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.

In Vitro Evaluation of Common Antimicrobial Solutions Used for Breast Implant Soaking and Breast Pocket Irrigation-Part 1: Efficacy Against Planktonic Bacteria.

BACKGROUND: Planktonic bacteria can be inadvertently introduced during breast surgery procedures, which are hypothesized to lead to complications such as infection, capsular contracture, breast implant-associated anaplastic large cell lymphoma, and a prolonged local inflammatory response. The utilization of antimicrobial solutions such as triple antibiotic solution (TAB) and/or 10% povidone-iodine (PI) in breast pocket irrigation or implant soaking has been proposed to reduce planktonic bacterial attachment and potential complications. OBJECTIVES: A series of in vitro assessments were performed to evaluate the antimicrobial utility of TAB and PI, either alone or in combination, against planktonic bacteria. METHODS: Planktonic gram-positive and gram-negative bacterial strains were exposed to TAB and PI ± TAB for up to 10 minutes in a bacterial time-kill assay. The efficacy of various dilutions of PI as well as the effects of serum protein on PI efficacy were also investigated. RESULTS: TAB was ineffective at the timeframes tested (≤10 minutes) when utilized alone; however, when utilized with PI, significant log reduction of all tested planktonic species was achieved. PI alone was also effective, even including dilute concentrations (eg, 0.5% PI), although the presence of serum proteins required higher concentrations of PI (eg, 2.5%) to eradicate the bacterial load. CONCLUSIONS: Our data suggest PI-containing solutions may be preferred over either saline or TAB without PI for primary breast pocket irrigation and implant soaking in primary breast surgeries as a means to significantly reduce planktonic bacteria. These data provide an impetus for surgeons to re-evaluate the efficacy of TAB solution in these clinical settings.

Betadine Soaking of Silicone Coupons Minimally Impacts Acellular Dermal Matrix Incorporation in a Preclinical Primate Model.

BACKGROUND: Microbial pathogens local to prosthetic breast devices may promote infection, inflammation, and capsular contracture. Although antimicrobial solutions have been used, their effects on human acellular dermal matrix (HADM) incorporation when used with prosthetic devices are unknown. The authors' objective was to histologically assess the effect of 10% povidone iodine (PI)-saturated tissue expander (TE) exposure on HADM biological response in a primate model. They hypothesized that PI exposure would not negatively affect the HADM biological response. METHODS: Samples (1.5 × 1.5 cm) from smooth silicone TEs were saturated in saline or PI for 2 minutes and sutured to HADM to create HADM/TE constructs. Primates implanted subcutaneously with saline ( n = 9) and PI-treated HADM/TE ( n = 9) construct pairs were evaluated histologically for biological response after 2 or 4 weeks by means of a host response scoring scale (1 to 9), including recellularization, neovascularization, and inflammation. Inflammatory cells (eosinophils, lymphocytes, neutrophils, histiocytes, foreign-body giant cells) and evidence of HADM remodeling (fibroblasts, vessels) were further evaluated by means of a cell-specific scoring scale (0 to 4) and corroborated by immunostaining (CD3, CD20, CD68, FSP-1, collagen type IV). RESULTS: Mean histology scores were similar between saline- and PI-exposed HADM at 2 weeks (5.3 ± 0.9 and 5.6 ± 0.5; P = 0.52) and 4 weeks (4.6 ± 1.0 and 4.2 ± 0.9; P = 0.44). There was no difference in inflammatory cell presence at 2 and 4 weeks between groups. Fibroblast infiltration differences were insignificant between groups but exhibited trends toward an increase between time points for saline (1.6 ± 0.7 to 1.8 ± 0.8) and PI (1.3 ± 0.8 to 1.8 ± 1.0) groups, suggesting HADM incorporation over time. CONCLUSION: Data suggest that HADM exposure to PI-treated TEs does not negatively affect inflammation, vascularization, recellularization, incorporation, or host response to HADM in this model. CLINICAL RELEVANCE STATEMENT: PI is a surgical pocket irrigant used to address bacterial colonization, but its impact on ADM incorporation is unknown. This study demonstrates similar biologic response to ADMs adjacent to PI- or saline-saturated TEs in a primate model.

The effects of normal saline instillation in conjunction with negative pressure wound therapy on wound healing in a porcine model.

UNLABELLED: Acute and chronic wounds impact the lives of millions of patients. Since its introduction, negative pressure wound therapy using reticulated open cell foam (NPWT/ROCF) has significantly improved the healing outcome for many of these wounds. METHODS: The effects of intermittent instillation of normal saline in conjunction with NPWT were investigated to determine if instillation therapy provides additional benefits in wound healing. Conventional NPWT/ROCF as delivered by V.A.C.® Therapy was compared to V.A.C. Instill® Therapy with normal saline in the treatment of porcine full-thickness excisional wounds. Wounds were treated with NPWT/ROCF or NPWT/ROCF with instillation therapy at approximately 4 cycles of normal saline instillation per day and dwell times of either 5 or 60 minutes for the instilled saline on the wound bed. RESULTS: Instillation therapy with normal saline at either dwell time elicited a faster rate of wound filling with granulation tissue that contained an increase in total collagen content compared to continuous NPWT/ROCF alone. Analyses of wound contraction and the hydration state of the treated tissue exhibited no apparent differences between the experimental instillation therapy groups and the control NPWT/ROCF group. CONCLUSION: Collectively, these data suggest that instillation therapy with normal saline may lead to wound fill with higher quality granulation tissue composed of increased collagen following wounding of cutaneous tissue compared to the use of NPWT/ROCF alone.  .

Characterization of microglial attachment and cytokine release on biomaterials of differing surface chemistry.

The clinical usefulness of central nervous system recording electrodes is currently limited by inconsistent long-term performance that is believed to be governed by the brain tissue response to the implant. In this study, we observed persistent macrophage biomarker expression at the biotic-abiotic interface surrounding implanted electrodes over a 12-week indwelling period. Using the cell type-specific marker CD11b to examine the cells attached to electrodes retrieved over the indwelling period, we found that most of the cells were activated microglia, the resident macrophage of brain tissue, indicating that the implanted electrodes behave as a persistent inflammatory stimulus. To determine the potential usefulness of different materials as coatings for implanted electrodes, we examined brain-derived microglial cell attachment and cytokine release on a number of medically relevant materials. Our results suggest that activated microglia attach to many of the materials used as external coatings for electrode manufacture, and likely serve as a source of pro-inflammatory and neurotoxic cytokines that may be responsible for reducing the biocompatibility of such implants. Our results also indicate that low protein-binding coatings may be useful in reducing microglial attachment upon implantation in brain tissue and may provide a means of improving electrode biocompatibility.

The Safety, Effectiveness, and Efficiency of Autologous Fat Grafting in Breast Surgery.

BACKGROUND: For years, the safety and effectiveness of autologous fat grafting (AFG) for breast reconstruction have been in question, with particular concern over fat necrosis, calcifications, cyst formation, and interfering with the detection of breast cancer. However, increasing evidence suggests that the complication rates and clinical results are generally acceptable to both clinicians and patients. The emerging challenge is the numerous AFG techniques and systems, where there are limited knowledge and data. The objective of this study was to conduct a literature review that focuses on the safety, effectiveness, and efficiency of various AFG techniques as applied to the breast. METHODS: A PubMed search using terms related to AFG was performed over a 5-year period (April 1, 2010-April 30, 2015). Original articles focused on AFG to the breast, with outcomes on safety, effectiveness, and efficiency, were included. RESULTS: Five hundred ninety-eight articles were identified with 36 articles included (n = 4306 patients). Satisfaction rates were high although the prevalence of complications was low-similar to previous findings. Seven studies reported average operating room time with an overall mean of 125 minutes (range: 40-210). The mean volume of fat harvested was 558 mL (range: 120-1299), and fat injected was 145 mL (range: 20-607). A positive association between injection volume and operating time was observed. CONCLUSIONS: This review validates previous findings on the safety and effectiveness of AFG to the breast and highlights its efficiency. The efficiency data available, although limited, suggest that there is an opportunity to achieve time and cost savings while not sacrificing safety and effectiveness.