Microbiologic Safety of the Transareolar Approach in Breast Augmentation

Breast Surgery Microbiologic Safety of the Transareolar Approach in Breast Augmentation Aesthetic Surgery Journal 2016, Vol 36(1) 51–57 © 2015 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: DOI: 10.1093/asj/sjv106 www.aestheticsurgeryjournal.com Dana Mihaela Jianu, MD, PhD; Oana Săndulescu, MD; Anca Streinu-Cercel, MD, PhD; Ioana Berciu, MD; Alexandru Blidaru, MD, PhD; Maria Filipescu, MD; Mihaela Vartic, MD, PhD; Oltjon Cobani, MD; Ștefan Adrian Jianu, MD, PhD; Daniela Tălăpan, MD; Olga Dorobăț, MD, PhD; Florica Stăniceanu, MD, PhD; and Adrian Streinu-Cercel, MD, PhD Abstract Background: In aesthetic breast augmentation, especially by the transareolar approach, there is increasing concern regarding the occurrence of capsular contracture and its potential correlation with intraoperative implant contamination from putative endogenous breast flora of the nipple and lactiferous ducts. However, detectable bacteria cannot be considered synonymous with established resident microflora. Objectives: The authors sought to elucidate the existence of endogenous breast flora and assess the microbiologic safety of transareolar breast augmentation. Methods: In this prospective study (BREAST-MF), the authors collected microbiologic samples from the breast skin, ductal tissue, and parenchyma of 39 consecutive female patients who underwent breast procedures in a plastic surgery clinic. Swabs collected pre-, intra-, and postoperatively were processed for bacterial and fungal growth. Positive cultures underwent identification through VITEK and MALDI-TOF, as well as antimicrobial susceptibility testing. Results: Staphylococcus species accounted for 95 of 106 (89.6%) positive results from native breast skin, 15 of 18 (83.3%) positive results from decontaminated breast skin, and 4 of 4 (100%) positive results from the breast parenchyma. Methicillin resistance was present in 26.4% of S. epidermidis, 25.3% of S. hominis, and 71.4% of S. haemolyticus strains. Conclusions: During transareolar breast augmentation, in the nipple-areola region it is more likely to find bacteria populating the skin, rather than endogenous breast flora, as previously considered. Appropriate preoperative decontamination is essential for minimizing the risk of postoperative infections. Level of Evidence: 3 Accepted for publication May 12, 2015; online publish-ahead-of-print November 20, 2015. Dr D.M. Jianu is a Plastic Surgeon and Associate Professor, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania. Dr Să ndulescu is a PhD Candidate and Assistant Lecturer, Department of Infectious Diseases, Carol Davila University of Medicine and Pharmacy; and is a Resident Physician in Infectious Diseases, Infectious Diseases Department II, National Institute for Infectious Diseases “Prof. Dr Matei Balş,” Bucharest, Romania. Dr Anca Streinu-Cercel is a Lecturer, Department of Infectious Diseases, Carol Davila University of Medicine and Pharmacy. Dr Berciu is a PhD Candidate, Department of Infectious Diseases, Carol Davila University of Medicine and Pharmacy. Dr Blidaru is a Professor, Department of Oncologic Surgery, Carol Davila Risk University of Medicine and Pharmacy. Dr Filipescu is a Senior Physician in Plastic Surgery, Dr Vartic is a Senior Physician in anesthesiology and intensive care, Dr Cobani is a Specialist Physician in Plastic and Aesthetic Surgery and Reconstructive Microsurgery, and Dr Jianu is a general surgeon, at a private medical clinic, Bucharest, Romania. Dr Tă lă pan is a PhD Candidate, Department of Infectious Diseases, Carol Davila University of Medicine and Pharmacy. Dr Dorobă t ̦ is a Senior Physician in Microbiology, National Institute for Infectious Diseases “Prof. Dr Matei Balş,” Bucharest, Romania. Dr Stă niceanu is a Professor, Department of Pathology, Carol Davila University of Medicine and Pharmacy. 52 The incidence of capsular contracture following breast augmentation is a source of increasing concern in aesthetic surgery. One of the factors behind capsule formation is considered to be the intraoperative contamination of the implant.1,2 The transareolar approach is considered prone to such contamination, owing to putative endogenous flora of the lactiferous ducts.1,3,4 Because the human body contains 10 times more bacterial cells than human cells,5,6 the identification of bacterial species should be expected when sampling virtually any compartment of the body, including the breast. However, the isolation of bacteria from an anatomic site is not synonymous with the existence of established local microflora. For bacterial communities to qualify as resident flora, the following 4 criteria must be met simultaneously: (1) The species identified are different from those of surrounding areas; (2) the habitat is rich in nutrients, enabling bacteria to survive and shielding them from the host’s local antiinfective protection; (3) the species isolated are nonpathogenic and consistently identified over a relatively large sample of subjects; and (4) the microorganisms perform a role in that anatomic area.7 To elucidate the controversy regarding the existence of endogenous breast flora, 8 we conducted a prospective study (BREAST-MF) to identify and characterize the microbial species present on the breast skin, ductal tissue, and parenchyma. METHODS The methodology of the prospective study BREAST-MF has been described previously.7 Microbiologic samples were systematically collected from 39 consecutive female patients who underwent breast surgery in the ProEstetica Medical Center (Bucharest, Romania) from February 2013 to September 2013. All patients signed a study-specific informed consent document endorsed by the Institutional Review Boards of the National Institute for Infectious Diseases “Prof. Dr Matei Balş” and the ProEstetica Medical Center prior to any study procedures. The study was conducted in line with the principles of Good Clinical Practice (ICH GCP). Thirty minutes before the initial incision, patients received a single dose of cefuroxime intravenously (1.5 g). The skin was prepared successively with 70% ethanol (Scandic Distilleries, Romania) and a solution of iodine tincture (50 mL) in 70% ethanol (50 mL). The skin was then draped in the standard manner. The surgical technique aimed to minimize implant contamination, tissue trauma, and bleeding, as these factors are implicated in the etiology Dr Adrian Streinu-Cercel is a Professor in the Department of Infectious Diseases, Carol Davila University of Medicine and Pharmacy; Bucharest, Romania. Aesthetic Surgery Journal 36(1) Figure 1. Microbial sampling procedure depicted as a flowchart. The axilla parenchyma was swabbed when it was within operative reach. Sample collection from intracapsular fluid, capsule biopsies and implant sonication for observation of biofilms corresponded to secondary breast implant procedures, where applicable. Tegaderm is manufactured by 3M. (...truncated)