Does Antibiotic Irrigation Really Reduce the Risk of Capsular Contracture of the Breast?

Does the Omission of Cefazolin in Irrigation Solution Affect Outcomes in Prepectoral Direct-to-Implant Breast Reconstruction?

PURPOSE

The widely used triple-antibiotics irrigation solution, comprising cefazolin, gentamycin, and povidone-iodine solution, has been employed for preventing infection and capsular contracture in implant-based breast reconstruction. However, potential overlapping in the coverage of such antimicrobial effects and the recent emergence of cefazolin-resistant gram-positive bacteria has prompted concerns regarding the efficacy of routine use of cefazolin in irrigation solutions. This study aims to evaluate clinical safety of omitting cefazolin from the traditional triple-antibiotic irrigation solution.

METHODS

Patients who underwent immediate prepectoral direct-to-implant breast reconstruction between September 2020 and April 2022 were reviewed. They were divided into two groups: cases using the traditional triple-antibiotics for the former third and those using dual-antibiotics (omitting cefazolin) for the latter. Development of postoperative complications were compared by the type of irrigation solution and its independent associations with the adverse outcomes were evaluated.

RESULTS

In total, 445 cases (126 using triple- and 319 using dual-regimen solution) were analyzed with a mean follow-up period of 12 months. The two groups had generally similar baseline characteristics. Overall complications developed in 126 cases (28.3%), including 12 (2.7%) of infection and 32 (7.2%) of capsular contracture. The complication profiles did not differ between the groups. Multivariable analyses exhibited that the type of irrigation solution was not associated with the development of overall and any kind of complication including infection and capsular contracture.

CONCLUSION

Omission of cefazolin from the irrigation solution may not elevate the risks of infection and capsular contracture in prepectoral direct-to-implant reconstruction. Further long-term studies would be warranted.

LEVEL OF EVIDENCE III

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Capsular Contracture After Breast Augmentation: Our Approach to Prevent Reoccurrence with Combined Total Capsulectomy and Implantation of Motiva Ergonomix® Implants

BACKGROUND

Breast augmentation is the second most common aesthetic surgery worldwide. Capsular contracture, a prevalent complication which affects up to 30% of patients post-surgery, often leads to further necessary surgeries.

OBJECTIVES

This study investigates the effectiveness of total capsulectomy combined with Motiva Ergonomix® implant replacement in resolving capsular contracture and minimizing recurrence rates.

METHODS

We conducted a retrospective study of 1067 patients and enrolled 51 women with capsular contracture post-breast augmentation. Patients were treated between 2014 and 2023 in a single center by three surgeons. Capsular contracture severity was graded using Baker's classification. Surgical interventions included total capsulectomy and implant replacement, using various incision techniques and changes in implant anatomical planes. Patients were followed up for a minimum of 12 months to a maximum of 9 years.

RESULTS

A total of 51 patients with grade III or IV capsular contracture underwent revisional surgery, involving the implantation of 102 Motiva Ergonomix® prostheses; 77 explanted implants resulted intact, 15 exhibited silicone bleeding, and 10 showed ruptured. Capsular contracture recurrence was observed in only 1.96% of cases during the follow-up period.

CONCLUSIONS

The combination of total capsulectomy and implantation of Motiva Ergonomix® implants significantly reduces the recurrence rate of capsular contracture. Despite the study's limitations, including its single-center design and a small sample size, our results suggest that this approach is a viable and effective solution to manage this common complication in breast augmentation patients. Further multicentric studies are recommended to validate these results.

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 https://www.springer.com/00266 .

Did the National Ban on Bacitracin Irrigation Affect Infection Rates in Implant-Based Breast Reconstruction? An Analysis of a National Database

INTRODUCTION

The current standard of practice in implant-based breast reconstruction is irrigation of the mastectomy pocket with antimicrobial solution before implant placement. Prior to being banned and formally recalled in January 2020, bacitracin was a very commonly utilized antibiotic. This study characterizes the effects of the national bacitracin ban on implant-based breast reconstruction infection rates by using a nationwide database to compare complication rates before and after bacitracin was banned.

MATERIALS AND METHODS

The American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP) database was queried retrospectively for all patients who underwent implant-based breast reconstruction before the bacitracin ban (2012-2019) and afterwards (2020). Demographics, comorbidities, and complications were collected. Univariate analysis and multivariate analysis were conducted to determine if there were significant changes in wound complications, local wound infections, and systemic infections between the 2 case-control matched cohorts.

RESULTS

A total of 37,126 patients were in the pre-ban cohort and 6333 patients were in the post-ban cohort. Before matching, there were significant differences in race distribution, BMI, ASA class, inpatient vs. outpatient status, preoperative smoking, and preoperative diabetes mellitus (all P < .05). After case-control matching, there were 6313 patients in each cohort. Univariate analysis revealed differences in postoperative superficial and organ space surgical site infection, wound complications/infections, all cause complications, and reoperations (all P < .05). Multivariate analysis showed that patients who underwent breast reconstruction before the ban had decreased odds of having wound infections, related infections, all cause complications, and reoperations (all P < .05).

CONCLUSION

This study provides a macroscopic view into the effects of the formal injectable bacitracin ban on breast reconstruction outcomes. Patients who underwent implant-based breast reconstruction after the ban of injectable bacitracin had higher odds of developing wound infections, related infections, and reoperations. More study into suitable alternatives to injectable bacitracin for surgical site antimicrobial irrigation is warranted.

Pharmacological Approaches for the Prevention of Breast Implant Capsular Contracture

Capsular contracture is a common complication associated with breast implants following reconstructive or aesthetic surgery in which a tight or constricting scar tissue capsule forms around the implant, often distorting the breast shape and resulting in chronic pain. Capsulectomy (involving full removal of the capsule surrounding the implant) and capsulotomy (where the capsule is released and/or partly removed to create more space for the implant) are the most common surgical procedures used to treat capsular contracture. Various structural modifications of the implant device (including use of textured implants, submuscular placement of the implant, and the use of polyurethane-coated implants) and surgical strategies (including pre-operative skin washing and irrigation of the implant pocket with antibiotics) have been and/or are currently used to help reduce the incidence of capsular contracture. In this article, we review the pharmacological approaches-both commonly practiced in the clinic and experimental-reported in the scientific and clinical literature aimed at either preventing or treating capsular contracture, including (i) pre- and post-operative intravenous administration of drug substances, (ii) systemic (usually oral) administration of drugs before and after surgery, (iii) modification of the implant surface with grafted drug substances, (iv) irrigation of the implant or peri-implant tissue with drugs prior to implantation, and (v) incorporation of drugs into the implant shell or filler prior to surgery followed by drug release in situ after implantation.