Implant-Based Breast Reconstruction: Hot Topics, Controversies, and New Directions

Implant-Based Breast Reconstruction: Hot Topics, Controversies, and New Directions

by Frey, Jordan D.; Salibian, Ara A.; Karp, Nolan S.; Choi, Mihye

Plastic and Reconstructive Surgery: February 2019 - Volume 143 - Issue 2 - p 404e–416e

Learning Objectives: After studying this article, the participant should be able to: 1. Evaluate appropriate patients best suited for one- or two-stage alloplastic breast reconstruction. 2. Discuss and apply the unique advantages and disadvantages of scaffold use and different implant types in breast reconstruction to maximize outcomes. 3. Develop a plan for patients undergoing implant-based breast reconstruction requiring postmastectomy radiation therapy. 4. Analyze the evidence with regard to antibiotic prophylaxis in implant-based breast reconstruction. 5. Recognize and critique novel technical and device developments in the field of alloplastic breast reconstruction, enabling appropriate patient selection. Summary: Implant-based, or alloplastic, breast reconstruction is the most common method of breast reconstruction in the United States. Within implant-based reconstruction, many techniques and reconstructive strategies exist that must be tailored for each individual patient to yield a successful reconstruction. Not unexpectedly, many hot topics and controversies in this field have emerged, including stages of reconstruction, use of scaffolds, permanent implant type, strategies for postmastectomy radiation therapy, and antibiotic prophylaxis. In addition, there has been an evolution in technical and device development in recent years. Therefore, plastic surgeons must be on the forefront of knowledge to approach implant-based breast reconstruction in an evidence-based fashion to best treat their patients.

Antibiotic Prophylaxis after Immediate Breast Reconstruction: The Reality of Its Efficacy

Antibiotic Prophylaxis after Immediate Breast Reconstruction: The Reality of Its Efficacy

by Ranganathan, Kavitha; Sears, Erika D.; Zhong, Lin; Chung, Ting-Ting; Chung, Kevin C.; Kozlow, Jeffrey H.; Momoh, Adeyiza O.; Waljee, Jennifer F.

Plastic and Reconstructive Surgery: April 2018 - Volume 141 - Issue 4 - p 865–877

Background: Numerous techniques are used to prevent infection after immediate implant-based breast reconstruction. Postoperative antibiotic prophylaxis is commonly prescribed to decrease the risk of reconstructive failure, despite conflicting evidence regarding its effectiveness. The authors studied whether postoperative antibiotic prophylaxis decreases the risk of infection-related explantation in the setting of immediate prosthesis-based breast reconstruction. Methods: Using Truven MarketScan databases, the authors identified all patients who underwent immediate implant reconstruction between January of 2010 and June of 2014 with at least 6 months of follow-up. Postoperative antibiotic prophylaxis was defined as any oral antibiotic course to be taken postoperatively based on prescriptions filled within 14 days preoperatively through 24 hours after discharge. Reconstructive failure, defined as explantation because of infection, was the primary outcome. Secondary outcomes of interest included wound complications, infection, and readmission for infection. Multivariable regression analyses controlled for demographic variables/comorbidities. Results: Of the 7443 patients, 6049 (81 percent) filled prescriptions for postoperative antibiotic prophylaxis. These patients were equally likely to develop a wound complication (OR, 0.93; 95 percent CI, 0.71 to 1.23) or infection (OR, 0.89; 95 percent CI, 0.70 to 1.14), undergo explantation because of infection (OR, 0.82; 95 percent CI, 0.57 to 1.18), or require readmission for infection (OR, 1.21; 95 percent CI, 0.82 to 1.78) compared with those who did not receive antibiotics. There was no significant difference in the risk of infection-related outcomes based on postoperative antibiotic prophylaxis duration. Conclusions: Postoperative antibiotic prophylaxis was not associated with a reduced risk of infection or explantation following prosthesis-based breast reconstruction. Given rising rates of antibiotic resistance, focusing instead on technical considerations and the management of comorbid conditions may more effectively enhance the safety of breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Antibiotic Prophylaxis following Implant-Based Breast Reconstruction: What Is the Evidence?

Antibiotic Prophylaxis following Implant-Based Breast Reconstruction: What Is the Evidence?

Phillips, BT, Halvorson, EG.

Plastic & Reconstructive Surgery:October 2016 - Volume 138 - Issue 4 - p 751–757

Background: Although data from other surgical disciplines do not support the use of prolonged postoperative prophylactic antibiotics, implant-based breast reconstruction is one area of plastic surgery where this may be warranted. The purpose of this study was to review the literature on antibiotic prophylaxis in prosthetic breast reconstruction, summarize findings, and provide recommendations. 
Methods: A literature review was performed to identify studies that compared different perioperative prophylactic antibiotic regimens with respect to infectious outcomes in prosthetic breast reconstruction. 
Results: Five studies and five systematic reviews were identified. One prospective randomized trial showed that a single preoperative dose was better than placebo, and another showed no difference between 24 hours versus until drain removal. Three studies were retrospective, one showing no difference between a single preoperative dose and prolonged antibiotic use, and two showing significant reduction in infectious complications with prolonged antibiotic use. One systematic review suggested an increased rate of infection with prolonged antibiotic use, and the other showed no difference between less than 24 hours and greater than 24 hours, but showed a reduction in infections compared to no treatment. 
Conclusions: The literature contains conflicting data regarding the optimal duration for perioperative antibiotic prophylaxis following prosthetic breast reconstruction. The authors’ opinion is that 24 hours of antibiotic prophylaxis is warranted. Further studies are needed. Patient-centered antibiotic prophylaxis based on a risk-assessment model may be a more effective alternative to the current indiscriminate model of surgical-site infection control.

Antibiotic Prophylaxis for Preventing Surgical-Site Infection in Plastic Surgery...

Antibiotic Prophylaxis for Preventing Surgical-Site Infection in Plastic Surgery: An Evidence-Based Consensus Conference Statement from the American Association of Plastic Surgeons

Plastic & Reconstructive Surgery: June 2015 - Volume 135 - Issue 6 - p 1723–1739 doi: 10.1097/PRS.0000000000001265

Ariyan, Stephan et al

http://journals.lww.com/plasreconsurg/Fulltext/2015/06000/Antibiotic_Prophylaxis_for_Preventing.34.aspx

Background: There is a growing concern for microbial resistance as a result of overuse of antibiotics. Although guidelines have focused on the use of antibiotics for surgery in general, few have addressed plastic surgery specifically. The objective of this expert consensus conference was to evaluate the evidence for efficacy and safety of antibiotic prophylaxis in plastic surgical procedures.

Methods: The authors: searched for existing high-quality systematic reviews for antibiotic prophylaxis in the literature from the MEDLINE, Cochrane Library, and Embase databases. All synonyms for antibiotics were combined with terms for relevant plastic surgery procedures. The searches were not limited by language, and included all study designs. In addition, supplemental hand searches were performed of bibliographies of relevant articles, and extensive “related articles.” Meta-analyses were performed and reviewed by experts selected by the American Association of Plastic Surgeons to reach consensus recommendations.

Results: Database searches identified 4300 articles, from which 2042 full-text articles were identified for eligibility. De novo meta-analyses were performed for each plastic surgical category. In total, 67 studies met the inclusion criteria, including nine for breast surgery, 17 for head and neck surgery, 10 for orthognathic surgery, seven for rhinoplasty/septoplasty, 19 for hand surgery, five for skin surgery, and two for abdominoplasty.

Conclusions: Systemic antibiotic prophylaxis is recommended for clean breast surgery and for contaminated surgery of the hand or the head and neck. It is not recommended to reduce infection in clean surgical cases of the hand, skin, head and neck, or abdominoplasty.

Antibiotic prophylaxis in hernia repair and breast surgery: a prospective randomized study comparing piperacillin/tazobactam versus placebo.
Journal of chemotherapy, Jun 2006, vol. 18, no. 3
p. 278-84
Esposito-S, Leone-S, Noviello-S, Ianniello-F, Marvaso-A, Cuniato-V, Bellitti-F.
Abstract
Although antibiotic prophylaxis is not explicitly indicated for hernia repair and breast surgery, its use for these clean procedures is widely adopted, albeit to a different extent in different countries, often on the personal decision of the individual surgeon. The present study was carried out to compare the efficacy of a single pre-operative dose of piperacillin-tazobactam with placebo in preventing surgical wound infections and to determine the main risk factors associated with infections following two main elective surgical clean procedures such as hernia repair and breast surgery.A total of 501 patients undergoing elective inguinal/femoral hernia repair or breast surgery were enrolled in this prospective randomized clinical study. Patients were randomly assigned to receive preoperative antibiotic prophylaxis or placebo. One dose of piperacillin-tazobactam 2.250 g or placebo was administered i.v. 30 minutes prior to the surgical procedure.Using statistical univariate analysis, the following variables were correlated with a higher infection risk: age >40 years, concomitant disease, WBC <3500,>9cm, use of drainages, non-prophylaxis. Using multivariate analysis, no antibiotic pre-operative prophylaxis, concurrent chronic diseases, especially diabetes (risk 15 times higher), and length of intervention >45 min (risk 6 times higher) were independent predictors of infection. Finally, patients with postoperative infections had a significantly longer hospitalisation .One pre-operative dose of piperacillin-tazobactam 2.250 g is more effective than placebo in preventing postoperative infections in breast surgery and hernia repair.