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A Rebuttal of the 12 Breast Reconstruction Points to Minimize Implant Contamination

Swanson, Eric MD

Plastic and Reconstructive Surgery – Global Open: May 2019 - Volume 7 - Issue 5 - p e2210
doi: 10.1097/GOX.0000000000002210
Letters to the Editor
United States

From the Swanson Center, Leawood, Kans.

Published online 17 May 2019.

Disclosure: Dr. Swanson receives royalties from Springer Nature (Cham, Switzerland). Dr. Swanson is a plastic surgeon in private practice in Leawood, Kansas. The author has no financial interest to declare in relation to the content of this article.

Eric Swanson, MD, Swanson Center, 11413 Ash Street, Leawood, KS 66211, E-mail:

This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Cagli et al1 adapt the 14-point plan2,3 to 165 women undergoing breast reconstruction with implants but report no data. The authors reportedly use 12 of the 14 points in most cases, but there are many exceptions. They describe an S-shaped incision, dissecting close to the nipple/areola complex (point 2).1 Nipple shields (point 3) are irrelevant to women undergoing a full mastectomy. The authors acknowledge that mastectomy is a traumatic dissection, so that a “careful atraumatic dissection” (point 4) is impractical. The breast parenchyma is dissected during any partial mastectomy (point 6). A dual plane (point 7) is not applicable to patients whose lower pole breast tissue has been removed; a subglandular plane no longer exists. An introductory sleeve (point 9) would not be advantageous in a breast reconstruction with wide exposure. The surgeon must still touch the implant to position it properly. Breast tissue is not sterile, but rather inhabited by commensal bacteria.4 The authors use drains (point 12) to avoid seromas. With these exceptions, the point total is reduced to 7.

Are the 7 remaining points valid? Almost all (99%5) plastic surgeons already routinely administer preoperative intravenous antibiotics (point 1). Performing “careful hemostasis” (point 5) is simply good surgical practice and not particularly relevant to bacterial contamination. Recent systematic reviews fail to show a clear benefit for triple antibiotic or betadine irrigation (point 8).6–8 In fact, triple antibiotic pocket irrigation may be counterproductive.8,9 Betadine may be nonsterile10 and should not be used to irrigate surgical wounds.10,11 Washing a sterile breast implant in its box cannot make it “more sterile.”12

Minimizing implant exposure to the air (point 10) does not make sense. Sterile instruments are exposed to the air in any sterile operation and are not changed routinely absent a break in sterility. Regardless, it is normal practice to open an implant container when it is time to insert the implant. Changing gloves and instruments (point 11) implies that the existing gloves and instruments are already contaminated, so the damage has already been done, so to speak. Logically, there is no reason to exchange sterile gloves and instruments for new sterile gloves and instruments.

Using a layered wound closure (point 13) reduces the risk of dehiscence. Like careful hemostasis, a layered wound closure is simply part of normal surgical practice. Future antibiotic prophylaxis for procedures that breach the skin or mucosa (point 14) is not recommended consistently by surgeons using the 14-point plan (fortunately).3 Unnecessary antibiotic use can lead to an opportunistic infection or allergic reaction and is known to promote antibiotic resistance in the community.13

Only one factor (not one of the points) is known to be linked to breast implant-associated anaplastic large-cell lymphoma—textured implants.14 Smooth implants offer a safe alternative. It is clear that the problem is a faulty product,14,15 not faulty surgeon technique, a notion that is driven by conflicted investigators.14 Implant manufacturers often fund microbiological studies that identify an infectious etiology,2 or simply pay the article processing fee.1 Evidence-based medicine must take precedence over unscientific formulas.

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1. Cagli B, Salzillo R, Santorelli A, et al. Minimizing breast implant contamination in breast reconstruction procedures: introducing the “12 breast reconstruction points”. Plast Reconstr Surg Glob Open. 2018;6:e2028.
2. Deva AK, Adams WP Jr, Vickery K. The role of bacterial biofilms in device-associated infection. Plast Reconstr Surg. 2013;132:1319–1328.
3. Adams WP Jr, Culbertson EJ, Deva AK, et al. Macrotextured breast implants with defined steps to minimize bacterial contamination around the device: experience in 42,000 implants. Plast Reconstr Surg. 2017;140:427–431.
4. Thornton JW, Argenta LC, McClatchey KD, et al. Studies on the endogenous flora of the human breast. Ann Plast Surg. 1988;20:39–42.
5. Gowda AU, Chopra K, Brown EN, et al. Preventing breast implant contamination in breast reconstruction: a national survey of current practice. Ann Plast Surg. 2017;78:153–156.
6. Drinane JJ, Chowdhry T, Pham TH, et al. Examining the role of antimicrobial irrigation and capsular contracture: a systematic review and meta-analysis. Ann Plast Surg. 2017;79:107–114.
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8. Samargandi OA, Joukhadar N, Al Youha S, et al. Antibiotic irrigation of pocket for implant-based breast augmentation to prevent capsular contracture: a systematic review. Plast Surg (Oakv). 2018;26:110–119.
9. Swanson E. The questionable role of antibiotic irrigation in breast augmentation. Plast Reconstr Surg. In press.
11. Alexander JW, Solomkin JS, Edwards MJ. Updated recommendations for control of surgical site infections. Ann Surg. 2011;253:1082–1093.
12. Myckatyn TM, Parikh RP. Discussion: breast implant-associated anaplastic large cell lymphoma in Australia and New Zealand: high-surface-area textured implants are associated with increased risk. Plast Reconstr Surg. 2017;140:655–658.
13. Ranganathan K, Sears ED, Zhong L, et al. Antibiotic prophylaxis after immediate breast reconstruction: the reality of its efficacy. Plast Reconstr Surg. 2018;141:865–877.
14. Swanson E. A 1-point plan to eliminate breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL). Ann Plast Surg. 2018;80:565–466.
15. Van Slyke AC, Carr M, Carr NJ. Not all breast implants are equal: a 13-year review of implant longevity and reasons for explantation. Plast Reconstr Surg. 2018;142:281e–289e.
Copyright © 2019 The Author. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.