Prolonged antibiotic prophylaxis in tissue reconstruction using autologous fat grafting: Is there a benefit for wound healing?

The Learning Curve of Total Breast Reconstruction With Autologous Fat Transfer

INTRODUCTION

Total breast reconstruction with autologous fat transfer (AFT) is a relatively new breast reconstruction method. Although AFT was predominantly used to correct postsurgical defects, the surgical skills of a total breast reconstruction with AFT are different and can be facilitated for novices to accelerate their learning process. This study aims to assess the learning curve of plastic surgeons in total breast reconstruction with AFT in the Netherlands.

METHODS

A mixed-methods study was performed based on the multicenter randomized clinical BREAST trial data. For the qualitative analysis, semistructured interviews were conducted. To test hypotheses derived from the qualitative data, retrospective data analysis was performed using multilevel linear regression analysis of the patients undergoing AFT as a total breast reconstruction method.

RESULTS

The interviews revealed that plastic surgeons need to perform the procedure several times to learn and experience the technical details of total breast reconstruction with AFT. Learning and improving this technique works best by scrubbing in with an expert. Before plastic surgeons learn the optimal volume of fat reinjection over time, they tend to inject too little fat and subsequently too much fat over multiple procedures. With more experience, the rigottomy technique becomes more important. Besides technical details, managing patient expectations before starting treatment is paramount. Multilevel linear regression revealed a significant decrease ( P < 0.001) in the number of surgical procedures and the total injected volume ( P = 0.002) to complete a total breast reconstruction with AFT.

CONCLUSIONS

This is the first study that explores the learning curve involved in using AFT as a total breast reconstruction method. The feeling of when fat transfer is sufficient, and how to release scars for a good result without causing seromas, is best learned by scrubbing in with experienced colleagues during several procedures, interchanged with starting one's own practice.

The efficacy of prolonged antibiotic prophylaxis in total breast reconstruction with Autologous Fat Transfer (AFT): A retrospective cohort study

BACKGROUND

Autologous fat transfer (AFT) is increasingly adopted as another total breast reconstruction option. The aim of this study was to investigate the efficacy of prolonged antibiotic treatment on the onset of surgical site infections (SSIs) in patients treated with AFT for total breast reconstruction.

METHODS

This retrospective cohort study was conducted on patients who received AFT for total breast reconstruction, with antibiotic prophylaxis during their (multiple) AFT procedure(s) from 9 December 2020 to 10 October 2023. Patients were divided into 2 groups according to their prophylactic antibiotic regimen. The primary outcome was analyzed, including the cumulative incidence, the relative risk (RR), the absolute risk reduction (ARR), and the number needed to treat (NNT). For the secondary outcome, a multilevel logistic regression analysis was performed.

RESULTS

Seven hundred sixty-five surgeries in 205 patients were analyzed. Six hundred twenty-four surgeries on 168 patients had perioperative antibiotic prophylaxis in combination with postoperative antibiotic prophylaxis administered (group 1). One hundred forty-one surgeries on 37 patients had only perioperative antibiotic prophylaxis administered (group 2). The RR was 0.68 (95% confidence interval [CI]; 0.14-3.31) of a SSI when receiving peri- and postoperative antibiotic prophylaxis in comparison with treatment with only perioperative prophylaxis. The ARR was 0.46% (95% CI; -1.40 to 2.32) with a NNT of 219 patients.

CONCLUSION

Prolonged antibiotic prophylaxis is ineffective for patients who receive total breast reconstruction with AFT. This study showed no statistically significant difference in SSIs of the reconstructed breast after receiving prolonged antibiotic treatment in comparison with single-shot perioperative antibiotic prophylaxis.

Contemporary Prophylactic Antibiotic Practices and Adjunct Therapies in Autologous Fat Grafting Procedures: A Survey of The Aesthetic Society Members

Background

Autologous fat grafting (AFG) is a widely used surgical technique that involves extracting a patient's own adipose tissue and transferring it to different areas of the body. This practice is still evolving. Guidelines for antibiotic prophylaxis and use of adjuncts in plastic surgery are currently limited, with a notable absence of standardized guidelines for AFG.

Objectives

In this survey, we assess contemporary antibiotic practices and adjuncts in AFG procedures.

Methods

A 52-question survey was emailed to 3106 active members of The Aesthetic Society. Two hundred and ninety-three responses were recorded, representing a 9% response rate.

Results

We analyzed 288 responses. The most common AFG procedures were facial (38%), gluteal (34%), and breast (27%) augmentation. Preoperative antibiotics were used by 84.0% overall, with rates of 74.3%, 88.0%, and 92.7% in face, breast, and gluteal AFG, respectively. Lipoaspirate-antibiotic mixing was reported by 19.8%, mainly during gluteal AFG (46.9%), and less so in face (2.8%) and breast (8%) AFG. Notably, 46.9% of surgeons administered prolonged prophylaxis for 72 h or more. Tranexamic acid was utilized by 39.9% of the surveyed surgeons. Platelet-rich plasma was used by 5.6%. Doppler ultrasound was incorporated by 16.7% in AFG, with 21.5% in gluteal AFG, 14% in the face, and 19% in breast procedures.

Conclusions

In this survey, we offer insights into antibiotic practices and adjunct therapies in AFG, especially intraoperative antibiotic mixing. Practices among members of The Aesthetic Society vary from guidelines. It is crucial to standardize practices and conduct further research to pave the way for evidence-based guidelines in AFG.

Level of Evidence 5

Antibiotic prophylaxis in clean and clean-contaminated plastic surgery: A critical review

Antibiotic prophylaxis is frequently used in plastic surgery procedures, despite the generally low rates of infection and few guidelines on the practice. The increasing prevalence of bacterial resistance to antibiotics calls for a reduction in unnecessary antibiotic use. The aim of this review was to create an updated summary of the available data on the effectiveness of antibiotic prophylaxis in reducing the postoperative infection in clean and clean-contaminated plastic surgery. A systematic literature search was performed on the databases Medline, Web of Science, and Scopus, limited to articles published January 2000 onward. Randomized controlled trials (RCTs) were included in the primary review, whereas older RCTs and other studies were sought if 2 or fewer relevant RCTs were identified. Overall, 28 relevant RCTs, 2 nonrandomized trials, and 15 cohort studies were identified. Although the number of studies for each type of surgery is limited, the data suggest that prophylactic systemic antibiotic may be unnecessary in noncontaminated facial plastic surgery, reduction mammaplasty, and breast augmentation. In addition, no benefit is apparent from extending the antibiotic prophylaxis over 24 h in rhinoplasty, aerodigestive tract reconstruction, and breast reconstruction. No studies assessing the necessity of antibiotic prophylaxis in abdominoplasty, lipotransfer, soft tissue tumor surgery, or gender affirmation surgery were identified. In conclusion, limited data are available on the effectiveness of antibiotic prophylaxis in clean and clean-contaminated plastic surgery. More studies on this topic are needed before strong recommendations can be made on the use of antibiotics in this setting.

Bilateral breast infection following total breast reconstruction with autologous fat transfer (AFT): A case report

INTRODUCTION AND IMPORTANCE

Total breast reconstruction with autologous fat transfer (AFT) has a low complication rate. Fat necrosis, infection, skin necrosis and hematoma are the most common complications. Infections are usually mild and manifested by a unilateral red painful breast and treated with oral antibiotics with or without superficial irrigation of the wound.

CASE PRESENTATION

One of our patients reported an ill-fitting pre-expansion device several days after surgery. This was due to a severe bilateral breast infection following a session of total breast reconstruction with AFT despite perioperative and postoperative antibiotic prophylaxis. Surgical evacuation was performed in combination with both systemic and oral antibiotic treatment.

CLINICAL DISCUSSION

Most infections can be prevented in the early post-operative period with antibiotic prophylaxis. If an infection does occur, it is treated with antibiotics or superficial irrigation of the wound. A delay in identification of an alarming course could be reduced by monitoring the fit to the EVEBRA device, implementing video consultations on indication, limiting the means of communication and better informing the patient on what complications to monitor. The recognition of an alarming course following a subsequent session of AFT is not guaranteed after a session without complication.

CONCLUSION

Besides temperature and redness of the breast, a pre-expansion device that doesn't fit can be an alarming sign. Patient communication should be adapted as severe infections can be insufficiently recognized by phone. Evacuation should be considered when an infection does occur.

Postoperative Antibiotics Confer No Protective Association After Fat Grafting for Breast Reconstruction

INTRODUCTION

Autologous fat grafting after breast reconstruction is a commonly used technique to address asymmetry and irregularities in breast contour. While many studies have attempted to optimize patient outcomes after fat grafting, a key postoperative protocol that lacks consensus is the optimal use of perioperative and postoperative antibiotics. Reports suggest that complication rates for fat grafting are low relative to rates after reconstruction and have been shown to not be correlated to antibiotic protocol. Studies have additionally demonstrated that the use of prolonged prophylactic antibiotics do not lower the complication rates, stressing the need for a more conservative, standardized antibiotic protocol. This study aims to identify the optimal use of perioperative and postoperative antibiotics that optimizes patient outcomes.

METHODS

Patients in the Optum Clinformatics Data Mart who underwent all billable forms of breast reconstruction followed by fat grafting were identified via Current Procedural Terminology codes. Patients meeting inclusion criteria had an index reconstructive procedure at least 90 days before fat grafting. Data concerning these patient's demographics, comorbidities, breast reconstructions, perioperative and postoperative antibiotics, and outcomes were collected via querying relevant reports of Current Procedural Terminology; International Classification of Diseases, Ninth Revision; International Classification of Diseases, Tenth Revision; National Drug Code Directory, and Healthcare Common Procedure Coding System codes. Antibiotics were classified by type and temporal delivery: perioperatively or postoperatively. If a patient received postoperative antibiotics, the duration of antibiotic exposure was recorded. Outcomes analysis was limited to the 90-day postoperative period. Multivariable logistic regression was performed to ascertain the effects of age, coexisting conditions, reconstruction type (autologous or implant-based), perioperative antibiotic class, postoperative antibiotic class, and postoperative antibiotic duration on the likelihood of any common postoperative complication occurring. All statistical assumptions made by logistic regression were met successfully. Odds ratios and corresponding 95% confidence intervals were calculated.

RESULTS

From more than 86 million longitudinal patient records between March 2004 and June 2019, our study population included 7456 unique records of reconstruction-fat grafting pairs, with 4661 of those pairs receiving some form of prophylactic antibiotics. Age, prior radiation, and perioperative antibiotic administration were consistent independent predictors of increased all-cause complication likelihood. However, administration of perioperative antibiotics approached a statistically significant protective association against infection likelihood. No postoperative antibiotics of any duration or class conferred a protective association against infections or all-cause complications.

CONCLUSIONS

This study provides national, claims-level support for antibiotic stewardship during and after fat grafting procedures. Postoperative antibiotics did not confer a protective benefit association against infection or all-cause complication likelihood, while administering perioperative antibiotics conferred a statistically significant increase in the likelihood that a patient experienced postoperative complication. However, perioperative antibiotics approach a significant protective association against postoperative infection likelihood, in line with current guidelines for infection prevention. These findings may encourage the adoption of more conservative postoperative prescription practices for clinicians who perform breast reconstruction, followed by fat grafting, reducing the nonindicated use of antibiotics.