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An Illuminating No-Touch Device for Breast Augmentation

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... More recently, many plastic surgeons consequently advocate a no-touch technique to minimize skin/parenchyma contamination and complications. [9][10][11][12][13][14] This is generally accomplished with a device composed of a nylon sleeve with a hydrophilic inner coating. 12 This present article describes a low-cost sleeve adapted to insert smooth, nanotextured, and texturized SGI. ...
... Sleeves have been used for a no-touch SGI delivery device since the 1990s. [10][11][12][13][14] The main advantages are reduced contamination risk, low-friction insertion with less force, and less risk of implant rupture. 11,12 The other devices available on the market include the Keller Funnel (Keller Medical, Stuart, Fla.), which consists of a rip-stop nylon sleeve with a hydrophilic inner coating. ...
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Contact between silicone implants and skin/breast parenchyma has been described as an agent of implant contamination and biofilm formation, resulting in implant complications. The no-touch technique was introduced to avoid implant contact and reduce skin/breast contamination. The authors propose an easily available sleeve option using a saline sterile plastic container that provides elastic and transparent protection for inserting silicone implants. These sterile containers can be easily converted into a sleeve by cutting off the narrow end of the container, which then easily fits into the small inframammary, periareolar, and transaxillary incisions. The authors have performed this technique in 10 patients (20 implants) undergoing primary breast augmentation or revision breast surgery, with microtexturized implants ranging in size from 255 to 500 ml (mean, 325 ml) and obtained satisfactory results with no cases of complications. Our clinical outcome shows that this new sleeve does not interact with the implant or the patient's skin and soft tissues and has the added advantage of low cost compared with similar available devices, but further randomized and controlled studies are required to corroborate this effect.
... Surgeons may use a "no-touch" aseptic technique to mitigate this potential source of bacterial infection. 77 However, there is evidence to suggest that late CC (occurring months to years after surgery) may result from remote infection occurring in a distant region of the body with transient bacteraemia allowing for translocation of bacteria. Miller et al. have reported that, in a rat model, haematogenous spread of Staphylococcus aureus from a remote infection resulted in increased capsule thickness, increased numbers of myofibroblasts and collagen density around implanted silicone blocks. ...
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Capsular contracture is a common complication associated with breast implants following reconstructive or aesthetic surgery in which a tight or constricting scar tissue capsule forms around the implant, often distorting the breast shape and resulting in chronic pain. Capsulectomy (involving full removal of the capsule surrounding the implant) and capsulotomy (where the capsule is released and/or partly removed to create more space for the implant) are the most common surgical procedures used to treat capsular contracture. Various structural modifications of the implant device (including use of textured implants, submuscular placement of the implant, and the use of polyurethane-coated implants) and surgical strategies (including pre-operative skin washing and irrigation of the implant pocket with antibiotics) have been and/or are currently used to help reduce the incidence of capsular contracture. In this article, we review the pharmacological approaches—both commonly practiced in the clinic and experimental—reported in the scientific and clinical literature aimed at either preventing or treating capsular contracture, including (i) pre- and post-operative intravenous administration of drug substances, (ii) systemic (usually oral) administration of drugs before and after surgery, (iii) modification of the implant surface with grafted drug substances, (iv) irrigation of the implant or peri-implant tissue with drugs prior to implantation, and (v) incorporation of drugs into the implant shell or filler prior to surgery followed by drug release in situ after implantation.
... One approach requires several assistants to hold retractors so that the implant can be inserted into the pocket without touching the skin (23). Others have adopted a no-touch approach that uses a sterile tube, a simple anoscope or a no-touch device carved out of a Toomey syringe acting as a sterile sleeve (24,25). Compared to other types of insertion devices, such as the Keller Funnel, it does not only facilitate the placement of the implant but also improves visibility during dissection and pocket fashioning (26). ...
Article
Background: We present our experience in using a disposable wound retractor commonly used in abdominal surgery named Alexis(®) (Applied Medical Resources Corporation, Rancho Santa Margarita, CA, USA), during breast augmentation in order to improve outcomes, particularly final scar length. Methods: Between January 2010 and November 2012, 40 patients undergoing breast augmentation with an inframammary approach were enrolled in the present study. Patients were randomly assigned to two groups: group 1 underwent breast augmentation with the standard technique; group 2 underwent breast augmentation by using the Alexis(®) (Applied Medical Resources Corporation) device. Patients were followed-up for a 12-month period. The time of surgery, the days of drain duration and the length of the incisions were recorded for both groups and statistical significance was evaluated with the Wilcoxon rank sum test. Also, final scar appearance was evaluated using a visual analogue scale (VAS). Results: Patients in group 2 reported a lower incidence of hematomas and had shorter drain duration. The difference in scar length between the two groups was statistically significant (P<0.05). Surgeons and patients were mostly satisfied with the final appearance of the scar. Conclusions: The use of the Alexis(®) (Applied Medical Resources Corporation) device has proven useful in reducing the length of the inframammary incision. Interestingly, the increased visibility obtained with the use of the Alexis device allowed a better hemostasis, as suggested by the shorter drain duration and lower incidence of hematomas. However, its use prolongs the operative time, for which we recommend surgeons to allow themselves some time to become familiar with the device. Level of evidence: level I, evidence obtained from at least one properly designed randomized controlled trial.
... 6 Bell et al have published the application of a modified Toomey syringe casing for insertion of saline implants. 7 However, this required cutting the casing with a saw and burning it with a butane torch, thus never became common practice. ...
Article
The no-touch technique of breast implant insertion is a well-described method to minimize skin contamination, which is thought to be a significant cause of capsular contracture after implant-based breast augmentation. Studies have detected bacterial growth in 76% to 89% of contracted implants,1,2 and the presence of biofilms has also been shown to increase the risk of capsular contracture in a porcine model.3 The original no-touch technique was described by Mladick in 1993. In the original iteration, several assistants held retractors to keep the skin incision open and avoid skin contact while the implant was inserted.4 Here, we describe the simple modification of a disposable, sterile light-handle glove into a sleeve for insertion of a saline prosthesis. In our experience, a Devon Lite Glove surgical light handle glove (Covidien, Masfield, MA) can be easily converted into a sleeve by cutting off the closed, narrow end of the …
... As the evidence for subclinical infection as a potentiator for contracture increases, surgeons using textured implants need to be especially aware of strategies to prevent the access of bacteria to the implant at the time of surgical implantation. Nipple shields, 33 pocket irrigation, 3,34 no-touch insertion, 35 perioperative antibiotic prophylaxis, 36 and avoiding the trans areolar incision 37 have all been recommended as strategies for reducing the risk of bacterial contamination at the time of breast implant insertion. It would be prudent, especially when using textured implants, to recommend mandatory use of these strategies to prevent the initial attachment and subsequent formation of bacterial biofilm on breast implants. ...
Article
Capsular contracture remains the most common complication following breast augmentation surgery, and evidence suggests that bacterial biofilm on the implant surface is responsible. The authors investigated whether the interaction of bacterial biofilm with implants independently determines progression to capsule formation. They also studied the rate of bacterial growth and adhesion to implants. Sixteen adult female pigs had 121 breast implants inserted. Sixty-six implants-23 smooth and 43 textured-were inoculated with a human strain of Staphylococcus epidermidis and received no other treatment. After an average period of 19 weeks, Baker grading was performed and implants were retrieved. For the in vitro study, samples underwent both quantitative bacterial analysis and imaging using confocal laser scanning and scanning electron microscopy. At explantation, there was no significant difference (p = 1.0) in the presence of capsular contracture (Baker grade III and IV) between smooth (83 percent) and textured implants (84 percent). Biofilm was confirmed on 60 of the 66 capsules. Capsules from smooth and textured implants had the same number of infecting bacteria (textured: 3.01 × 10 bacteria/g; smooth: 3.00 × 10 bacteria/g). In vitro, the surface of textured implants showed 11-, 43-, and 72-fold more bacteria at 2, 6, and 24 hours, respectively, compared with smooth implants (p < 0.001). These findings were confirmed by imaging analysis. These results show that textured implants develop a significantly higher load of bacterial biofilm in comparison with smooth implants. Furthermore, in vivo, once a threshold of biofilm forms on either smooth or textured implant surfaces, there seems to be an equal propensity to progress to capsular contracture.
Article
Silicone breast implants are used worldwide for breast augmentation. After an axillary, periareolar or inframmary incision has been made to create an adequately sized pocket; the surgeon usually uses his or her fingers to insert the implant. The use of fingers makes the insertion process time-consuming, a few minutes or more. There are some complications, including need to ensure that the incision is long enough for the implant to be inserted, scar hypertrophy caused by implant insertion friction damage to the edge of incision, and the occasional need to ask the surgical assistant to lend more fingers to facilitate satisfactory insertion and placement. In addition, the use of gloved fingers to repeatedly push on the implant can increase the risk of contamination, postoperative silicone microleakage, and capsular contracture. To resolve these problems, we developed an improved silicone breast implant injector (reusable stainless steel 2007; single use polypropylene 2018) that can be used more easily than fingers and other "no touch" devices. From 2013 to 2017, the first author, a plastic surgeon at our clinic, used the 2007 reusable stainless steel injector to perform breast augmentations in 53 patients (Ave. age 23.8 years; range 19-67 years), 5 (8.8%) receiving 250-ml implants, 41 (77.4%) 251-300-ml implants, and 7 (13.8%) 301-400-ml implants. Overall, results were satisfactory except for two patients (3.7%) in whom capsular contracture occurred. There were no ruptures. Use of the injector made it possible to shorten the length of the incisions from the traditional 4-7 to 3-4 cm and expedited insertion time from a few minutes to a few seconds. This "no touch" insertion technique reduced implant damage caused by finger pushing, leading to a decrease in silicone microleakage and capsular contracture rate. It was performed with no friction trauma to the incision edge or harm to the surgeon's fingers. It was found to be an effective alternative operative tool for the insertion of silicone breast implants.Level of evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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Background: A best practice goal to reduce surgical site infection includes administration of antibiotics in the ideal preoperative window. This article evaluates an office surgical suite antibiotic administration rate and compares it with the timing of a local hospital treating a similar patient population. The hypothesis was that similar or better compliance and surgical site infection rates can be achieved in the office-based suite. Methods: A total of 277 office-based surgeries were analyzed for antibiotic administration time before incision and their corresponding surgical site infection rate. Results: Our facility administered timely prophylactic antibiotics in 96% of cases with a surgical site infection rate of 0.36%. This rate was significantly lower than a reported rate of 3.7%. Conclusion: Low infection rates with high antibiotic administration rate suggest that compliance with best possible practice protocols is possible in the outpatient setting.
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Article
The Même implant may result in fewer capsular contractures. However, difficulty with insertion of this prosthesis may discourage the surgeon and result in the abandonment of a useful prosthesis. A simple technique has been evolved which allows for easy insertion and placement of this implant.
Article
This article represents a retrospective view of the author's 17-year experience with 2863 saline implants in 1327 patients and details his "no-touch" technique. The experience included almost an equal number of submammary and subpectoral procedures. The submammary procedures were done early on and were replaced with subpectoral procedures, done exclusively at the present time. There were significantly less complications--capsules, wrinkling (visible folds), and deflations--with the subpectoral procedures. Followup is longer for submammary procedures which could be the reason for the slight difference in number of deflations. Analyzing the results from three different periods, during which the technique changed, the last period in which the no-touch subpectoral technique was used had markedly fewer complications. The no-touch technique, which had been introduced in orthopedic surgery over 50 years ago, was added to the augmentation procedure in an attempt to eliminate any possible contact with skin or breast bacteria. There were no infections in the entire series, and, during the no-touch period, capsules were almost eliminated (0.6%). Saline implants can achieve excellent results when placed subpectorally using the no-touch technique.
Article
The pathogenesis of fibrous capsular contracture after augmentation mammaplasty is still debated. One hypothesis implicates low-grade bacterial infections as a cause. The presence of a staphylococcal biofilm in a patient with recurrent capsular contracture was previously reported. A comparative, prospective, blinded, clinical study of implants and capsules removed from patients with or without significant capsular contracture was conducted to investigate the association of biofilm contamination, breast implants, and capsular contracture. Capsule and implant samples obtained during explantation were tested by routine microbiological culture, sensitive broth culture (after maceration and sonication), and scanning electron microscopy. Clinical parameters were correlated with microbiological findings. A total of 48 implant and/or capsule samples were obtained from 27 breasts during a 22-month period. Of the 27 breasts, 19 exhibited significant contracture (Baker grade III/IV). The mean duration of implantation was 9.2 years (range, 0.4 to 26.0 years). Routine swab cultures obtained at the time of explantation were negative for bacterial growth for all samples. The sensitive broth culture technique yielded 24 positive samples (50 percent, n = 48). An analysis of capsules demonstrated that 17 of 19 samples obtained from patients with significant contracture were positive, compared with only one of eight samples obtained from patients with minimal or no contracture (p = 0.0006). Fourteen of the 17 positive cultures from significantly contracted breasts yielded coagulase-negative staphylococci, mainly, species of the Staphylococcus epidermidis group. The presence of coagulase-negative staphylococci was also significantly associated with capsular contracture (p = 0.01). There was no significant difference in the frequency of culture positivity for saline versus silicone implants (p = 0.885). Scanning electron microscopy confirmed the presence of extensive biofilm on implants and within capsules.Biofilm, in particular, S. epidermidis biofilm, was detected for a significant proportion of patients with capsular contracture. This implicates biofilm disease in the pathogenesis of contracture, and strategies for its prevention should be explored.
Article
Infection is the leading cause of morbidity that occurs after breast implantation and complicates 2.0-2.5% of interventions in most case series. Two-thirds of infections develop within the acute post-operative period, whereas some infections may develop years or even decades after surgery. Infection rates are higher after breast reconstruction and subsequent implantation than after breast augmentation. Risk factors for infection associated with breast implantation have not been carefully assessed in prospective studies with long-term follow-up. Surgical technique and the patient's underlying condition are the most important determinants. In particular, breast reconstruction after mastectomy and radiotherapy for cancer is associated with a higher risk for infection. The origin of infection in women with implants remains difficult to determine, but potential sources include a contaminated implant, contaminated saline, the surgery itself or the surgical environment, the patient's skin or mammary ducts, or, as suggested by many reports, seeding of the implant from remote infection sites. Late infection usually results from secondary bacteraemia or an invasive procedure at a location other than breasts. Diagnostic and management strategies are proposed and the value of peri-operative surgical prophylaxis is revisited. The current hypothesis of the possible role of low-grade or subclinical infection in the origin of capsular contracture is also reviewed.
Inserting the Même prosthesis Figure 4) The prosthesis is completely within the pocket after passing through the lumen of the shorter casing
  • Dolsky
Dolsky RL. Inserting the Même prosthesis. Plast Reconstr Surg 1984;73:466-8. Figure 4) The prosthesis is completely within the pocket after passing through the lumen of the shorter casing