Explore Plastic Surgery - Dr. Barry Eppley

Plastic Surgery is unique amongst the medical specialities in that many of our procedures involve using synthetic implants. Only Orthopedic Surgery rivals or exceeds the number of implants placed per procedures. As a result, plastic surgeons have a long history of implant handling and implantation, particularly for elective cosmetic surgery. Breast and facial implants come most commonly to mind.

As part of implanting synthetic materials comes the risk of postoperative infection. The majority of surgical implant infections occur early after surgery, within weeks or a  month, and are the result of being inoculated at the time of implantation.  Most commonly, the source of inoculation is bacteria from the patient themselves coming from the skin or other surfaces that are heavily colonized. Whether adhering onto the implant by passing through the skin or having cross-contamination from instruments or gloved hands, bacteria that lodge into the implant’s surface may turn into an infection later.

Antibiotics are widely used in plastic surgery and certainly are routinuely done when it involves a procedure in which a synthetic implant is used. Antibiotics are given intravenously during surgery and by the oral route afterwards. The purpose of antibiotics circulating through your blood stream is that they will reach the implant site by blood vessels that surround it. Once there, the antibiotic molecule will not only prevent any bacteria on the implant from replicating but will then destroy those that are present.

Another common plastic surgery practice, in addition to systemic antibiotics, is to soak or wash the implant in an antibiotic solution prior to implanting it. This intraoperative method is an insurance policy that has two purposes. First, it will hopefully wash any off any bacteria that may have inadvertently become stuck on the implant’s surface. Secondly, some of the antibiotic may remain attached to the implant so it may work its magic against any neighboring or remaining attached bacteria.

I have always wondered how effective, or if it is effective at all, that implant washing in antibiotics before implantation may be. Would washing the implant in saline alone be just as effective? After all, many implants have quite hydrophobic (water repelling) surfaces that do not have the capability to absorb any fluids even if they are antibiotics.

Therefore, I designed a simple bacterial culture experiment. Using 1 cm long pieces of surgical Gore-Tex tubes (fairly hydrophobic surfaces), they were both swabbed with staphalococcus aureus cultures and then soaked for one minute in an antibiotic solution or in a saline solution. They were then placed petri dishes that had also been wiped with the same bacteria and then grown in culture for a week. What did I observe?

Those implants that had been washed in saline were completely overgrown with bacteria that spread over the entire plate.

Those implants that had been soaked in antibiotics had a clear zone of growth inhibition around the implant while the rest of the plate was covered with bacterial growth.

The conclusion is that, not surprisingly, the soaking or washing of an implant is helpful for bacterial growth inhibition. Even in the face of an implant surface that does not appear to be particularly absorptive, a significant beneficial effect was seen.The combination of systemic and local antibiotic application when placing synthetic implants is a prudent approach that merits its continued use.   

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

Next to orthopedic surgery, plastic surgery as a medical specialty uses a significant number of implants and implant materials to help achieve its surgical outcomes. Whether it is breast implants or an injectable filler, the use of synthetic or foreign materials is common in plastic surgery. Often when a plastic surgery patient needs an implant for their procedure, they will ask the question….’What if my body rejects the implant?’…..or…..’What are my chances that I will react (adversely) to the implant?’ This understandable concern is reflective of a basic misunderstanding of how the body reacts to implanted foreign materials and what type of complications can develop.
In reality, the rejection of an implanted synthetic material (that has been evaluated and approved for human implantation by the FDA), in the most scientific sense, does not happen. A true rejection reaction in humans is an autoimmune response to an ‘implant’ that is composed of live or organic material. Therefore, you will develop a rejection or autoimmune reaction, for example, in any type of organ transplant which is from other human or animal origins. Your body’s cells mount a massive response to what it recognizes as foreign or an invading organic source. The body is quite smart and protective as this type of response is necessary for survival.
Synthetic implants are composed of inorganic materials, which do not cause a true allergic or autoimmune response. These are not live materials and were never composed of living organic materials. As a result, they can not elicit an allergic response. They may never become part of you or integrate into your body’s tissues, but they can safely occupy a space to do their job. Synthetic implants, while not causing allergic responses, can cause a different set of problems which patients mistakenly interpret as ‘rejection’.
Synthetic implants can get infected, exposed, or migrate, all of which are complications of the surgical implantation process not due to rejection. If bacteria inadvertently get on the surface of the implant, an infection can later develop. Most implant infections occur within weeks of the surgery as it takes time for the bacteria to multiply and become evident. Synthetic implants can migrate or move from their location where they were surgically placed if the implant material is very smooth or the tissue pocket into which it is placed is very big. This potential migration can be eliminated if the implant is secured into its desired location by some method such as sutures or metal screws. Implant exposure can result from migration of the implant, getting close to the original incision through which it is placed. Or implant exposure can result from not having enough good tissue closed over it or tissue that breaks down over the implant due to too much pressure that the implant exerted on it or the overlying tissue is of poor quality and it doesn’t heal well and then breaks down, thus exposing the implant.
The patient will understandably interpret these synthetic implant complications as ‘rejecting the implant’. In reality, the patient’s body has little to do with the development of these complications. They are more a function of surgical technique and not due to a patient’s immune response to them. The risk of these potential implant complications can be reduced by pre-surgery antibiotics, a properly sized implant that does not stress the surrounding tissues, and careful surgical implantation technique.
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis