Implant-Based Breast Reconstruction Outcomes Using Oxychlorosene for Pocket Irrigation.

Abstract

Breast implants are placed in over 400,000 patients annually, but up to 29 percent have postoperative infections.1 Pocket irrigation with antiseptic solutions is used to reduce implant contamination. The optimal irrigation solution and the efficacy of individual practices are unclear. Oxychlorosene sodium has been used historically as an antiseptic, but there are no data on its effectiveness in breast implant surgery. It is a derivative of hypochlorous acid and is a powerful antimicrobial.2 A survey of American Society of Plastic Surgeons members showed that 14 percent of responders used oxychlorosene for breast implant irrigation.3 Our institution has commonly used oxychlorosene irrigation. Following approval from our institutional review board, patients who underwent implant-based reconstruction after mastectomy with use of oxychlorosene breast pocket irrigation between 2016 to 2018 were retrospectively reviewed. One hundred seventeen patients underwent prosthetic-based breast reconstruction with oxychlorosene for surgical irrigation (Table 1). There were a total of 195 breast reconstructions; 107 (91.4 percent) had tissue expanders and 10 (8.6 percent) had direct-to-implant reconstruction. Eleven patients (5.6 percent) had cellulitis requiring oral antibiotics and five (2.6 percent) had cellulitis requiring intravenous antibiotics. Eight patients (4.1 percent) required device removal and nine (4.6 percent) had skin necrosis requiring surgical débridement. Table 1. - Demographics and Outcomes of Patients Undergoing Prosthetic-Based Breast Reconstruction with Oxychlorosene Used for Antibiotic Irrigation Characteristic Value (%) Total no. of patients 117 Total no. of breast reconstructions 195 Age, yr Mean 49 Range 24–74.3 BMI, kg/m2 27.1 Smoking 11 (9.6) Breast disease Breast cancer 90 (76.9) Ductal carcinoma in situ 15 (12.8) Lobular carcinoma in situ 1 (0.9) BRCA mutation 7 (6.0) Prophylactic (nongenetic mutation) 2 (1.7) Benign breast disease 2 (1.7) Reconstruction timing Immediate 111 (94.9) Delayed 6 (5.1) Mastectomy type Skin-sparing mastectomy 63 (53.8) Nipple-sparing mastectomy 54 (46.2) Type of reconstruction Tissue expander 107 (91.4) Direct to implant 10 (8.6) Additional oncologic treatment Neoadjuvant chemotherapy 31 (34.4) Adjuvant chemotherapy 40 (44.4) Adjuvant radiation therapy 37 (41.1) Infectious complications Cellulitis requiring oral antibiotics 11 (5.6) Cellulitis requiring intravenous antibiotics 5 (2.6) Infection requiring device removal 8 (4.1) Wound dehiscence requiring surgical débridement and closure 9 (4.6) BMI, body mass index. The use of antiseptic irrigation with implant placement has been associated with improved outcomes and reduced morbidity. We have found that oxychlorosene is a safe and effective antiseptic irrigation solution in breast reconstruction that deserves further investigation. An early report in 1955 on oxychlorosene as a surgical irrigation solution demonstrated rapid activity against organisms such as Staphylococcus aureus, Pseudomonas aeruginosa, and Bacillus species.2 Other early studies showed efficacy in a variety of settings such as breast surgery, skin grafting, and facial reconstruction.4 Oxychlorosene has caught the most traction in the treatment of resistant interstitial cystitis. An in vitro study recently found oxychlorosene to have similar efficacy as triple-antibiotic solution in reducing bacterial load of Staphylococcus species.5 Oxychlorosene has been shown to be effective in many routes of administration, including orally, subcutaneously, intraperitoneally, and intrapleurally. The contact time required for effect has been reported at 3 minutes, but there have been reports of efficacy at 1-minute contact time.4 Oxychlorosene is easily prepared by adding 2 g of oxychlorosene to 1 liter of sterile saline. It is inexpensive; at our institutional, the cost of a 2-g vial of oxychlorosene is approximately $5, which is less than other antibiotic irrigations. (See Table, Supplemental Digital Content 1, which shows the cost of commonly used surgical antibiotic irrigation solutions, https://links.lww.com/PRS/E589.) There has been recent concern for the role of chronic biofilm in breast implant-associated anaplastic large cell lymphoma and breast implant illness. As a derivative of hypochlorous acid, oxychlorosene is able to penetrate bacterial biofilm, which has made it useful for wound care.4 Oxychlorosene’s relationship to chronic biofilm reduction and incidence of anaplastic large cell lymphoma requires more investigation. Oxychlorosene is an inexpensive and effective antibiotic irrigation, and our experience with oxychlorosene has been encouraging. Future studies on surgical irrigation for breast implants should include oxychlorosene. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. Steven E. Dawson, B.S.Ravinder Bamba, M.D.Phu C. Tran, M.D.Division of Plastic SurgeryIndiana University School of MedicineIndianapolis, Ind. Brian Mailey, M.D.Institute for Plastic SurgerySouthern Illinois UniversitySpringfield, Ill. Jenny Lin, M.D., Ph.D.Mary Lester, M.DMithun Sinha, Ph.D.Aladdin H. Hassanein, M.D., M.M.Sc.Division of Plastic SurgeryIndiana University School of MedicineIndianapolis, Ind.