Abstract
Background
Despite the general safety of liposuction and fat grafting procedures, surgical-site infections (SSIs) remain a significant concern. These infections, ranging from minor to severe, can arise from various sources and pose a substantial burden. The overuse of antibiotics has led to increased antimicrobial resistance, highlighting the need for alternative infection prevention strategies like stabilized hypochlorous acid (s-HOCl).
Objectives
The aim of the authors of this study is to evaluate the efficacy and safety of s-HOCl in preventing SSIs following liposculpture and other body contouring procedures.
Methods
A prospective cohort study and matched control cohort were conducted at a single plastic surgery center in Bogota, Colombia (Dhara Clinic). Adult patients scheduled for liposculpture and fat grafting from January 2020 to December 2023 formed the intervention group, receiving s-HOCl as a washing solution for adipose grafts. A matched control cohort was drawn from patients who underwent similar procedures from January 2017 to December 2019 without s-HOCl. Data on demographics, surgical characteristics, and SSI outcomes were collected and analyzed.
Results
A total of 1008 patients were included, with 502 in the s-HOCl group and 506 in the control group. The infection rate in the s-HOCl group was 0.2 per 100 grafted muscles, compared with 0.54 in the control group. Relative risk of SSIs in the s-HOCl group was 0.4, indicating a reduction in infection rates. The small absolute risk reduction of 0.59% underscores the clinical importance, considering SSIs, although rare, are severe and life-threatening events, with significant impact on outcomes and healthcare costs. A reduction in the severity of infection and the level of required treatment was also observed.
Conclusions
s-HOCl demonstrated potential to reduce SSI risk following liposuction and fat grafting. This intervention offers a valuable alternative to antibiotics, effectively reducing infection rates and contributing to improved patient outcomes and public health in postantibiotic era.
Level of Evidence: 3 (Therapeutic)
Despite their popularity and generally high safety profile from liposuction and fat grafting, these procedures are not devoid of complications. Among the potential adverse outcomes, infections represent a significant concern for both patients and surgeons.1 Infections can arise from various sources, including the patient's skin flora, surgical instruments, or the surgical environment, and can range from minor localized infections to severe, systemic ones. The incidence of surgical-site infections (SSIs) in these procedures has been reported to vary, with some studies indicating a rate between 0.2% and 1.1% for liposuction-related infections.2 Key risk factors include the extent of the procedure, the volume of fat removed or grafted, and the patient's underlying health conditions, such as diabetes or immune deficiencies. Preventive measures are critical to minimizing the risk of infections. These include stringent aseptic techniques, prophylactic antibiotics, and proper postoperative care. Because of the severe burden on patients who suffer the devastating effects of SSIs, many surgeons have opted to use antibiotics postoperatively to reduce their incidence. However, there is growing evidence about the risk of local and broad antimicrobial resistance among many microorganisms because of the prolonged administration of antibiotics when not indicated. Currently, the only indication for prescribing antibiotics after surgery is for the treatment of confirmed infections, rather than for prophylactic purposes.3 As a result, other strategies, such as preventive aseptic techniques during surgery, could arise as the best intervention to decrease the incidence of SSI toward zero. One molecule that has arisen as a potential cleanser with a favorable safety profile for most cells and tissues is hypochlorous acid (HOCl).
HOCl is a known potent endogenous antimicrobial acid produced by myeloid-derived cells, including neutrophils, with well-characterized biological mechanisms. Its strong antimicrobial effects are produced through multiple mechanisms, including the inhibition of protein and DNA synthesis, thereby affecting microbial metabolism and cell viability. Although endogenous HOCl plays a crucial role in the body's defense system, its synthetic production and molecular stabilization have enabled its application in various clinical settings for infection prevention and control.
HOCl is a broad-spectrum, fast-acting, and safe antimicrobial, clinically utilized to control diverse infections (by different microorganisms and anatomical sites). However, in its natural form, HOCl is an unstable, toxic, and hyperreactive molecule, making it a challenge to create a compound with the highest amount of HOCl in solution to have high-efficacy antimicrobial activity while simultaneously not being harmful to cells. Calderon developed a method to obtain a stabilized form of HOCl (s-HOCl), which resembles the compound produced by neutrophils and other immune cells, and has a high oxidation potential.4 This s-HOCl molecule has been approved by the US FDA (approval #K180305) and the National Institute for Drug and Food Vigilance of Colombia (INVIMA) for the treatment of mucosal and skin disorders.
The authors of several studies have demonstrated the safety and antimicrobial efficacy of low-concentration HOCl solutions in oral and nasal cavities. Sam and Lu described the oxidizing and chlorinating mechanisms behind the HOCl pathogen-killing properties, as well as its effect on nuclear factor kappa B (NF-kB) and activator protein-1 (AP-1) in monocytes, which modulates inflammation.5 In 2008, Kim et al reported the safe use of HOCl in nasal epithelium after 2 h of treatment, while having over 99% of bactericidal and fungicidal action.6 In 2011, Yu et al reported the inhibition of rhinovirus replication in nasal cells utilizing HOCl, also decreasing the production of cytokines, potentially leading to reduced common cold symptoms.7 Posteriorly, in a randomized controlled clinical trial by Yu et al, nasal HOCl irrigation showed higher efficacy in controlling chronic sinusitis symptoms when compared with normal saline solution.8 In 2016, Cho and Kim described the use of HOCl as an adjuvant treatment for pediatric chronic sinusitis.9 Additionally, Castillo et al reported that the utilization of 1 min HOCl oral rinses inhibited 99.9% of bacterial proteins from common pathogenic oral cavity microorganisms, in concordance with previously reported basic studies.10,11 More recently, multiple authors have proved the efficacy and safety of HOCl in various clinical settings. In 2019, Harriott et al highlighted s-HOCl's superior antimicrobial activity against both gram-positive and gram-negative bacteria, as well as fungal biofilms, compared with mafenide acetate.12 In 2020, Fernández et al reported s-HOCl for intra-abdominal lavage in open abdomen patients reduced the frequency of surgical lavages without adverse events.13 In 2022, Gözüküçük and Çakıroğlu demonstrated s-HOCl's safety as a skin disinfectant before neonatal circumcision, showing fewer adverse events compared with povidone-iodine.14 In 2022, Gallagher et al reported that utilizing s-HOCl with negative pressure wound therapy for serious wounds resulted in fewer surgical lavages and shorter hospital stays, reducing healthcare costs without adverse effects.15 In 2023, Przybyl and Hegewald reported a statistically significant reduction in infections and hospital stays among patients undergoing posterior spinal fusion after implementing a protocol that included antiseptics, such as HOCl.16
We developed and implemented a surgical protocol named the ALOHA strategy (active lavage and out-killing by HOCl) to evaluate the efficacy and safety of s-HOCl in preventing and reducing SSIs following body contouring procedures. This protocol was designed to enhance infection control while maintaining optimal patient safety.
METHODS
Study Design
A prospective and matched control cohort was conducted in a single plastic surgery center in Bogota, Colombia (Dhara Clinic). This study was conducted following the Declaration of Helsinki and was approved by the IRB of our institution (Dhara Clinic). The study was considered a minimal risk. Nonprobabilistic convenience sampling was used. Based on available evidence of the efficacy and safety of s-HOCl use in surgery, patients fulfilling selection criteria were invited to participate and subsequently included upon written informed consent.
Population
We prospectively enrolled adult patients who were scheduled for liposculpture and fat grafting in our institution from January 2020 to December 2023. These could be carried out combined or not with other aesthetic procedures, such as breast, face, buttocks, or rib surgeries. Inclusion criteria were adult patients between 18 and 60 years old, without major comorbidities (American Society of Anesthesiologists class ≤ II), BMI < 30 kg/m2, and no history of massive weight loss (≥50% of excess weight loss). Known allergies to HOCl, follow-up period <1 month, incomplete clinical or surgical information, or no fat grafting as part of the procedure were considered exclusion criteria. An s-HOCl solution was added to the lipoaspirate to wash adipose cells before autologous grafting. A match-control historical cohort was obtained by retrieving information on all patients who underwent liposculpture + fat grafting procedures at our center in a similar time frame, from January 2017 to December 2019, following the same selection criteria. The cohort was retrospectively matched based on BMI, age, gender, and time frame within a single plastic surgery center in Bogota, Colombia (Dhara Clinic). All procedures were performed by the same surgeon at the same location, focusing on a consistent target population. This approach ensured uniformity in surgical technique and practice setting, minimizing confounding factors and enhancing the reliability of outcome comparisons. Every single step from surgery and institutional protocols was identical, except for the use of s-HOCl as a washing solution for the adipose graft. Follow-up appointments were scheduled with a board-certified plastic surgeon at 24 to 48 h, 1 week, 1 month, 6 months, and 12 months postoperatively. For patients residing abroad, follow-up visits at 1 month and beyond were conducted either virtually or in person, depending on feasibility and patient preference. The attending surgeon was responsible for establishing the diagnostic criteria and providing surgical clearance postoperatively. Infections were classified based on their severity and depth of involvement as follows: (1) mild or localized infections: redness, swelling, and mild pain at the incision or drainage sites, with no systemic symptoms and minimal clear or slightly cloudy drainage; (2) moderate infections extend beyond the incision site, often causing increasing pain, purulent drainage, fever, or systemic symptoms such as chills and tachycardia; and (3) severe cases were those with deep tissue infections or abscess formation, plus systemic symptoms.
Intervention
Patient prepping emphasizes meticulous skin disinfection to minimize infection risks and ensure patient safety. Patients were instructed to shower with a chlorhexidine-based antiseptic solution the night before and the morning of surgery. In preparation, all patients are given 60 min before surgery starts a single dose of intravenous (IV) first-generation cephalosporin (or clindamycin in case of allergy). In the operating room, the surgical site was disinfected using a combination of chlorhexidine gluconate and isopropyl alcohol, ensuring broad-spectrum antimicrobial coverage. Once the patient was under anesthesia on the operating table, sites for incisions were prepped in a circular motion, starting in the center and moving outward, allowing the antiseptic to dry completely for optimal effectiveness. After disinfection, sterile drapes were applied to maintain a sterile field and prevent contamination. Liposculpture was carried out through a traditional 3-step approach: infiltration with a tumescent technique, adipose tissue emulsification (VASER Lipo System,Solta Medical, Bausch Health Companies Inc., Laval, QC, Canada), and extraction using 3.0 and 4.0 mm Mercedes Cannulas connected to MicroAire System (MicroAire Surgical Instruments, LLC, Charlottesville, VA). Fat was harvested using a sterile bottle trap closed system (Wells Johnson Company, Tucson, AZ). Adipose cells were washed by adding 400 mL of s-HOCl solution at a concentration of 250 ppm to each liter of lipoaspirate to get a final concentration of 150 ppm of s-HOCL within the lipoaspirate. This solution was then processed through active decantation (VTS Vibratory Tissue Separator, Wells Johnson Company). Liquid infranatant was discarded, and only the adipose fraction was obtained and placed into syringes for fat grafting. After the procedure is completed, a third-generation oral cephalosporin is given for 3 to 5 days (or a fluoroquinolone in case of allergy).
Data Collection
The information on patient's demographics, type of procedure, surgical time, infiltration and suction volumes, pre- and postsurgical hemoglobin and hematocrit, anatomical sites and volume of fat grafted, and graft infection, were collected and included for analysis. All the data and variables were collected from clinical charts and annotated to a standard spreadsheet by a single nurse, trained in data collection but blinded to the study methods and aims, for data accuracy purposes. Fat grafting-site infection was considered the main outcome of the study, and information regarding its presentation and treatment was collected from clinical charts. Muscle groups were defined as the corresponding muscles on both sides of the body (bilateral) and used as the unit of measurement.
Statistical Analysis
A univariate analysis was conducted to consolidate the information. The analysis was performed in the complete population and then subdivided into the 2 study cohorts according to the use of the intervention (s-HOCl). Frequencies (both absolute and relative) and percentages were calculated for qualitative variables. The Shapiro–Wilk test was used to assess the normal distribution of quantitative variables. For variables with a normal distribution, the mean and standard deviation were estimated, whereas the median and interquartile range (IQR) were used for non-normal distributed variables. Relevant variables with clinical differences between women and men were analyzed both as the whole cohort and according to gender. The statistical analysis was performed using the Jamovi computer software (Version 2.3).
RESULTS
A total of 1008 patients were included in this study: 787 (78.1%) women and 221 (21.9%) men. A total of 1902 muscle groups (bilateral pairs) were fat grafted, with a proportion of 1.89 fat-grafted muscle groups per patient. The intervention cohort (s-HOCl) included a total of 502 patients, and the control cohort had 506 patients, most of them being women (78.3% and 77.9%, respectively). For the total study population, the median age was 36 years (IQR 12 years), median weight was 65 kg (IQR 16 kg), median height was 165 cm (IQR 12 cm) and median BMI of 24.1 kg/m2 (IQR 4 kg/m2). The most frequent additional aesthetic procedure was mammoplasty with implants in 196 patients (19.4%), followed by mastopexy without implants in 58 (58%), buccal fat removal in 33 (3.4%), and rib surgery in 34 (3.4%). The median surgery duration was 235 min (IQR 78 min), the median infiltration volume was 6200 cc (IQR 2800 cc), and the suction volume was 4000 cc (IQR 2200 cc). All the demographic and surgical characteristics of the total population and the differences between s-HOCl and control cohorts are described in Tables 1-3, respectively. The fat grafting procedure includes different muscle groups per patient. It is personalized according to the patient's gender, body structure, and aesthetic aims. The different features of the fat grafts, including muscle groups and grafted volume, are described in Table 4 (control) and Table 5 (s-HOCl).
Table 1.
Baseline Demographic and Clinical Characteristics
| Variable | Pre-HOCl use (2017-2019) | Post-HOCl use (2020-2023) | Total population |
|---|---|---|---|
| Gender, n (%) | |||
| Male | 112 (22.1) | 109 (21.7) | 221 (21.9) |
| Female | 394 (77.9) | 393 (78.3) | 787 (78.1) |
| Total | 506 (100) | 502 (100) | 1008 (100) |
| Age (years), M (IQR) | |||
| Male | 39.5 (12) | 38 (14) | 39 (13) |
| Female | 33 (10) | 36 (10) | 35 (11) |
| Total | 34 (11) (min 18, max 58) |
36 (11) (min 18, max 59) |
36 (12) (min 18, max 59) |
| Weight (kg), M (IQR) | |||
| Male | 85 (18) | 81.5 (14.3) | 83 (17) |
| Female | 62 (10) | 62 (10) | 62 (10) |
| Total | 64.5 (14) | 65 (18) | 65 (16) |
| Height (cm), M (IQR) | |||
| Male | 176 (7.5) | 177 (8) | 176 (8) |
| Female | 163 (7) | 163 (9) | 163 (8) |
| Total | 165 (12) | 166 (13) | 165 (12) |
| BMI (kg/m2), M (IQR) | |||
| Male | 26.9 (4.2) | 25.9 (4.2) | 26.5 (4.2) |
| Female | 23.4 (3.4) | 23.3 (3.4) | 23.3 (4) |
| Total | 24 (4.2) (min 16, max 30.1) |
24.2 (3.8) (min 17.6, max 30.4) |
24.1 (4) (min 16, max 30.4) |
HOCl, hypochlorous acid; IQR, interquartile range; M, median; max, maximum; min, minimum.
Table 3.
Additional Surgical Procedures and Used Technologies
| Variable | Pre-HOCl use (2017-2019) | Post-HOCl use (2020-2023) | Total population |
|---|---|---|---|
| Additional Breast procedures, n (%) | |||
| Mammoplasty with implants | 82 (16.2) | 114 (22.7) | 196 (19.4) |
| Breast reconstruction | 2 (0.4) | 2 (0.4) | 4 (0.4) |
| Breast reduction | 4 (0.8) | 5 (1) | 9 (0.9) |
| Gynecomastia correction | 10 (2) | 2 (0.4) | 12 (1.2) |
| Implants removal | 0 (NA) | 10 (2) | 10 (1) |
| Mastopexy | 34 (6.7) | 24 (4.8) | 58 (5.8) |
| Additional facial procedures, n (%) | |||
| Blepharoplasty | 12 (2.4) | 11 (2.2) | 23 (2.3) |
| Buccal fat removal | 21 (4.2) | 12 (2.4) | 33 (3.3) |
| Mentoplasty | 3 (0.6) | 1 (0.2) | 4 (0.4) |
| Otoplasty | 5 (1) | 1 (0.2) | 6 (0.6) |
| Rhinoplasty | 16 (3.2) | 6 (1.2) | 22 (2.2) |
| Other additional procedures, n (%) | |||
| Buttocks implants | NA | 1 (0.2) | 1 (0.1) |
| Buttocks implants removal | NA | 2 (0.4) | 2 (0.2) |
| Rib surgery | NA | 34 (6.8) | 34 (3.4) |
| Technologies, n (%) | |||
| VASER | 468 (92.5) | 476 (94.8) | 944 (93.6) |
| MicroAire | 412 (81.4) | 474 (94.4) | 886 (87.9) |
| Renuvion | 18 (3.6) | 31 (6.2) | 49 (4.9) |
| BodyTite | 4 (0.8) | 10 (3) | 14 (1.4) |
| Laser CO2 | 6 (1.2) | 8 (1.6) | 14 (1.4) |
HOCl, hypochlorous acid; NA, not applicable.
Table 4.
Fat Graft Procedure Features Before s-HOCl Use
| Anatomical site of fat graft | Frequency n (%) |
Fat grafted volume (cc)a mean (SD) min-max |
Reported infection |
|---|---|---|---|
| Breast | 288 cc (133 cc) | ||
| Female | 52 (13.2%) | 15-460 cc | |
| Pectorals | |||
| Male | 86 (76.8%) | 178 cc (61.8 cc) 50-350 cc |
2 infections of the fat graft Treatment: IV and oral antibiotics |
| Biceps | |||
| Male | 22 (19.6%) | ||
| Female | 2 (0.5%) | 88.9 cc (22 cc) | |
| Total | 24 (4.7%) | 50-100 cc | |
| Triceps | |||
| Male | 16 (14.3%) | 60 cc (14 cc) 50-70 cc |
|
| Deltoid | |||
| Male | 83 (74.1%) | ||
| Female | 6 (1.5%) | 69.9 cc (30.8 cc) | |
| Total | 89 (17.6%) | 35-200 cc | |
| Trapezius | |||
| Male | 19 (17%) | 59.5 cc (24.1 cc) 30-150 cc |
|
| Latissimus dorsi | |||
| Male | 17 (15.2%) | 120 cc (44.7 cc) 50-150 cc |
|
| Gluteus/buttocks | 2 infections of the fat graft Treatment: IV and oral antibiotics |
||
| Male | 94 (83.9%) | ||
| Female | 366 (92.9%) | 412.5 cc (163.5 cc) | |
| Total | 460 (90.9%) | 50-1000 cc | |
| Thighs | |||
| Female | 15 (3.8%) | 175 cc (177 cc) 50-300 cc |
|
| Calf | 1 infection of the fat graft on the left calf Treatment: IV and oral antibiotics |
||
| Male | 7 (6.3%) | ||
| Female | 24 (6.1%) | 144 cc (55.6 cc) | |
| Total | 31 (6.1%) | 50-270 cc | |
| Face | |||
| Male | 15 (13.4%) | ||
| Female | 56 (14.2%) | 18 cc (18.6 cc) | |
| Total | 71 (14%) | 2-125 cc | |
| Hands | |||
| Female | 3 (0.8%) | 6 cc | |
| Rectus abdominis | |||
| Male | 18 (16.1%) | ||
| Female | 24 (6.1%) | 101 cc (89.8 cc) | |
| Total | 42 (8.3%) | 20-300 cc |
HOCl, hypochlorous acid; IV, intravenous; SD, standard deviation.
aFat grafted volume (cc) is presented per side (right/left), corresponding to the volume injected into each individual muscle.
Table 5.
Fat Graft Procedure Features After s-HOCl Use
| Anatomical site of fat graft | Frequency n (%) |
Fat grafted volume (cc)a Mean (SD) min-max |
Reported infection |
|---|---|---|---|
| Breast | 1 infection of the fat graft | ||
| Female | 94 (23.9%) | 109 cc (93 cc) 15-350 cc |
Treatment: IV and oral antibiotics |
| Pectorals | |||
| Male | 67 (61.5%) | 143 cc (45.6 cc) 40-290 cc |
|
| Biceps | |||
| Male | 36 (33%) | 64 cc (26.7 cc) 25-150 cc |
|
| Triceps | |||
| Male | 21 (19.3%) | ||
| Female | 1 (0.3%) | 64.5 cc (28.4 cc) | |
| Total | 22 (4.4%) | 20-100 cc | |
| Deltoid | |||
| Male | 83 (76.2%) | ||
| Female | 2 (0.5%) | 72.4 cc (29 cc) | |
| Total | 85 (16.9%) | 30-150 cc | |
| Trapezius | |||
| Male | 41 (37.6%) | 59.9 cc (22.7 cc) 25-150 cc |
|
| Latissimus dorsi | |||
| Male | 28 (25.7%) | 100 cc (39 cc) 50-150 cc |
|
| Gluteus/buttocks | 1 infection of the fat graft Treatment: IV and oral antibiotics |
||
| Male | 78 (71.6%) | 383 cc (147 cc) | |
| Female | 372 (94.7%) | 30-850 cc | |
| Total | 450 (89.6%) | ||
| Thighs | |||
| Male | 5 (4.6%) | ||
| Female | 16 (4.1%) | 30 cc (31.1 cc) | |
| Total | 21 (4.2%) | 10-100 cc | |
| Calf | |||
| Male | 6 (5.5%) | ||
| Female | 22 (5.6%) | 108 cc (45.4 cc) | |
| Total | 28 (5.6%) | 50-200 cc | |
| Face | |||
| Male | 11 (10.1%) | ||
| Female | 41 (10.4%) | 56.4 cc (55.9 cc) | |
| Total | 52 (10.4%) | 3-240 cc | |
| Hands | |||
| Female | 6 (1.5%) | 54.1 cc (46.7 cc) 3-150 cc |
|
| Rectus abdominis | |||
| Male | 25 (22.9%) | ||
| Female | 22 (5.6%) | 82.1 cc (74.1 cc) | |
| Total | 47 (9.4%) | 10-200 cc |
HOCl, hypochlorous acid; SD, standard deviation.
aFat grafted volume (cc) is presented per side (right/left), corresponding to the volume injected into each individual muscle.
Table 2.
Surgical Characteristics of the Cohort
| Variable | Pre-HOCl use (2017-2019) | Post-HOCl use (2020-2023) | Total population |
|---|---|---|---|
| Surgery duration (min), M (IQR) | 210 (70) | 245 (80) | 235 (78) |
| min 40, max 475 | min 65, max 570 | min 40, max 570 | |
| Infiltration volume (cc), M (IQR) | 7200 (2600) | 5500 (2000) | 6200 (2800) |
| min 250, max 12,600 | min 400, max 14,000 | min 250, max 14,000 | |
| Suction volume (cc), M (IQR) | 4200 (2500) | 3600 (2400) | 4000 (2200) |
| min 100, max 10,700 | min 300, max 9400 | min 100, max 10,700 | |
| Preop hemoglobin (g/dL), M (IQR) | |||
| Male | 15.6 (1.6) | 16.1 (1.7) | 15.9 (1.7) |
| Female | 14 (1.6) | 14 (1.5) | 14 (1.5) |
| Total | 14.1 (1.7) min 11, max 18.5 |
14.4 (1.9) min 12, max 18.9 |
14.2 (2) min 11, max 18.9 |
| Postop hemoglobin (g/dL), M (IQR) |
|||
| Male | 12.4 (1.47) | 12.6 (1.7) | 12.5 (1.5) |
| Female | 10.7 (1.33) | 10.5 (1.4) | 10.6 (1.4) |
| Total | 10.9 (1.7) min 7.9, max 15.3 |
11.1 (1.8) min 8.2, max 15.6 |
11 (2) min 7.9, max 15.6 |
| Preop hematocrit (%), M (IQR) | |||
| Male | 46 (4.9) | 46.9 (4.7) | 46.6 (4.4) |
| Female | 41.6 (4.2) | 42.3 (4.5) | 41.9 (4.2) |
| Total | 42.3 (5) min 30.2, max 57.8 |
43.4 (5.4) min 30.2, max 55.8 |
42.8 (6) min 30.2, max 57.8 |
| Postop hematocrit (%), M (IQR) | |||
| Male | 37 (4.7) | 36.9 (5) | 36.9 (4.8) |
| Female | 31.5 (3.9) | 30.9 (3.9) | 31.2 (4) |
| Total | 32.3 (5.3) min 23.1, max 45.9 |
32.1 (5.5) min 23.5, max 43.7 |
32.2 (5) min 23.1, max 45.9 |
HOCl, hypochlorous acid; IQR, interquartile range; M, median; min, minimum, max, maximum; op, operative.
In the control group (n = 506 patients, 925 muscle groups), a total of 5 muscles with fat grafting developed postoperative infections. These infections occurred in 2 pectoral muscles, 2 buttocks, and 1 calf. Two infections were severe: 1 in the left pectoralis major muscle and 1 in the left buttock (Figures 1, 2). Both required IV and oral antibiotic treatment. The infection in the left buttock required intensive care unit (ICU) admission and multiple surgical lavages to resolve the infection. Multisensitive Escherichia coli was isolated from the secretion of the left buttock. No pathogen was isolated from the pectoral abscess, but it necessitated several surgical lavages to clear the infection. The other 3 infections (1 in a buttock, 1 in a pectoral muscle, and 1 in a calf) also required IV and oral antibiotic treatment. Typically, patients received a 3- to 5-day course of IV antibiotics, followed by a switch to oral therapy. No deaths were reported.
Figure 1.
A 34-year-old female patient from the control group. The patient presented with a severe systemic infection 7 days after dynamic definition liposculpture and fat grafting of the buttocks (650 cc right and 500 cc left). Multisensitive E. coli was isolated. Patient required intensive care unit admission for 1 week, and a 2 week course of intravenous antibiotics plus multiple surgical lavages to clear infection. Complete resolution was achieved after 3 weeks. No further aesthetic correction procedures were required. (A) Oblique view and (B) lateral view of the infection site.
Figure 2.
A 38-year-old male patient from the stabilized hypochlorous acid group. The patient presented with a localized infection 3 days after dynamic definition liposculpture and fat grafting of the pectoralis major muscle (200 cc to each side) + gynecomastia resection. A 7 day course of antibiotic treatment (375 mg ampicillin-sulbactam PO TID) and ultrasound-guided exploration plus physical means, including thermal therapy and manual massages, were enough to clear the infection completely. No systemic infection was reported, and complete resolution was achieved after 2 weeks. A cross-contamination with the surgical instruments was documented sometime afterwards during event vigilance. (A) Frontal view and (B) lateral view of the infection site.
In the s-HOCl group (n = 502 patients, 977 muscle groups), 2 sites developed mild-to-moderate infections: 1 in the right breast and 1 in the left buttock. Both infections required 3 days of IV antibiotic therapy, followed by a total of 8 days of oral antibiotic treatment. Neither case required ICU admission or surgical lavages. The infection rates in the s-HOCl group were 0.2 infections per 100 muscles fat grafted and 0.4 infections per 100 patients undergoing surgery, compared with rates of 0.54 and 0.99, respectively, observed in the control group. The relative risk (RR) for the outcome was 0.403 (95% CI, 0.08-2.07; P = .276). Table 6 summarizes the outcome description in the population.
Table 6.
Comparison Infections per Muscle Groups Pre- and Post-HOCl Use
| Intervention | Total muscle groups fat grafted | Total patients | Infections reported | Infection rate |
|---|---|---|---|---|
| Pre-HOCl use | ||||
| Male | 377 | 112 | 5 fat grafts infected | 0.54 infections per 100 muscle groups fat grafted 0.99 infection per 100 patients |
| Female | 548 | 394 | ||
| Total | 925 | 506 | ||
| Post-HOCl use | ||||
| Male | 401 | 109 | 2 fat grafts infected | 0.2 infections per 100 muscle groups fat grafted 0.4 infections per 100 patients |
| Female | 576 | 393 | ||
| Total | 977 | 502 |
HOCl, hypochlorous acid.
DISCUSSION
One of the primary uses of HOCl is in wound care and management. Its ability to effectively kill bacteria, viruses, and fungi makes it an ideal candidate for preventing infections in acute and chronic wounds. HOCl solutions are utilized to irrigate and cleanse wounds, which is thought to promote faster healing and reduce the risk of complications. Above all, its noncytotoxic nature ensures that healthy tissue is not damaged, making it safe for repeated use.
Graft infections are a rare outcome in fat grafting procedures; however, it is a severe clinical event associated with important morbidity and mortality, requiring hospital stay for antibiotic treatment, and imaging follow-up. Additionally, it has a negative impact on the final aesthetic outcomes. We found an RR of 0.403 in our cohort, indicating that the risk of SSI is about a third in the group exposed to HOCl compared with the nonexposed group. This substantial decrease is one of the most impactful achievements in our practice, reducing the economic and psychological burden for both surgeons and patients. Despite the small absolute risk reduction (0.59%), the context is crucial. SSIs derived from lipografts are rare but severe, making even a small absolute reduction significant for patient outcomes and healthcare costs. The intervention itself had a great impact on decreasing the graft infection rate; however, because of the rare nature of the outcome from both groups, because it is in the general population, it failed to obtain statistical significance. We believe that even combining data from multiple studies would not show a significant difference from our findings.
Although the clinical utilization of HOCl solutions in wounds lacks high-quality evidence to recommend its broad use, there exists ample evidence, including our own study, that provides substantial support for its efficacy and favorable safety profile.17-19 In 2018, Del Rosso and Bhatia published the clinical indications for the ready-to-use s-HOCl formula, describing its effect against many bacteria, fungi, and viruses, on top of its anti-inflammatory and immunomodulatory properties.20 Similarly, Anagnostopoulos et al reported in an in vitro study that 0.01% s-HOCl had better antiseptic effects than isopropyl alcohol 70%, chlorhexidine 4%, and povidone-iodine 5%.21 Gold et al described that topical s-HOCl exhibits powerful microbicidal and antibiofilm activity, promoting optimal wound healing and reducing scarring when combined with silicone.22 The stabilized molecule of HOCl has proved effective in reducing infection rates and treating wound infections in various clinical scenarios, grounded in biological and clinical reality rather than statistical artifacts. Moreover, s-HOCl has proved no concerns of eye or ear toxicity, unlike chlorhexidine. It is important to note that surgical antisepsis reduces but does not completely eliminate skin pathogens, which remain the primary source of SSIs in 70% to 90% of cases because of the normal skin microbiome. Residual bacteria, intraoperative contamination, host immune factors, and biofilm formation are key contributors to SSIs, even in healthy individuals undergoing surgery. This underscores the need for a multimodal infection prevention strategy, including preoperative antiseptic bathing, strict intraoperative aseptic techniques, optimized tissue handling and closure methods, and adjunctive measures, such as antibiotic prophylaxis and wound irrigation.
Remarkably, in the new postantibiotic era, characterized by high resistance to antibiotics because of overuse, the utilization of microbicidal molecules offers significant benefits. These molecules provide an effective alternative for preventing and treating infections, reducing reliance on traditional nonindicated use of postoperative antibiotics. By employing microbicidal agents such as HOCl, we can combat resistant pathogens more effectively and mitigate the spread of antibiotic resistance, ensuring better patient outcomes and enhancing overall public health.
Limitations
Although our paper has the benefits and quality of a prospective study, it also has limitations because of the matched-cohort nature of its design. Our sample size is significantly larger than any previously described study in fat grafting; however, we did not evaluate long-term follow-up of outcomes (fat graft retention) because it has already been demonstrated in many other studies. The cost–benefit of treating patients with infections is greatly surpassed by those who do not require treatment; furthermore, rare incidences make these risks inherently difficult to analyze with statistics.
CONCLUSIONS
Our study demonstrates that the use of s-HOCl reduces the risk of SSIs following liposuction and fat grafting procedures. This decrease in infection rates may represent a major advancement in effectively mitigating the economic and psychological burdens associated with SSIs. s-HOCl offers a valuable alternative to antibiotics, effectively reducing infection rates and contributing to improved patient outcomes. Larger clinical studies are required to further validate our findings.
Disclosures
The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.
Funding
The authors received no financial support for the research, authorship, and publication of this article.
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