- 1Step 7 : Pocket Irrigation with proven antibiotic/antiseptic irrigation
A common question for surgeons to ask is : what is the best solution to reduce the risk of bacterial contamination of the implant?
Boyd Burkhardt brought the sub-clinical infection etiology to plastic surgeons in the 1980’s. For this reason many surgeons used a variety of irrigations during breast implant procedures in the 1980 an 90’s.
Optimizing breast pocket irrigation is a concept that was popularized by Adams et al. (2000, 2001, 2006) where the polymicrobial nature of capsular contracture was detailed and many common breast pocket irrigations used in the 1990s were disproven as ineffective against many of the different species of bacteria implicated in capsular contracture.
The same studies determined the optimal irrigations for breast pocket irrigation and also provided clinical intraoperative recommendations to minimize implant contamination at the time of surgery. These recommendations have grown to become the 14 point plan.
The 3 key original studies are provided for easy access.
- 1Recommended pocket irrigation solutions and anti-bacterial efficacy
The 3 proven irrigations are
| Irrigation solution | Component 1 | Component 2 | Component 3 | Component 4 |
| Betadine (Povidone Iodine) + Antibiotics |
500cc Betadine (10% Povidone Iodine) | 1g Cefazolin | 80mg Gentamicin | 500cc Normal Saline |
| Betadine (Povidone Iodine) alone Maximum 50% dilution with N/S |
500cc Betadine (10% Povidone Iodine) | up to 500cc Normal Saline | – | – |
| Triple antibiotics (non-Betadine) | 50,000U Bacitracin | 1g Cefazolin | 80mg Gentamicin | 500cc Normal Saline |
The clinical study in 2006 reported a 5x lower capsular contracture rate for breast augmentation and a 8 x lower capsular contracture rate in breast reconstruction.
2 subsequent studies in 2013 reported a 10 x lower capsular contracture rate using the same triple antibiotic irrigations (Blount, Martin et al. 2013, Giordano, Peltoniemi et al. 2013)
Surgeons should use one of the above proven irrigations. The biggest issue that has been identified in the past 15 years is not following the specific recipes for the proven irrigations.
In the US betadine containing irrigations may be used off-label. Some surgeons follow with an optional post betadine rinse with saline prior to implant placement. This practice, however, can reduce the efficacy of the irrigation.
Also relevant is the finding of novel gram negatives ie Ralstonia Pickettii in BIA-ALCL. The breast pocket irrigation studies above have demonstrated better gram negative coverage with the betadine containing irrigations, and preliminary bacteriology suggests that betadine containing irrigation have sufficient coverage vs Ralstonia.
Our personal preference is to use one of the two betadine containing irrigations when possible for implant pocket preparation. Irrigation options for specific patient allergies is detailed in the 2006 publication (Adams, Rios et al. 2006).
- 1Key articles pdf download