Plastic and Reconstructive Surgery

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PRSonally Speaking
Thursday, March 6, 2014
In vitro and in vivo investigation of the influence of implant surface on the formation of bacterial biofilm in mammary implants
At least twice a month, PRSonally Speaking posts full abstracts of interesting or potentially controversial articles from a future issue. This 'sneak preview' of a hot article is meant to give you some food for thought and provide you with topic for conversation among colleagues.
When the article is published in print with the April issue, it will be FREE for a period of Two Months, to help the conversation continue in the PRS community and beyond. So read the abstract, join the conversation and spread the word.
This week we present the introduction to "In vitro and in vivo investigation of the influence of implant surface on the formation of bacterial biofilm in mammary implants" by Jacombs et al.

Background: Capsular contracture remains the most common complication following breast augmentation surgery. There is increasing evidence that bacterial biofilm on the implant surface is responsible for initiating inflammation leading to capsular contracture in the majority of cases. We have used pooled data from the in vivo porcine model of capsular contracture to determine if the interaction of bacterial biofilm with smooth and textured implants independently determines progression to capsule formation. In addition, we performed an in vitro experiment to investigate the rate of bacterial growth and adhesion on textured versus smooth implants.

Methods: A total of 16 adult female pigs had 121 breast implants inserted. Of these, 66 implants - 23 smooth and 43 textured - were inoculated with a human strain of Staphylococcus epidermidis and received no other treatment. The implants were left in situ for an average of 19 weeks, after which Baker grading was performed and implants retrieved for analysis. Analysis included scanning electron microscopy (n=66) and determination of the number of infecting bacteria in capsules (n=23) and implants (n=19) by quantitative polymerase chain reaction. For the in vitro analysis 14 sterile
smooth and 14 sterile textured mini implants were incubated separately in 10% tryptone soy broth (TSB, Oxoid) inoculated with 5.8 x 106 colony forming units of S. epidermidis. Samples were removed at 3 time points (2, 6 and 24 hours) for both quantitative bacterial analysis and imaging using confocal laser scanning and scanning electron microscopy.
Results: At explantation, there was no significant difference (p=1.0) in the presence of capsular contracture (Baker grade III and IV) between smooth implants (19/23, 83%) and textured implants (36/43, 84%). Biofilm was confirmed on 60 of the 66 capsules. Capsules from smooth and textured implants had the same number of infecting bacteria (3.01x108/gram for textured versus 3.00x108/gram for smooth). Interestingly, there were 20 fold more bacteria attached to the surface of textured implants when compared
with the surface of smooth implants (1.18x108/gram for textured versus 5.75x106/gram for smooth). For the in vitro analysis, the surface of textured implants showed 11x, 43x and 72x more bacteria at 2, 6, and 24 hours respectively when compared with smooth implants (p<0.001). These findings were confirmed by imaging analysis.
Conclusion: These results show that both in the porcine model of breast implant contracture and in vitro analysis, textured implants develop a significantly higher load of bacterial biofilm in comparison to smooth implants. Furthermore, in vivo, once a threshold of biofilm forms on either smooth or textured implant surfaces, there seems to be an equal propensity to progress to capsular contracture. The significantly higher
number of bacteria attached to the surface of textured implants is a novel finding and further investigation is warranted to delineate the host response to this higher bacterial
load at the implant/tissue interface.

The full article will be published with the April 2014 issue of PRS, and will be free online for non-subscribers. Until then, we hope this "sneak peek" will pique your interests and start a healthy, meaningful conversation.
About the Blog

Plastic and Reconstructive Surgery

PRSonally Speaking is the official blog of Plastic and Reconstructive Surgery, the journal of the American Society of Plastic Surgeons. Visit our blog for exclusive previews of and discussions on hot topics in plastic surgery as well as insider-tips on open access content. PRSonally Speaking is now powered by frequent contributions from the American Society of Plastic Surgeons’ Young Plastic Surgeons Forum (YPS); these practicing plastic surgeons provide the personal side of the plastic surgery story, from daily challenges to unique insights. PRSonally Speaking is home to lively, civil debate on hot topics and great discussions pertaining to our field. So, bookmark us, subscribe to the RSS feed and join in the on-going conversation with Plastic and Reconstructive Surgery. This is your Journal; have fun, be respectful, get engaged and interact with the PRS community.

The views and recommendations of guest contributors do not necessarily indicate official endorsements or opinions of the Journal, PRS, or the ASPS. All views are those of the authors and the authors alone.


Anureet K. Bajaj, MD is a practicing plastic surgeon in Oklahoma City. She completed residency and fellowship in 2004, had a brief stint in academia at the University of Cincinnati, and then chose to join her father (Paramjit Bajaj MD, also a practicing plastic surgeon) in private practice in OKC, where she focuses on breast reconstruction and general cosmetic surgeries.

Devra B. Becker, MD, FACS, is an Assistant Professor of Plastic Surgery in the Department of Plastic Surgery at University Hospitals/Case Western Reserve University School of Medicine in Cleveland, Ohio. She completed Plastic Surgery residency at Washington University School of Medicine in St. Louis, and completed fellowships with Daniel Marchac and with Bahman Guyuron. She currently has a primarily reconstructive practice.

Henry C. Hsia, MD, FACS is at Robert Wood Johnson Medical School of Rutgers University in New Brunswick, New Jersey and also holds an appointment at Princeton University.  When he’s not working hard trying to be a good father and husband, he runs a practice focused on reconstructive surgery and wound care as well as a research lab focused on wound biology and regenerative medicine.

Stephanie K. Rowen, MD is a senior physician at The Permanente Medical Group in San Jose, California.  She joined TPMG upon finishing residency and a hand surgery fellowship in 2005.  She has a primarily reconstructive practice, about 50% hand surgery.  Outside of work she enjoys participating in triathlons and spending time with her family.

Jon Ver Halen, MD is currently Chief of plastic surgery, Baptist Cancer Center; Research member, Vanderbilt- Ingram Cancer Center; Adjunct clinical faculty, St. Jude Children's Research Hospital. He also acts as Program Director for the plastic surgery microvascular surgery fellowship. His practice focuses on oncologic reconstruction.

Tech Talk Bloggers

Adrian Murphy is a plastic surgery trainee in London, England. He studied medicine in Dublin, Ireland and has trained in Ireland, Boston, MA and the United Kingdom. He is a self-confessed geek and gadget aficionado.

Ash Patel, MD is Assistant Professor of Plastic Surgery and Associate Program Director at Albany Medical College, in Albany NY. His practice is primarily reconstructive.