Sir: Surgical-site infections are troublesome problems, for they can prolong hospitalization,1 significantly increase the cost of treatment,2 and in plastic and reconstructive surgery, result in a negative impact on postoperative aesthetic outcomes, which often lead to the failure of a plastic and reconstructive surgery procedure. Nowadays, more attention has shifted to prevention of surgical-site infections rather than antibiotic treatment. Well-established evidence has proved that the bacterial carriage state is a significant risk factor for the development of surgical-site infections, especially for Staphylococcus aureus. Bode et al.3 reported a randomized controlled trial with a large sample size (6496) to confirm that hospital-acquired surgical-site infections can be strongly predicted by preoperative S. aureus carriage states. Plastic and reconstructive surgery procedures involve a large number of practices dealing with scar tissue, such as cicatrectomy. According to evidence-based clinical observation, the surgical-site infection rate of cicatrectomy is 2.7-fold higher than that for those procedures without scar tissue excision (4.3 percent versus 1.6 percent). This outcome indicates that scar tissue is an independent risk factor for surgical-site infections, but few articles in the literature have placed an emphasis on this question of whether there is a different bacteria colonization pattern on scar tissue compared with a normal surgical site. To determine the microbiology colonization profile of scar tissue, swabs of scar and surgical-site specimens for microbiological testing were obtained the day before surgery. A total of 125 patients who underwent plastic and reconstructive surgery were involved in the present prospective cohort study. The outcome demonstrated significantly more positive results from the scar tissue surface than from normal surgical sites (73.2 percent versus 34.8 percent, p < 0.001). The most common leading pathogen was S. aureus (22.4 percent), 19.4 percent of which were resistant to multiple antibiotics. Table 1 demonstrates the distribution of bacteria colonization for all surgical sites, including scar tissue.Table 1: Culture Results for the Bacteria SpectrumThe potential mechanism behind this phenomenon can be explained from three viewpoints. First, from a macroscopic view, the physical property of scar tissue is different from that of normal skin. It is usually unsmooth and harsh, which are obstacles for a thorough disinfection. Second, from a microcosmic view, the abnormalities of colonization result from the increased fibronectin of the scar tissue (in both the epidermis layer and the dermis layer). Scar tissue has been proven to produce enhanced fibronectin more than normal skin tissue.4 Moreover, the ability of an organism to colonize the surface of the skin relies on the fibronectin in the epithelium, which plays a role in adhesions and provides an available adherence environment to the organism. Third, repeated and long-term antibiotic administration during the treatment of post-burn or huge-area trauma patients can also explain the persistence of abnormal flora on the scar tissue, since antibiotics may suppress the normal flora and increase colonization by other organisms.5 The present study sheds light on the importance of the role scar tissue plays in the prevention of surgical-site infections. We first revealed that scar tissue, as an independent risk factor for surgical-site infections, is colonized by significantly more antibiotic-resistant bacteria than normal surgical sites. Consequently, more attention should be paid to preoperative preparation and disinfection of scar tissue for the purpose of reducing the chance of surgical-site infections. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. ACKNOWLEDGMENTS This work was supported by grants from the National Natural Science Foundation of China (no. 30925034, 81101437), the National Key Project of Scientific and Technical Supporting Programs funded by the Ministry of Science and Technology of China (no. 2012BAI11B03), and the Joint Research Project of Shanghai Municipal Level Hospital for Emerging Cutting Edge Technology (no. SHDC12010105). Xiaolu Huang, M.D. Yun Xie, M.D. Ph.D. Yimin Liang, M.D. Ph.D. Wenhui Liu, M.D. Qingfeng Li, M.D. Ph.D. Department of Plastic and Reconstructive Surgery Shanghai Ninth People’s Hospital Shanghai Jiao Tong University School of Medicine Shanghai, People’s Republic of China