Biofilms, 3-D breast imaging dominate international discussions

INTERNATIONAL REPORT — Breast surgery is one of the most frequently performed aesthetic procedures, both in the United States and internationally, and 3-D breast imaging and biofilms are two of the leading issues with this procedure, according to surgeons at this year's International Hot Topics in Aesthetic Surgery symposium, at the annual meeting of the American Society for Aesthetic Plastic Surgery in Washington in April.

Brad Bengtson, M.D., of Bengtson Center for Aesthetics and Plastic Surgery, Grand Rapids, Mich., says the use of 3-D imaging equipment — particularly for breast augmentation, revision and reconstruction surgery — has transformed his practice. In fact, he suggests that it is only a matter of time before this technology becomes the norm in all cosmetic surgery practices.

"The biggest barriers for patients are safety, cost, followed by outcome. Once you get through the cost and safety issues, patients focus on what they will look like following surgery, and current 3-D imaging technology gives them a very close representation of what they can look like," Dr. Bengtson says.

3-D breast imaging helps with patient documentation, communication and surgical planning. This simulation system is Canfield Scientific's Vectra imaging system. (Photo credit: Brad Bengtson, M.D.)

"This technology gives patients a very close representation of what they will look like postoperatively, but," he stresses, "it is just a range, and patients shouldn't expect an exact duplicate of the digital image."

BATTLING BIOFILMS Dr. Bengtson is a strong proponent of 3-D imaging equipment for breast surgery, but he acknowledges that no matter how much preoperative planning one does or how carefully a patient's expectations are managed, there are no guarantees concerning surgical outcomes. Nowhere is this more apparent than in the growing body of literature documenting the incidence of biofilms, which are responsible for an increasing number of reported prosthesis failures, including the contracture of breast implants, according to Anand Deva, M.S., associate professor, head of cosmetic plastic and reconstructive surgery, Australian School of Advanced Medicine, Macquarie University, Sydney.

"Bacteria prefer to exist in a sessile state. Contact with a surface initiates the secretion of sticky proteins that bind the bacteria irreversibly to it. The combination of live bacteria protected by their protein armor is termed biofilm," Dr. Deva says. "Once formed, biofilm is difficult to remove, because of the nature of the attachment and its resistance to antibiotics and antiseptics. It initiates chronic inflammation, and, ultimately, will lead to failure of the implant."

Dr. Deva also says that surgeons who deal with the implantation of medical prosthetics need to be aware of the potential for biofilm contamination, as well as steps for reducing the risk of bacterial contact with the prosthesis at the time of surgery. "This is critical to reducing the risk of subsequent biofilm formation and implant failure," he says. Surgeons should also be aware of the signs of implant failure and recognize that at this time the only treatment for a biofilm-contaminated implant is removal.

To avoid experiencing biofilm, Dr. Deva recommends using routine antibiotic prophylaxis when anesthesia is administered and antibiotic irrigation of the pocket prior to placing the implant. "We also no longer recommend the transareolar incision, as this increases the risk of bacterial contamination of the implant," Dr. Deva says. He also recommends using sterile draping on the nipple areolar complex to prevent bacterial spillage, using sleeves to reduce skin contamination (the "no-touch technique") and routinely changing gloves prior to handling the implant. "These measures are not currently supported by scientific research, but we are looking at generating data on this."

Dr. Deva also stresses that the risk of contracture and biofilm contamination is highest in patients undergoing prosthetic breast reconstruction, especially following adjuvant chemotherapy and radiotherapy. "Cosmetic surgeons should be aware of the growing literature on biofilms in other areas of surgical practice, and should also be on the lookout for more advances in this area, including work from our laboratory on anti-biofilm technologies," he says. "A study investigating new technology is under way, and we hope to have some preliminary results to report next year. It is hoped, if these strategies prove effective in reducing biofilm formation, that they will be translated into clinical practice in the near future."