Breast implants- whether for cosmetic breast augmentation or breast cancer reconstruction– can have complications. We know of infections (which could require implant removal) and biofilm (a low grade chronic infection that causes inflammation and is a likely source of capsular contracture and breast implant illness.)
So how can we minimize the risk of infection for the foreign object?
This was a study in December 2023 Plastic & Reconstructive Surgery Journal, “Close the GAPS: A Standardized Perioperative Protocol Reduces Breast Reconstruction Implant Infections.” Yes, this is not an exciting study, but these studies are important to see how we can do prevention to reduce risk and complications. And what applies to breast cancer reconstruction would also apply to cosmetic breast augmentation.
Study:
- All patients in a single institution from 2018 to 2021. Infections were listed as minor (managed with outpatient antibiotics) and major (readmission or reoperation).
- 69 patients (120 breasts) were compared to historic patients. No difference in demographics, comorbidities, or type of reconstruction.
- Overall infection rate was significantly lower in protocol group 8.7% vs 17%, true for minor and major issues.
- Rate of reconstructive failure due to infection was significantly lower in protocol group.
So what was their protocol?
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PRE SURGERY:
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- Skin decolonization: twice daily mupirocin in the nose & Hibiclens showers for 5 days prior to surgery
- Weight based preop IV antibiotics for 30 minutes prior to incision- Kefzol or Clindamycin (if allergy to penicillin)
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DURING SURGERY
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- Skin prep with ChlroaPrep. This prep was performed or supervised by member of plastic surgery team
- Draping performed by surgeon
- Towels secured to patient with Ioban strips
- Double gloving of team members
- Implant soaked in Irrisept during pocket preparation
- Mastectomy pocket irrigated with Irrisept before implant placements
- Mastectomy pocked isolated with new sterile towels
- Glove change by placing provider
- New set of sterile instruments to close
- Sterstrips over incisions
- Tegaderm used to secure drains
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AFTER SURGERY
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- Perioperative antibiotics
- Instructions to patient about wound and drain care
- Drains removed when <30cc for 2 consecutive days.
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My thoughts?
I drank the water of biofilm over a decade ago. I already do most of this. It is just good practice, whether it is cosmetic or breast reconstruction. Low grade infections are found to increase capsular contracture rates and are thought to be a lead issue with breast implant illness. So this is just good medicine. Prevent issues.
I don’t do the nose decolonization, and I do not use the Irrispet brand solution. Irrisept is a low concentration chlorhexidine gluconate in sterile water. I am not sure this is better than antibiotic irrigation or dilute betadine-I will have to research that next. For my breast augmentations I do not use drains or pain pumps- I think it is important to not have a plastic tube connect the “dirty” outside world with the newly placed implant. I didn’t see that they used a Keller funnel. Given this is mostly reconstruction, perhaps it is because the incision is so large, but I believe in the Keller funnel protection of the implant. Here they have a larger wound, so they used iodine adhesive drapes. As for a new set of sterile instruments, I already do that as those instruments are not used and are on the back table until the end. I also soak all of my instruments I use to close the wound in antibiotic solution and don’t touch the implant after placement.