Microbial evaluation: 139 implants removed from symptomatic patients

Pharmacokinetics of Locally Applied Antibiotic Prophylaxis for Implant-Based Breast Reconstruction

Importance

Antibiotic irrigation of breast implants is widely used internationally, but no clinical study has investigated the pharmacokinetics of antibiotic prophylaxis in the breast implant pocket.

Objectives

To evaluate how long locally applied gentamicin, cefazolin, and vancomycin concentrations in the implant pocket remain above the minimum inhibitory concentration (MIC) for the most common bacterial infections and to measure systemic uptake.

Design, Setting, and Participants

This prospective cohort study was performed at the Department of Plastic Surgery and Burns Treatment, Rigshospitalet, Copenhagen, Denmark, between October 25, 2021, and September 22, 2022, among 40 patients undergoing implant-based breast reconstruction who were part of the ongoing BREAST-AB trial (Prophylactic Treatment of Breast Implants With a Solution of Gentamicin, Vancomycin and Cefazolin Antibiotics for Women Undergoing Breast Reconstructive Surgery: a Randomized Controlled Trial). Patients were randomized to receive locally applied gentamicin, cefazolin, and vancomycin or placebo. Samples were obtained from the surgical breast drain and blood up to 10 days postoperatively.

Exposures

The breast implant and the implant pocket were irrigated with 160 μg/mL of gentamicin, 2000 μg/mL of cefazolin, and 2000 μg/mL of vancomycin in a 200-mL saline solution.

Main Outcomes and Measures

The primary outcome was the duration of antibiotic concentrations above the MIC breakpoint for Staphylococcus aureus according to the Clinical and Laboratory Standards Institute: gentamicin, 4 μg/mL; cefazolin, 2 μg/mL; and vancomycin, 2 μg/mL. Secondary outcomes included the time above the MIC for Pseudomonas aeruginosa and other relevant bacteria, as well as systemic uptake.

Results

The study included 40 patients (median age, 44.6 years [IQR, 38.3-51.4 years]; median body mass index, 23.9 [IQR, 21.7-25.9]) with a median number of 3 drain samples (range, 1-10 drain samples) and 2 blood samples (range, 0-6 blood samples). Vancomycin and cefazolin remained above the MIC for S aureus significantly longer than gentamicin (gentamicin, 0.9 days [95% CI, 0.5-1.2 days] for blood samples vs 6.9 days [95% CI, 2.9 to 10.9 days] for vancomycin [P = .02] vs 3.7 days [95% CI, 2.2-5.2 days] for cefazolin [P = .002]). The gentamicin level remained above the MIC for P aeruginosa for 1.3 days (95% CI, 1.0-1.5 days). Only cefazolin was detectable in blood samples, albeit in very low concentrations (median concentration, 0.04 μg/mL [range, 0.007-0.1 μg/mL]).

Conclusions and Relevance

This study suggests that patients treated with triple-antibiotic implant irrigation during breast reconstruction receive adequate prophylaxis for S aureus and other common implant-associated, gram-positive bacteria. However, the protection against P aeruginosa may be inadequate.

Is Iatrogenic Implant Contamination Preventable Using a 16-Step No-Touch Protocol?

BACKGROUND

Intraoperative contamination of the surgical field during aesthetic breast augmentation may lead to implant infection with devastating consequences. This study covers a period of 30 years and is divided into 2 phases: a retrospective phase from 1992-2004 when a standard approach was used and a prospective phase from 2004-2022 when a no-touch approach was implemented to avoid contamination.

METHODS

Patients in the standard and no-touch groups underwent aesthetic breast augmentation by the same senior surgeon (FDP) in the same outpatient surgical facility during the 30-year period of the study. Patients are divided into 2 groups: from 1992-2004 and from the implementation of the no-touch protocol in 2004-2022.

RESULTS

Patients who underwent breast augmentation using the no-touch approach developed no infections, whereas the standard group had an infection rate of 3.54% (P = .017). The validity of this finding is discussed.

CONCLUSIONS

The no-touch approach as described in this article was effective in reducing implant infection rate when performing aesthetic breast augmentation by 1 surgeon at 1 surgical center during an 18-year observation period. Multicenter prospective cooperative studies are necessary to validate perioperative iatrogenic contamination as the cause of implant infection and to explore optimal approaches that could eliminate implant contamination.

Microbes, Histology, Blood Analysis, Enterotoxins, and Cytokines: Findings From the ASERF Systemic Symptoms in Women-Biospecimen Analysis Study: Part 3

BACKGROUND

There has been an increasing need to acquire rigorous scientific data to answer the concerns of physicians, patients, and the FDA regarding the self-reported illness identified as breast implant illness (BII). There are no diagnostic tests or specific laboratory values to explain the reported systemic symptoms described by these patients.

OBJECTIVES

The aim of this study was to determine if there are quantifiable laboratory findings that can be identified in blood, capsule tissue pathology, or microbes that differentiate women with systemic symptoms they attribute to their implants from 2 control groups.

METHODS

A prospective blinded study enrolled 150 subjects into 3 cohorts: (A) women with systemic symptoms they attribute to implants who requested implant removal; (B) women with breast implants requesting removal or exchange who did not have symptoms attributed to implants; and (C) women undergoing cosmetic mastopexy who have never had any implanted medical device. Capsule tissue underwent detailed analysis and blood was sent from all 3 cohorts to evaluate for markers of inflammation.

RESULTS

No significant histologic differences were identified between the cohorts, except there were more capsules with synovial metaplasia in the non-BII cohort. There was no statistical difference in thyroid-stimulating hormone, vitamin D levels, or complete blood count with differential between the cohorts. Next-generation sequencing revealed no statistically significant difference in positivity between Cohort A and B. Of the 12 cytokines measured, 3 cytokines, interleukin (IL)-17A, IL-13, and IL-22, were found to be significantly more often elevated in sera of subjects in Cohort A than in Cohorts B or C. The enterotoxin data demonstrated an elevation in immunoglobulin G (IgG) anti-Staphylococcus aureus enterotoxin A in Cohort A. There was no correlation between the presence of IgE or IgG anti-Staphylococcal antibody and a positive next-generation sequencing result.

CONCLUSIONS

This study adds to the current literature by demonstrating few identifiable biomedical markers to explain the systemic symptoms self-reported by patients with BII.

Environmental, Microbiological, and Immunological Features of Bacterial Biofilms Associated with Implanted Medical Devices

The spread of biofilms on medical implants represents one of the principal triggers of persistent and chronic infections in clinical settings, and it has been the subject of many studies in the past few years, with most of them focused on prosthetic joint infections. We review here recent works on biofilm formation and microbial colonization on a large variety of indwelling devices, ranging from heart valves and pacemakers to urological and breast implants and from biliary stents and endoscopic tubes to contact lenses and neurosurgical implants. We focus on bacterial abundance and distribution across different devices and body sites and on the role of environmental features, such as the presence of fluid flow and properties of the implant surface, as well as on the interplay between bacterial colonization and the response of the human immune system.

Breast Implant Illness: Treatment Using Total Capsulectomy and Implant Removal

BACKGROUND

Breast implant illness (BII) is extramammary systemic symptoms that are caused by breast implants. The emergence of this controversial topic has spurred patients with breast implants who are experiencing these symptoms to seek implant removal, hoping to feel better. This article presents novel outcomes and suggestions for plastic surgeons in managing BII using total capsulectomy and breast implant removal.

METHODS

In this retrospective cohort study conducted between 2016 and 2020, medical records of all patients undergoing breast implant removal were reviewed. Inclusion criteria consisted of all patients with history of breast implant placement presenting with mastodynia and capsular contracture on physical examination. Patients with history of implant-based reconstruction following mastectomy and patients who underwent implant exchange were excluded. All patients underwent bilateral implant removal and total capsulectomies.

RESULTS

A total of 200 patients who fulfilled the inclusion criteria were identified. Average age was 45.5 (range: 29-73) years and average body mass index was 26.28 (range: 19-36.8), with an average follow-up time of 5 months postoperatively. Of patients with a presentation of BII, 96% reported improved or complete resolution of their systemic symptoms after implant removal and total capsulectomy. A positive microbial culture was found in 68.5% of patients, and all culture-positive patients reported improvement post-treatment. The most common organisms found were Propionibacterium acnes (49.6%). There were no associations between implant characteristics and rate of positive microbiology findings.

CONCLUSIONS

Our study shows that implant removal with capsulectomy drastically improves BII symptoms. Further large prospective cohort studies are needed to better understand this entity.

Breast Implant Illness and Cutibacterium acnes: A Case Report

Breast implant illness (BII) is a term to describe a wide range of nonspecific symptoms after breast implant placement. At present, no specific diagnostic criteria for BII exist, and there is limited solid understanding of what causes BII. There is some evidence that biofilm infections such as those caused by Cutibacterium acnes may play a role in the development of BII. We present a case of a 38-year-old White woman who developed BII symptoms (psychological and integumentary). After en bloc explantation, her tissue cultures resulted in C. acnes growth. Plastic surgeons should be aware of this potential complication and discuss it thoroughly with patients before breast implantation. Evidence suggests that biofilm infection with C. acnes may play a role in BII development. En bloc explantation is the typical treatment of choice. Plastic surgeons should be aware of C. acnes as a potential cause of BII and should counsel patients on the potential risks and remedies for BII.

Review of Early Signs of Breast Implant Infection

BACKGROUND

Breast implant infection remains a problem despite various prevention methods. Common pathogens such as staphylococcus aureus typically present acutely with fever, erythema, swelling, and pain. However, with the increasing occurrence of mycobacterial infections, associated early signs and symptoms are typically absent, making early detection difficult.

METHOD

A retrospective chart review of patients who underwent esthetic breast augmentation by senior surgeon FDP in an outpatient surgical facility from 1992 to 2021 was conducted. Cases of infections and related information including infection onset, presenting signs and symptoms, and culture results were recorded. Presentation differences between infections caused by common pathogens and mycobacteria were compared.

RESULTS

A total of nine infections were reported in 365 patients. Seven cases were due to common pathogens: staphylococcus aureus, pseudomonas aeruginosa, methicillin-resistant staphylococcus aureus (MRSA), and staphylococcus epidermidis. Fever, erythema was presented within an average of 10 days after surgery. Two cases were due to mycobacterium chelonae (non-tuberculous mycobacterium) infection. In the latter, the earliest signs and symptoms consisted of mild pain and swelling in the absence of fever and erythema, which began on average of 54 days after the operation.

CONCLUSION

Common breast implant infection pathogens usually present early with fever and erythema. However, our study found that non-tuberculous mycobacteria infections occur much later and fever and erythema are typically absent. The purpose of this study is to increase the awareness of clinicians with this rare but rapidly increasing variety of infections and to advise the operating surgeon to include mycobacteria infections in the differential diagnosis.

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 .

Comparing the Antimicrobial Effect of Silver Ion-Coated Silicone and Gentamicin-Irrigated Silicone Sheets from Breast Implant Material

BACKGROUND

Post-operative infection is a significant complication of breast implant surgery that may require extensive use of antibiotics and surgical interventions. Here, we developed a biomaterial coating that is chemically bonded to silicone implants which delivers antimicrobial ions over time.

METHODS

After coating the silicone implants with a "mediator" polymer (γ-PGA), the implants were impregnated with silver (Ag) ions. Antimicrobial effects of these implants were assayed with modified Kirby-Bauer disk diffusion method. The silicone disks were transferred to a plate with fresh bacteria. Control was intended to simulate an intra-operative wash.

RESULTS

The Ag-γ-PGA coated silicone demonstrated antimicrobial effects against the most common etiological agents of breast implant infections, including Pseudomonas aeruginosa, Staphylococcus aureus, Staphylococcus epidermidis, Escherichia coli and Klebsiella pneumoniae. There was no effect of inhibition of bacterial growth around the control silicone or the silicone coated only with γ-PGA. The zone of inhibition was generally larger around the Ag-γ-PGA coated silicone as compared to the silicone irrigated with gentamicin, and continued antibacterial effect was also observed at 48 hours in the Ag-γ-PGA coated silicone for all bacteria groups with the exception of P. aeruginosa. Gentamicin-irrigated silicone did not inhibit bacterial growth at 48 hours.

CONCLUSION

The observed antibacterial performance of the Ag-γ-PGA coating as compared to simulated intra-operative antibiotic wash is promising and should be further evaluated to develop the next generation of implants with diminished risk for post-operative implant infections.

Challenges in the Microbiological Diagnosis of Implant-Associated Infections: A Summary of the Current Knowledge

Implant-associated infections are characterized by microbial biofilm formation on implant surface, which renders the microbiological diagnosis challenging and requires, in the majority of cases, a complete device removal along with a prolonged antimicrobial therapy. Traditional cultures have shown unsatisfactory sensitivity and a significant advance in the field has been represented by both the application of the sonication technique for the detachment of live bacteria from biofilm and the implementation of metabolic and molecular assays. However, despite the recent progresses in the microbiological diagnosis have considerably reduced the rate of culture-negative infections, still their reported incidence is not negligible. Overall, several culture- and non-culture based methods have been developed for diagnosis optimization, which mostly relies on pre-operative and intra-operative (i.e., removed implants and surrounding tissues) samples. This review outlines the principal culture- and non-culture based methods for the diagnosis of the causative agents of implant-associated infections and gives an overview on their application in the clinical practice. Furthermore, advantages and disadvantages of each method are described.

In Vitro Evaluation of Common Antimicrobial Solutions Used for Breast Implant Soaking and Breast Pocket Irrigation-Part 2: Efficacy Against Biofilm-Associated Bacteria

Background

Biofilm-associated bacteria have been observed in both breast implant revision and tissue expander-implant exchange surgeries. The utilization of antimicrobial solutions in breast surgery, especially those containing triple antibiotics (TAB) and/or 10% povidone-iodine (PI), may help reduce existing biofilm-associated bacteria, which is particularly important in a mature breast pocket that may contain residual bacteria from a previously colonized implant surface or, theoretically, bacteria that may arrive postoperatively through hematogenous spread.

Objectives

A series of in vitro assessments was performed to evaluate the antimicrobial utility of TAB and PI, either alone or in combination, against preformed biofilm-associated bacteria.

Methods

Preformed biofilm-associated gram-positive and gram-negative bacterial strains were exposed to TAB and PI ± TAB for up to 30 minutes in a bacterial time-kill assay. Efficacy of various dilutions of PI and the effects of serum protein on PI efficacy were also investigated.

Results

TAB was ineffective at the timeframes tested when utilized alone; when utilized in conjunction with PI, significant log reduction of all biofilm-associated bacterial species tested was achieved when treated for at least 5 minutes. PI alone at a concentration of 25% or higher was also effective, although its efficacy was negatively affected by increasing serum protein concentration only for Staphylococcus epidermidis.

Conclusions

Our data indicate that PI-containing solutions significantly reduce biofilm-associated bacteria, suggesting potential utility for breast pocket irrigation during revision or exchange surgeries. Care should be taken to minimize excessive dilution of PI to maintain efficacy.

Characterizing the Microbiome of the Contracted Breast Capsule Using Next Generation Sequencing

BACKGROUND

Recent work suggests that bacterial biofilms play a role in capsular contracture (CC). However, traditional culture techniques provide only a limited understanding of the bacterial communities present within the contracted breast. Next generation sequencing (NGS) represents an evolution of polymerase chain reaction technology that can sequence all DNA present in a given sample.

OBJECTIVES

The aim of this study was to utilize NGS to characterize the bacterial microbiome of the capsule in patients with CC following cosmetic breast augmentation.

METHODS

We evaluated 32 consecutive patients with Baker grade III or IV CC following augmentation mammoplasty. Specimens were obtained from all contracted breasts (n = 53) during capsulectomy. Tissue specimens from contracted capsules as well as intraoperative swabs of the breast capsule and implant surfaces were obtained. Samples were sent to MicroGenDX Laboratories (Lubbock, TX) for NGS.

RESULTS

Specimens collected from 18 of 32 patients (56%) revealed the presence of microbial DNA. The total number of positive samples was 22 of 53 (42%). Sequencing identified a total of 120 unique bacterial species and 6 unique fungal species. Specimens with microbial DNA yielded a mean [standard deviation] of 8.27 [4.8] microbial species per patient. The most frequently isolated species were Escherichia coli (25% of all isolates), Diaphorobacter nitroreducens (12%), Cutibacterium acnes (12%), Staphylococcus epidermidis (11%), fungal species (7%), and Staphylococcus aureus (6%).

CONCLUSIONS

NGS enables characterization of the bacterial ecosystem surrounding breast implants in unprecedented detail. This is a critical step towards understanding the role this microbiome plays in the development of CC.

LEVEL OF EVIDENCE: 4

The Microbiota of the Human Mammary Ecosystem

Human milk contains a dynamic and complex site-specific microbiome, which is not assembled in an aleatory way, formed by organized microbial consortia and networks. Presence of some genera, such as Staphylococcus, Streptococcus, Corynebacterium, Cutibacterium (formerly known as Propionibacterium), Lactobacillus, Lactococcus and Bifidobacterium, has been detected by both culture-dependent and culture-independent approaches. DNA from some gut-associated strict anaerobes has also been repeatedly found and some studies have revealed the presence of cells and/or nucleic acids from viruses, archaea, fungi and protozoa in human milk. Colostrum and milk microbes are transmitted to the infant and, therefore, they are among the first colonizers of the human gut. Still, the significance of human milk microbes in infant gut colonization remains an open question. Clinical studies trying to elucidate the question are confounded by the profound impact of non-microbial human milk components to intestinal microecology. Modifications in the microbiota of human milk may have biological consequences for infant colonization, metabolism, immune and neuroendocrine development, and for mammary health. However, the factors driving differences in the composition of the human milk microbiome remain poorly known. In addition to colostrum and milk, breast tissue in lactating and non-lactating women may also contain a microbiota, with implications in the pathogenesis of breast cancer and in some of the adverse outcomes associated with breast implants. This and other open issues, such as the origin of the human milk microbiome, and the current limitations and future prospects are addressed in this review.

Safe and Efficient Implant-based Breast Reconstruction

Implant-based breast reconstruction is a safe and effective option associated with high patient satisfaction. Techniques have evolved significantly over the past several decades, characterized mostly by a reduction in the number of stages and time required to complete reconstruction, with maximal preservation of native breast elements. Nevertheless, both old and new techniques of implant-based breast reconstruction have a role depending on the specific clinical scenario, and thus plastic surgeons should be well versed in the full spectrum of options. This article reviews the key considerations underlying decision-making in implant-based breast reconstruction and the most effective techniques, with a focus on optimizing safety and efficiency.

Novel Histopathologic and Immunohistochemical Observations in Explanted Orbital Peri-implant Capsules

PURPOSE

To describe the histopathologic and immunohistochemical characteristics of peri-orbital implant capsule and correlate the observed changes with delayed implant extrusion.

MATERIALS AND METHODS

Prospective, ex-vivo, histopathologic, immunohistochemical study of peri-implant capsules excised from capsules surrounding a poly-methyl metha acrylate (PMMA) implant. Thirteen capsules were harvested and divided into two groups. Group 1 (implant extrusion group) consisted of capsules harvested from around exposed/extruded implants and Group 2 (implant non-extrusion group) from implants that were surgically exchanged for volume augmentation. Data collected included demography, clinical presentations, etiology of the explantation, age of the capsule in months, inflammatory cells noted/high power field (HPF), CD3, CD20, and CD68, percentage Masson's trichrome staining and mean capsular thickness.

RESULTS

Mean patient age at presentation was 33 ± 13 years. Of the 13 capsules included, 7 belonged to group 1and 6 to group 2. Mean age of the fibro-collagenous membranes were 33 ± 57 months (median 13 months). Median CD3, CD20, and CD68 positivity was 80%, 9%, and 7% denoting a predominant T-lymphocytic response. Mean capsular thickness was 733 ± 422µ (median 678µ). Age of the harvested capsule showed a linear correlation with inflammatory cells/HPF (r = 0.93, p < .0001, 95% C.I. 0.73 to 0.98), with CD3 positivity (r = 0.6, p = .04, 95% C.I. 0.02 to 0.9), with capillary proliferation/HPF (r = 0.85, p = .003, 95% C.I. 0.43 to 0.96) and with percentage of cells showing Masson's trichrome stain positivity (r = 0.71, p = .03, 95% C.I. 0.08 to 0.93). In the extrusion group, the capsules demonstrated high inflammation and low fibrosis.

CONCLUSIONS

PMMA orbital spherical implant incites a predominantly T-cell mediated inflammatory response which clinically presents as a peri-implant capsule. Increasing inflammation in the absence of significant fibrosis may be responsible for delayed PMMA implant exposure and extrusion.

Breast Implant Illness: A Biofilm Hypothesis

Background

"Breast implant illness" (BII) is a poorly defined cluster of nonspecific symptoms, attributed by patients as being caused by their breast implants. These symptoms can include joint pain, skin and hair changes, concentration, and fatigue. Many patients complaining of BII symptoms are dismissed as psychosomatic. There are currently over 10,000 peer-reviewed articles on breast implants, but at the time of commencing this study, only 2 articles discussed this entity. At the same time, mainstream media and social media are exploding with nonscientific discussion about BII.

Methods

We have prospectively followed 50 consecutive patients, self-referring for explantation due to BII. We analyzed their preoperative symptoms and followed up each patient with a Patient-Reported Outcome Questionnaire. All implants and capsules were, if possible, removed en bloc. Explanted implants were photographed. Implant shell and capsule sent for histology and microbiological culture.

Results

BII symptoms were not shown to correlate with any particular implant type, surface, or fill. There was no significant finding as to duration of implant or location of original surgery. Chronic infection was found in 36% of cases with Propionibacterium acnes the most common finding. Histologically, synoviocyte metaplasia was found in a significantly greater incidence than a matched cohort that had no BII symptoms (P = 0.0164). Eighty-four percent of patients reported partial or complete resolution of BII symptoms on Patient-Reported Outcome Questionnaire. None of the 50 patients would consider having breast implants again.

Conclusion

The authors believe BII to be a genuine entity worthy of further study. We have identified microbiological and histological abnormalities in a significant number of patients identifying as having BII. A large proportion of these patients have reported resolution or improvement of their symptoms in patient-reported outcomes. Improved microbiology culture techniques may identify a larger proportion of chronic infection, and further investigation of immune phenotypes and toxicology may also be warranted in this group.

Amplification of probiotic bacteria in the skin microbiome to combat Staphylococcus aureus infection

Staphylococcus aureus (S. aureus) is a Gram-positive bacterium. When pathogenic S. aureus colonises onto a skin wound or diabetic ulcer, it can cause a serious infection and lead to amputation or death. The current solutions (e.g. antibiotics and probiotics) are not sufficient enough to be a cure for this infection. To worsen the situation, the S. aureus bacteria continue to develop greater resistance towards antibiotics and are becoming more commonplace. An effective solution is to amplify the activity of probiotic bacteria in the skin microbiome by using selective fermentation initiators (SFIs) to induce fermentation. Our data demonstrated that the numbers of Cutibacterium acnes (C. acnes) and Staphylococcus epidermidis (S. epidermidis), two major bacteria in skin microbiome, on human skin did not vary significantly over the span of seven days. This stimulates probiotic bacteria such as S. epidermidis to produce sufficient short-chain fatty acids (SCFAs) to suppress the growth of S. aureus. The development of this new cure to S. aureus may reduce hospitalisation greatly as S. aureus accounts for the hospitalisation of more than five thousand people per year. Besides antibiotic, probiotics and bacteriophages, SFIs may become novel agents for treatment of infection.

Back to Basics: Could the Preoperative Skin Antiseptic Agent Help Prevent Biofilm-Related Capsular Contracture?

BACKGROUND

Capsular contracture (CC) has remained an unresolved issue throughout history. Strong evidence focuses on bacterial biofilm as its main source. A literature review revealed that more than 90% of bacteria found in capsules and implants removed from patients with Baker grade III-IV CC belong to the resident skin microbiome (Staphylococcus epidermidis, predominant microorganism). The use of an adequate preoperative skin antiseptic may be a critical step to minimize implant contamination and help prevent biofilm-related CC.

OBJECTIVES

The authors sought to compare the effect of 2 different antiseptic skin preparations: povidone-iodine (PVP-I) vs chlorhexidine gluconate (CHG) on CC proportions after primary breast augmentation through a periareolar approach.

METHODS

In June of 2014, The Society for Healthcare Epidemiology of America proposed to use CHG for preoperative skin preparation in the absence of alcohol-containing antiseptic agents as strategy to prevent surgical site infection. The clinical safety committee of a surgical center in Colombia decided to change PVP-I to CHG for surgical site preparation thereafter. The medical records of 63 patients who underwent to primary breast augmentation through a periareolar approach during 2014 were reviewed. In the first 6 months PVP-I was used in 32 patients, and later CHG was employed in 31 patients.

RESULTS

Pearson's chi-squared test to compare CC proportions between subgroups showed a statistically significant difference. The CC proportion was higher for patients who had antisepsis with PVP-I. CC was absent when CHG was employed.

CONCLUSIONS

CHG as preoperative skin antiseptic for primary breast augmentation surgery was more effective than PVP-I to help prevent biofilm-related CC.

LEVEL OF EVIDENCE: 3

Bacterial profile of suction drains and the relationship thereof to surgical-site infections in prosthetic breast reconstruction

BACKGROUND

Despite the increasing popularity of prosthetic breast reconstruction, scant data exist on the microbiological profile of drainage fluid from closed-suction drains and the relationship thereof to surgical-site infections (SSIs) in breast reconstruction surgery. This study aimed to determine whether bacteria isolated from drainage fluid were associated with the development of SSIs, and whether the bacterial profile of drainage fluid could be a clinically useful predictor of SSIs.

METHODS

We performed a retrospective chart review of 61 women who underwent tissue expander/implant or direct-to-implant reconstructions. Patient demographics and culture studies of drainage fluid from suction drains collected on postoperative day 7 were evaluated.

RESULTS

Sixteen patients (26.23%) were culture-positive, and 45 patients (73.77%) were culture-negative. The most frequently isolated bacteria were coagulase-negative staphylococci, followed by Staphylococcus aureus. SSIs were diagnosed in seven patients and were mostly resolved by systemic antibiotics; however, the tissue expander or implant was explanted in two patients. Positive culture of drainage fluid from closed-suction drains was significantly associated with the development of SSIs (P<0.05). The positive predictive value was 37.50%, and the negative predictive value was 97.78%.

CONCLUSIONS

To our knowledge, this study is the first to demonstrate a significant association between the microbiological profile of drainage fluid from closed-suction drains and the development of SSIs in patients with prosthetic breast reconstructions. The high negative predictive value suggests that microbial testing of drainage fluid from closed-suction drains may have clinical utility. Further prospective studies with larger sample sizes are required to confirm our findings.

Surgical Site Irrigation in Plastic Surgery

BACKGROUND

The incidence of infection following breast implant reconstruction remains high at the level of 24%. Surgical site irrigation is commonly used for its prevention. However, the lack of evidence-based guidelines for antibiotic prophylaxis in breast implant surgery necessitates research for optimal irrigation technique.

OBJECTIVES

composition and exposure time of irrigation solution for surgical site infection (SSI) prophylaxis using an in vitro model of a surgical site.

METHODS

The study design was an in vitro model to assess antibiotic irrigation of a surgical site. Strains of Staphylococcus aureus, Methicillin-resistant Staphylococcus aureus, Group A Streptococcus, and Pseudomonas aeruginosa were seeded on blood agar growth medium and irrigated with various antibiotic and antiseptic solutions under different exposure times. The presence and quantity of the colonies grown were estimated after 24-hour incubation. Repetition of the studies for 5 times with each investigated irrigation solution and microorganism was performed. Optimal irrigation agents were chosen based on the ability to achieve sterility with minimal tissue toxicity.

RESULTS

The optimal wound irrigation agents for SSI prophylaxis in our study were found to be 0.05% chlorhexidine or triple antibiotic antibiotic solutions. Adding of vancomycin to the irrigation solutions did not show an increase in their effectiveness. Prolonged irrigation exposure time was necessary to achieve sterility of the in vitro model of a surgical site.

CONCLUSIONS

We recommend 0.05% chlorhexidine or triple antibiotic solution for topical SSI prophylaxis in breast implant surgery. Sufficient time of irrigation can be achieved by maintaining some of the solution in the pocket and delaying drainage for at least 30 minutes.

LEVEL OF EVIDENCE 5

Follistatin and the Breast Implant Capsule

Supplemental Digital Content is available in the text.

Background:

Breast capsular contracture remains an elusive problem faced by plastic surgeons and is the leading long-term complication after breast implantation. Follistatin (Fst) is a protein with known anti-inflammatory and antifibrotic properties and has the potential to limit the severity of diseases associated with inflammation and fibrosis such as capsular contracture. The aim of this study was to examine the effect of Fst288 on capsular fibrosis around silicone implants in a mouse model.

Methods:

BALB/c mice were implanted subcutaneously with untreated silicone implants (baseline control). In the experimental group, immediately after silicone implant insertion, the implant pocket received either a single injection of 1 µg Fst288 or normal saline (internal control). The animals were killed at 3, 5, 7, 14, 28, and 90 days after surgery, and serum, implants, and the surrounding tissue were removed for histological and immunohistochemical analyses.

Results:

Fst288 treatment resulted in significant decreases in capsule thickness at 28 days (P < 0.05) and 3 months (P < 0.001), decreased collagen production at 14 days (P < 0.05) and 3 months (P < 0.01), decreased angiogenesis at 3 months (P < 0.001), decreased α-smooth muscle actin levels at 3 months (P < 0.05), and a decrease in the number of CD45+ cells at days 5 (P < 0.05) and 7 (P < 0.01), respectively, when compared with control implants.

Conclusions:

A single injection of Fst288 at the time of silicone implant insertion into the mice results in a significant reduction in pericapsular inflammation and capsular fibrosis.

Prosthetic Device Infections

The immunocompromised host is a particularly vulnerable population in whom routine and unusual infections can easily and frequently occur. Prosthetic devices are commonly used in these patients and the infections associated with those devices present a number of challenges for both the microbiologist and the clinician. Biofilms play a major role in device-related infections, which may contribute to failed attempts to recover organisms from routine culture methods. Moreover, device-related microorganisms can be difficult to eradicate by antibiotic therapy alone. Changes in clinical practice and advances in laboratory diagnostics have provided significant improvements in the detection and accurate diagnosis of device-related infections. Disruption of the bacterial biofilm plays an essential role in recovering the causative agent in culture. Various culture and nucleic acid amplification techniques are more accurate to guide directed treatment regimens. This chapter reviews the performance characteristics of currently available diagnostic assays and summarizes published guidelines, where available, for addressing suspected infected prosthetic devices.

Improving Antimicrobial Regimens for the Treatment of Breast Tissue Expander-Related Infections

Background:

Infectious complications in tissue expander (TE) breast reconstruction can be devastating and costly. Therefore, to optimize care, we examined patient’s demographics, microbiology of TE infections, and the efficacy of empiric antimicrobial regimens and thereafter generated an algorithm for the treatment of these complex infections.

Methods:

We retrospectively reviewed all patients who underwent TE breast reconstruction between 2003 and 2012 and analyzed those patients who developed a “definite” device-related infection leading to TE explantation and had a positive intraoperative culture.

Results:

A total of 3,082 patients underwent immediate breast reconstruction with TE. Of these, 378 patients (12.3%) developed an infection, 189 (6.1%) eventually proceed with explantation, and 118 (3.8%) had a positive intraoperative culture. Gram-positive organisms caused 73% of infections, and Gram-negative organisms caused 27% of infections. Narrow-spectrum empiric antimicrobials with predominantly Gram-positive coverage were deemed appropriate in only 62% of cases, and those with Gram-negative coverage were appropriate in 46%. Broad-spectrum antimicrobials were used in 47% of cases, mainly recommended by infectious disease specialists, and were considered appropriate in >90% of the occasions.

Conclusions:

Current empiric antibiotic regimens do not cover the vast spectrum of organisms causing TE infections. To increase the salvage rate of an infected TE, at the first sign of infection, in addition to benefiting with an infectious diseases consultation, empiric coverage with broad-spectrum antibiotics active against biofilm-embedded organisms should be administered.

Breast Implant-Associated Infections: The Role of the National Surgical Quality Improvement Program and the Local Microbiome

BACKGROUND

The most common cause of surgical readmission after breast implant surgery remains infection. Six causative organisms are principally involved: Staphylococcus epidermidis and S. aureus, Escherichia, Pseudomonas, Propionibacterium, and Corynebacterium. The authors investigated the infection patterns and antibiotic sensitivities to characterize their local microbiome and determine ideal antibiotic selection.

METHODS

A retrospective review of 2285 consecutive implant-based breast procedures was performed. Included surgical procedures were immediate and delayed breast reconstruction, tissue expander exchange, and cosmetic augmentation. Patient demographics, chemotherapy and/or irradiation status, implant characteristics, explantation reason, time to infection, microbiological data, and antibiotic sensitivities were reviewed.

RESULTS

Forty-seven patients (2.1 percent) required inpatient admission for antibiotics, operative explantation, or drainage by interventional radiology. The infection rate varied depending on surgical procedure, with the highest rate seen in mastectomy and immediate tissue expander reconstruction (6.1 percent). The mean time to explantation was 41 days. Only 50 percent of infections occurred within 30 days of the indexed National Surgical Quality Improvement Program operation. The most commonly isolated organisms were coagulase-negative Staphylococcus (27 percent), methicillin-sensitive S. aureus (25 percent), methicillin-resistant S. aureus (7 percent), Pseudomonas (7 percent), and Peptostreptococcus (7 percent). All Gram-positive organisms were sensitive to vancomycin, linezolid, tetracycline, and doxycycline; all Gram-negative organisms were sensitive to gentamicin and cefepime.

CONCLUSIONS

Empiric antibiotics should be vancomycin (with the possible inclusion of gentamicin) based on their broad effectiveness against the authors' unique microbiome. Minor infections should be treated with tetracycline or doxycycline as a second-line agent. National Surgical Quality Improvement Program data are adequate for monitoring and comparing breast infections but certainly not comprehensive.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

The Relationship of Bacterial Biofilms and Capsular Contracture in Breast Implants

Capsular contracture is a common sequelae of implant-based breast augmentation. Despite its prevalence, the etiology of capsular contracture remains controversial. Numerous studies have identified microbial biofilms on various implantable materials, including breast implants. Furthermore, biofilms have been implicated in subclinical infections associated with other surgical implants. In this review, we discuss microbial biofilms as a potential etiology of capsular contracture. The review also outlines the key diagnostic modalities available to identify the possible infectious agents found in biofilm, as well as available preventative and treatment measures.

Staphylococcus aureus infections: epidemiology, pathophysiology, clinical manifestations, and management

Staphylococcus aureus is a major human pathogen that causes a wide range of clinical infections. It is a leading cause of bacteremia and infective endocarditis as well as osteoarticular, skin and soft tissue, pleuropulmonary, and device-related infections. This review comprehensively covers the epidemiology, pathophysiology, clinical manifestations, and management of each of these clinical entities. The past 2 decades have witnessed two clear shifts in the epidemiology of S. aureus infections: first, a growing number of health care-associated infections, particularly seen in infective endocarditis and prosthetic device infections, and second, an epidemic of community-associated skin and soft tissue infections driven by strains with certain virulence factors and resistance to β-lactam antibiotics. In reviewing the literature to support management strategies for these clinical manifestations, we also highlight the paucity of high-quality evidence for many key clinical questions.

Propionic acid and its esterified derivative suppress the growth of methicillin-resistant Staphylococcus aureus USA300

Previously, we demonstrated that Propionibacterium acnes, a human skin commensal bacterium, ferments glycerol into short-chain fatty acids, including propionic acid. Propionic acid suppressed the growth of Staphylococcus aureus USA300, a community-acquired methicillin-resistant bacterium, in vitro and in vivo. In this study, it is demonstrated that the anti-USA300 activity of propionic acid persisted after buffering the acid with 4-(2-hydroxyethyl)-1- piperazineethanesulfonic acid. This suggests that the growth suppression of USA300 mainly resulted from the antimicrobial activity of propionic acid per se and not from the acidity of the medium. In addition, proprionic acid significantly reduced the intracellular pH of USA300 and exhibited broad-spectrum antimicrobial activity against Escherichia coli and Candida albicans. P. acnes showed a higher tolerance to propionic acid. Next, an esterified derivative of propionic acid was synthesised. Propionic acid and the esterified derivative were equivalent in their efficacy to suppress the growth of USA300 in vitro. The esterified derivative thus provides an alternative to propionic acid as an antimicrobial agent against S. aureus.

In vitro and in vivo investigation of the influence of implant surface on the formation of bacterial biofilm in mammary implants

BACKGROUND

Capsular contracture remains the most common complication following breast augmentation surgery, and evidence suggests that bacterial biofilm on the implant surface is responsible. The authors investigated whether the interaction of bacterial biofilm with implants independently determines progression to capsule formation. They also studied the rate of bacterial growth and adhesion to implants.

METHODS

Sixteen adult female pigs had 121 breast implants inserted. Sixty-six implants-23 smooth and 43 textured-were inoculated with a human strain of Staphylococcus epidermidis and received no other treatment. After an average period of 19 weeks, Baker grading was performed and implants were retrieved. For the in vitro study, samples underwent both quantitative bacterial analysis and imaging using confocal laser scanning and scanning electron microscopy.

RESULTS

At explantation, there was no significant difference (p = 1.0) in the presence of capsular contracture (Baker grade III and IV) between smooth (83 percent) and textured implants (84 percent). Biofilm was confirmed on 60 of the 66 capsules. Capsules from smooth and textured implants had the same number of infecting bacteria (textured: 3.01 × 10 bacteria/g; smooth: 3.00 × 10 bacteria/g). In vitro, the surface of textured implants showed 11-, 43-, and 72-fold more bacteria at 2, 6, and 24 hours, respectively, compared with smooth implants (p < 0.001). These findings were confirmed by imaging analysis.

CONCLUSIONS

These results show that textured implants develop a significantly higher load of bacterial biofilm in comparison with smooth implants. Furthermore, in vivo, once a threshold of biofilm forms on either smooth or textured implant surfaces, there seems to be an equal propensity to progress to capsular contracture.

Porphyrin metabolisms in human skin commensal Propionibacterium acnes bacteria: potential application to monitor human radiation risk

Propionibacterium acnes (P. acnes), a Gram-positive anaerobic bacterium, is a commensal organism in human skin. Like human cells, the bacteria produce porphyrins, which exhibit fluorescence properties and make bacteria visible with a Wood's lamp. In this review, we compare the porphyrin biosynthesis in humans and P. acnes. Also, since P. acnes living on the surface of skin receive the same radiation exposure as humans, we envision that the changes in porphyrin profiles (the absorption spectra and/or metabolism) of P. acnes by radiation may mirror the response of human cells to radiation. The porphyrin profiles of P. acnes may be a more accurate reflection of radiation risk to the patient than other biodosimeters/biomarkers such as gene up-/down-regulation, which may be non-specific due to patient related factors such as autoimmune diseases. Lastly, we discuss the challenges and possible solutions for using the P. acnes response to predict the radiation risk.

Propionibacterium acnes: an underestimated pathogen in implant-associated infections

The role of Propionibacterium acnes in acne and in a wide range of inflammatory diseases is well established. However, P. acnes is also responsible for infections involving implants. Prolonged aerobic and anaerobic agar cultures for 14 days and broth cultures increase the detection rate. In this paper, we review the pathogenic role of P. acnes in implant-associated infections such as prosthetic joints, cardiac devices, breast implants, intraocular lenses, neurosurgical devices, and spine implants. The management of severe infections caused by P. acnes involves a combination of antimicrobial and surgical treatment (often removal of the device). Intravenous penicillin G and ceftriaxone are the first choice for serious infections, with vancomycin and daptomycin as alternatives, and amoxicillin, rifampicin, clindamycin, tetracycline, and levofloxacin for oral treatment. Sonication of explanted prosthetic material improves the diagnosis of implant-associated infections. Molecular methods may further increase the sensitivity of P. acnes detection. Coating of implants with antimicrobial substances could avoid or limit colonization of the surface and thereby reduce the risk of biofilm formation during severe infections. Our understanding of the role of P. acnes in human diseases will likely continue to increase as new associations and pathogenic mechanisms are discovered.

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.

Bacterial biofilms and capsular contracture in patients with breast implants

Background

It has been hypothesized that bacterial biofilms on breast implants may cause chronic inflammation leading to capsular contracture. The association between bacterial biofilms of removed implants and capsular contracture was investigated.

Methods

Breast implants explanted between 2006 and 2010 at five participating centres for plastic and reconstructive surgery were investigated by sonication. Bacterial cultures derived from sonication were correlated with patient, surgical and implant characteristics, and the degree of capsular contracture.

Results

The study included 121 breast implants from 84 patients, of which 119 originated from women and two from men undergoing gender reassignment. Some 50 breast prostheses were implanted for reconstruction, 48 for aesthetic reasons and 23 implants were used as temporary expander devices. The median indwelling time was 4·0 (range 0·1–32) years for permanent implants and 3 (range 1–6) months for temporary devices. Excluding nine implants with clinical signs of infection, sonication cultures were positive in 40 (45 per cent) of 89 permanent implants and in 12 (52 per cent) of 23 temporary devices. Analysis of permanent implants showed that a positive bacterial culture after sonication correlated with the degree of capsular contracture: Baker I, two of 11 implants; Baker II, two of ten; Baker III, nine of 23; and Baker IV, 27 of 45 (P &lt; 0·001). The most frequent organisms were Propionibacterium acnes (25 implants) and coagulase-negative staphylococci (21).

Conclusion

Sonication cultures correlated with the degree of capsular contracture, indicating the potential causative role of bacterial biofilms in the pathogenesis of capsular contracture. Registration number: NCT01138891 (http://www.clinicaltrials.gov).

Fermentation of Propionibacterium acnes, a commensal bacterium in the human skin microbiome, as skin probiotics against methicillin-resistant Staphylococcus aureus

Bacterial interference creates an ecological competition between commensal and pathogenic bacteria. Through fermentation of milk with gut-friendly bacteria, yogurt is an excellent aid to balance the bacteriological ecosystem in the human intestine. Here, we demonstrate that fermentation of glycerol with Propionibacterium acnes (P. acnes), a skin commensal bacterium, can function as a skin probiotic for in vitro and in vivo growth suppression of USA300, the most prevalent community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA). We also promote the notion that inappropriate use of antibiotics may eliminate the skin commensals, making it more difficult to fight pathogen infection. This study warrants further investigation to better understand the role of fermentation of skin commensals in infectious disease and the importance of the human skin microbiome in skin health.

The response of human skin commensal bacteria as a reflection of UV radiation: UV-B decreases porphyrin production

Recent global radiation fears reflect the urgent need for a new modality that can simply determine if people are in a radiation risk of developing cancer and other illnesses. Ultraviolet (UV) radiation has been thought to be the major risk factor for most skin cancers. Although various biomarkers derived from the responses of human cells have been revealed, detection of these biomarkers is cumbersome, probably requires taking live human tissues, and varies significantly depending on human immune status. Here we hypothesize that the reaction of Propionibacterium acnes (P. acnes), a human resident skin commensal, to UV radiation can serve as early surrogate markers for radiation risk because the bacteria are immediately responsive to radiation. In addition, the bacteria can be readily accessible and exposed to the same field of radiation as human body. To test our hypothesis, P. acnes was exposed to UV-B radiation. The production of porphyrins in P. acnes was significantly reduced with increasing doses of UV-B. The porphyrin reduction can be detected in both P. acnes and human skin bacterial isolates. Exposure of UV-B to P. acnes- inoculated mice led to a significant decrease in porphyrin production in a single colony of P. acnes and simultaneously induced the formation of cyclobutane pyrimidine dimers (CPD) in the epidermal layers of mouse skin. Mass spectrometric analysis via a linear trap quadrupole (LTQ)-Orbitrap XL showed that five peptides including an internal peptide (THLPTGIVVSCQNER) of a peptide chain release factor 2 (RF2) were oxidized by UV-B. Seven peptides including three internal peptides of 60 kDa chaperonin 1 were de-oxidized by UV-B. When compared to UV-B, gamma radiation also decreased the porphyrin production of P. acnes in a dose-dependent manner, but induced a different signature of protein oxidation/de-oxidation. We highlight that uncovering response of skin microbiome to radiation will facilitate the development of pre-symptomatic diagnosis of radiation risk in a battlefield exposure, nuclear accidents, terrorist attacks, or cancer imaging/therapy.

Prevention of biofilm-induced capsular contracture with antibiotic-impregnated mesh in a porcine model

BACKGROUND

A growing body of evidence implicates subclinical (biofilm) infection around breast implants as an important cause of capsular contracture (CC).

OBJECTIVES

The authors use an in vivo porcine model to investigate the potential of antibiotic-impregnated mesh as a prophylactic measure against biofilm formation and CC.

METHODS

A total of 28 implants (14 untreated controls, 14 treated with antibiotic mesh) were inserted into 5 adult female pigs. All implants and pockets were inoculated with a human clinical strain of Staphylococcus epidermidis. The implants were left in situ for 16 weeks and then analyzed for contracture using both Baker grading and applanation tonometry. The presence of biofilm infection was assessed by subsequent microbiological analysis of implants and capsules.

RESULTS

One untreated implant had extruded and was excluded from analysis. The tissue surrounding the 13 untreated control implants had Baker Grade III/IV CC, whereas no CC was identified around the 14 antibiotic mesh-treated implants. This difference was highly significant (P < .001). Tonometry findings were consistent with the Baker assessments. Although bacterial biofilm was detected on all implants and capsules, the biofilms on the antibiotic-treated implants and surrounding capsules were generally single-layered or isolated in contrast to the multilayer biofilms found on untreated implants and capsules.

CONCLUSIONS

Based on the findings from this study of a porcine model, the use of antibiotic-impregnated mesh reduces bacterial access to breast implants at the time of surgical insertion and may subsequently protect against subclinical infection and CC.

Infection risk from surgeons' eyeglasses

PURPOSE

To assess bacterial contamination of 20 eyeglasses from surgeons.

METHODS

40 samples were taken from the nose pad (n=20) and earpiece (n=20) of 20 eyeglasses from orthopaedic surgeons using a sterile swab stick soaked in sterile distilled water. Swabs were incubated and inoculated onto 3 plates: Staphylococcus/Streptococcus agar plate, Mannitol salt plate, and Chromogenic agar plate. Organisms isolated were identified.

RESULTS

Of 20 eyeglasses, 19 were contaminated with Staphylococcus epidermidis (3 of them additionally grew S haemolyticus or S xylosus) and the remaining one grew S aureus .

CONCLUSION

Eyeglasses are a source of surgical infection. Contamination can be caused by direct contact of the eyeglasses to the wound and indirect contact by the surgeon's fingers, splashes from saline irrigation, and through air. Therefore, disinfection should be performed for eyeglasses of surgeons. The use of surgical visor masks or filtered exhaust helmets (space suits) are alternatives.

Capsular contracture - What are the risk factors? A 14 year series of 1400 consecutive augmentations

The modern era of breast augmentation and reconstruction began in 1963, with the introduction of silicone implants by Cronin and Gerow. To date, the demand for cosmetic augmentation continues to increase exponentially. However, whilst the surgical techniques and quality of mammary prosthesis have improved dramatically in recent years, patients are still confronted with significant potential complications. We performed a retrospective study of 1400 consecutive primary breast augmentations performed between March 1995 and March 2009 by a single surgeon. We specifically examined the incidence of capsular contracture and the possible causative factors. Follow up ranged from 1 to 16 years. The mean age at the time of surgery was 32.8 years and fill volume was between 195 ml and 800 ml. Our capsular contracture rate was in the order of 26.9%. BMI >30, fill volumes >350 ml, smoking and alcohol consumption did not significantly increase capsular contracture rate. Implant type, pregnancy, infection and delayed haematoma significantly increased the risk of capsular contracture. Our series has given us a unique insight into the frequency of capsular contracture and identified several risk factors. To our knowledge, this is the first report of pregnancy having a significant effect on capsular contracture. We now counsel patients thoroughly into the detrimental effects of pregnancy on the implant.