
==== Front
Plast Reconstr Surg Glob Open
Plast Reconstr Surg Glob Open
GOX
Plastic and Reconstructive Surgery Global Open
2169-7574
Lippincott Williams & Wilkins Hagerstown, MD

GOX-D-24-00442
00062
10.1097/GOX.0000000000006176
3
Research
Original Article
The Surfactant Properties of Clindamycin as a Useful Adjunct for Removing Ruptured Silicone Implants
Alnaseri Tahera MPH *
Musavi Leila MD *
Deming Timothy PhD †‡
Roostaeian Jason MD *
Da Lio Andrew MD *
Mason Thomas G. PhD ‡§
DeLong Michael R. MD *
From the * Division of Plastic Surgery, University of California Los Angeles, Los Angeles, Calif.
† Department of Bioengineering, University of California Los Angeles, Los Angeles, Calif.
‡ Department of Chemistry and Biochemistry, University of California Los Angeles, Los Angeles, Calif.
§ Department of Physics and Astronomy, University of California Los Angeles, Los Angeles, Calif.
Michael R. Delong, MD, Division of Plastic Surgery, Department of Surgery, University of California at Los Angeles Health System, 200 Medical Plaza Drive Suite 460, Los Angeles, CA 90095, E-mail: mdelong@mednet.ucla.edu
9 2024
18 9 2024
12 9 e617630 4 2024
24 7 2024
Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

Background:

Silicone gel removal after breast implant rupture is a difficult task. Silicone is hydrophobic and thus cannot be irrigated effectively with saline. Attempts at mechanical removal with sponges are often partially successful. Incomplete removal results in persistent silicone contamination with possible local inflammation, infection, and silicone granulomata. In this partially quantitative investigation, we assess the de-adhesion ability of different clindamycin formulations against known surfactant controls when combined with silicone gel.

Methods:

To demonstrate surfactant properties in vitro, clindamycin phosphate, clindamycin hydrochloride, and a known surfactant, sodium dodecyl sulfate (SDS), were compared. An amount of 170 g of silicone gel placed in a dry glass container exhibited strong adherence to the container walls. In separate trials, clindamycin phosphate (300 mg in 100 mL), clindamycin HCl (300 mg in 100 mL), and SDS (1 g in 100 mL) solutions with normal saline were added to the silicone aggregate, and de-adhesion properties were compared.

Results:

All solutions aided in the de-adhesion of the sticky silicone from glass substrate. The SDS had the strongest effect, followed by clindamycin phosphate and then clindamycin HCl. The observed interactions suggested that all of the solutions behaved as ionic surfactant coating the silicone with negative charges via adsorption. However, the phosphate anionic formulation was associated with a greater surfactant effect than HCl.

Conclusions:

Clindamycin acts as a surfactant to aid in the clinical removal of ruptured silicone gel. Clindamycin phosphate seems to have a stronger effect than clindamycin HCl, likely related to the negative charges on the phosphate groups.

OPEN-ACCESSTRUE
COUNTRYUNITED STATES
==== Body
pmcTakeaways

Question: What is a convenient method to assist in the removal of ruptured silicone breast implants?

Findings: A semiqualitative study demonstrated that the surfactant properties of clindamycin phosphate solution aided in the de-adhesion of sticky silicone, both in vitro and in vivo.

Meanings: Clindamycin is a readily available solution that acts as a surfactant to aid in the clinical removal of ruptured silicone gel.

INTRODUCTION

Breast implants are surgically implanted into approximately 400,000 women per year in the United States alone for cosmetic augmentation, reconstruction, and gender affirmation. Since the end of the moratorium in 2006, the majority of these have been silicone gel-filled implants, constructed with a silicone elastomer shell around a viscous silicone gel.1 One of the primary concerns with silicone implants is the risk of rupture and gel leak into patient tissues. For this reason, periodic screening is currently recommended with magnetic resonance imaging or ultrasound at 5–6 years postimplantation and then every 2–3 years thereafter.2 Ruptures can exist as intracapsular or extracapsular, and in some cases the silicone materials migrate to the lymph nodes or other anatomic locations. Although the clinical significance of a ruptured silicone implant is still not fully understood, surgical removal is currently recommended by professional societies and regulatory agencies to remove the contamination.3

However, complete removal of a silicone implant and its ruptured contents can be surgically challenging and messy. The internal silicone gel is composed of hydrophobic linear chain polydimethylsiloxanes (PDMS), which are not soluble in aqueous solutions and have a tendency to stick to patient tissues. Special suction devices such as the barrel suction and bottle suction methods have been reported, however; they may not completely extract all the free silicone gel from the ruptured implant. Incomplete removal of silicone gel presents concerns for persistent contamination, inflammation, infection, silicone granulomata, or silicone lymphadenopathy.4–7

Due to the limitations of mechanical extraction, a solution that effectively aids in removal of silicone materials would be a beneficial resource for plastic surgeons. Clindamycin is a readily available antibiotic which can be diluted into solution for irrigation. Anecdotally, clindamycin solution is capable of assisting with extraction of silicone gels, although the mechanism is not understood. Additionally, the relative performance of different clindamycin formulations has not been assessed and may provide insight into the interaction between silicone gels and the clindamycin solutions.

In this partially quantitative investigation, we compare the de-adhesion ability of different clindamycin formulations against a known surfactant control when combined with silicone gel. We classify the interactions based on magnitude of the effect and subjectively assess the specific interaction between the silicone gel and test formulations to determine a proposed mechanism of action.

METHODS

To assess surfactant properties in vitro, solutions of clindamycin phosphate, clindamycin hydrochloride, normal saline, and sodium dodecyl sulfate (SDS)—a known surfactant—were compared. A 170-cm3, MENTOR MemoryGel breast implant was incised sharply to extract the internal silicone gel. A small unweighted portion of sticky PDMS was placed in a dry glass container and exhibited strong adherence to the container walls, as expected. In an attempt to stir the silicone material with a spatula, the strength of adherence to the walls and bottom of the container increased.

The bulk rheological properties of soft, deformable PDMS complicated measurement of surface adhesion using standard macroscopic test devices that are designed primarily for adhesive strength of coating. Therefore, a semiquantitative observational investigation was performed. In four separate trials, clindamycin phosphate (300 mg in 100 mL), clindamycin HCl (300 mg in 100 mL), and SDS (1 g in 100 mL) solutions with normal saline were added to the silicone aggregate for comparison. A fourth solution of normal saline was used as negative control. The solutions mixed with silicone gel were agitated and the interaction was observed. The de-adhesion properties were subjectively ranked in order of strength, and the interaction of the silicone gel, glass container, and solution were observed. By assessing the behavioral change in the silicone gel with further agitation, the surface interaction between the solutions and the silicone gel was subjectively evaluated.

The clinical benefits of clindamycin were then demonstrated in vivo by instilling clindamycin through a capsulotomy in a patient with ruptured implants and assessing the ease of removal of free silicone.

RESULTS

In Vitro

The three test solutions, except normal saline, induced de-adhesion of the silicone gel from the glass slides. As the solutions were agitated, it appeared that the test formulations all behaved as ionic surfactants coating the surface of the silicone with negative charges via adsorption. Additionally, the solutions appeared to wet the glass walls and passivate them with negative charges leading to charge repulsion between the glass walls and the silicone aggregate as agitation continued. Normal saline solution induced little-to-no de-adhesion in the silicone aggregate, which remained mostly adherent to the glass wall.

Behavioral differences were observed between the three solutions. This was observed when the silicone aggregate (already coated with surfactant solution) was placed on dry glass, which allowed the silicone to eventually re-adhere. SDS solution was the most successful in preventing re-adherence of silicone on the dry glass, followed by clindamycin phosphate, then clindamycin HCl. The behavioral difference between clindamycin phosphate and clindamycin HCl was subjectively assessed. Clindamycin phosphate facilitated de-adhesion more dramatically compared with clindamycin HCl, which may be attributed to the more negative charge of the phosphate ion leading to stronger repulsion forces between the silicone and glass. These differences in de-adhesion were clearly observable from this experimental protocol, and this qualitative observation motivates future development of an apparatus suitable for measuring surface de-adhesion of soft deformable PDMS, or other soft sticky solids, in contact with both inorganic and organic substrates that can have varying degrees of rigidity.

In Vivo

The in vivo benefits of clindamycin solution were then demonstrated in clinical patients with ruptured silicone implants. The technique developed at our institution involves performing a small surgical capsulotomy and instilling clindamycin in saline solution into the implant pocket. [See Video (online), which displays in vivo application of clindamycin solution to assist with removing a ruptured silicone implant.] Once the solution is allowed to fill the pocket, the capsulotomy is completed, and the ruptured implant and free silicone are easily removed with laparotomy pads while continuing to irrigate the ruptured implant with clindamycin solution. As the ruptured implant begins to be extruded, there will be silicone gel that has not been exposed to the clindamycin solution; therefore, continued irrigation will help as a surfactant agent. A laparotomy sponge is then soaked in clindamycin solution and used to remove any remaining silicone gel adhering to the patient’s skin without the need to change gloves. Pocket irrigation with clindamycin is then performed to ensure removal of any potential remaining gel and for the antimicrobial benefits before implant replacement or closure. Contrarily, saline irrigation has a minimal effect on silicone gel de-adhesion when used for implant removal, leaving the gel adherent on the patient’s skin, surgical instruments, and surgeon’s gloves.

Video 1 displays in vivo application of clindamycin solution to assist with removing a ruptured silicone implant.

1_5srj9mng Kaltura

DISCUSSION

Approximately 3.5 million people in the United States have breast implants, and a majority of these are filled with silicone gel. Unlike saline implants, silicone gel-filled implant ruptures can be silent and result in tissue contamination that can spread systemically in rare cases. Due to the unclear clinical sequelae of ruptured silicone implants, the current recommendation is to remove them and the entirety of the ruptured contents. However, the complete removal of ruptured silicone implants can be challenging due to the adhesive and hydrophobic properties of silicone gel. Retained silicone products and gross contamination of tissues and the surgical field can occur.

Saline irrigation is minimally effective, and mechanical removal with laparotomy sponges is often incompletely successful, per clinical use in our institution. Clindamycin solution has been anecdotally suggested as an option for aiding in the removal of silicone debris during these procedures.8,9 Because clindamycin is a readily available antibiotic, it can be easily acquired and adopted into clinical practice at most surgical centers. We evaluated the mechanism of clindamycin for this purpose and compared the relative efficacy of two common clindamycin formulations, clindamycin phosphate and clindamycin HCl.

We demonstrated in vitro that clindamycin phosphate interacts with silicone gel similarly to SDS (a known surfactant), verifying that clindamycin possesses similar surfactant properties. By adding the test solutions to silicone gel adherent to a glass slide and agitating the solutions, we were able to determine a proposed mechanism for the interaction between the clindamycin and silicone gel. All three solutions exhibited similar effects with progressive agitation of the silicone leading to a wetting effect on the silicone surface as well as the surface of the glass. This coating effect then seemed to drive a repulsive interaction between the silicone and the glass, preventing re-adhesion and effectively extracting the silicone from the glass. Because SDS is a known surfactant with amphipathic qualities, it can be inferred that the very similar behavior of the clindamycin is the result of a similar molecular characteristic. We therefore concluded that the clindamycin causes de-adhesion of the silicone by acting as a surfactant and coating the surfaces of tissues and silicone gel.

Additionally, we tested two common formulations of clindamycin to evaluate relative performance. The clindamycin phosphate solution demonstrated a clearly stronger effect than clindamycin HCl. We posit that this difference stems from the greater negative charges present in the phosphate groups, which may act to coat the silicone and glass substrates with a stronger repulsive force. We believe that this finding helps establish the proposed mechanism, while also suggesting that clindamycin phosphate should be adopted as the preferred formulation for these procedures.

Based on our findings, we have adopted clindamycin phosphate in our practice with significantly improved experiences removing ruptured implants clinically for patients with no known allergy to clindamycin. One major advantage of this technique is the general availability of clindamycin and dual purpose as an antibiotic irrigant, particularly for cases with planned implant replacement. We believe this technique could be implemented as a useful adjunct for surgeons who routinely remove ruptured silicone implants.

Limitations

This study is classified as semiquantitative due to the lack of a standardized metric for gel de-adhesion. The main objective of this investigation is to explore the surfactant capabilities of different clindamycin formulations and compare them to a known surfactant, SDS. If an appropriate de-adhesion gel assay were to be discovered, the findings here could be verified quantitatively.

DISCLOSURES

The authors have no financial interest to declare in relation to the content of this article. The study was supported by the University of California Los Angeles.

Published online 18 September 2024.

Disclosure statements are at the end of this article, following the correspondence information.

Related Digital Media are available in the full-text version of the article on www.PRSGlobalOpen.com.
==== Refs
REFERENCES

1. Center for Devices and Radiological Health U.S. Food and Drug Administration. FDA update on the safety of silicone gel-filled breast implants. Published 2011. Available at https://www.fda.gov/files/medical%20devices/published/Update-on-the-Safety-of-Silicone-Gel-Filled-Breast-Implants-%282011%29.pdf. Accessed March 15, 2024.
2. FDA. Saline, silicone gel, and alternative breast implants guidance for industry and food and drug administration staff. Available at https://www.fda.gov/media/71081/download. Published September 29, 2020.
3. Swezey E Shikhman R Moufarrege R . Breast implant rupture. In: StatPearls. Treasure Island, FL: StatPearls Publishing; 2024. Available at https://www.ncbi.nlm.nih.gov/books/NBK459308/.
4. Kappel RM Klunder AJH Pruijn GJM . Silicon chemistry and silicone breast implants. Eur J Plast Surg. 2014;37 :123–128.
5. O’Neill JK Taylor GI . A novel method to remove silicone gel after breast implant rupture. J Plast Reconstr Aesthet Surg. 2006;59 :889–891.16876095
6. Hajdu SD Vercler CJ Tobias AM . The barrel-suction method for silicone gel removal from ruptured breast implants. J Plast Reconstr Aesthet Surg. 2010;63 :2197–2198.20570230
7. Hwang Y Youngberg R Sutton D . How to do the bottle suction method for removal of a silicone gel breast implant. ANZ J Surg. 2019;89 :758–759.31087473
8. Fell C Kachare MD Nixon A . The “clinda-clumper”—a quick and efficient method to remove free silicone after a breast implant rupture using a clindamycin solution. Eplasty. 2024;24 :QA8.38715633
9. Avila FR Mazer LS Borna S . Breast pocket lavage with clindamycin solution for silicone removal after implant rupture. Aesthet Surg J. 2024;44 :NP233–NP235.37966376
