I do a lot of breast implant surgery. I drank the water on biofilm and its association with capsular contracture (a low great infection / colonization of bacteria) years ago after I went the TIPS plastic surgery meeting. All of the associations we knew about capsular contracture make sense when looking at it through the lens of a low grade infection. Biofilm is not a traditional infection- it is not a red skin, tender, pus, fever type infection, but a constantly irritated, constantly fighting at a low level infection.
This is a study out of the Aesthetic Surgery Journal March 2016. “The Relationship of Bacterial Biofilms and Capsular Contracture in Breast Implants.” For my prior blogs on biofilm click For blogs on biofilm . This article is a summary of what we know and prior studies. I won’t bore you with most of it. As it says in the opening paragraphs, “It appears that microbial biofilms form on breast implants as well and might contribute to a chronic inflammatory response and thus formation of capsular fibrosis and subsequent contracture.”
How do you detect biofilm?
- This has been tricky, as traditional cultures don’t grow out biofilm well. These new studies are not readily available yet to us in most hospitals. Traditional cultures on breast implant capsules only detected bacteria on 3 of 27 implants. When tested with other methods, they found bacteria on 15 of the 27 implants.
- PCR (Polymerase chain reaction)- this amplifies a few strands of bacteria DNA. It is a rapid process.
- 16S RNA sequencing (identifies bacterial DNA)
- SEM for direct visualization
- Sonication- this uses sonic energy to cause the bacteria to “release” from the biofilm matrix. They are then cultured. But this technique is not available widely.
Okay. So we know there is an association. How do we prevent it?
- Nipple shields
- Total removal of biofilm from prior operations
- Breast pocket irrigation with multiple antibiotics. (the best solution may be betadine, gentamycin, and cefazolin, though some don’t like betadine because it is thought to cause implant shell issues. So betadine was replaced by bacitracin. This is the triple antibiotic irrigation I use.)
- Prophylactic IV antibiotics. (IV Antibiotics are not effective against established biofilm. They are only good before the biofilm has set up.)
- Antibiotic coating on implants. (Would help prevent biofilm establishing).
- Keller funnel. ( I use this. There was a cadaver study done to see the skin and breast contact with the implant during placement during surgery. With the funnel, bacterial transfer was 37%, without it bacterial transfer was 62%)
- Incision site. (inframammary is lowest rate. 0.59%)
- Pocket site. (Behind the muscle is lower rate)
- If doing a surgery for capsular contracture, you must remove the entire capsule and change the implant to a new one. (you can’t soak the old one).
- Possibly leukotriene inhibitors (like singulair)
So?
So I believe in this. I do most of the prevention things listed (other than nipple shields). I think there is real correlation here, and I want to prevent complications as much as I can. Biofilm establishes early. I would add to this list to do surgical skin prep for days ahead of surgery to “decontaminate” your skin as well. When you hear of breast implant illness, and those who feel bad from implants and feel better when they are removed, I do think biofilm and chronic inflammation could be the culprit.