Management of the Contaminated Graft in Aesthetic Surgery
Ankit R. Desai, MD, and Robert F. Centeno, MD
INTRODUCTION: The use of autografts in aesthetic and reconstructive surgery has
become a more common tool in a plastic surgeon’s arsenal. To date, the clinical
experience, management, and outcome of graft contamination in plastic surgery have
not been reported. On the basis of a literature review and a survey of plastic
surgeons across the country, the authors propose an algorithm for the management of
contaminated autografts in aesthetic surgery.
METHODS: An internet link to a questionnaire was sent via email by the Aesthetic
Surgery Education and Research Foundation (ASERF) to members of the American Society
of Aesthetic Plastic Surgery. This anonymous survey was designed to obtain data on
the frequency of autograft contamination, treatment preferences, clinical outcomes,
and management of patient disclosure.
RESULTS: A total of 223 surgeons responded to the online survey, a response rate of
12%. Of those responding, 87% were in practice for 10 or more years. A majority
(70%) reported either witnessing or experiencing graft contamination during a
plastic surgery procedure. Among the 156 surgeons with contamination experience, 27%
reported a single occurrence, 33% reported 2 instances, 13% reported 3 occurrences,
and 25% experienced 4 or more contaminated grafts. The methods of contamination are
presented in Table 1. Grafts from the craniofacial region and lower extremity were
the most commonly contaminated. The autograft most frequently contaminated was skin
(97 instances) followed by cartilage.
Table 1. Method of Contamination
Exposure to nonsterile part of field/drape
Exposure to nonsterile specimen container/suction cathetercanister/instrument
Exposure to contaminated part of operating field (ear,
nasopharynx, ano-rectal, GU)
Graft/Flap fell on floor
Graft/Flap discarded in trash
Other
# Occurrences
71
26
46
120
45
1
None of the respondants aborted a procedure after graft contamination occurred. Only
one surgeon opted to use alloplastic material as a substitute. Eight surgeons
harvested a graft from another site, and 3 employed an alternate reconstructive
technique. However, all surgeons reported at least 1 instance in which the surgery
was completed following graft decontamination.
Only 3 of the 156 respondents with contamination experience reported a surgical site
infection as an outcome of using a decontaminated graft. The extent of infections
was not reported. These 3 clinical infections correlate to a complication rate of
1.9%, which is similar to clean non-contaminated cases.1 Sixty percent of surgeons
who experienced graft contamination did not disclose the incident, and 24% made a
notation in the chart only. However, 33 surgeons (20%) reported the contamination to
the patient and/or family postoperatively.
DISCUSSION: Inadvertent contamination of autografts poses a dilemma for the
surgeon, but the medical literature provides little guidance on appropriate
management of contaminated grafts. The most common decontamination agent used by
survey respondents was povidone-iodine, followed closely by antibiotic solution.
Several in vitro studies have demonstrated that fibroblasts are inhibited by
povidone-iodine,2 including an investigation that found skin fibroblast growth to be
completely inhibited by a concentration of 0.1%, which is only a tenth of the usual
concentration.3 Consequently, alternative antiseptic solutions are recommended.
Our literature review revealed that decontamination of bone and tendon grafts have
received the most attention, with various antibiotic solutions, 10% povidone-iodine,
and 4% chlorhexidine gluconate examined for decontamination effectiveness. In one
study, 4% chlorhexidine gluconate had the greatest sterilization impact, with only
2% of grafts remaining culture positive after a 90 second soak.4 Other studies have
found brief exposure to chlorhexidine to be safe for a variety of tissue types.5-7
Although decontamination with chlorhexidine gluconate is very effective, it has been
found to be toxic to bone allografts and reduce osteoblast density and alkaline
phosphatase activity.8 Because some antibiotic solutions are less toxic and provide
comparable antisepsis,9 chlorhexidine should not be needed for bone decontamination.
Instead, a combination antibiotic solution produces a similar reduction in bacterial
counts with fewer cytotoxic effects.10 Regardless of the agent used, low-pressure
lavage is preferred over soaks and high pressure lavage,9,11 which may cause
decreased bone formation and less viable bone at fracture sites.
Based on the limited data in the literature, we propose the algorithm presented in
Figure 1 for graft contamination. As with most adverse events, the best solution is
prevention, but the potential for graft contamination should be included in the
written and verbal informed consent process. Prevention strategies should be
implemented and discussed with all O.R. staff before autograft harvests. After
harvest, the graft should be wrapped in saline-soaked gauze and placed in a labeled,
sterile cup. The autograft also should be included in the surgical count process. In
addition, tissue should not be discarded without confirmation from the surgeon.
If an autograft does become contaminated, we propose decontamination of skin,
cartilage, and composite tissue with 1 liter of low-pressure pulse lavage solution
containing 4% chlorhexidine gluconate. Although no studies exist related to
decontamination of fat grafts, the limited added morbidity from harvesting another
fat graft should make decontamination unnecessary in most cases. For cancellous
bone, we recommend re-harvesting, but cortico-cancellous bone may be decontaminated
with 1 liter of low-pressure lavage using a triple antibiotic solution.
Within our algorithm, we advocate disclosure to the patient. In addition, root cause
analysis along with an incident report should be part of the postoperative process.
With the assistance of the Quality Assessment and Assurance Committee, steps can be
implemented to reduce the risk of future graft contaminations.
REFERENCES
1
Culver DH, Horan TC, Gaynes RP, et al. Surgical wound infection rates by wound
class, operative procedure, and patient risk index. National Nosocomial
Infections Surveillance System. Am J Med 91(3B):152S-157S, 1991.
2
Lineaweaver W, Howard R, Soucy D, et. al. Topical antimicrobial toxicity. Arch
Surg 120(3):267-270, 1985.
3
Balin AK, Pratt L. Dilute povidone-iodine solutions inhibit human skin
bibroblast growth. Dermatol Surg 28(3):210-214, 2002.
4
Molina ME, Nonweiller DE, Evans JA, et. al. Contaminated anterior cruciate
ligament grafts: the efficacy of 3 sterilization agents. Arthroscopy 16(4):387391, 2000.
5
Burd T, Conroy BP, Meyer SC, et. al. The effect of chlorhexidine irrigation
solution on contaminated bone-tendon allografts. Amer J Sports Med 28:241-244,
2000.
6
Gunal I, Turgut A, Acar S, et. al. Effects of various irrigating solutions on
articular cartilage. An experimental study in rabbits. Bull Hosp Jt Dis
59(2):73-75, 2000.
7
Reading AD, Rooney P, Taylor GJ. Quantitative assessment of the effect of 0.05%
chlorhexidine on rat articular cartilage metabolism in vitro and in vivo. J
Orthop Res 18(5):762-767, 2000.
8
Kaysinger KK, Nicholson NC, Ramp WK, et. al. Toxic effects of wound irrigation
solutions on cultured tibiae and osteoblasts. J Orthop Trauma 9:303-311, 1995.
9
Bhandari M, Adili A, Schemitsch EH.
The efficacy of low-pressure lavage with
different irrigating solutions to remove adherent bacteria from bone. J Bone
Joint Surg Am 83-A(3):412-419, 2001.
0
Hirn M, Laitinen M, Pirkkalainen S, et. al. Cefuroxime, rifampicin and pulse
lavage in decontamination of allograft bone. J Hosp Infect 56:198-201, 2004.
1
Dirschl DR, Duff GP, Dahners LE, et. al. High pressure pulsatile lavage
irrigatrion of intraarticular fractures: effects on fracture healing. J Orthop
Trauma 29:187-190, 1998.
Figure 1: Algorithm for Management of Contaminated Autografts
AUTOGRAFT HARVEST
[Pre-incident]
Implement preventive strategies
(process analysis)
Informed consent
Immediate placement of
graft into labeled sterile
cup in saline-soaked gauze
Time Out
Continuing education &
process improvement
Autograft implanted w/o
complication
AUTOGRAFT CONTAMINATED
Yes  REHARVEST
(Fat/Dermal Grafts)
Complete operation
Obtain graft culture
BONE
Cancellous
SKIN, CARTILAGE, &
COMPOSITE TISSUE
Corticocancellous
REHARVEST
Complete
operation
Low-pressure pulse lavage
off sterile field with 1 L of
triple antibiotic solution
Confirm with surgeon prior
to discarding any tissue
POST-INCIDENT
Can another autograft be harvested with minimal morbidity?
No
Incorporate into surgical
count & during change of
shift staff sign out
Incident Report
Submit to Quality Assessment
& Assurance Committee
Root Cause analysis
Rinse with normal saline
Disclosure to patient
Low-pressure pulse lavage off
sterile field with 1 L of 4%
chlorhexidine gluconate
Implement strategies to
prevent recurrence and
improve process