Commentary on: Surgical Site Irrigation in Plastic Surgery: What is Essential?

Commentary on: Surgical Site Irrigation in Plastic Surgery: What is Essential? Searching for the Holy Grail for the ideal surgical site irrigation solution has been a preoccupation of clinicians and researchers for decades. Due to the complexity of the problem, it is difficult to evaluate the myriad of proposed solutions. Also, what happens in a Petri dish may have limited relevance to what is occurring in a complex biologic system, further compromised by a foreign body, such as a breast implant. The authors are to be commended for their work in the continuing search for the optimal irrigation solution associated with breast implant surgery.1 The clinician is confronted with an abundance of conflicting data often with confusing recommendations. This critical point is stressed by the authors. For many years, clinicians have been culturing pockets of infected breast implant patients. Frequently, the results have shown no growth of organisms, even in the setting of overt clinical infection. This phenomenon of no growth is most likely due to two factors. First, many of these patients have already received extended courses of antibiotics, which will suppress the culture results. Second, the offending organisms, if associated with an establish biofilm, will be very difficult to culture using standard techniques. The experimental science associated with in vitro studies may not reflect what is occurring in this complex clinical environment. The complexity is enhanced when one considers all of the factors associated with a surgical site. Different agents have very different effects on fibroblasts, keratinocytes, and tissue cytotoxicity. Also, the stability of using different products in a solution is a major factor. Placing different agents in the same pocket may create compatibility issues. Further complicating the situation is the presence of a silicone implant, which is a foreign body and has a major effect on the body’s ability to manage surgical site infection. Another factor often ignored in evaluating in vitro tests, which has been pointed out by the authors, is the importance of time. In this study, there was prolonged exposure necessary for some of the agents studied to eradicate the bacteria. As the authors state, it takes very few organisms in the presence of a foreign body to cause infection. They also state why antibiotics may not be an ideal choice as an irrigant. They discuss that in the absence of a microcirculation associated with a foreign body, such as a breast implant, the migration of neutrophils and antibodies may be impeded. It has been known for many years that it is an oxidative burst, which releases hypochlorous acid from white blood cells that is actually attacking bacteria after the process of phagocytosis. One interesting option to consider is to directly use hypochlorous solution as an irrigant in a surgical site. It is documented that hypochlorous acid has a wide spectrum of antibacterial efficacy against Gram-negative, Gram-positive bacteria and fungi. Using this solution directly bypasses the need for neutrophils to be present and functioning in the wound implant interface.2 This study showed a significant variability in the time kill data, depending on both treatment regiments and the specific organisms evaluated. Their data reveal that the time kill may have been as short as five minutes and as long as thirty minutes to eradicate the bacteria. This information has significant implications for the clinical setting. It reveals that just irrigating with different agents requires knowledge of the length of time they must be allowed to interact with the operative site. This fact raises the issue of the potential need to lengthen the surgical exposure time and possible impact on operating cost. The authors also point out that the data related to capsular contraction in the presence of positive bacterial cultures and biofilms have led to many treatment options. This fact raises the question, what is the effect of broad spectrum antibiotics as an operative site irrigant over time, and can they significantly increase bacterial resistance. The discussion includes an excellent summary of the abundant data on clinical studies related to types of bacteria and the rate of capsular contraction. The authors have recommended 0.05% chlorhexidine and triple antibiotic solution for topical surgical site infection prophylaxis in breast reconstruction surgery. An unresolved issue is that, although many of the products currently used may be effective against the planktonic forms of bacteria associated with surgical site infection, there are little data as far as efficacy once a biofilm is established. Our recent studies looked specifically at Ralstonia pickettii and its sensitivity to different agents not only in the planktonic form but also with an associated biofilm on the surface of different types of breast implants.3 The results showed that 0.05% chlorhexidine, although highly effective at killing this organism in the planktonic form, was unable to penetrate the biofilm associated with Ralstonia pickettii. Thus, once there was an established biofilm, the chlorhexidine was unable to kill the organism on the implants surface.4 In summary, the authors have made a very important point that is usually ignored in discussing this particular topic and it is the critical issue of time. It is not just what agents may be used but the time exposure that may be a critical factor in addressing surgical site infections. Adding to the complexity of this topic is the simple fact that, as we use more and more antibiotics, either systemically or as irrigation, we must consider the real risk of increasing bacterial resistance. Disclosures Dr Fisher is Chief Medical Officer and Dr Porter is Chief Scientific Advisor, Integrated Healing Technologies (Franklin, TN). Funding The authors received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Zhadan O, Becker H. Surgical site irrigation in plastic surgery: what is essential? Aesthet Surg J . 2018; 38( 3): 265- 273. 2. Rani SA, Hoon R, Najafi RR, Khosrovi B, Wang L, Debabov D. The in vitro antimicrobial activity of wound and skin cleansers at nontoxic concentrations. Adv Skin Wound Care . 2014; 27( 2): 65- 69. Google Scholar CrossRef Search ADS PubMed  3. Hu H, Johani K, Almatroudi Aet al.   Bacterial Biofilm Infection Detected in Breast Implant-Associated Anaplastic Large-Cell Lymphoma. Plast Reconstr Surg . 2016; 137( 6): 1659- 1669. Google Scholar CrossRef Search ADS PubMed  4. Fisher J. Antimicrobial Activity of Hypochlorous Acid and its Impact on Breast Implant Surgery. Presented at The Aesthetic Meeting 2017, San Diego, CA, April 27-May 2, 2017. © 2017 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Aesthetic Surgery Journal Oxford University Press

Commentary on: Surgical Site Irrigation in Plastic Surgery: What is Essential?

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Publisher
Mosby Inc.
Copyright
© 2017 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com
ISSN
1090-820X
eISSN
1527-330X
D.O.I.
10.1093/asj/sjx169
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Abstract

Searching for the Holy Grail for the ideal surgical site irrigation solution has been a preoccupation of clinicians and researchers for decades. Due to the complexity of the problem, it is difficult to evaluate the myriad of proposed solutions. Also, what happens in a Petri dish may have limited relevance to what is occurring in a complex biologic system, further compromised by a foreign body, such as a breast implant. The authors are to be commended for their work in the continuing search for the optimal irrigation solution associated with breast implant surgery.1 The clinician is confronted with an abundance of conflicting data often with confusing recommendations. This critical point is stressed by the authors. For many years, clinicians have been culturing pockets of infected breast implant patients. Frequently, the results have shown no growth of organisms, even in the setting of overt clinical infection. This phenomenon of no growth is most likely due to two factors. First, many of these patients have already received extended courses of antibiotics, which will suppress the culture results. Second, the offending organisms, if associated with an establish biofilm, will be very difficult to culture using standard techniques. The experimental science associated with in vitro studies may not reflect what is occurring in this complex clinical environment. The complexity is enhanced when one considers all of the factors associated with a surgical site. Different agents have very different effects on fibroblasts, keratinocytes, and tissue cytotoxicity. Also, the stability of using different products in a solution is a major factor. Placing different agents in the same pocket may create compatibility issues. Further complicating the situation is the presence of a silicone implant, which is a foreign body and has a major effect on the body’s ability to manage surgical site infection. Another factor often ignored in evaluating in vitro tests, which has been pointed out by the authors, is the importance of time. In this study, there was prolonged exposure necessary for some of the agents studied to eradicate the bacteria. As the authors state, it takes very few organisms in the presence of a foreign body to cause infection. They also state why antibiotics may not be an ideal choice as an irrigant. They discuss that in the absence of a microcirculation associated with a foreign body, such as a breast implant, the migration of neutrophils and antibodies may be impeded. It has been known for many years that it is an oxidative burst, which releases hypochlorous acid from white blood cells that is actually attacking bacteria after the process of phagocytosis. One interesting option to consider is to directly use hypochlorous solution as an irrigant in a surgical site. It is documented that hypochlorous acid has a wide spectrum of antibacterial efficacy against Gram-negative, Gram-positive bacteria and fungi. Using this solution directly bypasses the need for neutrophils to be present and functioning in the wound implant interface.2 This study showed a significant variability in the time kill data, depending on both treatment regiments and the specific organisms evaluated. Their data reveal that the time kill may have been as short as five minutes and as long as thirty minutes to eradicate the bacteria. This information has significant implications for the clinical setting. It reveals that just irrigating with different agents requires knowledge of the length of time they must be allowed to interact with the operative site. This fact raises the issue of the potential need to lengthen the surgical exposure time and possible impact on operating cost. The authors also point out that the data related to capsular contraction in the presence of positive bacterial cultures and biofilms have led to many treatment options. This fact raises the question, what is the effect of broad spectrum antibiotics as an operative site irrigant over time, and can they significantly increase bacterial resistance. The discussion includes an excellent summary of the abundant data on clinical studies related to types of bacteria and the rate of capsular contraction. The authors have recommended 0.05% chlorhexidine and triple antibiotic solution for topical surgical site infection prophylaxis in breast reconstruction surgery. An unresolved issue is that, although many of the products currently used may be effective against the planktonic forms of bacteria associated with surgical site infection, there are little data as far as efficacy once a biofilm is established. Our recent studies looked specifically at Ralstonia pickettii and its sensitivity to different agents not only in the planktonic form but also with an associated biofilm on the surface of different types of breast implants.3 The results showed that 0.05% chlorhexidine, although highly effective at killing this organism in the planktonic form, was unable to penetrate the biofilm associated with Ralstonia pickettii. Thus, once there was an established biofilm, the chlorhexidine was unable to kill the organism on the implants surface.4 In summary, the authors have made a very important point that is usually ignored in discussing this particular topic and it is the critical issue of time. It is not just what agents may be used but the time exposure that may be a critical factor in addressing surgical site infections. Adding to the complexity of this topic is the simple fact that, as we use more and more antibiotics, either systemically or as irrigation, we must consider the real risk of increasing bacterial resistance. Disclosures Dr Fisher is Chief Medical Officer and Dr Porter is Chief Scientific Advisor, Integrated Healing Technologies (Franklin, TN). Funding The authors received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Zhadan O, Becker H. Surgical site irrigation in plastic surgery: what is essential? Aesthet Surg J . 2018; 38( 3): 265- 273. 2. Rani SA, Hoon R, Najafi RR, Khosrovi B, Wang L, Debabov D. The in vitro antimicrobial activity of wound and skin cleansers at nontoxic concentrations. Adv Skin Wound Care . 2014; 27( 2): 65- 69. Google Scholar CrossRef Search ADS PubMed  3. Hu H, Johani K, Almatroudi Aet al.   Bacterial Biofilm Infection Detected in Breast Implant-Associated Anaplastic Large-Cell Lymphoma. Plast Reconstr Surg . 2016; 137( 6): 1659- 1669. Google Scholar CrossRef Search ADS PubMed  4. Fisher J. Antimicrobial Activity of Hypochlorous Acid and its Impact on Breast Implant Surgery. Presented at The Aesthetic Meeting 2017, San Diego, CA, April 27-May 2, 2017. © 2017 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com

Journal

Aesthetic Surgery JournalOxford University Press

Published: Mar 1, 2018

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