Pocket Irrigation and Technique During Reconstructive Surgery

Abstract

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.

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

“…However, nearly 75% of surveyed plastic surgeons utilized a dwell time of 2 minutes or less for their pocket irrigation solution in reconstructive procedures. 15 Our in vitro study results show that short exposure times (eg, ≤10 minutes) do not necessarily support TAB (containing bacitracin, cefazolin, and gentamicin) as an effective treatment for significant log reduction of biofilm-associated bacteria for the strains that were tested. This makes sense because the individual components of TAB (ie, bacitracin, cefazolin, and gentamicin) generally require longer exposure times and often only affect metabolically active bacteria.…”

“… 43 , 44 As such, plastic surgeons often utilize antimicrobial solutions for breast pocket irrigation during revision or exchange surgeries. According to recent American Society of Plastic Surgeons surveys, 15 , 16 over one-half of all plastic surgeons perform breast pocket irrigation in reconstructive procedures with either TAB or PI, with TAB being generally favored. 15 However, little consistency regarding clinical utilization parameters such as specific concentrations of antimicrobial solutions and treatment times have been documented.…”

“…According to recent American Society of Plastic Surgeons surveys, 15 , 16 over one-half of all plastic surgeons perform breast pocket irrigation in reconstructive procedures with either TAB or PI, with TAB being generally favored. 15 However, little consistency regarding clinical utilization parameters such as specific concentrations of antimicrobial solutions and treatment times have been documented. The current study evaluates the effect of different antimicrobial solution concentrations and exposure times on various bacterial species utilizing a series of in vitro assays.…”

“…As highlighted in a recent American Society of Plastic Surgeons survey on utilization patterns around breast pocket irrigation in reconstructive breast surgery, 15 approximately 60% of plastic surgeons utilize TAB. Various clinical studies, as summarized in Lynch et al 46 , suggest that irrigation with Adams’s TAB is effective at reducing infection and capsular contracture rates compared with saline or no irrigation.…”

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

“…There is a prevalent and long history of antimicrobial solution utilization in breast surgery, particularly in breast pocket irrigation and more recently for implant soaking. 13 , 14 For the latter, soaking the implant in an antimicrobial solution is meant to address potential bacterial attraction due to an electrostatic charge imparted on opening the sterile package. 2 , 4 , 15 , 16 A variety of antimicrobial solutions have been utilized, 13 , 14 including but not limited to bacitracin and other individual antibiotics; 17 TAB as per Adams; 18 , 19 PI (Betadine) at full strength (100%), half strength (50%), 20 , 21 or diluted in combination with TAB; 17 , 22 stabilized hypochlorous acid (0.025% HOCl); 23-25 and chlorhexidine.…”