shift attention away from the operating field. In delicate or time-sensitive cases, these small delays can compound, increasing the risk of fatigue for the entire team and potentially prolonging the patient’s anesthesia.

For lengthy, complex surgeries, clinicians want and need a mask that offers enhanced comfort, a snug fit, and reduced fogging. For example, the Cardinal Health Hydrogel Anti-Fog Surgical Mask uses a strip of hydrogel to form a moisture barrier across the bridge of the nose. This provides strong adhesion that prevents air from escaping, helping to reduce fogging. Compared with conventional antifog masks that use other adhesives, hydrogel has an absorptive capacity that better manages sweat and exhaled moisture. This helps maintain the adhesion in a high-moisture environment and balances with the skin’s moisture content, so the skin doesn’t macerate or prune up.

ICT: What practical steps can infection prevention and perioperative leaders take to reduce mask-related issues and improve consistency during procedures?

DWS: Skin irritation can stem from long-term mask wearing. A 2021 study found that 65% of health care workers reported mask-related skin issues, such as itching, rashes, or acne, after wearing masks for extended periods.1 Also, a 2021 research review published in the Journal of the American Academy of Dermatology found that occupational skin problems caused by personal protective equipment are an emerging health challenge that should be addressed to ease the burden on health care workers.2

Perioperative leaders should remind team members to change masks when they are soiled or moist. They should also be changing disposable masks periodically throughout the day. Mask providers offer a variety of disposable masks to accommodate skin sensitivities and provider preferences.

Education is also key for both leaders and frontline clinicians. While most health care professionals understand the importance of masking, there are often gaps in knowledge about mask features and levels of protection, including ASTM F2100 mask classifications. These are designed to indicate the amount of fluid resistance and barrier protection a mask provides in different clinical environments.

1. Level 1 masks provide low fluid resistance and are typically appropriate for low-risk environments or short procedures with minimal exposure to blood or bodily fluids. Examples include routine patient exams, general patient care (such as standard isolation settings), and patient visitation.
2. Level 2 masks offer moderate fluid resistance and may be appropriate for general surgical procedures, endoscopy, labor and delivery, or situations where moderate fluid exposure is anticipated.
3. Level 3 masks provide the highest level of fluid resistance among surgical masks, as defined by ASTM F2100-23, and are designed for procedures where higher fluid resistance may be desired per facility protocol and clinical judgment. Examples include orthopedic surgery, trauma procedures, cardiovascular surgery, cesarean sections, and certain ENT or oral/maxillofacial procedures where blood and fluid exposure can be significant.

Understanding these distinctions is important because selecting the appropriate mask is not only about comfort, but also about matching protection levels to procedural risk. Clinicians should also recognize that higher fluid resistance, mask fit, breathability, and antifog performance may influence clinician comfort, visibility, and mask wear experience. This knowledge can better equip clinicians to evaluate and consistently use the most appropriate option for their environment.

ICT: As masking remains a baseline infection control practice, what lessons should health care organizations carry forward to improve long-term clinician buy-in and adherence?

DWS: Clinicians generally understand why masking matters; what determines adherence over time is whether a mask can be realistically worn long-term in fast-paced, high-pressure environments without adding more challenges to patient care.

The compliant use of PPE in health care should be viewed through a human lens and not just as a policy requirement. When clinicians experience discomfort or other issues with their mask, it can be hard to maintain perfect adherence, especially during long or complex procedures. Organizations that acknowledge these issues and address them proactively send a message to their staff that their experiences matter.

Another important takeaway is to involve clinicians in decisions. Clinician engagement in product evaluation may support acceptance and adherence. They also have hands-on experience and a unique understanding of what works in the operating room. This frontline feedback helps leadership understand which mask features support safe behavior over hours of wear, rather than relying on an overly standardized mask portfolio and protocol for all individuals and settings.

Finally, organizations should recognize that sustained adherence can be supported by reducing barriers to mask use. Investing in masks designed for clinician comfort, monitoring for skin irritation, allowing appropriate mask changes when saturation occurs, and routinely reassessing products as clinical demands evolve all contribute to trust and acceptance.

Note: Dana Weaver Storm is a paid employee of Cardinal Health.

References

1. Valk B, Ivanov NN, Nahhas A, et al. Mask-related skin changes among healthcare workers in a community-based hospital. J Osteopath Med. 2022;122(12):609-615. doi:10.1515/jom-2022-0097
2. Keng BMH, Gan WH, Tam YC, Oh CC. Personal protective equipment-related occupational dermatoses during COVID-19 among health care workers: a worldwide systematic review. JAAD Int. 2021;5:85-95. doi:10.1016/j.jdin.2021.08.004

For more information

• Periop Today. AORN guidelines for surgical attire in the operating room. Association of periOperative Registered Nurses. Published January 30, 2025. Accessed September 21, 2026. https://www.aorn.org/article/surgical-attire-in-the-operating-room--an-aorn-guideline
• AORN Staff. Sterile technique in the operating room. Association of periOperative Registered Nurses. Published March 20, 2025. Accessed September 21, 2026. https://www.aorn.org/article/aorn-guideline-in-focus--sterile-technique-in-the-or
• Sprinkle T. Standards for medical face masks and protective clothing. ASTM International. Published March 24, 2020. Accessed September 21, 2026. https://www.astm.org/news/standards-medical-face-masks-and-protective-clothing