Bacterial biofilms and capsular contracture in patients with breast implants.

BACKGROUND: It has been hypothesized that bacterial biofilms on breast implants may cause chronic inflammation leading to capsular contracture. The association between bacterial biofilms of removed implants and capsular contracture was investigated. METHODS: Breast implants explanted between 2006 and 2010 at five participating centres for plastic and reconstructive surgery were investigated by sonication. Bacterial cultures derived from sonication were correlated with patient, surgical and implant characteristics, and the degree of capsular contracture. RESULTS: The study included 121 breast implants from 84 patients, of which 119 originated from women and two from men undergoing gender reassignment. Some 50 breast prostheses were implanted for reconstruction, 48 for aesthetic reasons and 23 implants were used as temporary expander devices. The median indwelling time was 4·0 (range 0·1-32) years for permanent implants and 3 (range 1-6) months for temporary devices. Excluding nine implants with clinical signs of infection, sonication cultures were positive in 40 (45 per cent) of 89 permanent implants and in 12 (52 per cent) of 23 temporary devices. Analysis of permanent implants showed that a positive bacterial culture after sonication correlated with the degree of capsular contracture: Baker I, two of 11 implants; Baker II, two of ten; Baker III, nine of 23; and Baker IV, 27 of 45 (P < 0·001). The most frequent organisms were Propionibacterium acnes (25 implants) and coagulase-negative staphylococci (21). CONCLUSION: Sonication cultures correlated with the degree of capsular contracture, indicating the potential causative role of bacterial biofilms in the pathogenesis of capsular contracture. REGISTRATION NUMBER: NCT01138891 (http://www.clinicaltrials.gov).

Sonication of removed breast implants for improved detection of subclinical infection.

BACKGROUND: Capsular fibrosis is a severe complication after breast implantation with an uncertain etiology. Microbial colonization of the prosthesis is hypothesized as a possible reason for the low-grade infection and subsequent capsular fibrosis. Current diagnostic tests consist of intraoperative swabs and tissue biopsies. Sonication of removed implants may improve the diagnosis of implant infection by detachment of biofilms from the implant surface. METHODS: Breast implants removed from patients with Baker grades 3 and 4 capsular contracture were analyzed by sonication, and the resulting sonication fluid was quantitatively cultured. RESULTS: This study investigated 22 breast implants (6 implants with Baker 3 and 16 implants with Baker 4 capsular fibrosis) from 13 patients. The mean age of the patients was 49 years (range, 31-76 years). The mean implant indwelling time was 10.4 years (range, 3 months to 30 years). Of the 22 implants, 12 were used for breast reconstruction and 10 for aesthetic procedures. The implants were located subglandularly (n = 12), submuscularly (n = 6), and subcutaneously (n = 4). Coagulase-negative staphylococci, Propionibacterium acnes, or both were detected in the sonication fluid cultures of nine implants (41%), eight of which grew significant numbers of microorganisms (>100 colonies/ml of sonication fluid). CONCLUSIONS: Sonication detected bacteria in 41% of removed breast implants. The identified bacteria belonged to normal skin flora. Further investigation is needed to determine any causal relation between biofilms and capsular fibrosis.

Breast cancer in previously burned skin: a postburn skin adnexal malignancy?

An unstable postburn scar at the submammarian fold 6.5 months after a burn injury turned out to be breast cancer. The unexpected histological findings and a possible correlation between the burn and the malignancy are discussed. This care report emphasizes the importance of histopathologic examination and the chance of unusual findings in a postburn ulcer.

Is soft tissue expansion in lower limb reconstruction a legitimate option?

From 1986 to 1994, a consecutive series of 34 patients had 37 expanders placed in their legs. Indications for expansion included removal of painful ro unstable scars, chronic post-traumatic ulcers and one benign skin lesion. In 13 patients the lesion or scar was greater than 5 cm in diameter. The area of expansion was mainly in the proximal and distal thirds of the lower limb. On three occasions two expanders were simultaneously used in the same patient. The treatment with this technique was ultimately successful in 23 patients (67.6%) but 15 of the 23 patients (44% of the 34 patients) had minor wound healing problems. Before 1990, technical complications such as leaking injection ports caused further small interventions in 6 patients without compromising the ultimate outcome. The goal was not achieved with the expansion technique in 11 patients (32%). 5 of these 11 patients could be treated successfully with another surgical modality. All 34 patients were re-evaluated with an average follow-up of 4.5 years. We conclude that tissue expansion is ideal for removal of localised areas of scar, repair of contour defects and excision of benign tumours. Contraindications of soft tissue expansion are, in general, extensive scarred areas with compromised blood supply after trauma, vascular disease and osteomyelitis. These conditions require reconstruction with well vascularised tissue such as muscle flaps. A compliant patient is essential for lower limb reconstruction with tissue expansion. In spite of the tempting simple method of tissue expansion, success in the lower limb depends not only on the indication but also on the operating technique of the plastic surgeon.

How does a pure muscle cross-leg flap survive? An unusual salvage procedure reviewed.

An exceptional indication for a cross-leg gastrocnemius flap used as a pure muscle flap in the distal third of the lower leg is presented. The vascular status of the patient after the accident and extensive colonized wounds in the injured lower leg did not favor any microvascular reconstruction. Because no cross-leg muscle flap has been mentioned in the literature so far, technical details of the procedure are explained. This case report leads to a discussion of the principles of wound healing in cross-leg muscle flaps as an example for early loss of axial blood supply. Furthermore, it adds new variety to the numerous procedures that use the gastrocnemius flap.

The pattern of cytokine gene expression in freshly excised human metastatic melanoma suggests a state of reversible anergy of tumor-infiltrating lymphocytes.

Expression of an extended panel of cytokine genes was investigated by reverse polymerase chain reaction (PCR) in 10 freshly excised melanoma metastases infiltrated by lymphocytes (TIL). cDNA encoding for CD3-delta and tyrosinase could be amplified in all samples, confirming the presence of T lymphocytes and melanoma cells. Cytokine genes possibly transcribed by both cell types, such as GM-CSF, IL-6 and IL-10 could be amplified from 5, 2 and 2 samples respectively. In contrast, IL-1 beta and TNF-alpha mRNA were never detectable, IL-1 alpha, IL-3 and IL-7 mRNA could be observed only in one case each. Transcripts encoding for TGF-beta 1 were observed in 8 samples, while TGF-beta 2 and 3 mRNA were detectable in only 2 specimens. mRNA encoding for cytokine genes typically transcribed by antigen-stimulated T lymphocytes, such as IL-2, IL-4 and IFN-gamma were rarely or never detectable (none, none and 1 of the samples respectively). In one case, where no cytokine gene transcription was detectable at the time of surgery, we addressed the question of the antigenicity of the tumor and of the functional competence of TIL. A primary tumor cell line was generated and cultured TIL were induced to transcribe IL-2 and IFN-gamma genes by incubation with the autologous irradiated tumor cell line, but not with autologous EBV-transformed cells. In these conditions, tumor-specific cytotoxic T lymphocytes (CTL) could be generated only after 3 weekly re-stimulations. In contrast, if autologous irradiated EBV-transformed cells were added to the cultures, specific CTL could be detected after one single tumor stimulation. Thus, signs of active responsiveness in terms of lymphokine gene mRNA are seldom detectable in melanoma metastases. Tumor-specific responses, however, including IL-2 and IFN-gamma gene expression and generation of CTL can be produced in vitro from specimens in which no cytokine gene mRNA is detectable ex vivo.

Epidemiological data and costs of burn injuries in workers in Switzerland: an argument for immediate treatment in burn centres.

A complete statistical evaluation of epidemiological data and costs of burn injuries in 1984 with a follow-up for 5 years is presented, considering a collective of 1.77 million workers in Switzerland. The majority of burns are minor injuries; only about 5 per cent of the burn victims are admitted to a hospital, 0.2 per cent died. Burn injuries at work are rare, mainly owing to strict safety measures. Only one-fifth of the costs caused by burns are due to medical treatment. All other expenses result from continuation of payments of salaries and annuities. The treatment of the few severely burned patients in burn units produces effective costs which are higher than the tariff paid by the insurance. Even so, the predominant portion of the enormous costs is taken up by wages while off work and annuities. As our conclusion we stress the importance of primary care for all severe burns including all burns of the hands in a specialized centre. Any economic effort for primary burn treatment, however high it may be, is justified if the duration of rehabilitation and invalidity can be reduced.

[Burns in workers in Switzerland: epidemiology and financial sequelae]. / Brandverletzungen bei Werktätigen in der Schwiez: Epidemiologie und Kostenfolgen.

A complete statistical evaluation of epidemiologic data and costs of burn injuries in 1984 with a follow-up for 5 years is presented, considering a collective of 1.77 million workers in Switzerland. The majority of burns are minor injuries; only about 5% of the burn victimes are admitted to a hospital, 0.2% die. Only one fifth of the costs caused by burns are due to medical treatment and rehabilitation. All other expenses result from continuation of payments of salaries and annuities. The few treatments of severely burnt patients in the burn units cause effective costs higher than the tariff paid by the insurance. Even so, the predominant portion of the enormous costs is taken up by wages while off work and annuities. As our conclusion we stress the importance of primary care for all severe burns including all burns of the hands in a specialized centre. Any economic effort for primary burn treatment, however high it may be, is justified if the duration of rehabilitation and invalidity can thus be reduced.

The neurosensory musculocutaneous tensor fasciae latae flap: long term results.

In 1971 we started covering pressure sores and unstable scars with transposition-rotation-muscle and musculocutaneous flaps. In 1980 we published the first results with 6 neurosensory musculocutaneous tensor fasciae latae flaps. Until April 1989, 31 tensor fasciae latae flaps (TFL) were used, and we review a consecutive series of 19 neurosensory TFL-flaps. Questions such as whether to delay the procedure; early and late complications; evolution of the sensation; and indications are outlined under the aspects of long term follow up studies. The conclusion is that if the neurological pattern permits a neurosensory flap, such flaps should be done because no local recurrence occurred. In extended neurosensory TFL-flaps sensation of the filling status of the rectum is improved, and sitting control and perception of the 'body scheme' are also improved.

[Reconstructive measures in local recurrence after breast saving therapy of breast cancer]. / Rekonstruktive Massnahmen beim Lokalrezidiv nach brusterhaltender Therapie des Mammakarzinoms.

Local recurrence after breast preserving treatment of breast cancer will usually be treated by simple mastectomy. Safe immediate reconstruction is only possible by use of a musculocutaneous flap, the latissimus dorsi flap or better by the rectus abdominis musculocutaneous flap in it's vertical (VRAM) or transverse (TRAM) variation. As a sequel of the irradiation, one stage reconstruction with a simple submuscular implant or an expander prosthesis has a higher complication rate. Personal experience with 42 rectus flaps is reported. The rate of total necrosis was 5%, in one patient a late desmoid tumor was found in the donor area.

[Surgical vascular anatomy of the thoracic wall]. / Chirurgische Gefässanatomie der Brustwand.

Since the rediscovery of the latissimus dorsi flap in 1976 axial skin- and musculocutaneous flaps have dramatically improved the possibilities of plastic reconstruction. Better knowledge of the microvascular anatomy of the thoracic wall is the condition for safe flap surgery. The frequent topographic variations and the possibility of a reversed flow through vascular anastomosis are shown. This paper is ment to be a basic introduction to the following communications on flaptechniques in the same journal.

[Value of surgical treatment of decubitus ulcer in geriatric patients]. / Stellenwert der chirurgischen Behandlung eines Dekubitus beim geriatrischen Patienten.

Geriatric patients have a high incidence of pressure sores. Pain, chronic and acute infection and protein loss may impair their general condition. Pressure relief, local débridement, disinfection and physiologic wound dressing are the first steps in local treatment. The spontaneous healing time of a pressure sore is very slow, even if concomitant diseases as diabetes, urinary tract infection and pneumonia could be stabilized and the general condition of the patient be improved. In these selected and stable cases, surgical débridement and plastic pressure sore closure may be indicated. Simple skinflaps can give good results in superficial sores without bone involvement and have a low operative morbidity. Musculocutaneous flaps are technically more difficult, but resist better to infection and may fill bigger and deeper defects. In any operation, vascular territories (angiosomes) of further flaps, suitable for a recurrent or second decubitus closure, must be preserved. Long-term results in 30 operated patients over 60 are presented. Although the postoperative complication rate is very high, healing could be achieved in all surviving patients.

The sensory tensor fasciae latae flap: a 9-year follow-up.

From January 1979 to April 1989, 19 neurosensory tensor fasciae latae flaps were used to cover ischial pressure sores in paraplegic patients. This flap provides protective sensation and improves the sensory control of the filling status of the rectum and the sitting control in a wheelchair. Patients were reexamined between 12 and 110 months; no recurrence or new pressure sores were seen. Indications, early and late complications, and evolution of the sensation are discussed.

Why the denervated gastrocnemius muscle flap should be encouraged.

The superiorly based, denervated gastrocnemius muscle flap is able to perform an aesthetically excellent and functionally good cover for defects of the upper one-third of the calf, including the knee, and the lower one-third of the thigh. A consecutive series of 41 muscle and musculocutaneous gastrocnemius flaps was analyzed. Thirty-six patients (88% of the patients who underwent surgery) could be reexamined. The mean follow-up time was 36 months, with a minimum time of 12 months. At the time of examination, all skin defects as well as the incidental concomitant osteomyelitis had completely healed; however, 40% of the patients have required secondary operations. One-half of the patients have a functional deficiency, and 20% showed areas with loss of sensation. After surgery with musculocutaneous flaps, all patients complained about the sensory loss of the saphenous nerve, and peripheral edema was seen more often than after surgery with a simple muscle flap. Muscle flaps with residual innervation showed more secondary wound breakdown and more contraction pain, due to spasms. The best results concerning function and aesthetics are achieved with denervated muscle flaps covered by a split-thickness skin graft. In this variation, the flap showed good and stable coverage without bulk, as well as minimal donor-site deformity; therefore, primary denervation must be considered. The anatomy of the motor nerves to the gastrocnemius muscle is shown.

[Facial injuries in bicyclists: epidemiological analysis and prophylactic consequences]. / Gesichtsverletzungen des Radfahrers: Epidemiologische Analyse und prophylaktische Konsequenzen.

Bicycle accidents in adults are common and concern frequently injuries to head and face. 150 of totally 216 patients with cycle accidents in a six month' prospective study at the Basel University Hospital showed face and head trauma. 85 severe facial injuries treated operatively by the Clinic for Reconstructive Surgery between 1985 and 1989 are analysed in detail. These facial injuries are rarely life threatening and normally the postoperative outcome is good. Nevertheless, usual bicycle helmets cannot avoid facial trauma. Therefore traffic educational programs are the most important prophylactic efforts. Technical progress and improvement of the bicycles ask for better trained cyclists. Further more, the importance of really respecting the traffic rules as well as the construction of separate cycle routes is stressed.

[Follow-up of extensive burns in an HIV positive patient. Case report]. / Verlauf einer ausgedehnten Verbrennung beim HIV-positiven Patienten. Fallbericht.

The case of a 33-year-old HIV-positive patient who suffered from second- and third-degree burn injuries involving 30% of the body surface is reported. She was treated by early tangential excision of the burnt skin and split-thickness mesh grafting. The burn wounds healed without complications within the usual time, with excellent cosmetic and functional results. In spite of the successful treatment, she suffered from fever and various infections for several months. With the appearance of these constitutional symptoms, we recognized the AIDS-related complex. Her general condition deteriorated continuously and 10 months after the accident she had to be admitted to a hospital again. The skin had nevertheless healed perfectly and in spite of not having compression treatment for the grafts or physiotherapy, she did not show any signs of hypertrophic scars. Some important conclusions drawn from this case are discussed. The fact that healing occurred without complications is in contrast to the results reported in the literature concerning impaired wound healing in AIDS patients with anorectal surgery. We therefore believe that the reluctant and perhaps even anxious attitude of the medical and nursing staff towards performing technical and expensive procedures in HIV-positive burn patients is not justified.

Impaired migration of epidermal cells from decubitus ulcers in cell cultures. A cause of protracted wound healing?

Cultured epidermal cells of explants from decubitus ulcer edges showed significant (P less than 0.05) decreased maximal growth rate (range, 1.3-15.6%) and decreased area of outgrowth per explant (mean and SD, 1.6 +/- 1.7 mm2) when compared with explants obtained 4-5 cm distant from the ulcer edge (range, 46.7-68.8% and 4.6 +/- 2.7 mm2, respectively) and from healthy skin (range, 78.8-93.3% and 6.6 +/- 1.2 mm2, respectively). In contrast, epidermal cells in biopsies from the ulcer edge were significantly (P less than 0.05) more prevalent (range, 1.9-48.2%) as compared with biopsies of healthy skin (range, 3.1-5.1%). Therefore, the decreased growth rate and decreased area of outgrowth may be caused by a defective migration potential rather than an impaired mitotic activity. The latter seems to be normal, as demonstrated by the histomorphometry, which indicates the in vivo situation. Decreased migration potential of epidermal cells could explain the clinically observed protracted epithelialization of decubitus ulcers.