Devil's Advocate: Evidence-Based Recommendation for "One Breast-One Insertion Funnel" Policy.

BACKGROUND: Rates of capsular contracture have reduced significantly since the use of insertion funnels to place breast implants became routine. However, due to financial constraints, the same funnel is usually used for implantation of both sides. OBJECTIVES: The aim of this study was to determine whether the risk of capsular contracture is higher for the second breast when the same insertion funnel is used for both breasts. METHODS: The authors collected a sample of the insertion funnel tip immediately after removing the funnel from its sterile packaging and another tip sample after the funnel had been used to insert the first implant. These samples were sent for microbiological culture evaluations. Capsular contracture rates in the first implanted breast vs the second implanted breast were then retrospectively analyzed. RESULTS: All samples taken from the funnel before the first implantation showed no bacterial growth. All 10 samples taken from the funnel after the first implantation showed organism growth (8 were positive for Staphylococcus epidermidis and 2 for Cutibacterium acnes). Retrospective analysis of the results revealed that the overall capsular contracture rate had reduced after the authors began to use insertion funnels. However, this complication was still more common on the second implanted breast. CONCLUSIONS: Surgeons should consider the use of separate insertion funnels for each breast. This might help to slightly reduce the incidence of capsular contracture.See the abstract translated into Hindi, Portuguese, Korean, German, Italian, Arabic, and Chinese (Simplified and Traditional) online here: https://doi.org/10.1093/asj/sjad288.

Preventing Bacterial Contamination of Breast Implants Using Infection Mitigation Techniques: An In Vitro Study.

BACKGROUND: Bacterial contamination of implants has been linked to biofilm formation and subsequent infection, capsular contracture, and breast implant-associated anaplastic large cell lymphoma. Reducing contamination during implant insertion should therefore reduce biofilm formation disease sequelae. OBJECTIVES: The aim of this study was to compare levels of contamination between preventative techniques. METHODS: A model to simulate the passage of implants through a skin incision was designed that utilized a sterile textured polyvinyl plastic sheet contaminated with Staphylococcus epidermidis. In the first stage of the polyvinyl contamination model, implants were subject to infection-mitigation techniques and passed through the incision, then placed onto horse blood agar plates and incubated for 24 hours. In the second stage of the study the same contamination was applied to human abdominal wall specimens. A 5 cm incision was made through skin and fat, then implants were passed through and levels of contamination were measured as described. RESULTS: Smooth implants grew a mean of 95 colony-forming units (CFUs; approximately 1 CFU/cm2) and textured implants grew 86 CFUs (also approximately 1 CFU/cm2). CFU counts were analyzed by the Mann-Whitney U-test which showed no significant difference between implant types (P < .05); independent-sample t-tests showed a significant difference. The dependent-variable techniques were then compared as groups by one-way analysis of variance, which also showed a significant reduction compared with the control group (P < .01). CONCLUSIONS: This in vitro study has shown the effectiveness of antiseptic rinse and skin/implant barrier techniques for reducing bacterial contamination of breast implants at the time of insertion.

Microbiologic Profile of Nipple Swab Culture and its Association With Postoperative Complications in Prosthetic Breast Reconstruction.

BACKGROUND: In breast surgeries, a lactiferous duct leading to lactic glands of breast parenchyma allows direct contamination by normal bacterial flora of the nipple-areola complex. Complete blockage of nipple flora from the intraoperative field is almost impossible. OBJECTIVES: We aimed to analyze the microbiological profile of nipple flora of breast cancer patients who underwent an implant-based immediate breast reconstruction after a total mastectomy, and to evaluate the association of nipple bacterial flora with postoperative complications. METHODS: A retrospective chart review was performed of patients who underwent an implant-based immediate breast reconstruction after a total mastectomy. A nipple swab culture was performed preoperatively. Patient demographics, surgical characteristics, and complications were compared between positive and negative nipple swab culture groups. Microbiological profile data including antibacterial resistance were collected. RESULTS: Among 128 breasts, 60 cases (46.9%) had positive preoperative nipple swab culture results. Staphylococcus epidermidis accounted for 41.4% of microorganisms isolated. A multivariate logistic regression analysis of postoperative complications revealed that the presence of nipple bacterial flora was a risk factor for capsular contracture. Seven cases of postoperative infection were analyzed. In 2 cases (40% of pathogen-proven infection), the causative pathogen matched the patient's nipple bacterial flora, which was methicillin-resistant S. epidermidis in both cases. CONCLUSIONS: Nipple bacterial flora was associated with an increased risk of capsular contracture. Preoperative analysis of nipple bacterial flora can be an informative source for treating clinically diagnosed postoperative infections. More studies are needed to determine the effectiveness of active antibiotic decolonization of the nipple.

Breast Implant-associated Double Capsules: What Do We Know So Far? A Systematic Review of the Literature.

INTRODUCTION: A double capsule is a recently described rare occurrence following breast implant placement in which an inner capsule envelope totally or partially adheres to the implant surface while a distinct outer capsule adheres to surrounding tissues, with an intercapsular space developing between the two. The objective of this study is to review all available literature related to formation of double capsules and propose a treatment algorithm. METHODS AND MATERIALS: A systematic review of the literature was conducted using Embase, Medline, and Cochrane databases. Articles reporting management of breast implant-associated double capsules were included in this review. RESULTS: A total of 9 studies (68 implants) were included in the review. 94.1% of double capsules occurred with textured Biocell shaped and round implants independently from implant pocket (p value=0.64). In all cases, double capsules were diagnosed fortuitously intra-operatively for another surgical indication. Capsular contracture was present in 50% of double capsules patients and was the most common indication for secondary breast surgery, 81.5% of which being clinically evident (p value<0.001). Treatment consisted in 84.4% in an inner capsulectomy with smooth implants exchange, and management of the outer capsule as per the capsular contracture algorithm. CONCLUSION: Double capsule formation is caused by delamination of a tight adhering capsule to a textured implant surface into two layers and continuous micro-shearing forces, and the probable contribution of bacterial biofilm. The only treatment reported so far includes inner with or without outer capsulectomy with smooth implant exchange. LEVEL OF EVIDENCE III: 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 .

Environmental factors associated with etiology of microbiologically confirmed reconstructive breast implant infections: impact on clinical management and treatment.

Even if wide differences exist in the incidence of Gram-negative infections following breast cancer implant reconstructions (2-20%), its occurrence needs to be considered to optimize antibiotic therapy, which is usually directed towards Gram-positive cocci. There is a general notion on the possible source of Gram-negative microorganisms during outdoor activities. For this reason, we administered a specific questionnaire to infected patients to investigate this aspect. In 450 consecutive implant reconstructions between January 1, 2016 and March 31, 2018, 27 patients (6%) developed proven infection. For each patient, we collected age, tumor stage and recurrence, chemo/radiotherapy, infecting microorganism, fate of implant, type and duration of antibiotic treatment, and administered a questionnaire on exposure to contaminated environments. Twenty patients (74%) had Gram-positive and 7 (26%) had implants infected by Gram-negative agents. The two groups were homogeneous as regards age and no statistically significant difference was observed for other parameters. A significant difference was detected with regard to environmental risk factors in the Gram-negative group (p=0,049). Length of antibiotic therapy was longer in the Gram-negative patients (17.4 vs 11.05 days) and antibiotic treatment was ineffective in 43% of the Gram-negative group. Environmental factors may be an element to evaluate in order to improve patient management. Surveys on larger cohorts are warranted.

[DELAYED PERSISTENT BREAST IMPLANT INFECTION WITH MYCOBACTERIUM FORTUITUM].

INTRODUCTION: Non-Tuberculous Mycobacteria (NTM) are opportunistic environmental pathogens that can produce a wide range of diseases, including infection of the skin and soft tissues. Mycobacterium fortuitum is a predominant causative agent of postsurgical wound infection, especially in breast surgery. Peri-prosthetic infection due to Mycobacterium fortuitum are uncommon, but increasingly reported. This report summarizes the case of a young healthy female who underwent bilateral breast mastopexy with insertion of silicone implants. Shortly after the procedure she presented with clinical signs of wound infection that failed to heal completely in spite of repeated drainage and empiric antibiotic therapy. Additional microbiological investigation allowed for a diagnosis of Mycobacterium fortuitum. A prolonged course of anti-mycobacterial therapy, combined with removal of the implants initiated eradication of the infection and enabled re-implantation of the prosthesis. This case report underscores the importance of awareness to this type of pathogen especially in cases of exudative infection with sterile cultures. Timely identification can lead to prompt therapy of patients preventing further complications, costs and remaining aesthetic damage.

Pocket Irrigation and Technique During Reconstructive Surgery: An American Society of Plastic Surgery Survey of Current Practice.

BACKGROUND: Expander-to-implant is the most common breast reconstruction procedure in the United States. Irrigation with triple antibiotic solution (TAS), as described by Adams et al in 2006, has become standard of care to lower bacterial bioburden. However, several alternative solutions have been implemented with the literature lacking a consensus regarding use (Plast Reconstr Surg. 2006;117:30-36). OBJECTIVE: We distributed a peer-reviewed survey among a cohort of American Society of Plastic Surgery (ASPS) members to assess pocket irrigation technique during implant-based reconstructive surgery. We then conducted a pilot in vitro study to determine antibacterial efficacy of the most preferred irrigation at preferred dwell times against select bacterial species linked to breast pocket contamination during reconstructive implant-based surgery. METHODS: The survey was distributed a total of 3 times to a random cohort of 2488 ASPS members in January 2018. During in vitro studies, pure cultures of common breast flora were exposed to TAS versus saline control at 1, 2, and 5 minutes in a simulated in vivo cavity. Viable plate counts were used to assess cell viability. RESULTS: The response rate was above the ASPS survey average at 16% (n = 407). The population reflected a cross-section of practice types and experience levels. Triple antibiotic solution without Betadine was the favored irrigation at 41%, with 73% of its users preferring dwell times of 2 minutes or less. Over 30 distinct breast pocket irrigation solutions were identified. Bacteria added to the in vivo cavity survived a 2-minute dwell time with TAS as follows: 51% Staphylococcus epidermidis, 69% Escherichia coli, 88% Enterococcus faecalis, 88% Pseudomonas aeruginosa, and 98% Acinetobacter baumannii. CONCLUSION: Our survey data demonstrate significant variability in practice and lack of consensus among ASPS members regarding antimicrobial irrigation during reconstructive breast surgery. Our in vitro data underscores the importance of relating clinical practices with laboratory studies of microorganisms potentially linked to breast pocket contamination and suggests that TAS requires either dwell times greater than 5 minutes and/or the inclusion of efficacious antimicrobial agents (eg, Betadine). This finding has the potential to impact antimicrobial pocket irrigation and technique during breast reconstruction.

Bacterial Adhesion and Biofilm Formation on Textured Breast Implant Shell Materials.

BACKGROUND: Bacterial biofilms have been implicated with breast implant complications including capsular contracture and anaplastic large-cell lymphoma. The actual mechanisms for either are still under active investigation and are not clear. Due to their increased surface area, implants with textured surfaces may harbor greater biofilm loads than those with smooth surfaces. METHODS: Biofilm formation on the outer surface material was compared using implants with various surface areas and roughness, including Natrelle® (Smooth), SmoothSilk®/SilkSurface® (Silk), VelvetSurface ® (Velvet), Siltex®, and Biocell®. The roughness and surface area of each material were assessed using non-contact profilometry. Bacterial attachment (2 h) and biofilm formation (24 h) were evaluated for Staphylococcus epidermidis, Pseudomonas aeruginosa, and Ralstonia pickettii over nine independent experiments using a CDC biofilm reactor and viable plate counts (VPCs) as well as confocal scanning laser microscopy. VPCs of the textured implants were compared relative to the Smooth implant. RESULTS: Surface areas increased with roughness and were similar among the three least rough implants (Smooth, Silk, and Velvet) and among the roughest implants (Siltex and Biocell). Overall, VPC indicated there was significantly more bacterial attachment and biofilm formation on the Siltex and Biocell implants than the Silk or Velvet implants, although there were differences between species and time points. CSLM confirmed the formation of thicker biofilms on the implants with rougher surface textures. CONCLUSION: This in vitro study confirmed that implant surfaces with rougher texture, resulting in more surface area, harbored greater biofilm loads than those with smoother surfaces. NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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 .

PCR Characterization of Microbiota on Contracted and Non-Contracted Breast Capsules.

BACKGROUND: The aetiology of capsular contracture around breast implants remains unclear. The leading theory is that a subclinical infection around the implant plays a role in the development of capsular contractions. Several studies found associations between the presence of bacteria and the occurrence of capsular contraction. However, it is unclear whether detected bacteria originate from the breast capsule, breast glandular tissue or skin contamination. Moreover, this has never been investigated with molecular techniques. The aim of this study was to assess the bacterial microbiota on breast capsules, glandular tissue and skin using a highly sensitive PCR assay. MATERIALS AND METHODS: Fifty breast capsules were collected during implant removal or replacement. Ten specimens of glandular breast tissue and breast skin were collected in females who were undergoing reduction mammoplasty. A sample specimen (4 mm) was sterilely obtained from all tissues. All specimens were analysed by IS-pro, a 16S-23S interspace region-based PCR assay. RESULTS: Low numbers of Staphylococcus spp. (four species in four capsules) were found on breast capsules. There was no difference in bacterial presence between normal and contracted capsules. The skin of the breast-harboured Streptococcus spp. and Staphylococcus spp. while the glandular tissue was sterile. CONCLUSION: The low numbers of bacteria found on the capsules are most likely caused by contamination during capsule removal. More and larger studies are needed to investigate the bacterial presence on breast capsules using a PCR assay. This is the first study in which breast capsules have been studied using a highly sensitive PCR assay. 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 .

Evaluation of Antibiotic-Impregnated Mesh in Preventing the Recurrence of Capsular Contracture.

BACKGROUND: Capsular contracture (CC) is the most frequently reported complication following breast augmentation. A growing body of evidence implicates subclinical (biofilm) infection around breast implants as an important cause of CC; however, effective prophylactic and treatment modalities remain controversial. OBJECTIVES: This article aims to review a single surgeon's experience using an antibiotic-impregnated mesh as a prophylactic measure against biofilm formation and recurrent CC. METHODS: This study retrospectively reviewed 5 consecutive patients presenting with CC (Baker grades III and IV) who were managed by capsulectomy with implant replacement and simultaneous insertion of an antibiotic-impregnated mesh. Patient demographics and major complications were recorded, including CC recurrence, reoperation, and infection. RESULTS: Complete correction of the contracture with no recurrence was achieved in all patients at a median followup of 25 months. CONCLUSIONS: This study demonstrates a novel technique using an antibiotic mesh to reduce bacterial access to breast implants at the time of insertion. Further investigation is warranted with more clinical cases in order to recommend this technique for the management of subclinical infection and CC.

[Breast pain and fever in a 46-year-old immunosuppressed patient with breast implants]. / Schmerzen im Bereich der Mamma und Fieber bei einer 46­Jährigen mit Immunsuppression und Mammaaugmentation.

A 46-year-old immunosuppressed patient presented with a breast implant-associated infection 10 years after breast augmentation in Southeast Asia. No pathogen was identified in the initial conventional microbiological workup. Subsequently, infection with Mycobacterium abscessus-a nontuberculous mycobacteria-was diagnosed using a special culture technique. Increased rates of such infections are reported after cosmetic surgery in foreign countries, presumably due to inoculation with these ubiquitous pathogens. This case highlights the fact that the differential diagnosis and thus the microbiological workup should be extended in cases without initial pathogen detection.

Preliminary Results of the Use of a Stabilized Hypochlorous Acid Solution in the Management of Ralstonia Pickettii Biofilm on Silicone Breast Implants.

BACKGROUND: Ralstonia Pickettii biofilms are associated with pocket infections following breast implant surgeries. Biofilm protects bacteria most topically applied antimicrobial irrigations. OBJECTIVES: To evaluate the effectiveness of four antimicrobial solutions on the planktonic form and established biofilm of Ralstonia Pickettii grown on 3 different types of silicone breast implants. METHODS: Time kill assays at clinical concentrations of chlorhexidine gluconate, povidone iodine, triple-antibiotic solution, and a 0.025% hypochlorous acid solution stabilized in amber glass were evaluated. Normal saline was the control. Three types of silicone implants, two with a textured surface and one smooth surface, were selected. Planktonic assays were performed after implants were soaked for one, five, 30, and 120 minute time points. Biofilm assays were performed after 5 and 120 minutes of implant soak time. Both tests evaluated cell-forming units (CFU/mL). RESULTS: Triple antibiotic solution had no effect on R. pickettii and was dropped from the study. Remaining solutions showed total kill of planktonic bacteria at one minute. Saline control showed no significant effect on biofilm as anticipated. Stabilized hypochlorous acid was the only solution tested capable of eradicating R. pickettii biofilm on all implant surfaces tested within the first five minute soak time. CONCLUSIONS: Noncytotoxic, 0.025% hypochlorous acid in normal saline, stabilized in amber glass, successfully eradicated Ralstonia pickettii in planktonic and mature biofilm on three types of silicone implants during initial five minute soak time and may be the preferred antimicrobial solution for pocket lavage. This preliminary study requires further investigation. Leaching and implant compatibility testing is currently in progress.

Antimicrobial Prophylaxis Practice Patterns in Breast Augmentation: A National Survey of Current Practice.

BACKGROUND: Breast augmentation is one of the most commonly performed aesthetic surgery procedures worldwide. Bacterial contamination is of paramount concern due to its role in biofilm formation and capsular contracture. Plastic surgeons have adopted a variety of perioperative interventions in efforts to reduce implant contamination, however definitive evidence supporting these practices is lacking. OBJECTIVE: The goal of this study was to assess current practice patterns aimed at reducing implant-related infections in breast augmentation and comparing them to current evidence-based medicine recommendations. METHODS: A 20-question survey assessing practices aimed at preventing breast implant associated infections was generated and distributed via SurveyMonkey to members of the American Society of Plastic Surgery whose electronic mail addresses were listed on the American Society of Plastic Surgery member website in April 2015. RESULTS: A total of 253 responses were received from the survey. Of the respondents, 81% were in private practice. Respondents averaged 21 ± 9 years in practice, and 69 ± 111 breast augmentations performed per year. A majority of surgeons used Chlorhexidine to prepare the surgical site (45%) and triple antibiotic solution both as a soak for the implant before placement (40%) as well as for implant pocket irrigation (47%). A no-touch technique using the Keller Funnel was adopted by 42% of surgeons. Regarding antibiotic use in the postoperative period, first-generation cephalosporins were used by the majority of respondents (79%), and the most common duration was for 4 to 6 days (45%). CONCLUSIONS: Although there is heterogeneity in specific aspects of antimicrobial prophylaxis during breast augmentation, there is a clear trend toward practice modification geared towards preventing bacterial contamination in breast augmentation. Surgeons may benefit from high-level studies designed to create standardized evidence-based practice guidelines.

Preventing Breast Implant Contamination in Breast Reconstruction: A National Survey of Current Practice.

BACKGROUND: Implant-based breast reconstruction is commonly performed by plastic surgeons worldwide. Bacterial contamination is of paramount concern because of its role in biofilm formation and capsular contracture. Plastic surgeons have adopted a variety of perioperative interventions in efforts to reduce implant contamination; however, definitive evidence supporting these practices is lacking. OBJECTIVE: The goal of this study was to assess current practice patterns aimed at reducing implant-related infections. METHODS: A 20-question survey assessing practices aimed at preventing breast implant-associated infections was generated and distributed via SurveyMonkey to members of the American Society of Plastic Surgery whose e-mail addresses were listed on the American Society of Plastic Surgery member Web site in April 2015. RESULTS: A total of 1979 invitations to participate in the survey were sent, and 253 responses were received during the 4-month study period. Of respondents, 81% were in private practice. Respondents averaged 21 ± 9 years in practice, and 34 ± 50 implant-based breast reconstructions were performed per year. A majority of surgeons used chlorhexidine to prepare the surgical site (52%), a triple antibiotic soak for the implant prior to placement (50%) and povidone-iodine for implant pocket irrigation (44%). A no-touch technique utilizing the Keller funnel was adopted by 69% of surgeons. Regarding antibiotic use in the postoperative period, first-generation cephalosporins (eg, cephalexin, cefadroxil) were used by a majority of surgeons (84%), and the most common duration was until drain removal (45%). CONCLUSIONS: There is considerable heterogeneity in surgical practices aimed at preventing bacterial contamination in implant-based breast reconstruction. Surgeons may benefit from high-level studies designed to create standardized evidence-based practice guidelines.

CD30+ T Cells in Late Seroma May Not Be Diagnostic of Breast Implant-Associated Anaplastic Large Cell Lymphoma.

The objective was to analyze and discuss the implications of a nonmalignant CD30+ late seroma. Methods included collection of seroma fluid and peripheral blood from a patient with a late seroma 22 years after initial breast reconstruction. A panel of 24 monoclonal antibodies was used to detect T-cell receptor Vß regions present on ~70% of normal human peripheral blood T lymphocytes. Flow cytometry gated on CD3+ and CD30+ activated T lymphocytes. Cytospins were used to inspect the morphology of the T lymphocytes. Results from the seroma fluid cytology revealed a spectrum of activated T lymphocytes as seen in the blood of patients with immune disorders such as infectious mononucleosis. Cells were judged to be nonmalignant by routine pathology. Flow cytometry revealed >23% of CD3+ T lymphocytes belonged to an expanded T-cell family expressing TCRVß13.2. Most Vß13.2 cells expressed T-cell activation antigen CD30 indicating that CD30 is not restricted to anaplastic large cell lymphoma (ALCL) in seroma fluids. A smaller expanded population of CD30+ T lymphocytes expressing TCRVß 13.2 was detected in the blood. In conclusion, in this index case, an expanded population of CD30+ activated T lymphocytes was detected in seroma fluid surrounding a textured breast implant as well as in peripheral blood, consistent with a local and systemic immune response. The demonstration of an expanded CD30+ T-cell population in a polyclonal background suggests a possible role for bacterial superantigens as a pathogenic factor. These data further suggest that breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) may be the end stage of a CD30+ T-cell lymphoproliferative disorder. LEVEL OF EVIDENCE: 5.

Antibiogram for Periprosthetic Infections: A Tool for Better Informed Selection of Empiric Antibiotics for Surgical Site Infections.

INTRODUCTION: Periprosthetic infection after breast reconstruction is not an uncommon complication, with incidence up to 24%. These infections are often treated empirically without knowing the causative bacteria or its sensitivities to various antibiotics. Even if cultures are obtained, results may not be available for several days. METHODS: A retrospective chart review of 553 patients at a single institution between January 2009 and July 2014 was performed, identifying patients who (1) underwent implant-based breast reconstruction and subsequently suffered an infection and (2) had cultures available with sensitivities. We reviewed patient demographics, implant characteristics, prophylactic intravenous antibiotics, oral antibiotic maintenance used, microbiologic details, and outcomes. The goal was to identify the most common causative bacteria, as well as their sensitivities to commonly used antibiotics, to help guide antibiotic decision-making. RESULTS: Of the 553 patients who underwent implant-based reconstruction, 114 (20.6%) patients suffered periprosthetic infections. Of these patients, 32 (28.1%) patients (56 reconstructions, with 33 tissue expanders and 23 implants) had cultures performed revealing 43 bacterial species, with the most common being Staphylococcus aureus (23.2%) and Pseudomonas aeruginosa (26.8%). Ceftazidime and piperacillin/tazobactam were equally effective covering 100% of Pseudomonas, enteric, and atypical organisms (P = 1), whereas vancomycin covered 100% of gram-positive organisms. Trimethoprim/sulfamethoxazole covered 100% of S. aureus, whereas clindamycin only covered 71% of S. aureus (P = 0.03). Additionally, trimethoprim/sulfamethoxazole was better able to cover atypical and enteric organisms. Ciprofloxacin covered 71% of Pseudomonas compared with 56% for levofloxacin (P = 0.14). Interestingly, cephalexin, a common choice for perioperative prophylaxis, was highly ineffective for gram-positive species in patients who later returned with infections. CONCLUSIONS: This study supports the efficacy of current intravenous antibiotics protocols but questions the efficacy of both clindamycin and levofloxacin in empirically treating periprosthetic infections and cephalexin in providing effective perioperative prophylaxis against skin flora. Because bacterial sensitivities vary by location and patient population, this study encourages other centers to develop their own antibiogram specifically tailored to periprosthetic infections to improve antimicrobial decision making and potentially improve implant salvage.

Plastic Expander-Related Gordonia Sputi Infection: Case Report and Literature Review.

Gordonia sputi causes rare bacterial infections resulting from a contaminated indwelling medical device. We report the case of a postoperative plastic expander abscess in a woman, with G. sputi identification by 16S ribosomal RNA sequencing. This report indicates that Gordonia spp. should be included in the list of organisms causing plastic implant infections.

Histologic, Molecular, and Clinical Evaluation of Explanted Breast Prostheses, Capsules, and Acellular Dermal Matrices for Bacteria.

BACKGROUND: Subclinical infections, manifest as biofilms, are considered an important cause of capsular contracture. Acellular dermal matrices (ADMs) are frequently used in revision surgery to prevent recurrent capsular contractures. OBJECTIVE: We sought to identify an association between capsular contracture and biofilm formation on breast prostheses, capsules, and ADMs in a tissue expander/implant (TE/I) exchange clinical paradigm. METHODS: Biopsies of the prosthesis, capsule, and ADM from patients (N = 26) undergoing TE/I exchange for permanent breast implant were evaluated for subclinical infection. Capsular contracture was quantified with Baker Grade and intramammary pressure. Biofilm formation was evaluated with specialized cultures, rtPCR, bacterial taxonomy, live:dead staining, and scanning electron microscopy (SEM). Collagen distribution, capsular histology, and ADM remodeling were quantified following fluorescent and light microscopy. RESULTS: Prosthetic devices were implanted from 91 to 1115 days. Intramammary pressure increased with Baker Grade. Of 26 patients evaluated, one patient had a positive culture and one patient demonstrated convincing evidence of biofilm morphology on SEM. Following PCR amplification 5 samples randomly selected for 16S rRNA gene sequencing demonstrated an abundance of suborder Micrococcineae, consistent with contamination. CONCLUSIONS: Our data suggest that bacterial biofilms likely contribute to a proportion, but not all diagnosed capsular contractures. Biofilm formation does not appear to differ significantly between ADMs or capsules. While capsular contracture remains an incompletely understood but common problem in breast implant surgery, advances in imaging, diagnostic, and molecular techniques can now provide more sophisticated insights into the pathophysiology of capsular contracture. LEVEL OF EVIDENCE: 4 Therapeutic.

Mycobacterial infection of breast prosthesis--a conservative treatment: a case report.

BACKGROUND: Bacterial infection is a well-known risk of breast implant surgery. It is typically caused by bacterial skin flora, specifically Staphylococcus aureus and the coagulase negative staphylococci. There have been infrequent reports of breast implant infection caused by the atypical mycobacteria, of which Mycobacterium canariasense not yet reported in the literature. CASE PRESENTATION: This report summarizes the case of a female patient who underwent mastectomy followed by bilateral breast augmentation and presented approximately three years later with clinical evidence of infected breast prosthesis by Mycobacterium canariasense. One year after thoroughly follow-up, appropriate antibiotherapy and the change of the infected prosthesis, the patient presented no signs of reinfection. CONCLUSION: Our case demonstrates that Mycobacterium canariasense should be considered as a new potential cause of infected breast prosthesis.