Protocol for Prevention and Monitoring of Surgical Site Infections in Implant-Based Breast Reconstruction: Preliminary Results

Monitoring and Management of Infection following Prepectoral Implant-based Breast Reconstruction: Retrospective Analysis of Conservative Treatment Versus Implant Removal

Background

Infection following implant-based breast reconstruction (IBBR) represents a major complication, potentially leading to prosthesis removal. However, no clear protocol for its prevention and management exists. This study aimed to evaluate the efficacy of conservative treatment methods in preventing implant removal and analyze factors responsible for implant loss in the context of prepectoral IBBR.

Methods

A single-institution retrospective review chart of patients undergoing immediate prepectoral IBBR for breast cancer between October 2020 and January 2024 was performed. The inclusion criteria were the presence of at least one of the following postoperative complications: seromas, cellulitis, clinically suspected prosthesis infection, and confirmed periprosthetic infection. A comparative analysis between patients with successful conservative treatment (ultrasound-guided aspiration and antibiotic therapy) and patients undergoing implant removal was performed.

Results

A total of 219 immediate prepectoral IBBR cases were identified, 38 of which met inclusion criteria. Implant removal was required in 11 cases, whereas implant retention was achieved in 27 patients with conservative treatment. Implants were invariably removed when bacterial cultures were positive (P < 0.05). Conversely, when pathogens were not identified, the likelihood of implant removal decreased significantly (P < 0.05). Conservative treatment allowed implant salvage in all patients presenting with postoperative seroma alone, without other associated complications (P < 0.05).

Conclusions

This study suggests that when bacterial cultures are positive, implant removal is unavoidable. Conversely, noninfected seromas correlated with implant salvage. Infections from Bacillus pumilus and Corynebacterium pseudodiphtheriticum are reported for the first time.

Concentration of Povidone-Iodine Pocket Irrigation in Implant-Based Breast Surgery: A Scoping Review

BACKGROUND

In implant-based breast surgery, microbial contamination of implant surfaces predisposes complications such as overt periprosthetic infection and has been linked to capsular contracture (CC). Anti-microbial practices, including povidone-iodine (PVP-I) breast pocket irrigation, are routinely employed to minimise these risks. No standardised protocol for using this antiseptic exists, particularly concerning the ideal concentration. This review investigates how PVP-I concentration affects outcomes in these procedures while highlighting research gaps.

METHODS

Using PRISMA-ScR guidelines, a systematic search was conducted across MEDLINE, Embase, Scopus, and PubMed databases from their inception to June 2024. Studies were screened using pre-determined criteria for inclusion. The methodological quality of relevant studies was assessed using the MINORS tool. Data regarding basic characteristics, PVP-I irrigation implementation, and outcomes (primarily periprosthetic infection and CC) were extracted for analysis.

RESULTS

Nine articles, primarily observational studies, and retrospective analyses were included. These mainly focused on breast augmentation with a few including reconstruction. There was considerable heterogeneity in surgical techniques, and reported PVP-I concentrations ranged from 4 to 20%. This was further confounded by frequent mixing of irrigation solution with antibiotics. Although infection and CC rates were frequently reported, most studies did not specify outcome data for patients receiving PVP-I irrigation.

CONCLUSIONS

While PVP-I irrigation is extensively used in implant surgeries, the current evidence base is insufficient to determine the optimal concentration and application techniques. This review underscores the need for further detailed research to establish evidence-based guidelines for PVP-I use, aiming to improve patient care and surgical outcomes in breast surgery.

LEVEL OF EVIDENCE III

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A Multi-Center Retrospective Observational Analysis of Three-Year Experience of Our Protocol for Prevention and Monitoring of Surgical Site Infections in Implant-Based Breast Reconstruction

BACKGROUND

With the rise in the mastectomy rate, the number of patients who choose to undergo postmastectomy reconstruction has been increasing, and implant-based procedures are the most performed methods for postmastectomy breast reconstruction. Among the possible complications, the most feared is the loss of reconstruction. It can be related to several reasons, but one of the most common is infection of the implant, which can lead to prolonged antibiotic treatment, undesired additional surgical procedures, increased incidence of capsular contracture, and unsatisfactory aesthetics results, with a huge psychological impact on patients.

AIMS

The primary intent of this study is to analyze the status of infection rates at our institution and evaluate the effectiveness of our prevention protocol since its introduction. Secondly, we compared data of the surgical site infections (SSIs) after implant-based breast reconstruction at Trieste Hospital, where the protocol has been employed since 2020, and in another center, where plastic surgeons of our team are involved, with different prevention procedures.

METHODS AND RESULTS

We enrolled 396 female patients, who underwent implant-based breast reconstruction, using definitive mammary implants or breast tissue expanders, with or without ADM (acellular dermal matrix), both for breast cancer and risk-reducing surgery in BRCA1/2 patients. Patients treated at the Hospital of Trieste, with the use of the prevention protocol, were considered the experimental group (group 1), while patients treated in Gorizia by the same breast team with standardized best-practice rules, but without the use of the prevention protocol, were considered the control group (group 2). Infected patients were 5 in the first group (1.7%) and 8 in the second one (7.9%), with a global infection rate of 3.2%.

CONCLUSION

After the introduction of our prevention protocol, we faced a lower incidence of infection after breast surgery with implants or tissue expanders.

The Impact of Nasal Staphylococcus aureus Carriage on Surgical-Site Infections after Immediate Breast Reconstruction: Risk Factors and Biofilm Formation Potential

BACKGROUND Despite the benefits of implant-based breast reconstruction in patients with breast cancer, the procedure can be complicated by surgical site infections (SSI). This study aimed to evaluate the association between nasal carriage of Staphylococcus aureus strains and the incidence of SSI among patients who underwent reconstructive procedures. We also assessed the ability of colonizing S. aureus strains to form biofilm. MATERIAL AND METHODS Medical data from 124 patients with 132 post-mastectomy breast reconstructions performed at the Oncology Center in Bydgoszcz, Poland, between June 2020 and August 2021 were analyzed. A 90-day incidence of SSI was found in 7/132 reconstructions (5.3%). The study group included 132 reconstructions, and was divided into those with infection (n=7) and without infection (n=125). Between-group differences were assessed using the t test for continuous variables and chi-square test for categorical variables. Biofilm formation among 32 S. aureus strains was determined by using quantitative and qualitative assays. RESULTS There were no significant differences in relation to the patients' S. aureus colonization status. Infections occurred both in patients colonized and not colonized with S. aureus. S. aureus nasal carriage did not affect the rate of SSI at 90 days after surgery. About 97.0% of the strains had a strong capacity for biofilm formation. CONCLUSIONS There was no association between nasal carriage of strains of S. aureus and the incidence of SSI. However, further investigations on a larger group of patients and longer observation time are needed to investigate this potential risk factor in detail.

Impact of Surgical Care Bundle on Surgical Site Infection after Non-Reconstructive Breast Cancer Surgery: A Single-Centre Retrospective Comparative Cohort Study

BACKGROUND

Surgical-site infections (SSIs) are the commonest cause of healthcare-related infections. Although a surgical care bundle (SCB), defined as a group of preventative measures, is effective in reducing SSIs, it has not been well documented in breast cancer surgery. We aimed to investigate the impact of SCB on SSI.

METHODS

A single-centre retrospective comparative cohort study between 2016 and 2020 was carried out. An SCB including eight different measures was implemented in October 2018 at Sahlgrenska University Hospital, Sweden. Patients who underwent non-reconstructive breast cancer surgery were included for analysis. The primary endpoint was SSI within 30 days after surgery.

RESULTS

Overall, 10.4% of patients (100/958) developed SSI. After SCB implementation, the overall SSI rate reduced from 11.8% to 8.9% (p = 0.15). The largest SSI rate reduction was seen in the subgroup that underwent breast conservation and sentinel lymph node biopsy (SLNB), from 18.8% to 9.8% (p = 0.01). In this multivariable analysis adjusting for patient and treatment factors, the implementation of SCB resulted in a statistically significant reduction in SSI risk (OR 0.63, 95% CI 0.40-0.99, p = 0.04).

CONCLUSIONS

The implementation of a SCB could reduce the incidence of SSI in breast cancer surgery.

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.

Effect of proprioceptive neuromuscular facilitation technique on the treatment of frozen shoulder: a pilot randomized controlled trial

Background and objectives

Frozen shoulder is a common painful disease of the shoulder joint characterized by structural changes in the shoulder joint, restricting both active and passive shoulder joint activities. Proprioceptive neuromuscular facilitation (PNF) effectively improved and maintained the range of motion; however, it is not clear whether it can improve the shoulder joint structure in patients with frozen shoulder. This pilot study used magnetic resonance imaging (MRI) observation to assess the improvement of the local structure of the shoulder joint upon PNF treatment to elucidate a target based on structure for the treatment of frozen shoulder.

Materials and methods

Forty-eight patients with frozen shoulder were randomly divided into the traditional manual therapy group and the PNF technique group. Changes in the thicknesses of the coracohumeral ligament (CHL) and capsule in axillary recess (CAR) of the shoulder joint were observed via MRI upon admission and at 4 weeks after treatment. A visual analog scale (VAS) and passive shoulder range of motion (ROM) at abduction, anteflexion and external rotation position were used to evaluate the improvement of shoulder joint pain and function in the initial, mid-term, and discharge of the two groups of patients.

Results

The primary outcome results shown that the PNF joint mobilization significantly reduced the thickness of the CHL (p = 0.0217) and CAR (p = 0.0133). Compared with simple joint mobilization, The mid-term and discharge rehabilitation assessment results showed that PNF has a better effect on shoulder pain. At the mid-term evaluation, the ROM of the PNF group was significantly better than that of the Control group in the three directions (p < 0.05).

Conclusion

As an adjunctive therapy, PNF can improve the shoulder joint structure of patients with frozen shoulder and is an effective treatment strategy for frozen shoulder.