Sixteen patients were treated for sternal wound infections after undergoing cardiac procedures. Their management involved prompt surgical debridement and quantitative wound biopsies. At the time of the initial debridement, the Vacuum-Assisted Closure Device (V.A.C.) was placed in the open sternal wound. A subatmospheric environment was maintained by the device at a level of 75 to 150 mmHg. The V.A.C. sponge was changed every 2 to 3 days, and operative debridement was performed until quantitative biopsies showed resolution of infection or until systemic signs of sepsis had resolved. At this time the sternal wounds were closed with regional muscle flaps. Patients were excluded from the use of the device if the pleural cavity was entered during operative debridement. Fifteen of the 16 patients survived and went on to complete wound healing and discharge from the hospital (average length of stay, 16.7 days). One patient sustained a cardiac dysrhythmia during the muscle flap procedure and died. There were no complications related directly to the use of the V.A.C. It is the opinion of the authors that the V.A.C. offers several advantages over their traditional methods of treatment. They noted improvement in sternal wound stabilization during the perioperative period and a decreased need for paralysis and mechanical ventilation. Wound management was improved by avoiding the need to perform debridement or to make desiccating dressing changes to an open sternum. Moreover, they also think that this device may lessen the risk for ventricular rupture because of better control of the wound environment and markedly improved stabilization of the debrided sternal elements.
Removal of silicone gel from surrounding tissues after implant rupture is difficult. Local inflammation, infection, and silicone granulomas warrant thorough removal of the silicone gel. Shur-Clens (20% solution of the surfactant poloxamer 188), povidone-iodine, and saline are agents that are used to aid in the removal of silicone gel from tissue. The purpose of this study was to compare the efficacy of silicone gel removal by these three agents in vitro. Shur-Clens, povidone-iodine, and saline were compared as solvents for silicone gel. Four weight increments of silicone gel (0.02 g, 0.04 g, 0.06 g, and 0.08 g) were placed on glass slides. These slides were placed in separate beakers containing 40 ml test solution. The slides were soaked for 1 minute with gentle agitation. The slides were removed, rinsed gently with de-ionized water, and placed in a vacuum desiccator to dry. The slides were weighed to determine the amount of silicone removed after soaking in the solution. Analysis of variance was used to determine the significance between the three solvents. The percentages of silicone gel removed for the four weight increments (0.02 g, 0.04 g, 0.06 g, and 0.08 g) in saline were 5.6%, 2.9%, 2.1%, and 5.8%, respectively. In povidone-iodine solution, the percentages were 18.9%, 25.4%, 28.8%, and 51.9%. In Shur-Clens, the percentages were 31.3%, 43.0%, 63.5%, and 79.9%. The greater percentage of silicone gel removed by Shur-Clens was significant compared with the other solutions (p < or = 0.05). Shur-Clens was shown to be a more effective solvent for removal of silicone gel in vitro. This enhanced efficacy is a result of the fact that Shur-Clens contains 20% of the surfactant poloxamer 188. The authors' clinical experience with 7 patients who underwent ruptured silicone breast implant removal demonstrated the superiority of Shur-Clens. Shur-Clens is a surfactant cleanser that is widely available, is inexpensive, and has a good safety profile. They propose the use of Shur-Clens to clean silicone gel spillage to decrease local complications resulting from residual silicone gel.
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