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Moyer HR, Sisson KM. The Effect of Early Cultures and Dual-port Expanders on Two-stage, Prepectoral Breast Reconstruction: The 25/25 Study. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5507. [PMID: 38196846 PMCID: PMC10773836 DOI: 10.1097/gox.0000000000005507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 11/06/2023] [Indexed: 01/11/2024]
Abstract
Background Two-stage tissue expander to implant surgery remains the predominant technique for breast reconstruction. Unfortunately, there is a high incidence of reconstruction failure which portends a financial and emotional burden. Most failures are related to postmastectomy skin flap necrosis and infection. Recently, a dual-port tissue expander was introduced to the market, and the authors hypothesize that early cultures from the peri-implant fluid will guide antibiotic treatment and decrease reconstruction failure. Methods This is a cohort study of 50 consecutive patients treated for breast cancer or genetic susceptibility via a two-stage, prepectoral technique. The first 25 patients (46 breasts) were treated with a variety of tissue expanders, and the subsequent 25 patients (47 breasts) received a dual-port expander. Routine cultures from the drain port were taken from the dual-port group at the second postoperative visit, and cultures were taken in the control group only when signs of infection were present. All other procedures and interventions were similar. Results Fifty patients, totaling 93 breasts, completed the study with a mean follow-up of 145 days. There were no statistically significant demographic or pathologic differences between groups. Fifteen tissue expanders were explanted in the control group and five in the dual-port cohort (32.6% versus 10.6%, P = 0.012). All bacteria in the control group failures were either methicillin-resistant Staphylococcus aureus or Staphylococcus epidermidis, whereas failures in the dual-port group varied. Conclusion Treatment of routine, early cultures from a dual-port expander led to a statistically significant decrease in tissue expander explantation.
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Affiliation(s)
- Hunter R. Moyer
- From the Monument Health Division of Plastic Surgery, Rapid City, S. Dak
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Myckatyn TM, Duran Ramirez JM, Walker JN, Hanson BM. Management of Biofilm with Breast Implant Surgery. Plast Reconstr Surg 2023; 152:919e-942e. [PMID: 37871028 DOI: 10.1097/prs.0000000000010791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Understand how bacteria negatively impact aesthetic and reconstructive breast implants. 2. Understand how bacteria infect breast implants. 3. Understand the evidence associated with common implant infection-prevention strategies, and their limitations. 4. Understand why implementation of bacteria-mitigation strategies such as antibiotic administration or "no-touch" techniques may not indefinitely prevent breast implant infection. SUMMARY Bacterial infection of aesthetic and reconstructive breast implants is a common and expensive problem. Subacute infections or chronic capsular contractures leading to device explantation are the most commonly documented sequelae. Although bench and translational research underscores the complexities of implant-associated infection, high-quality studies with adequate power, control groups, and duration of follow-up are lacking. Common strategies to minimize infections use antibiotics-administered systemically, in the breast implant pocket, or by directly bathing the implant before insertion-to limit bacterial contamination. Limiting contact between the implant and skin or breast parenchyma represents an additional common strategy. The clinical prevention of breast implant infection is challenged by the clean-contaminated nature of breast parenchyma, and the variable behavior of not only specific bacterial species but also their strains. These factors impact bacterial virulence and antibiotic resistance.
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Affiliation(s)
- Terence M Myckatyn
- From the Division of Plastic and Reconstructive Surgery, Washington University in St. Louis School of Medicine
| | | | - Jennifer N Walker
- Department of Microbiology and Molecular Genetics
- Center for Infectious Diseases, Department of Epidemiology, School of Public Health, University of Texas Health Science Center at Houston
| | - Blake M Hanson
- Center for Antimicrobial Resistance and Microbial Genomics, McGovern Medical School
- Center for Infectious Diseases, Department of Epidemiology, School of Public Health, University of Texas Health Science Center at Houston
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Teotia SS, Kadakia Y, Amaya J, Liu Y, Haddock NT. Evaluating the Efficacy of Povidone-Iodine Solution Infection Prophylaxis in Immediate Tissue Expander-Based Breast Reconstruction: A Controlled Retrospective Analysis. Plast Surg (Oakv) 2023; 31:29-35. [PMID: 36755822 PMCID: PMC9900035 DOI: 10.1177/22925503211024762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 04/25/2021] [Indexed: 11/16/2022] Open
Abstract
Background: There is currently no consensus among plastic surgeons regarding the optimal infection prophylaxis for immediate tissue expander placement following mastectomy. The goal of this study was to determine whether irrigation with 1 L of standard triple antibiotic solution (TAS) can achieve similar infection rates compared to a regimen of 180 mL of TAS with povidone-iodine solution (Betadine) painted on the field immediately prior to the placement of the expander. Methods: The 2 regimens were compared via retrospective propensity matching of all patients of the 2 senior authors who underwent bilateral tissue expander placement immediately following mastectomy with one of 3 mastectomy surgeons from January 2013 to December 2019 (n = 281). Groups were controlled for mastectomy surgeon, mastectomy type, mastectomy weight, age, race, body mass index, diabetes, hypertension, smoking, smoking status, prepectoral/subpectoral placement, use of acellular dermal matrix, operating room time, and duration of postoperative antibiotics. Results: Compared to the Betadine cohort (n = 65), the non-Betadine cohort (n = 65) experienced a similar rate of infections (13.8% vs 12.3%, P = 1.00), including major injections requiring intravenous antibiotic treatment (10.8% vs 9.2%, P = 1.00), after propensity matching. Infections in the non-Betadine cohort did not grow different bacteria on culture, require different antibiotic coverage, or result in prolonged duration of average antibiotic therapy (12.0 days vs 19.3 days, P = .19). Rates of subsequent expander washout and exchange (P = 1.00) and overall complications that required return to the operating room (P = .826) were similar between groups. Conclusion: The addition of Betadine solution to TAS added no benefit to infection prophylaxis or reduction of surgical complications in immediate tissue expander placement procedures.
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Affiliation(s)
- Sumeet S. Teotia
- Department of Plastic Surgery, University of Texas Southwestern
Medical Center, Dallas, TX, USA
| | - Yash Kadakia
- Department of Plastic Surgery, University of Texas Southwestern
Medical Center, Dallas, TX, USA
| | - Joshua Amaya
- Department of Plastic Surgery, University of Texas Southwestern
Medical Center, Dallas, TX, USA
| | - Yulun Liu
- Department of Plastic Surgery, University of Texas Southwestern
Medical Center, Dallas, TX, USA
| | - Nicholas T. Haddock
- Department of Plastic Surgery, University of Texas Southwestern
Medical Center, Dallas, TX, USA
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Griggs R, Karpman E, Jones L, Twomey C, Henry G. Effect of 0.05% chlorhexidine gluconate in water on the hydrophilic inflatable penile prosthesis: biocompatibility, adherence, and dip time. J Sex Med 2023; 20:113-117. [PMID: 36897235 DOI: 10.1093/jsxmed/qdac007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 08/26/2022] [Accepted: 09/18/2022] [Indexed: 01/14/2023]
Abstract
BACKGROUND Rates of infection after inflatable penile prosthesis range from 1% to 3%; however, a new surgical irrigation solution is Food and Drug Administration cleared as antimicrobial wound lavage and appears to be safe for patients and noncaustic during hydrophilic inflatable penile prosthesis (hIPP) dipping and irrigation. AIM To evaluate if 0.05% chlorhexidine (CHG) lavage is caustic to the hIPP coating and if dip adherence is dependent on time. METHODS Preconnected hIPP devices were tested at a Coloplast research and development laboratory. The devices were soaked in the 0.05% CHG lavage solution or normal saline for 1, 15, 30, and 60 minutes. Subsequently, all parts were dried for 15 minutes in a 35 °C oven. A Congo red dye test was performed following a Coloplast-validated and Food and Drug Administration-cleared test method to ensure product reliability. Implants were then visually inspected for deleterious effects as well as dip coverage. In addition, we evaluated 0.05% CHG lavage solution vs previously published hIPP dipping solutions. OUTCOMES 0.05% CHG lavage does not appear to damage the hIPP coating, and adherence of this solution is not dependent on dip time. RESULTS All components of the preconnected hydrophilic IPPs were tested for coating adherence and defects. All tested IPPs achieved a "satisfactory" coating, meaning a uniform coat without flaking or clumping. Furthermore, there were no noticeable caustic effects or differences in coating adherence between the normal saline-soaked control and 0.05% CHG-coated arms with increasing dip time. A review of the literature for 0.05% CHG lavage solutions vs previously published hIPP dipping solutions revealed that it may have some advantages over previously reported antibiotic solutions. CLINICAL IMPLICATIONS This study serves as a foundation to introduce 0.05% CHG lavage to the urologic literature as a potentially new "magic bullet" irrigation. STRENGTHS AND LIMITATIONS Major strengths of the study are that it is the first study of its kind to address the question of what dip duration should be used and whether it is scientifically reproducible. A limitation is the in vitro model, thus needing validation in a clinical setting. CONCLUSION 0.05% CHG does not appear to negatively affect the hIPP coating or differ in adherence with increasing dip time; however, long-term device performance has not been verified.
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Affiliation(s)
- Ryan Griggs
- Willis Knighton Advanced Urology, Bossier City, LA 71111, United States
| | - Edward Karpman
- El Camino Health Urology, Mountain View, CA 94040, United States
| | - LeRoy Jones
- Urology San Antonio, San Antonio, TX 78229, United States
| | - Carolyn Twomey
- Department of Medical Affairs and Research, Irrimax Corporation, Lawrenceville, GA 30043, United States
| | - Gerard Henry
- Willis Knighton Advanced Urology, Bossier City, LA 71111, United States
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Baker NF, Brown O, Hart AM, Danko D, Stewart CM, Thompson PW. Preventing Infection in Implant-based Breast Reconstruction: Evaluating the Evidence for Common Practices and Standardized Protocols. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2022; 10:e4208. [PMID: 35350150 PMCID: PMC8939924 DOI: 10.1097/gox.0000000000004208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 03/22/2022] [Accepted: 01/25/2022] [Indexed: 12/14/2022]
Abstract
Infection following implant-based breast reconstruction (IBBR) results in increased rates of hospital readmission, reoperation, patient and hospital expenses, and reconstructive failure. IBBR is a complex, multistep procedure, and there is a relative lack of high-quality plastic surgery evidence regarding "best practices" in the prevention of implant infections. In the absence of strong data, standardizing procedures based on available evidence can reduce error and improve efficacy and outcomes. Methods We performed a focused literature review of the available evidence supporting specific interventions for infection prevention in the preoperative, intraoperative, and postoperative phases of care that are applicable to IBBR. In addition, we examined previously published standardized perioperative protocols for implant reconstruction. Results Preoperative, intraoperative, and postoperative planning and organization is crucial in IBBR. Preoperative planning involves skin decolonization in advance of surgery with either chlorhexidine gluconate or mupirocin. Intraoperative methods that have shown potential benefit include double-gloving, breast pocket irrigation, separate closing instruments, and the utilization of "no-touch" techniques. In the postoperative period, the duration of drain removal and postoperative antibiotic administration play an important role in the prevention of surgical site infection. Conclusions There is a crucial need to establish an evidence-based set of "best practices" for IBBR, and there exists a paucity of evidence in the breast literature. These data can be utilized to develop a standardized protocol as part of a rigorous quality improvement methodology.
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Affiliation(s)
| | - Owen Brown
- Emory Department of Surgery, Division of Plastic Surgery, Atlanta, Ga
| | - Alexandra M. Hart
- Emory Department of Surgery, Division of Plastic Surgery, Atlanta, Ga
| | - Dora Danko
- From the Emory University School of Medicine, Atlanta, Ga
| | | | - Peter W. Thompson
- Emory Department of Surgery, Division of Plastic Surgery, Atlanta, Ga
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Thompson PW. Commentary on: Post-Mastectomy Surgical Pocket Irrigation With Triple Antibiotic Solution vs Chlorhexidine Gluconate: A Randomized Controlled Trial Assessing Surgical Site Infections in Immediate Tissue Expander Breast Reconstruction. Aesthet Surg J 2021; 41:NP1529-NP1531. [PMID: 34447982 DOI: 10.1093/asj/sjab325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Peter W Thompson
- Division of Plastic and Reconstructive Surgery, Emory University School of Medicine, Atlanta, GA, USA
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Nguyen L, Afshari A, Green J, Joseph J, Yao J, Perdikis G, Higdon KK. Post-Mastectomy Surgical Pocket Irrigation With Triple Antibiotic Solution vs Chlorhexidine Gluconate: A Randomized Controlled Trial Assessing Surgical Site Infections in Immediate Tissue Expander Breast Reconstruction. Aesthet Surg J 2021; 41:NP1521-NP1528. [PMID: 34291796 DOI: 10.1093/asj/sjab290] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Post-mastectomy pocket irrigation solution choice is debated and primarily surgeon dependent. We compare triple antibiotic solution (TAS) with 0.05% chlorhexidine gluconate (CHG). OBJECTIVES The purpose of this study was to determine surgical site infection (SSI) rates after utilizing TAS vs CHG for breast pocket irrigation in immediate tissue expander (TE) breast reconstruction. METHODS A prospective, blinded, randomized controlled trial was performed in patients (18-81 years old) who underwent bilateral mastectomy with TE reconstruction. In each patient, 1 mastectomy pocket was randomized to TAS and the other to CHG. Both the TE and the pocket were irrigated in the respective solution. The primary outcome was the incidence of SSI. Secondary outcomes were rates of mastectomy flap necrosis, hematoma, and seroma. RESULTS A total of 88 patients who underwent bilateral immediate breast reconstruction were enrolled. Demographic and operative characteristics were equivalent because each patient served as their own control. Between the TAS and CHG groups, the incidence of SSI did not differ (5 [4.5%] vs 7 [8.0%], P = 0.35), including minor infections (2 [2.3%] vs 1 [1.1%], P = 0.56), major infections (2 [2.3%] vs 6 [6.8%], P = 0.15), and those resulting in explantation (2 [2.3%] vs 5 [4.5%], P = 0.25). Necrosis, hematoma, or seroma formation also did not differ. No patients who developed SSI received radiation. CONCLUSIONS This study does not demonstrate a statistically significant difference in SSI between TAS and CHG irrigation, though TAS approached statistical significance for lower rates of infectious complications. LEVEL OF EVIDENCE: 2
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Affiliation(s)
- Lyly Nguyen
- Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ashkan Afshari
- Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Japjit Green
- Department of Plastic Surgery, Wexner Medical Center, Ohio State University, Columbus, OH, USA
| | - Jeremy Joseph
- Department of Surgery, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Jun Yao
- Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Galen Perdikis
- Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kent K Higdon
- Department of Plastic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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Baker NF, Hart AM, Carlson GW, Losken A. A Systematic Review of Breast Irrigation in Implant-Based Breast Surgery. Ann Plast Surg 2021; 86:359-364. [PMID: 33555689 DOI: 10.1097/sap.0000000000002481] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Aesthetic and reconstructive implant-based breast surgeries are some of the most frequently performed procedures by plastic surgeons. As such, prevention of implant infection is of high importance. However, there remains no criterion-standard protocol for irrigation of the breast pocket. This review focuses on current irrigation practices in implant-based breast surgery. METHODS Four databases were used to search for all studies, including randomized controlled trials, retrospective cohort, and prospective cohort, containing original data related to the outcomes investigated in this study. Search terms included "breast," "irrigation," and "infection" in different combinations to isolate studies that focused on irrigation methods in both reconstructive and augmentation surgeries. Our selection criteria specifically concentrated on those studies that explicitly related irrigation procedures to rates of clinical infection and/or capsular contracture. Each was compiled into a table in chronological order to make comparisons between the differing irrigation methods. RESULTS Our search returned 239 full-text articles eligible for our review. Two independent screeners identified 9 studies that met the inclusion criteria. This included 1 prospective study and 8 retrospective studies. Two studies reported the use of chlorhexidine gluconate irrigation resulting in protection from clinical infection. Two studies investigated the role of triple antibiotic solution (TAS) either alone or combined with something else on risk of infection, and 3 reported TAS use on rates of capsular contracture. Two additional studies investigated the role of single antibiotic irrigation, concluding that some antibiotic regimen for irrigation may be sufficient in the breast pocket. Interestingly, one study noted the potential use of povidone-iodine (Betadine) as a method of irrigation. CONCLUSIONS These data suggest that chlorhexidine gluconate, Betadine, and TAS irrigation of the breast pocket can provide protection against infection and implant loss in both reconstruction and augmentation surgeries.
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Affiliation(s)
| | | | | | - Albert Losken
- Division of Plastic Surgery, Emory University, Atlanta, GA
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9
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Schwartz JCD. Early Expander-to-Implant Exchange after Postmastectomy Reconstruction Reduces Rates of Subsequent Major Infectious Complications. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e3275. [PMID: 33425590 PMCID: PMC7787320 DOI: 10.1097/gox.0000000000003275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 10/02/2020] [Indexed: 04/11/2023]
Abstract
Major infectious complications after implant-based postmastectomy reconstruction commonly occur late (>30 days postoperative). We set out to determine if early expander-to-implant exchange (3-6 weeks after tissue expander placement) reduced rates of subsequent major infectious complications. METHODS We retrospectively examined patients after mastectomy and tissue expander reconstruction followed by early expander-to-implant exchange versus exchange at least 6 months after initial tissue expander placement (the control group). Multivariate logistic regression analysis was performed to determine whether the timing of implant exchange independently predicted major infectious complications occurring more than 30 days after initial tissue expander placement after adjusting for differences in patient variables between groups. RESULTS In total, 252 consecutive patients (430 breasts) between August 2014 and October 2019 were included. While the rates of major early infectious complications after mastectomy and tissue expander placement were similar between the groups, the control group had more subsequent major infectious complications during the reconstructive process [9.8% (n = 22) versus 1.9% (n = 4), P < 0.001]. CONCLUSIONS Early implant exchange results in a reduced subsequent rate of major infectious complications. This protocol reduces the window of time for late infectious complications to develop by proceeding with exchange within 6 weeks of tissue expander placement instead of the standard 6 months, which is common practice. We hypothesize that early exchange allows for washout of the mastectomy cavity, eliminating indolent bacterial contamination that could have subsequently manifested as a late infection. This protocol also obviates the need to operate on patients that undergo post-mastectomy radiotherapy, which also reduces reconstructive failure rates.
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Affiliation(s)
- Jean-Claude D. Schwartz
- From the Northside Gwinnett Surgical Associates, Northside Hospital Gwinnett, Lawrenceville, Ga
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