Evaluating the role of postoperative prophylactic antibiotics in primary and secondary breast augmentation: a retrospective review

Efficacy of antibiotic prophylaxis for reducing capsular contracture in prosthesis-based breast surgery: a systemic review and meta-analysis

Antibiotics Prophylaxis to prevent capsular contracture in prosthesis-based breast surgery is common in clinical practice. However, there is currently a dearth of high-quality evidence concerning the effectiveness of antibiotic usage in this field. To identify all pertinent studies prior to January 2023, a comprehensive literature search was conducted in the PubMed, Embase, Web of Science, Cochrane Library, and Medline databases. The extracted data was then subjected to meta-analysis. Fourteen studies were retained in the analysis. According to the results, perioperative antibiotic prophylaxis did not reduce the risk of capsular contracture (RR 1.15, 95% CI 0.82-1.59, p = 0.55) or surgical-site infection (RD 0.01, 95% CI - 0.01 to 0.03, p = 0.59) compared to nonantibiotic prophylaxis. There was no statistically significant difference between extended antibiotic prophylaxis and perioperative antibiotic prophylaxis in terms of preventing capsular contracture, whether calculated by patient numbers (RD 0.01, 95% CI - 0.01 to 0.02, p = 0.87) or by total procedures (RD 0.00, 95% CI - 0.00 to 0.01, p = 0.88), or controlling surgical-site infection (RR 1.05, 95% CI 0.77-1.44, p = 0.27). Additionally, topical antibiotic irrigation did not decrease the risk of infection (RR 0.61, 95% CI 0.34-1.08, p = 0.29) and capsular contracture, regardless of patient number (RR 0.41, 95% CI 0.27-0.63, p = 0.18) or total number of procedures (RR 1.29, 95% CI 0.73-2.28, p < 0.01). Current evidence revealed that both systemic and topical antibiotic prophylaxis may not provide benefits in preventing capsular contracture in prosthesis-based breast surgery. When the occurrence of surgical-site infections is minimized to the greatest extent, the administration of additional antibiotics for reducing capsular contracture should be carefully and judiciously considered.

Evaluating Access and Outcomes in Gender-affirming Breast Augmentation: A Comparative Study of a County Hospital and an Academic Center

Background

Research on the diverse patient population undergoing gender-affirming breast augmentation remains scarce. We compared patients undergoing this procedure at San Francisco General Hospital (ZSFG), a county hospital, and the University of California, San Francisco (UCSF), an academic medical center.

Methods

This was a retrospective cohort study of patients who underwent primary gender-affirming breast augmentation at ZSFG (August 2019 to June 2023) and UCSF (March 2015 to June 2023). Differences in sociodemographic characteristics, surgical access, and outcomes between sites were assessed.

Results

Of 195 patients, 122 patients had surgery at UCSF and 73 patients at ZSFG. ZSFG patients were more likely to be unstably housed (P < 0.001), Spanish-speaking (P = 0.001), and to have obesity (P = 0.011) and HIV (P = 0.004). Patients at ZSFG took hormones for longer before surgical consultation (P < 0.001) but had shorter referral-to-surgery intervals (P = 0.024). Patients at ZSFG more frequently underwent a subglandular approach (P = 0.003) with longer operative times (P < 0.001). Major surgical complications were uncommon (2.1%) with no differences between sites. Aesthetically, implant malposition/rotation occurred more often in patients at UCSF (P = 0.031), but revision rates were similar at both sites. Patients at UCSF had longer follow-up periods (P = 0.008).

Conclusions

County hospital patients seeking gender-affirming breast augmentation have distinct sociodemographic profiles and more comorbidities than academic medical center patients. County patients might experience greater barriers that delay surgical eligibility, such as stable housing. Nevertheless, this procedure can be safely and effectively performed in both patient populations.

Impact of post-operative infection on revision procedures in breast reconstruction: A marketscan database analysis

BACKGROUND

Esthetic complications, such as capsular contracture and soft-tissue contour defects, hinder the desired outcomes of breast reconstruction. As subclinical infection is a prevailing theory behind capsular contracture, we investigated the effects of post-operative infections on these issues and revision procedures.

METHODS

We conducted a retrospective database study (2007-2021) on breast reconstruction patients from the MarketScan® Databases. Esthetic complications were defined by their associated revision procedures and queried via CPT codes. Severe capsular contracture (Grade 3-4) was defined as requiring capsulotomy or capsulectomy with implant removal or replacement. Moderate and severe soft-tissue defects were determined by the need for fat grafting or breast revision, respectively. Generalized linear models were used, adjusting for comorbidities and surgical factors (p < 0.05).

RESULTS

We analyzed the data on 62,510 eligible patients. Post-operative infections increased the odds of capsulotomy (OR 1.59, p < 0.001) and capsulectomy (OR 2.30, p < 0.001). They also raised the odds of breast revision for severe soft-tissue defects (OR 1.21, p < 0.001). There was no significant association between infections and fat grafting for moderate defects. Patients who had post-operative infections were also more likely to experience another infection after fat grafting (OR 3.39, p = 0.0018). In two-stage reconstruction, infection after tissue expander placement was associated with greater odds of infection after implant placement.

CONCLUSION

Post-operative infections increase the likelihood of developing severe soft-tissue defects and capsular contracture requiring surgical revision. Our data reinforce the role of infections in the pathophysiology of capsular contracture. Additionally, infections elevate the risk of subsequent infections after fat grafting for moderate defects, further increasing patient morbidity.

Reducing Peri-implant Capsule Thickness in Submuscular Rodent Model of Breast Reconstruction With Delayed Radiotherapy

INTRODUCTION

Capsular contracture remains the most common complication following device-based breast reconstruction, occurring in up to 50% of women who also undergo adjuvant radiotherapy either before or after device-based reconstruction. While certain risk factors for capsular contracture have been identified, there remains no clinically effective method of prevention. The purpose of the present study is to determine the effect of coating the implant with the novel small molecule Met-Z2-Y12, with and without delayed, targeted radiotherapy, on capsule thickness and morphologic change around smooth silicone implants placed under the latissimus dorsi in a rodent model.

METHODS

Twenty-four female Sprague Dawley rats each had 2 mL smooth round silicone breast implants implanted bilaterally under the latissimus dorsi muscle. Twelve received uncoated implants and twelve received implants coated with Met-Z2-Y12. Half of the animals from each group received targeted radiotherapy (20 Gray) on postoperative day ten. At three and 6 months after implantation, the tissue surrounding the implants was harvested for analysis of capsular histology including capsule thickness. Additionally, microCT scans were qualitatively analyzed for morphologic change.

RESULTS

Capsules surrounding Met-Z2-Y12-coated implants were significantly thinner (P = 0.006). The greatest difference in capsule thickness was seen in the irradiated 6-month groups, where mean capsule thickness was 79.1 ± 27.3 μm for uncoated versus 50.9 ± 9.6 μm for Met-Z2-Y12-coated implants (P = 0.038). At the time of explant, there were no capsular morphologic differences between the groups either grossly or per microCT.

CONCLUSIONS

Met-Z2-Y12 coating of smooth silicone breast implants significantly reduces capsule thickness in a rodent model of submuscular breast reconstruction with delayed radiotherapy.

The Role of Antibiotic Prophylaxis in Primary and Secondary Implant-Based Breast Augmentation: A Systematic Review and Meta-Analysis

BACKGROUND

The administration of antibiotic prophylaxis for implant-based breast augmentation (IBBA) is commonplace among many plastic surgeons. However, the current literature lacks evidence-based recommendations to support this practice. Although few studies have demonstrated a reduction in surgical site infection (SSI) and capsular contracture (CC) with antibiotics, these studies were underpowered and poorly designed. The aim of this study was to provide an updated comprehensive analysis of the literature to revisit the benefit of antibiotic prophylaxis.

METHODS

A comprehensive literature search of PubMed, Embase, Web of Science, and Cochrane was performed from January 1989 to January 2022. Observational studies and randomized controlled trials (RCTs) involving primary and secondary IBBA and use of antibiotic prophylaxis were included. Primary outcomes included SSI and CC. Study quality and risk of bias were evaluated using standardized tools. A meta-analysis was performed for eligible studies. Trial Sequential Analysis was used to assess the need for future RCTs.

RESULTS

A total of 5 studies (3 observational and 2 RCTs) with 2383 patients were included in this study. Rates of SSI ranged from 0% to 2.3%, whereas CC ranged from 0% to 53%. Antibiotic prophylaxis showed no benefit for both SSI (odds ratio, 1.77; 95% confidence interval, 0.76-4.13) and CC (odds ratio, 0.46; 95% confidence interval, 0.00-45.72). Trial Sequential Analysis demonstrated that further high-quality RCTs are needed.

CONCLUSIONS

Antibiotic prophylaxis for IBBA failed to demonstrate improvements in SSI and CC in this comprehensive review. Current evidence was shown to be of low quality because of heterogeneity and high risk for bias. Further high-quality multicentered RCTs are warranted to fully evaluate the role of antibiotic prophylaxis for IBBA.

Does the Duration of Perioperative Antibiotic Prophylaxis Influence the Incidence of Postoperative Surgical-Site Infections in Implant-Based Breast Reconstruction in Women with Breast Cancer? A Retrospective Study

BACKGROUND

Perioperative antibiotic prophylaxis is an established concept to reduce the risk of surgical-site infections; however, the optimal treatment duration in prosthetic breast reconstruction is still controversial. This study evaluated a potential association between the perioperative antibiotic prophylaxis duration (≤24 hours versus >24 hours) and incidence of postoperative surgical-site infections in immediate implant-based breast reconstruction in breast cancer patients.

METHODS

A descriptive, retrospective analysis of surgical-site infections after immediate implant-based breast reconstruction in breast cancer patients between January of 2011 and December of 2018 was performed. The incidence of postoperative surgical-site infections in patients with more than 24 hours of perioperative antibiotic prophylaxis was compared to patients treated for 24 hours or less.

RESULTS

A total of 240 patients who met criteria were included. There were no relevant epidemiologic, clinical, or histopathologic differences between groups. Surgical-site infections as defined by the Centers for Disease Control and Prevention criteria occurred in 25.8 percent. A risk factor-adjusted analysis by a prespecified multiple logistic regression model showed that 24 hours or less of perioperative antibiotic prophylaxis was not inferior to treatment for more than 24 hours. The upper limit of the one-sided 95 percent confidence interval of the risk difference was 9.4 percent (below the prespecified noninferiority margin of 10 percent leading to statistical significance). Risk factors for a surgical-site infection included obesity and postoperative wound complications.

CONCLUSIONS

The study found no association between short-course perioperative antibiotic prophylaxis (≤24 hours) and an increased rate of postoperative surgical-site infection. This is of high clinical relevance because short-course treatment can help reduce side effects and the emergence of antimicrobial resistance and prevent surgical-site infections as effectively as a prolonged perioperative antibiotic prophylaxis course.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Current Concepts in Capsular Contracture: Pathophysiology, Prevention, and Management

Over 400,000 women in the United States alone will have breast implant surgery each year. Although capsular contracture represents the most common complication of breast implant surgery, surgeons continue to debate the precise etiology. General agreement exists concerning the inflammatory origin of capsular fibrosis, but the inciting events triggering the inflammatory cascade appear to be multifactorial, making it difficult to predict why one patient may develop capsular contracture while another will not. Accordingly, researchers have explored many different surgical, biomaterial, and medical therapies to address these multiple factors in an attempt to prevent and treat capsular contracture. In the current paper, we aim to inform the reader on the most up-to-date understanding of the pathophysiology, prevention, and treatment of capsular contracture.

Capsular Contracture in Breast Implant Surgery: Where Are We Now and Where Are We Going?

Capsular contracture is the leading complication after surgery with breast implants. A lot of progress has been made investigating this complication over the years, and knowledge has been gained on this complication. Currently, the exact cause for capsular contracture is still unclear. It has been hypothesized that immunobiological factors (i.e., immunological and bacterial factors) and several risk factors play a central role in its development. In this paper, we give an overview of the known immunological factors that have been investigated in contracted and non-contracted capsules, as well as the role of bacterial formation around breast implants. We also report on risk factors that might increase the risk of capsular development. Lastly, it provides the latest research on this matter and discusses future perspectives as follow-up research is needed to unravel the pathogenic process leading to capsular contracture. This knowledge is of interest to establish medical therapies in order to prevent such side effects. Overall, capsular contracture seems to be a multifactorial condition consisting of several risk factors. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Preliminary Outcomes of Hypochlorous Acid as an Adjunct for Pocket Irrigation in Revision Aesthetic Breast Surgery

BACKGROUND

Capsular contracture is a challenging problem for plastic surgeons despite advances in surgical technique. Breast pocket irrigation decreases bacterial bioburden. Studies have shown that hypochlorous acid (HOCl; PhaseOne Health, Nashville, TN) effectively penetrates and disrupts biofilms; however, there are limited clinical data regarding this irrigation in breast augmentation.

OBJECTIVES

The aim of this study was to investigate the effects of HOCl pocket irrigation in revision breast augmentation by evaluating rates of capsular contracture recurrence, infection, and allergic reactions.

METHODS

We performed an institutional review board-approved retrospective chart review of revision breast augmentation cases for Baker grade III/IV capsular contractures in which pockets were irrigated with HOCl. Data were obtained from 3 board-certified plastic surgeons.

RESULTS

The study included 135 breasts in 71 patients, who ranged in age from 27 to 77 years (mean, 53.7 years). Follow-up ranged from 12 to 41 months (mean, 20.2 months). Postoperatively, there were 2 unilateral Baker grade III/IV recurrences at 13 months and 1 bilateral Baker grade II recurrence at 3 months. There were no infections or allergic reactions. The overall Baker grade III/IV capsular contracture recurrence rate was 0% at 12 months and 1.5% at 15 months.

CONCLUSIONS

Breast pocket irrigation decreases bioburden, which may influence capsular contracture recurrence. We evaluated 3 varied applications of HOCl in revision aesthetic breast surgery and found a low capsular contracture recurrence rate and no adverse reactions. We plan to report our findings with HOCl in primary breast augmentation in the future, and other studies are being conducted on the efficacy of HOCl in aesthetic surgery.

LEVEL OF EVIDENCE: 4

Antibiotic Prophylaxis in Plastic Surgery Correlation Between Practice and Evidence

Background:

The use of appropriate preoperative antibiotic prophylaxis decreases the risk of surgical site infections (SSI); however, the breadth of plastic surgery procedures makes it challenging to ensure appropriate use for each unique procedure type. Currently, plastic surgeons lack a cohesive and comprehensive set of evidence-based guidelines (EBG) for surgical prophylaxis. We sought to profile the perioperative antibiotic prescribing patterns for plastic surgeons in British Columbia to investigate if they are congruent with published recommendations. In doing so, we aim to determine risk factors for antibiotic overprescribing in the context of surgical prophylaxis.

Methods:

A literature review identifying EBG for antibiotic prophylaxis use during common plastic surgery procedures was performed. Concurrently, a provincial survey of plastic surgery residents, fellows, academic and community plastic surgeons was used to identify their antibiotic prophylaxis prescribing practices. These findings were then compared to recommendations identified from our review. The compliance of the provincial plastic surgery community with current EBG was determined for 38 surgical scenarios to identify which clinical factors and procedure types were associated with unsupported antibiotic use.

Results:

Within the literature, 31 of the 38 categories of surveyed plastic surgery operations have EBG for use of prophylactic antibiotics. When surgical procedures have EBG, 19.5% of plastic surgery trainees and 21.9% of practicing plastic surgeons followed recommended prophylaxis use. Average adherence to EBG was 59.1% for hand procedures, 24.1% for breast procedures, and 23.9% for craniofacial procedures. Breast reconstruction procedures and contaminated craniofacial procedures were associated with a significant reduction in adherence to EBG resulting in excessive antibiotic use.

Conclusion:

Even when evidence-based recommendations for antibiotic prophylaxis exist, plastic surgeons demonstrate variable compliance based on their reported prescribing practices. Surgical procedures with low EBG compliance may reflect risk avoidant behaviors in practicing surgeons and highlight the importance of improving education on the benefits of antibiotic prophylaxis in these clinical situations.

Plastic Surgery Complications: A Review for Emergency Clinicians

The number of aesthetic surgical procedures performed in the United States is increasing rapidly. Over 1.5 million surgical procedures and over three million nonsurgical procedures were performed in 2015 alone. Of these, the most common procedures included surgeries of the breast and abdominal wall, specifically implants, liposuction, and subcutaneous injections. Emergency clinicians may be tasked with the management of postoperative complications of cosmetic surgeries including postoperative infections, thromboembolic events, skin necrosis, hemorrhage, pulmonary edema, fat embolism syndrome, bowel cavity perforation, intra-abdominal injury, local seroma formation, and local anesthetic systemic toxicity. This review provides several guiding principles for management of acute complications. Understanding these complications and approach to their management is essential to optimizing patient care.

PCR Characterization of Microbiota on Contracted and Non-Contracted Breast Capsules

BACKGROUND

The aetiology of capsular contracture around breast implants remains unclear. The leading theory is that a subclinical infection around the implant plays a role in the development of capsular contractions. Several studies found associations between the presence of bacteria and the occurrence of capsular contraction. However, it is unclear whether detected bacteria originate from the breast capsule, breast glandular tissue or skin contamination. Moreover, this has never been investigated with molecular techniques. The aim of this study was to assess the bacterial microbiota on breast capsules, glandular tissue and skin using a highly sensitive PCR assay.

MATERIALS AND METHODS

Fifty breast capsules were collected during implant removal or replacement. Ten specimens of glandular breast tissue and breast skin were collected in females who were undergoing reduction mammoplasty. A sample specimen (4 mm) was sterilely obtained from all tissues. All specimens were analysed by IS-pro, a 16S-23S interspace region-based PCR assay.

RESULTS

Low numbers of Staphylococcus spp. (four species in four capsules) were found on breast capsules. There was no difference in bacterial presence between normal and contracted capsules. The skin of the breast-harboured Streptococcus spp. and Staphylococcus spp. while the glandular tissue was sterile.

CONCLUSION

The low numbers of bacteria found on the capsules are most likely caused by contamination during capsule removal. More and larger studies are needed to investigate the bacterial presence on breast capsules using a PCR assay. This is the first study in which breast capsules have been studied using a highly sensitive PCR assay.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Modern Primary Breast Augmentation: Best Recommendations for Best Results

LEARNING OBJECTIVES

After reading this article, the participant should be able to: 1. Develop a practical method for preoperative implant size selection. 2. List characteristics and examples of fourth- and fifth-generation silicone implants. 3. Recognize the differences in "profile" designations across implant manufacturers. 4. Recall updated statistics on breast implant-associated anaplastic large cell lymphoma and describe current guidelines on disease diagnosis and treatment. 5. Apply atraumatic and aseptic surgical techniques in primary breast augmentation.

SUMMARY

Modern primary breast augmentation requires an intimate knowledge of the expanding breast implant market, including characteristics of current generation silicone implants and "profile" types. Optimal implant size selection requires balancing patient desires with tissue qualities. Evidence and awareness of breast implant-associated anaplastic large cell lymphoma continue to grow, and patients and surgeons alike should be informed on the most updated facts of the disease entity. Atraumatic surgical technique and aseptic adjuncts are critical in reducing periprosthetic inflammation and contamination, both of which are known instigators of capsular contracture and potentially breast implant-associated anaplastic large cell lymphoma.

Periprosthetic Capsule Formation and Contracture in a Rodent Model of Implant-Based Breast Reconstruction With Delayed Radiotherapy

INTRODUCTION

Capsular contracture (CC) is the most common complication of breast implantation, with an incidence of nearly 50% in patients undergoing breast reconstruction with subsequent radiotherapy. Although the move toward submuscular (SM) device placement led to a decreased incidence of CC, subcutaneous (SQ) implantation has seen a resurgence. The purpose of this study was to use a rodent model of breast reconstruction with smooth silicone implants and delayed radiotherapy to assess the occurrence of CC in SQ versus SM implantation.

METHODS

Custom 2 mL smooth round silicone implants were placed bilaterally into 12 female Sprague Dawley rats that were randomized into 4 groups of 3, with each group differing by implantation plane (SQ vs SM) and irradiation status (irradiated vs nonirradiated). Rats from the SQ group received implants bilaterally underlying the skin on the flank. Rats in the SM groups received implants bilaterally under the latissimus dorsi muscle. Irradiated rats received 20 Gy localized to each implant on postoperative day 10. One rat from each group was imaged with a micro-computed tomography scanner at baseline and at explant 3 months later, whereupon capsules from all rats were examined histologically.

RESULTS

Rats in the SQ group showed evidence of contracture on gross examination and greater evidence of morphologic disruption per micro-computed tomography scan. There was no evidence of contracture or morphologic disruption in either SM group. Mean ± SD capsule thickness was 39.0 ± 9.0 μm in the SQ versus 37.6 ± 9.8 μm in the SM nonirradiated groups and 43.9 ± 14.9 μm in the SQ versus 34.3 ± 8.3 μm in the SM irradiated groups (all P > 0.05).

CONCLUSIONS

In a rodent model of smooth silicone breast implantation and delayed radiotherapy, although there did not appear to be differences in capsule thickness regardless of device placement plane, SQ implants demonstrated gross evidence of CC. These data indicate that capsule thickness is only part of a larger pathogenetic picture, which should take into consideration the contribution from all peri-implant tissue.

Risk factors for developing capsular contracture in women after breast implant surgery: A systematic review of the literature

BACKGROUND

Capsular contracture is the most frequent complication in breast augmentation or reconstruction with breast implants. The exact mechanism for this complication is not completely understood. Yet, it is most likely to be a multifactorial condition. Several patient-, surgery-, and implant-specific risk factors have been related to cause capsular contracture. This review aims to provide a clear overview of all risk factors for capsular contracture.

METHODS

A systematic literature review was performed focusing on patient-, surgery-, and/or implant-related factors related to capsular contracture in breast implants. PubMed, Embase, and Wiley/Cochrane Library databases were searched for relevant articles published from inception up to October 20, 2016. The included studies were assessed for the following main variables: study characteristics, patient characteristics, indication for surgery, type of surgery, implant characteristics, and other characteristics.

RESULTS

Data on the risk factors for the development of capsular contracture were retrieved from 40 studies. A presumptive increased risk in the development of capsular contracture is shown for the following variables: longer duration of follow-up, breast reconstructive surgery in patients with a history of breast cancer, subglandular implant placement, postoperative hematoma, and a textured implant surface. There is little, weak, or no evidence for the association of other factors with capsular contracture. This review also shows a large heterogeneity between studies and within the definition of capsular contracture.

CONCLUSION

This review provides an overview of the relationship between patient-, surgery-, and implant-specific risk factors in the development of capsular contracture.

Low rate of capsular contracture in a series of 214 consecutive primary and revision breast augmentations using microtextured implants

Capsular contracture is the most common major complication after implant-based breast augmentation. The aetiology of capsular contracture is multifactorial. The author reports a retrospective personal series of patients managed over a seven-year period with a nearly unchanged surgical strategy implementing most of known measures for capsular contracture prevention. A microtextured silicone gel-filled implant from a single manufacturer was used in all cases.

There were 214 consecutive patients (126 primary augmentations and 88 revision augmentations) operated on over the study period. Mean age of the population was 40.0 years, and mean BMI was 22.0 kg/m². Of the patients in the revision cohort, 44.3% were reoperated on because of previous capsular contracture.

Average follow-up was 20.2 months. There was a 0% capsular contracture rate in the primary augmentation cohort and a 3.4% capsular contracture rate in the revision cohort. At last follow-up, 91.2% of breasts received a Baker I grading.

Although the follow-up was relatively short, this rate of capsular contracture would still be considered very low. Determining the reason for such a low rate of capsular contracture on Multivariate Analyses would be difficult due to the potential myriad of confounding variables. However, given the constancy of the technique and implant type employed by a single surgeon, the author is of the opinion that the microtexturing topography on the implant surfaceused in this series contributed to the low rate of capsular contracture formation. However, this would need to be tested in arandomized controlled trial comparing microtextured devices with implants that have macrotextured surfaces.

The aetiopathogenesis of capsular contracture: A systematic review of the literature

BACKGROUND

Capsular contracture is the most frequent complication after breast augmentation or reconstruction with breast implants. The immune system plays a prominent role in capsular contracture formation, albeit to an unknown extent. Bacterial contamination in situ has been hypothesized to be causative for capsular contracture. How this relates to the immunological processes involved is unknown. This article aims to provide an overview of immunological and bacterial factors involved in development of capsular contracture.

MATERIALS AND METHODS

We undertook a systematic literature review focused on immunological factors and microbiota in relation to capsular contraction around implants. This systematic review was performed in accordance with the PRISMA guidelines. PubMed, EMBASE, and the Cochrane databases were searched from inception up to October 2016. Included studies were assessed for the following variables: subject characteristics, number of capsules, primary indication for surgery, surgical procedure, follow-up or implant duration, study methods, type of antibiotics or medical therapies and outcomes related to microbiota and immunological factors.

RESULTS

Data on immunological factors and bacterial contamination were retrieved from 64 included studies. Notably the presence of macrophages and Staphylococcus epidermidis within capsules was often associated with capsular contracture.

CONCLUSION

This review provides a clear overview of the immunological factors associated with capsular contracture and provides a hypothetical immunological model for development of the disease. Furthermore, an overview of bacterial contamination and associations with capsular contracture has been provided. Follow-up research may result in clinical recommendations to prevent capsular contracture.

Evidence-Based Medicine: Breast Augmentation

LEARNING OBJECTIVES

After reading this article, the participant should be able to: 1. Understand the key decisions in patient evaluation for cosmetic breast augmentation. 2. Cite key decisions in preoperative planning. 3. Discuss the risks and complications, and key patient education points in breast augmentation.

SUMMARY

Breast augmentation remains one of the most popular procedures in plastic surgery. The integral information necessary for proper patient selection, preoperative assessment, and surgical approaches are discussed. Current data regarding long term safety and complications are presented to guide the plastic surgeon to an evidence-based approach to the patient seeking breast enhancement to obtain optimal results.

What can we learn from sonication results of breast implants?

Background

Different research groups have identified microorganisms on breast implants by sonication with significant correlation to the rate of capsular contracture. This substantiated the hypothesis of an infectious etiology of capsular contracture. However, no clinical consequence has been drawn from these results yet. Aim of this study was to review sonication results from breast implants and to evaluate the current preoperative antibiotic regime for breast-implant surgery.

Methods

We compared breast implant sonication culture results from published reports and our own database. Current perioperative antibiotic recommendations were compared with the susceptibility profile of the found organisms.

Results

We found Coagulase-negative staphylococci and Propionibacteria to be the main group of microorganism found by sonication on explanted breast implants. Most guidelines recommend cephalosporins for preoperative antibiotical prophylaxis for breast-implant surgery.

Conclusion

There is a discrepancy between antibiotic activity of commonly used antibiotics for preoperative prophylaxis of surgical site infections, and microorganisms found by sonication on breast implants, suspected to trigger the formation of capsular contracture. A targeted antibiotic prophylaxis for breast implant surgery with glycopeptides (e.g. Vancomycin) should be considered for the prevention of capsular contracture.

Is antibiotic prophylaxis in breast augmentation necessary? A prospective study

BACKGROUND

The role of prophylactic antibiotics in breast augmentation remains controversial. However, the majority of surgeons are administering antibiotics.

OBJECTIVE

To investigate the effect of antibiotic(s) use in the incidence of infection and capsular contracture following breast augmentation.

METHODS

From September 2004 to November 2010, 180 patients underwent primary bilateral breast augmentation. They were prospectively divided into two equal groups: in group A (n=90), no antibiotics were given and, in group B (n=90), only one intravenous dose of cephalosporin was administered during the induction of general anesthesia. Preoperative data included age, body mass index, smoking status, medical history and implant volume. All operations were performed by the same surgeon using the same surgical technique and implant type. No drains were used. Operative data included operative time and estimated blood loss. Patients were evaluated for complications such as infection, hematoma and capsular contracture. The study concluded when all of the patients underwent the one-year follow-up. The Student's t test was used to analyze the results.

RESULTS

All patients completed the study and both groups had similar demographic data. No differences in operative data were observed. The mean operative time was 35 min and the mean blood loss was found to be minimal. In group A, no implant infections were reported, while a wound infection that occurred was treated successfully with oral antibiotics. In group B, no implant or wound infection was noticed. No capsular contractures or hematomas were observed.

CONCLUSIONS

The number of patients who underwent primary breast augmentation without antibiotics (n=90) was insufficient to draw any definitive conclusions. However, the present prospective study demonstrated that prophylactic use of antibiotics in breast augmentation had no significant effect on infection and capsular contracture rates. Further randomized clinical trials, in combination with guidelines from aesthetic plastic surgery societies, appear to be warranted.

Antibiotic prophylaxis in reduction mammaplasty: study protocol for a randomized controlled trial

Background

The role of antibiotics in surgical procedures where the risk of surgical site infection (SSI) is low remains uncertain. There is, to date, no evidence to justify the routine use of antibiotics in postoperative reduction mammaplasty. The aim of this study is to evaluate the effect of postoperative antibiotic treatment on the occurrence of SSI after breast reduction surgery.

Methods

This is a double-blind randomized clinical trial with 124 breast hypertrophy patients allocated to two treatment groups: antibiotic (n = 62) and placebo (n = 62). All patients will undergo reduction mammoplasty, performed by the same surgical team. The surgeons will raise the nipple-areola complex by the superomedial pedicle technique. The patients will receive antibiotics intravenously during anesthetic induction and every 6 hours thereafter during their 24-hour hospital stay. During discharge from the hospital, each patient will receive a numbered package containing either cephalexin or placebo capsules and will be directed to take one capsule every 6 hours for 7 days. Neither the surgery team nor the patients will know the contents of the capsules. Patients will be monitored for the occurrence of SSI once weekly during the first 30 days following hospital discharge by a single surgeon who is blinded to their treatment group. SSI will be evaluated based on the definition adopted by the Centers for Disease Control and Prevention.

Discussion

Due to the variety of risk factors for SSI and limited case studies, conclusions regarding the effect of antibiotics on the occurrence of SSIs following reduction mammaplasty are potentially biased. In recent studies, perioperative antibiotic prophylaxis was effective in preventing infection and is therefore recommended in clinical practice. However, antibiotic use in the postoperative period still remains controversial.

Trial registration

Clinicaltrials.gov Identifier: NCT02569866. Registered on 4 October 2015.

Open Capsulotomy: An Effective but Overlooked Treatment for Capsular Contracture after Breast Augmentation

Background:

The prevailing theory for capsular contracture after breast augmentation is a subclinical capsular infection. A capsulectomy, site change, and implant replacement are recommended. An open capsulotomy leaves the capsule in the patient. Theoretically, such a procedure would be ineffective because it does not remove the infected tissue. Recurrences occurred frequently in women treated in the 1970s when leaky silicone gel implants were in use. Open capsulotomy has not been studied in women implanted with third-generation devices.

Methods:

Seventy-five consecutive women with Baker III/IV capsular contractures after breast augmentation treated with open capsulotomies between 1996 and 2016 were retrospectively evaluated. The original implants were usually saline-filled (72.2%). Replacements were all smooth and round, and 92.6% were also saline-filled.

Results:

Seventeen women (22.7%) developed a recurrent capsular contracture. Two patients (2.7%) experienced a second recurrence. Patients with ruptured silicone gel implants (n = 13) had a significantly greater risk of recurrence (P = 0.01). There was no significant difference in recurrence rates comparing patients whose intact implants were reinserted (12.5%) with women whose intact implants were replaced (18.2%). Povidone–iodine irrigation did not affect the recurrence rate. Capsular contracture was corrected with 1 procedure in 77.3% of patients and 2 procedures in 97.3% of patients.

Conclusions:

Open capsulotomy is a safe and effective treatment that avoids the additional morbidity and cost of a capsulectomy. The findings challenge the infected biofilm theory of capsular contracture. Open capsulotomy deserves reconsideration by plastic surgeons.

Is antibiotic prophylaxis in breast augmentation necessary? A prospective study

Background

The role of prophylactic antibiotics in breast augmentation remains controversial. However, the majority of surgeons are administering antibiotics.

Objective

To investigate the effect of antibiotic(s) use in the incidence of infection and capsular contracture following breast augmentation.

Methods

From September 2004 to November 2010, 180 patients underwent primary bilateral breast augmentation. They were prospectively divided into two equal groups: in group A (n=90), no antibiotics were given and, in group B (n=90), only one intravenous dose of cephalosporin was administered during the induction of general anesthesia. Preoperative data included age, body mass index, smoking status, medical history and implant volume. All operations were performed by the same surgeon using the same surgical technique and implant type. No drains were used. Operative data included operative time and estimated blood loss. Patients were evaluated for complications such as infection, hematoma and capsular contracture. The study concluded when all of the patients underwent the one-year follow-up. The Student's t test was used to analyze the results.

Results

All patients completed the study and both groups had similar demographic data. No differences in operative data were observed. The mean operative time was 35 min and the mean blood loss was found to be minimal. In group A, no implant infections were reported, while a wound infection that occurred was treated successfully with oral antibiotics. In group B, no implant or wound infection was noticed. No capsular contractures or hematomas were observed.

Conclusions

The number of patients who underwent primary breast augmentation without antibiotics (n=90) was insufficient to draw any definitive conclusions. However, the present prospective study demonstrated that prophylactic use of antibiotics in breast augmentation had no significant effect on infection and capsular contracture rates. Further randomized clinical trials, in combination with guidelines from aesthetic plastic surgery societies, appear to be warranted.

Infection prevention in breast implant surgery - A review of the surgical evidence, guidelines and a checklist

INTRODUCTION

As a result of increasing use of implant-based breast reconstruction, complications such as infection are being encountered more frequently. Surgical Site Infections (SSIs) cause morbidity for the patient, can lead to capsular contracture or implant loss and are costly to healthcare systems. National Guidelines suggesting methods to reduce SSI related complications have been produced, but are limited in the scope of interventions covered and underlying evidence presented.

METHODS

We performed a literature review encompassing a wide variety of possible SSI prevention strategies. We aimed to present summaries of the available evidence and give pragmatic recommendations as to their validity to use as guidelines for infection prevention strategies for implant-based breast reconstruction.

RESULTS

A lack of high quality data relating to the benefit of SSI prevention strategies in implant-based breast reconstruction exists. Many papers relate to orthopaedic implant surgery, or clean surgery in general. Following review of the evidence, sufficient data exists to support use of perioperative antibiotics at implant-based breast reconstruction, with continuation for an extended period in "high risk" patients. Alcohol containing skin preparations should be used over aqueous solutions. Laminar air flow use is suggested. Theatre traffic should be kept to a minimum, as should duration of operative procedure. The implant pocket should be washed prior to implantation. Double gloving and conductive warming are also endorsed.

CONCLUSIONS

We have produced a perioperative "Theatre Implant Checklist" for SSI prevention in implant-based breast surgery, with a set of pragmatic up to date guidelines, which allows the reader to evaluate the evidence upon which our recommendations are based.

Application time for postoperative wound dressing following breast augmentation with implants: study protocol for a randomized controlled trial

Background

Breast augmentation with silicone implants is one of the most frequently performed cosmetic surgeries worldwide. Surgical site infection (SSI) remains an important complication of this procedure. One of the most important risk factors for SSI is the presence of microorganisms on the skin surrounding the wound. Guidelines by the Centers for Disease Control (CDC) recommend that surgical wounds be covered with a sterile dressing for 24 to 48 hours. However, a recent study showed that the application of a dressing for six days after breast reduction reduced wound colonization by coagulase-negative staphylococci.

Methods/Design

A randomized clinical trial was designed to assess two protocols of postoperative wound care to determine how the application duration of the postoperative dressing influences wound colonization in patients undergoing breast augmentation with silicone implants. Women aged between 18 and 60 years who are candidates for breast augmentation with silicone implants will be randomly allocated to group I (n = 48), in which the dressing will be removed on the first postoperative day, or group II (n = 48), in which the dressing will be removed on the sixth postoperative day. Cutaneous colonization will be assessed by cultures of samples of skin flora taken from the wound region. The incidence of SSI, using standardized CDC criteria, and the perceptions of patients towards the dressing will be secondary outcomes.

Discussion

An important component of SSI prevention is to minimize all possible risk factors, and the application of postoperative dressing plays a key role in this endeavor. The results of this clinical trial may help to standardize postoperative wound care after breast augmentation with silicone implants.

Trial registration

This trial was registered on 12 March 2012 with ClinicalTrials.gov (identifier: NCT01553604).

Effectiveness of prophylactic antibiotics in outpatient plastic surgery

BACKGROUND

The effectiveness of prophylactic antibiotics has not been established for patients who undergo plastic surgery as outpatients, and consensus guidelines for antibiotic administration in clean-contaminated plastic surgery are not available.

OBJECTIVES

In a retrospective study of outpatients, the authors examined preoperative timing of prophylactic antibiotics, whether postoperative antibiotics were administered, and whether any correlations existed between these practices and surgical complications.

METHODS

The medical records of 468 plastic surgery outpatients were reviewed. Collected data included preoperative antibiotic timing, postoperative antibiotic use, comorbidities, and complications. Rates of complications were calculated and compared with other data.

RESULTS

All 468 patients received antibiotics preoperatively, but only 93 (19.9%) received them ≥1 hour before the initial incision. Antibiotics were administered 15 to 44 minutes before surgery in 217 patients (46.4%). There was no significant difference in complication rates between the 315 patients who received postoperative prophylactic antibiotics (16.2%) and the 153 who did not (20.9%). Comorbidities had no bearing on postoperative complications.

CONCLUSIONS

Postoperative antibiotic prophylaxis may be unnecessary for outpatient plastic surgery patients.

LEVEL OF EVIDENCE

3.

Efficacy and safety profile of antibiotic prophylaxis usage in clean and clean-contaminated plastic and reconstructive surgery: a meta-analysis of randomized controlled trials

BACKGROUND

There is no consensus with regard to antibiotic prophylaxis usage in clean and clean-contaminated plastic and reconstructive surgery. This meta-analysis sought to assess the efficacy and safety of antibiotic prophylaxis and to determine appropriate duration of prophylaxis.

METHODS

An English language literature search was conducted using PubMed and the Cochrane Collaboration for randomized controlled trials (RCTs) that evaluate the use of antibiotic prophylaxis to prevent postoperative surgical site infection (SSI) in patients undergoing clean and clean-contaminated plastic and reconstructive surgery. Data from intention-to-treat analyses were used where available. For the dichotomous data, results for each study were odds ratio (OR) with 95% confidence interval (CI) and combined for meta-analysis using the Mantel-Haenszel method or the DerSimonian and Laird method. Study quality was critically appraised by 2 reviewers using established criteria. STATA version 12 was used for meta-analyses.

RESULTS

Twelve RCTs involving 2395 patients were included, of which 8 trials were considered to be of high methodological quality. Effect of antibiotic prophylaxis in plastic and reconstructive surgery was found favorable over placebo in SSI prevention (13 studies; 2449 participants; OR, 0.53; 95% CI, 0.4-0.7; P < 0.01) and the other wound complication (OWC) prevention (9 studies; 1843 participants; OR, 0.36; 95% CI, 0.15-0.84; P < 0.02). Subgroup analysis performed according to surgical wound type or the duration of prophylaxis did not modify the results except for the OWC with short-term antibiotic treatment. Compared with short-term antibiotic prophylaxis, long-term administration showed no evidence of a difference in risk of SSI (7 studies; 1012 participants; OR, 0.99; 95% CI, 0.63-1.55; P < 0.95), OWC (5 studies; 824 participants; OR, 0.92; 95% CI, 0.46-1.86; P < 0.82), and adverse event relative to antibiotic administration (3 studies; 653 participants; OR, 0.23; 95% CI, 0.01-4.92; P < 0.35).

CONCLUSIONS

This meta-analysis of RCTs provides evidence supporting that antibiotic prophylaxis reduced postoperative SSI in clean plastic surgeries with high-risk factors and clean-contaminated plastic surgeries. Besides, a short-course administration regimen seemed to be of adequate efficacy and safety. High-quality prospective trials on larger scale are needed to further confirm these findings.

Breast augmentation

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Assess patient physical characteristics that influence implant selection. 2. Adopt a system to aid in implant size selection. 3. Become cognizant of the advantages and disadvantages of incision, pocket plane, and implant options. 4. Understand implant positioning concepts and aseptic implant handling methods. 5. Manage untoward postoperative sequelae 6. Understand secondary surgery concepts.

SUMMARY

Breast augmentation is the most commonly performed aesthetic surgical procedure. Choices of incisions, pocket plane, and myriad implant characteristics constitute the basis for surgical planning. Analysis of physical characteristics and inclusion of the patient in implant selection contribute to overall satisfaction and reduce requests for secondary surgery. Technical expertise in implant positioning and aseptic handling helps to prevent capsular contracture, implant malposition, and other shape problems. Despite the need for secondary surgery in some, patient satisfaction is high.

Povidone-iodine combined with antibiotic topical irrigation to reduce capsular contracture in cosmetic breast augmentation: a comparative study

BACKGROUND

Antibacterial lavage with topical antibiotics may reduce the occurrence of capsular contracture (CC) in breast augmentation.

OBJECTIVES

The authors investigate the efficacy of povidone-iodine combined with antibiotic irrigation in reducing the CC rate.

METHODS

The charts of 330 consecutive women who underwent cosmetic breast augmentation during 2 different periods (group A: 2004-2009, n = 165; group B: 2009-2010, n = 165) were retrospectively reviewed. All patients in the series underwent augmentation with the same surgeon (A.S.) via the inframammary approach and dual-plane pocket. In group A, patients received a single perioperative dose of 1.5 g of intravenous cephalothin and 750 mg of oral cephalexin twice a day for 7 days after discharge. In group B, patients perioperatively received 750 mg of intravenous cefuroxime, and each implant and pocket were irrigated with 25 mL of a 10% povidone-iodine solution mixed with 750 mg of cefuroxime and 80 mg of gentamicin diluted in 15 mL of 0.9% sodium chloride solution. After discharge, patients received 500 mg of oral levofloxacin once a day for 5 days. Postoperative complications included occurrence of infection, hematoma, seroma, and CC.

RESULTS

Mean (SD) postoperative follow-up in groups A and B was 24 (+/- 13) months and 22 (+/- 3) months, respectively. The postoperative superficial wound infection rate was 1.8% and 1.2%, the seroma rate was 1.8% and 1.2%, and the hematoma rate was 0.6% and 1.2% in groups A and B, respectively. Ten CC cases (Baker grade 3 or 4) in group A and 1 in group B were reported (6% vs 0.6%; P = .006).

CONCLUSIONS

Povidone-iodine and antibiotic irrigation in cosmetic breast augmentation yielded a lower CC rate than standard perioperative antibiotics in this series of patients.

Infections associated with body modification

Although exact statistics are lacking, body modifications for cosmetic purposes are performed in many countries. The commonest forms include tattooing, body piercing, and breast and facial augmentation using implants or injectable fillers. Liposuction and, to a lesser extent, mesotherapy are also practiced in many countries. Infective complications of these procedures include local infections, transmission of bloodborne pathogens (viral hepatitis and human immunodeficiency virus), and distant infections such as infective endocarditis. Presence of foreign bodies, long healing time of piercing wounds, and poor compliance with infection control practices of some practitioners all predispose the recipients to infections. Apart from the endogenous microbial flora of the skin and mucosae, atypical mycobacteria, especially the rapid growers, have emerged as some of the most important pathogens in such settings. Outbreaks of infection are commonly reported. We hereby review the current knowledge of the topic with specific focus on infections associated with tattooing, body piercing, breast augmentation, mesotherapy, liposuction, and tissue filler injections. Greater awareness among consumers and health-care professionals, as well as more stringent regulations by the health authorities, is essential to minimize the health risks arising from these procedures.