2017-18 HSC Section 4 Green Book

A L - HADDA B E T A L

and published in 1992 by Davis and colleagues. The study demonstrated the rarity of bacterial contami- nation associated with reusing stored collagen, despite frequent contamination of the needle tips. 5 Regardless of the studies mentioned above, a review of the liter- ature revealed a paucity of studies that evaluated the safety of storing and reusing HA fi llers by in vitro testing for microbial contamination of material stored for different periods of time. Package inserts state that HA should not be conserved or resterilized after opening for later use. Based on this, we investigated for gram-positive and gram-negative bacteria, fungal and acid-fast organisms in products that were stored for longer durations at room temperature. Viral cultures were not performed because of the low likelihood of viral growth after a long storage period without cel- lular or organic elements. Of the 36 syringes cultured, no fungal or acid-fast bacilli organisms were found. There were 5 positive bacterial cultures found to be gram-positive species, predominantly S. epidermidis , which indicated con- tamination from the normal fl ora of the skin. Normal fl ora of the skin can be either resident or transient. Resident fl oras are microorganisms that help protect the host from infection by competing with pathogens for substrate and tissue receptors. They inhabit the surface of the skin, and deeper structures such as the pilosebaceous unit. Organisms that are deeply embedded are resistant to mechanical removal and are beyond the reach of topical antiseptic solutions. Given this limiting factor, the goal of preoperative skin cleansing is to decrease resident fl ora to its lowest possible level, understanding that it cannot be com- pletely eradicated. One study concluded that skin appendages are potential microbial reservoirs and there is a need to develop new antiseptic formulations that suf fi ciently penetrate into the hair follicles. 6 The most common resident organisms are the coagulase- negative staphylococci, with S. epidermidis being the most predominant, accounting for more than 90% of resident aerobes. 7 Anaerobic diphtheroids, such as Propionibacterium acnes , are common in lipid-rich locations such as the pilosebaceous unit. In contrast, transient fl ora is loosely attached to the surface of the skin and is susceptible to removal by preoperative skin cleansing. The predominant transient pathogen

responsible for infection in clean skin surgery is Staphylococcus aureus , found most frequently in the patient ’ s anterior nares. However, our cultures did not yield any S. aureus bacteria, which may be attributed to good skin preparation because of the amenable nature of such transient organisms. 8 Our routine approach for preparing the skin before injection was to use both alcohol and povidone iodine. In many circumstances, physicians prepared the skin with alcohol swabs, which, when applied as a single agent, is rapidly germicidal, but does not have signif- icant residual activity once evaporated. 9 For this rea- son, alcohol as a single agent is not commonly used for preoperative skin preparation for sterile procedures and the use of povidone iodine provides a more per- sistent effect throughout the procedure once a thin dried layer is left on the skin. In reality, there is still great variation in practitioners ’ opinions and practices with regards to storing fi ller syringes for long periods of time at room temperature or in a refrigerator, but not freezing it, for reuse. The high cost of the fi ller materials and the high possibility for the need to retreat the patients are important fac- tors that necessitate storing the fi ller regardless of the lack of suf fi cient evidence of its safety. We suggest injecting the entire syringe in the fi rst sessionwhen that is possible. When this is not feasible, we recommend detaching the needle at the end of the procedure and fi tting the rubber cap back on the syringe, given that it was kept sterile, or preferably, using a new needle to remove the risk from an accidently contaminated cap. The name of the patient and the date of the procedure should be noted on the packaging. Alternatively, before injection, an amount of the material could be injected into another sterile syringe to be used and the remainder saved in the original syringe. We recommend using the fi llers used for deeper injections in the fi rst session or discarding the remainder given the higher risk of bio fi lms and because touch-up procedures in deep injection are usually unnecessary unlike injecting lips or tear troughs where minimal quantities can make a differ- ence. At a touch-up visit, we suggest squeezing out tiny drops of the HA (less than 0.05 mL) and changing to

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