Reducing infection risk in implant-based breast-reconstruction surgery: challenges and solutions

Figures & data

Table 1 Significant risk factors from the literature for the development of implant-based breast-reconstruction infection and proposed interventions

Risk factor	Intervention
Patient characteristics
• Smoking	• No smoking for at least 2 weeks prior to surgery
	• If patient is still smoking and surgery is nonurgent, delay surgery until compliant
• Patient age >50 years	• Consider autologous reconstruction
• Obesity	• Consider autologous reconstruction
	• If surgery is nonurgent, encourage weight loss and delay reconstruction until patient BMI <30 kg/m^2
• Hypertension	• Adequate anti-hypertensive medication
• Diabetes mellitus	• Blood-sugar control 70–150 mg/dL
• Hypercholesterolemia	• Adequate diet or medication control of cholesterol levels
• Larger breast size	• Advise patient to downsize
	• Consider autologous reconstruction
• Local or systemic immunocompromised states	• Normal white-cell count
	• Avoid systemic steroid use
	• Consider autologous reconstruction
Disease characteristics
• Immediate reconstruction	• Consider delayed and/or autologous reconstruction in higher-risk patients
• Bilateral procedures	• Consider delayed and/or autologous reconstruction in higher-risk patients
• Mastectomy skin necrosis	• Close communication with resecting surgeon
	• Submuscular placement of implant
	• Consider adjuncts, such as incisional negative-pressure wound therapy
• Axillary lymph-node procedures	• Perform axillary lymph-node procedures in a separate session premastectomy
Adjuvant therapy
• Radiotherapy	• Avoid implant reconstruction
	• Consider autologous tissue reconstruction
• Chemotherapy	• Closer follow-up and early detection of infection

Abbreviation: BMI, body mass index.

Table 2 Recommended antibiotic irrigation solutions⁷³

Allergen	Recommended irrigation solution
First line/iodine allergy	50,000 U bacitracin, 80 mg gentamicin, 1 g cefazolin, 500 cc normal saline
β-Lactam antibiotics	250 cc povidone iodine solution, 80 mg gentamicin, 250 cc normal saline
Bacitracin	50 cc povidone–iodine solution, 1 g cefazolin, 80 mg gentamicin, 500 cc normal saline
Aminoglycosides	250 cc povidone–iodine, 250 cc normal saline

Note: Reprinted from Adams WP Jr, Rios JL, Smith SJ, Enhancing patient outcomes in aesthetic and reconstructive breast surgery using triple antibiotic breast irrigation: six-year prospective clinical study. Plast Reconstr Surg. 2006;118(7 Suppl):46S–52S. Promotional and commercial use of the material in print, digital or mobile device format is prohibited without the permission from the publisher Wolters Kluwer. Please contact [e-mail] for further information.

Figure 1 Inframammary skin-sparing mastectomy approach demonstrating suture of ADM to PM muscle prior to insertion of implant.

Notes: (A) ADM sutured with absorbable monofilament to lower lateral edge of PM muscle and (B) ADM reflected upward, showing pocket for insertion of implant.
Abbreviations: ADM, acellular dermal matrix; PM, pectoralis major.

Table 3 Perioperative guidelines for reducing infection in implant-based breast reconstruction

Challenge	Solution
Surgical team and environment
• Colonization of patient	• Screening for MRSA and eradication as indicated
	• Avoidance of activities placing patient at risk of colonization
• Colonization of medical staff	• Regular screening
	• Strict barrier controls
• Colonization of operating room	• Hygienic operating room environment with laminar airflow systems
• Multiple surgical teams	• Familiar high-volume surgical teams
	• Low operating room traffic
Perioperative antibiotics
• Timing	• 30–60 minutes before surgical skin incision
• Duration	• Intravenous for at least 24 hours
	• Total of 1 week antibiotic use
	• Consider prolonging antibiotic use in high-risk or previously irradiated patients
• Antibiotic choice	• First-line antibiotic of choice is first-generation cephalosporin, with clindamycin in β-lactam antibiotic-sensitive patients
• Known carriers of MRSA or areas where MRSA is prevalent	• Intravenous vancomycin perioperatively
Preoperative planning
• Operative time	• Preoperative dimensional planning
	• Minimize operative time through standardized protocols
• Implant choice	• Smooth, round silicone implants are adequate for the majority of implant-based reconstructive cases
• Expander fill	• Keep intraoperative expansion to <50% or <300 mL
• Insufficient/doubtful mastectomy skin flaps	• Consider autologous flap reinforcement

Abbreviation: MRSA, methicillin-resistant Staphylococcus aureus.

Table 4 Operative sequence and steps to reduce infection in implant-based breast reconstruction

Challenge	Solution
Skin preparation and draping
• Operative skin preparation	• Chlorhexidine with 95% alcohol skin preparation
	• Disposable drapes
• Breast milk-duct colonization	• Shield implant from contamination by nipple-duct flora
• MRSA carriers	• 5-day course of topical mupirocin and daily chlorhexidine body scrub
Mastectomy and pocket preparation
• Adequate recipient-site preparation	• Communication with resecting surgeons
	• Minimize trauma to mastectomy skin flaps
	• Meticulous hemostasis
• Implant-pocket preparation	• Precise pocket dissection
	• Triple-antibiotic or povidone–iodine irrigation
Lower-pole reinforcement
• Use of acellular dermal matrix (ADM)	• Aseptic technique even more important
	• Consider native tissue reinforcement if available
	• Suture in place before implant placement
• Red-breast syndrome	• Can occur with ADM use
	• Early treatment if any suspicion of infection
Implant handling and insertion
• Minimize contamination of implant	• Single surgeon handling implant
	• Fresh pair of talc-free gloves
	• Reclean implant-entry site with povidone–iodine
	• Minimize implant-exposure time
	• Triple-antibiotic irrigation of implant in packaging
	• “No-touch” insertion technique
Closure and drains
• Minimize harboring of bacteria	• Layered closure with absorbable monofilament
• Postoperative drains	• Drains can be placed, but should be removed as early as possible
	• Appropriate drain care to minimize contamination
Postoperative care
• Hospital stay	• Stay overnight for intravenous antibiotics
	• Discharge postoperative day 1
• Follow-up	• Avoid potential breast-skin contaminants
	• Prophylactic antibiotics for bacteremic procedures
	• Follow-up beyond 30 days

Abbreviation: MRSA, methicillin-resistant Staphylococcus aureus.

AdamsWPJrRiosJLSmithSJEnhancing patient outcomes in aesthetic and reconstructive breast surgery using triple antibiotic breast irrigation: six-year prospective clinical studyPlast Reconstr Surg20061187 Suppl46S52S17099483

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