Infections are relatively uncommon after cosmetic surgery, yet many patients are concerned about their risk for infection before undergoing elective cosmetic surgery—and with good reason. Surgical-site infections, or SSIs, are responsible for significant morbidity and mortality after surgery. Research shows that infections can double the risk of death after surgery, double the length of hospital stay, and increase the risk of readmission to the hospital by 30% and admission to the ICU by 60%.
SSIs occur as a result of a complex interaction of host factors, surgical/environmental factors, and the endogenous flora of the patient and surgical site. Such infections occur in one to three out of 100 cases and typically present as redness, pain, warmth, and drainage at the surgical site.
But following these 10 “common sense” strategies can control some of the controllable risk factors.
1) Wipe or wash with Chlorhexidine before surgery
Chlorhexidine gluconate is an over-the-counter antimicrobial soap with broad-spectrum antimicrobial activity. It is effective at decolonizing the skin as it can accumulate to within the stratum corneum of the skin. Patients should wash and let Chlorhexidine stand on the skin for 5 minutes or wipe with a Chlorhexidine towel the morning of surgery. For patients with significant intertriginal folds, washing for several days before surgery may be prudent.
2) Avoid shaving the surgical site before surgery
Shaving of the skin of the surgical or surrounding site causes micro-tears that lead to colonization with skin flora. Not shaving is associated with the lowest risk of SSIs compared to clipping and shaving with a razor. If hair removal is used, the patient should be clipped at the time of surgery by the treating physician.
3) Get the right antibiotic, at the right time, for the right duration
While the research and controversy regarding proper antimicrobial prophylaxis continues, a dose of prophylactic second-generation cephalosporin such as Cefazolin within 1 hour of incision time is generally considered appropriate in most elective cases. Postoperatively, these antibiotics must be stopped within 24 hours of surgery to reduce the risk of selecting out resistant organisms. If a case has a significant blood loss or is longer than 3 hours, it is recommended that the patient be given another weight-appropriate dose to maintain adequate tissue levels.
4) Eat a healthy diet before surgery
Surgery initiates a catabolic state in which more calories and protein are consumed than in the normal state. If the patient does not supplement their intake with increased protein in the 100-gram range per day, this catabolic state may have a negative impact on wound healing and increase the risk of an SSI. Massive weight loss patients and bariatric patients are especially at risk due to potential malabsorption and vitamin deficiencies.
5) Avoid hypothermia during surgery
Hypothermia during surgery has been associated with altered coagulation, a higher risk of SSIs in certain populations, and arrhythmias in extreme situations. Even mild intraoperative hypothermia has been associated with a three-fold increase in the risk of infection, longer postanesthesia care unit stays, and delayed wound healing. Prewarming patients with a forced air warming blanket, using warm intravenous fluids, and increasing the ambient operating room temperature are effective strategies for avoiding this problem altogether.
6) Increase oxygenation
In certain surgical populations such as in colorectal surgery, increased oxygenation with a fraction of inspired oxygen (FI02) level of at least 50% to 80% during the procedure and oxygen supplementation for up to 2 hours after surgery has been shown to reduce the risk of SSIs. There is also some evidence to suggest that a higher FIO2 during the last 2 hours of surgery may be associated with a lower incidence of postoperative nausea and vomiting.
7) Police smoking cessation
Most surgeons know that smoking is deleterious to wound healing due to carbon monoxide inhibition of the red blood cells and vasoconstriction from nicotine in cigarette smoke. The typical recommendation is to stop smoking 2 weeks before and 2 weeks after surgery for procedures that require extensive undermining to avoid skin necrosis or wound- healing complications. Devitalized tissue is also a contributing factor to SSIs. A significant percentage of patients will not disclose smoking habits even when asked directly. A desire to have a cosmetic operation is a powerful motivator for hiding this habit. Surgeons can protect their patients by testing them using a very inexpensive test for Cotinine, a nicotine by-product.
8) Ask about MRSA
Hospital and community-acquired methicillin resistant Staphylococcus aureus (MRSA) colonization is on the rise in many communities. MRSA-colonized patients would benefit from decolonization prior to surgery with Chlorhexidine washes and Mucopericin ointment. Perioperative prophylactic antibiotics with Vancomycin in elective patients with a history of colonization is warranted. Vancomycin and Flouroquinolones require a 2-hour infusion time and should be scheduled appropriately.
9) Maintain tight blood sugar control
Diabetics are more prone to wound-healing problems and SSIs due to immunologic alterations, microvascular changes, and delayed healing due to changes in collagen synthesis. Tight glucose control with lowering of the Hemoglobin A1c level to less than seven preoperatively can reduce the risk of SSIs. Checking a level preoperatively can be a good way to manage the risk of diabetes on wound healing in a diabetic patient seeking cosmetic surgery.
10) Practice proper hygiene
Primary incisions should be protected for 24 to 72 hours with a sterile dressing. Re-epithelialization occurs during this time and protects the wound from bacterial contamination. Skin-closure adhesives can also be used to protect the primary wound from bacterial contamination and allow for earlier dressing removal and showering. Staff and family should be counseled to adhere to strict hand hygiene with an alcohol-based cleanser prior to changing dressings or handling drain sites.
These strategies will not eliminate the risk of SSIs, but they can dramatically lower the risk of such complications.
Robert F. Centeno MD, FACS, MBA, is a plastic surgeon at Bitar Cosmetic Surgery Institute, Fairfax, Va. He can be reached at [email protected].
