Penile Implant: Review of a “No-Touch” Technique

J. Francois Eid, MD

ABSTRACT

Introduction: Over 25% of the more than 725,000 cases of nosocomial infection in the United States are related
to an implantable device. Despite the standard typical strategies available, infection rates for breast implants,
cerebrospinal shunts, and penile implants remain unacceptably high. This paper will review use of a “no-touch”
technique in varied surgical procedures from orthopedic fracture repair, cerebrospinal fluid shunt placement, and
breast reconstruction/augmentation to penile prosthesis implantation.
Aim: One of our aims was to investigate whether the “no-touch” concept was unique to the field of penile
implants and if similar results were obtained in other subspecialties. The other was to examine whether the low
infection rate initially obtained with the “no-touch” technique was maintained for a larger number of penile
implant procedures.
Methods: The literature was reviewed for the use of the “no-touch” technique in procedures as varied as
orthopedic fracture repair, cerebrospinal fluid shunt placement, breast reconstruction/augmentation, and penile
prosthesis implantation. In addition, a single surgeon’s experience with 3342 penile implant surgeries with and
without the use of the “no-touch” technique was reviewed.
Main outcome measure: Penile implant infection rate was examined for 3342 consecutive cases between
January 2002 and December 2014. Infection of standard technique was compared with rate of infection with
antibiotic impregnated devices and starting in 2006 with the addition of the “no-touch” enhancement.
Results: Literature review revealed that the “no-touch” technique decreased postoperative cerebral shunt
infection from 9.1% to 2.9%. Breast implant reconstruction surgical site infection decreased from 19% to none
with the “no-touch” technique. Penile implant infection rate fell from 5.3% in 2002 to 1.99% with the use of
antibiotic impregnated devices and to 0.44% with the addition of the “no-touch” technique.
Conclusion: Use of a “no-touch” technique involving a mechanical barrier makes a difference in preventing
infection of an implantable device.
Sex Med Rev 2016;-:1e7. Copyright
2016, International Society for Sexual Medicine. Published by Elsevier Inc.
All rights reserved.
Key Words: Penile Prosthesis; Surgical Technique; Infection Prevention

INTRODUCTION infections associated with mammary or penile implants can cause

There are more than 725,000 cases of nosocomial infection in
the United States each year, over 25% of which are device-
related.1 Of these, the most difficult to manage tend to be
infections associated with surgical implants, as follow-up typi-
cally requires lengthy courses of antibiotics, as well as repeated
surgical procedures.2 Such infections occur across a number of
medical specialties, including neurosurgical, orthopedic, plastic,
and urologic surgery, and can have serious clinical consequences.
For example, infections associated with ventricular shunts or
fracture-fixation devices can result in serious disability, whereas
Received December 2, 2015. Accepted January 23, 2016.
Advanced Urological Care, PC, New York, NY, USA
Copyright ª 2016, International Society for Sexual Medicine. Published by
Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.sxmr.2016.01.002
Sex Med Rev 2016;-:1e7
significant disfigurement and psychological trauma. These types
of infections also can have considerable economic consequences
related to the costs of device removal and replacement, regardless
of the type of implant.3
Because infections associated with surgical implants can be
difficult and costly to manage, as well as devastating to the
patient, prevention is critical. Typical strategies include pre- and
postoperative systemic antibiotic administration, topical appli-
cation of antibiotics and/or antiseptics, irrigation of the surgical
field with antimicrobial or saline solution, and use of antibiotic-
coated devices. Even with such strategies, infection rates remain
unacceptably high. For example, postoperative infection has
been reported in 4% and 18% of primary and revised penile
implant cases, respectively,4 1% to 6% of prosthetic breast
implant cases,5 and 8% to 10% of cerebrospinal fluid shunt
operations.6
1
2 Eid

AIMS Table 1. Comparison of no-touch vs conventional technique for

ventricular shunt implantation
This paper will review the use of a relatively novel “no-touch”
technique found to reduce the risk of postoperative infection No-touch Conventional
following surgery for orthopedic fracture, cerebrospinal fluid technique technique
shunt placement, breast reconstruction/augmentation, and penile Operating room environment
prosthesis implantation. It will focus primarily on the latter Limit personnel traffic Yes Yes
application. Educated assistants Yes No
Patient preparation
Hair shaved Yes Yes
Early Use of the “No-Touch” Technique During Supine or lateral decubitus Yes Yes
Orthopedic Surgery position
In the 1890s, Sir William Arbuthnot Lane developed a Shunt tunneled posteriorly in Yes Yes
“no-touch” surgical technique as part of his effort to maintain a patient with tracheostomy,
more aseptic environment during open reduction of orthopedic gastrostomy-jejunostomy,
fracture using screws, wires, and steel plates.7e9 The technique colostomy, halo
involved the use of thick gauze to cover the patient’s skin and Vancomycin and gentamicin Yes Yes
prophylactic antibiotics
wound edges, as well as long-handled instruments that increased
Surgical field
the distance between the surgeon’s hands and the open incision.
Wide, occlusive, 2 layers of Yes Yes
Additionally, the knife used to make the initial skin incision was drapes
discarded and a new knife was used in the wound, and Lane’s Double gloves Yes Yes
operating room assistants used forceps to pass instruments to him Prevent wound skin-edge Yes Yes
and thread needles for suturing. exposure
Shunt touched by surgeon’s No Yes
hands
Use of the “No-Touch” Technique During Shunt instruments kept Yes No
Neurosurgery separate from skin dissection
Ashpole acknowledged the benefit of using a “no-touch” instruments on a separate
technique when implanting ventricular shunts, but noted that it table
was difficult to accomplish due to the “small and slippery” shunt
components.10 He therefore designed a set of instruments that
could be used to handle and assemble shunt systems without
touching them. The instruments included a block to hold the placement.6 These included (1) using Michelle clips to secure
valve, as well as several different types of forceps, each for specific bacitracin-soaked gauze to the edges of the skin incisions to
tasks. In addition to reducing the risk of infection, he pointed minimize contact between instruments or fingers and the inci-
out that the technique decreased the risk of damaging the shunt- sion edges; (2) handling shunt components only with latex-free
related devices and catheters, although no data were provided for silastic-tipped forceps, to decrease mechanical injury to shunt
either endpoint. tubing, thereby limiting potential sites for bacterial adherence;
and (3) assuring that the instruments used to place the shunt
Faillace avoided some of challenges noted by Ashpole by using
never come into contact with skin edges. The authors reported
a 1-piece shunt that did not require assembly, thus circum-
that their infection rate was limited to 1.33% during a 62-month
venting the need for special instruments.11 His “no-touch”
period when they placed or revised 526 shunts.
approach attempted to avoid bacterial contamination by taking
extreme care not to touch the skin incision edges and shunt
components during the implantation procedure. Instead, only Use of the “No-Touch” Technique During Plastic
instruments were used to handle the shunt and shunt sutures, Surgery
and those instruments were kept separate from the instruments Use of a “no-touch” technique has also been reported by several
used to dissect the skin and soft tissue. When compared with his different plastic surgeons for breast augmentation or reconstruc-
previous surgical protocol, the “no-touch” technique decreased tion procedures. For example, Mladick used a “no-touch” tech-
the postoperative shunt infection rate from 9.1% (based on nique for 557 saline implants during a period from 1987 to
120 surgeries) to 2.9% (based on 67 surgeries), reflecting a 1992.12 He described it as a “superiorly sterile technique that
clinically significant improvement. Table 1 describes the differ- eliminates any possible source of bacterial contamination,”
ences in the 2 protocols. although he acknowledged that the technique described by Fair-
Although a more recent study of ventricular shunt infection by bank was more strictly sterile. The objective of Mladick’s tech-
Kanev and Sheehan did not cite Faillace’s work, it noted several nique was to avoid contact between the implant and the patient’s
features that distinguish their “no-touch” technique during shunt skin, as well as to minimize contact with the breast tissue. For

Sex Med Rev 2016;-:1e7

Penile Implant: No-Touch Technique
example, to insert a drain without touching skin or breast tissue,
the surgeon grasps a long trocar with a sterile sponge instead of a
gloved hand, while an assistant uses a hemostat instead of a gloved
hand to hold the drain. Then, to insert the implant, the surgeon
wears a new pair of gloves that have never touched the patient, and
retractors are placed by the assistant to ensure that the implant is
inserted in a manner that avoids contact with the skin and breast
tissue. Or, if the size of the incision is so small that contact between
the implant and tissue cannot be avoided, a sterile sleeve is placed
over the implant.
Mladick retrospectively compared complications during
2 periods, from 1980 to 1986 (ie, prior to using the “no-touch”
technique) and from 1987 to 1992 (ie, while using the “no-touch”
technique); however, he noted that the study included a number of
uncontrolled variables and only modest follow-up. There were no
infections during either period. Mladick reported significantly less
wrinkling (visible folds), deflations, and capsular contracture
during the second period, and attributed the latter at least in part to
the theory that the “no-touch” technique may help decrease the
rate of subclinical staph epidermidis contamination, which is a
significant cause of contracture.
More recently, Moyer et al studied the use of the Keller
Funnel, a device developed to permit “no-touch” insertion of a
breast implant.5 By painting the thorax of cadavers with fluo-
rescein dye prior to implantation and then measuring fluorescein
emission from the implant following insertion, the investigators
determined that use of the funnel permitted a 27-fold decrease in
skin contact when compared with a digital implantation tech-
nique (P ¼ .00059). By swabbing the cadaver breast tissue with
methicillin-sensitive Staphylococcus aureus and then culturing the
implant surfaces following implantation, the investigators also
determined that use of the funnel decreased bacterial contami-
nation from breast parenchyma to less than half the contami-
nation rate observed with the digital implantation technique;
however, this finding approached, but did not reach, statistical
significance (P ¼ .06).
Instead of using a funnel, Zhang and Blanchet modified a
Devon Lite Glove (a light handle cover; see Figure 1) by cutting
off the closed end of the glove, thus converting it to a sleeve with
a narrow end that could be placed into the small inframammary
incision.13 A folded, deflated saline prosthesis then could be
introduced into the lubricated sleeve and implanted without skin
contact. The authors report using the technique in a series of 64
patients with no incidence of capsular contracture; however, they
note that the sleeve works only with saline implants and not with
gel implants.
Wilson studied the use of a “no-touch” technique during
immediate, expander-based, post-mastectomy breast reconstruc-
tion which, compared with breast augmentation, involves a
surgical field that is less controlled and more contaminated.14
During the “no-touch” procedure, instruments used for the
preliminary surgical steps (eg, the electrocautery apparatus, light
handles, and suction tools) were removed from the field, so that
Sex Med Rev 2016;-:1e7
3
Figure 1. Devon light glove.
the implant was not contaminated by instruments that have
touched the skin. The “no-touch” procedure also involved
placement of a sterile transparent drape that completely covers
the exposed skin and is stapled to edges of the wound to hold it
in place, around which a second set of surgical drapes are placed.
A self-retaining retractor is then placed in a slit made in the
transparent drape between the mastectomy skin edges. The
retractor includes hooks that simultaneously retract the skin edge
and gather the transparent drape, so that it wraps inward and
completely covers the cut edge of the skin, ensuring that neither
the graft nor the implant can become contaminated by the skin.
Prior to using the “no-touch” technique, the rate of post-
operative surgical site infection or seroma during a series of 16
breast reconstructions was 19%, compared with no postoperative
surgical site infections or seromas during a series of 25 breast
reconstructions using the “no-touch” technique (P ¼ .025).
Use of the “No-Touch” Technique During Urologic
Surgery
The use of a “no-touch” surgical procedure was pioneered for
implantation of an inflatable penile prosthesis to treat erectile
dysfunction, which incorporates aspects of several of the tech-
niques described above.15,16 The surgery begins traditionally:
first, the surgeon delivers the penis and scrotum through a small
hole in an iodophor-impregnated drape and makes an incision in
the penoscrotal raphe, with dissection carried down through the
subcutaneous tissue and dartos to the level of Buck’s fascia. Five
yellow hooks are then utilized to secure and retract the edges of
the skin and held with a Scott retractor (Figure 2).
At that point, all surgical instruments are considered
contaminated and are removed from the surgical field, and
everyone who has touched the patient’s skin replaces their sur-
gical gloves. A 3M #1012 drape (3M, St. Paul, MN, USA) is
then brought onto the surgical field loosely placed over the penis,
scrotum, and surrounding surgical field, and secured with its
adhesive edges (Figure 3).
Over the retracted incision, the surgeon makes a small
fenestration in the 3M drape (Figure 4). An additional 4 blunt
4 Eid

Figure 3. A sterile drape loosely covers the entire surgical field to

limit contact with the patient’s skin.

performed all penile implants through the standardized peno-

scrotal approach. Also, since 2002 every case performed was
logged into a database and tracked in a prospective fashion.
Figure 2. Five yellow hooks secure the edges of the skin and are
held with a Scott retractor.

hooks are used to simultaneously retract the edges of the opening

of the 3M drape and the edges of the skin incision, and are then
secured to the retractor.
The surgeon then performs the remainder of the implant
procedure through the opening in the drape, thus eliminating all
direct and indirect contact between the patient’s skin and the
surgeon’s hands, the surgical instruments, and the implant. The
corporotomies are closed with a 3-0 PDS- RB1 suture in a
running fashion and 4 cc of a hemostatic matrix (Surgiflo,
Ethicon, Somerville, NJ, USA) is injected into each corpus
before the suture is ligated. Once the prosthesis is implanted, a
layer of tissue is closed entirely, covering all of the implanted
components, and then the drape is removed and the subcu-
taneous tissue and skin are closed. No drains are utilized and
patients are discharged to home the same day. The “no-touch”
enhancement added on average 10 minutes to the procedure and
the average total operating time was 1 hour, 15 minutes.
Implantation of all devices, including removal and replacements
were conducted in an identical fashion through the fenestration
of the 3M drape and all surgeries were performed as mentioned
and documented on the pictures.
Figure 4. A small fenestration is made in the drape. Blunt hooks
This review is of a single surgeon’s experience in 3 private are used to simultaneously retract the edges of the opening in the
ambulatory surgery centers. A single surgeon, the author, drape and the edges of the skin incision.

Sex Med Rev 2016;-:1e7

Penile Implant: No-Touch Technique 5

Table 2. Infection rates of virgin and revised implants by IPP type and surgical procedure
Virgin implants Revised implant Total

Number Number Number

No touch Number infected, Number infected, Number infected,
Prosthesis type procedure implanted n (%) P value* implanted n (%) P value* implanted n (%) P value*

Without infection No 116 6 (5.17%) 16 1 (6.25%) 132 7 (5.30%)

retardant (2002)
With infection No 600 10 (1.67%) .0317† 104 4 (3.85%) .5175† 704 14 (1.99%) .0350†
retardant
(2003-2005)
With infection Yes 2038 9 (0.44%) < .0001‡ 468 2 (0.43%) .0961‡ 2506 11 (0.44%) <.0001‡
retardant
(2006-2014)
.0042U .0115U .0002U

*Fisher’s Exact Test.

†2002 vs 2003-2005.
‡2002 vs 2006-2014.
U2003-2005 vs 2006-2014.

Patients were examined or contacted at 2, 4, and 12-week, and
then 6 and 12-month intervals.
A total of 3342 penile prostheses were implanted between
January 2002 and December 2014 as summarized in Tables 2
and 3. The data are divided into 3 distinct periods: (1) during
2002, the prostheses used were neither coated with infection
retardant nor implanted using the “no-touch” technique
(n ¼ 132); (2) from 2003 through 2005, the prostheses used
were coated with infection retardant, but the “no-touch” tech-
nique was not used (n ¼ 704); and (3) from 2006 through 2014,
the prostheses used were both coated with infection retardant
and implanted using the “no-touch” technique (n ¼ 2506).
Type and Brand of Implants
Of the total 3342 implantations performed over a 13-year
period, 132 (85 American Medical Systems [AMS, Minne-
tonka, MN, USA] and 47 Coloplast [Coloplast, Minneapolis,
MN, USA]) were noncoated in 2002; there were 701 coated
implantations (250 AMS,454 Coloplast) from 2003 to 2005;
and a total of 2506 implantations (626 AMS, 1880 Coloplast)
performed using the “no-touch” enhancement over the next 9
years starting in 2006. Primary implants accounted for 2038
cases, whereas 468 were removals and replacements. Since 2002,
the AMS 700CX and LGX accounted for 959 cases, AMS
Ambicor devices, 2 cases; 2335 cases used Coloplast Titan de-
vices and 46 cases used Coloplast Genesis semi-malleable devices.
The Genesis was used for cases with severe fibrosis in which
corporal dilation to 13mm was not possible, and 43 were later
converted to an inflatable device after a 3-month period.
Of the 132 patients implanted during 2002, 7 developed
infections, reflecting an infection rate of 5.30%. Cultures of the
infected patients grew coagulase-negative Staphylococcus (n ¼ 3),
Enterococcus faecalis (n ¼ 1), or had no growth (n ¼ 2). Of the 704
patients implanted from 2003 to 2005, 14 developed infections,
reflecting an infection rate of 1.99%. Cultures of the infected
patients grew coagulase-negative Staphylococcus (n ¼ 3), Staphy-
lococcus aureus (n ¼ 1), Enterococcus faecalis (n ¼ 1), or had no
growth (n ¼ 10). Of the 2506 patients implanted from 2006 to

Table 3. Organisms cultured according to IPP type and surgical procedure

Device Type “No-touch” procedure Implanted Infected Organism(s) n

Without infection No 132 7 (5.3%) Coagulase-negative staphylococcus 3 (42.9%)

retardant (2002) Enterococcus faecalis 1 (14.3%)
No growth 3 (42.9%)
With infection No 704 14 (1.99%) Coagulase-negative staphylococcus 3 (21.4%)
retardant (2003-2005) Staphylococcus aureus 1 (7.1%)
No growth 10 (71.4%)
With infection Yes 2506 11 (0.44%) Coagulase-negative staphylococcus 3 (27.3%)
retardant (2006-2014) Enterococcus faecalis and Candida 1 (9.1%)
Escherichia coliLactobacillus acidophilus 2 (18.2%)
Enterococcus faecalis 1 (9.1%)
No growth 1 (9.1%)
3 (27.3%)

Sex Med Rev 2016;-:1e7

6 Eid
2014, 11 developed infections, reflecting an infection rate of
0.44%. Cultures of the infected patients grew coagulase- negative
Staphylococcus (n ¼ 3), Enterococcus faecalis and Candida (n ¼ 1),
Escherichia coli (n ¼ 2), Lactobacillus acidophilus (n ¼ 1), and
Enterococcus faecalis (n ¼ 1), or had no growth (n ¼ 3). The total
infection rate significantly decreased between the first 2 periods
(P ¼ .0350) and between the first and third period (P < .0001), as
well as between the second and third period (P ¼ .0002).
DISCUSSION
The use of a “no-touch” technique during surgeries as varied
as orthopedic fracture repair, cerebrospinal fluid shunt place-
ment, breast reconstruction/augmentation, and penile prosthesis
implantation highlights a common concern about contamination
of implanted devices by skin flora. Although modification of a
device surface to inhibit bacterial presence in the biofilm (ie, with
an microbial coating or other type of infection retardant) is one
of the most commonly used methods of preventing device-
related infection, its success appears to depend on variables
such as device location, type of infecting pathogens, and coating
agents used.2 However, improvements in the incidence of in-
fections caused by the use of these coated devices is further ev-
idence that bacterial contamination occurs during implantation
and provides an incentive to develop a surgical technique which
completely isolates the skin from the device. The first publication
on the use of the “no-touch” technique for penile prosthesis
surgery was published by the author in 2012 to explore whether a
“no-touch” enhancement to the penoscrotal surgical approach
further reduced infections beyond the use of coated implants.15
In the case of inflatable penile prosthetic implantation, aug-
menting the use of a coated device with a “no-touch” technique
appeared initially to further reduce infection rates from 1.8% to
0.46%.15 The current review aims to examine whether this low
infection rate could be sustained for a larger number of implant
procedures. For the next 4 years the total number of implanted
patients increased from 1511 to 2506 and the infection rate
remained at 0.44%. In addition a review of the literature on the
use of the “no-touch” technique in other types of surgeries was
made to further support its use for penile prosthesis implanta-
tion. Indeed, similar results have been reported in the fields of
orthopedic surgery, neurosurgery, and plastic surgery; however,
many of those studies were published more than a decade ago.6,8
Prior to the use of infection retardant coating, skin flora (eg,
S epidermidis) appeared to be responsible for approximately 65% to
75% of infected urologic devices.17,18 Subsequent research
suggested that the introduction of infection retardant coating
primarily targets these organisms, but not infections caused by
Enterococcus, S aureus, E. coli, and Pseudomonas.19 Indeed, the data
in Table 3 reflect an increase in some of these less common, albeit
more aggressive, skin pathogens during the periods when patients
were implanted with devices coated with infection retardant. It was
logical, therefore, to explore the use of a skin barrier to attempt a
further reduction of infections. Although the iodophor-
impregnated drape has been shown to be effective and is used in
our technique, it is not used as a skin barrier. Because the iodophor-
impregnated drape has an adhesive backing to it, it restricts the
necessary intraoperative manipulation of the penile shaft and
scrotum. With the loose surgical drape used in the “no-touch”
enhancement, the barrier function is preserved, while allowing
mobility of the penis and scrotum. This mobility is essential to
manipulate and examine the shaft of the penis flaccid and erect
after cylinder insertion as well as to inflate and deflate the scrotal
pump. Because the tissue spaces for the components are fashioned
without contact with the patient’s skin, contamination of the intra-
cavernosal, scrotal, and space of Retzius is thought to be minimal.
Also, because the components of the devices are prepped and
implanted by gloved hands that have never touched the patient’s
skin; the contamination of the implant with organisms from the
patient’s skin is thought to be negligible. Lastly, another unrec-
ognized benefit of the “no-touch” technique is that it allows for
intraoperative repositioning and/or length adjustment of the
cylinders with minimal exposure to skin flora. A drawback of the
“no-touch” enhancement is that it increases the cost of the oper-
ation to a mild degree by requiring duplication of some
instruments and supplies, and increases the operative time by
approximately 10 minutes. When compared with the pain and
suffering as well as the substantial cost of an infection in both real
money and emotional distress on the patients, these increases
appear to be trivial. Although data to date strongly suggest that the
use of a “no-touch” technique involving a mechanical barrier
makes a difference in preventing infection of an implantable
device, it does not unequivocally prove this hypothesis. For
example, other variables, such as improved surgical technique over
time, could potentially explain the decrease in infections, regardless
of the use of the “no-touch” technique. A study in which patients
are randomized to receive an implanted device using either a
“no-touch” technique or a more traditional surgical technique
could help further elucidate this issue; however, it would not be
possible to blind the surgeon to the procedure used. Nevertheless
our 9-year experience with the “no-touch” enhancement in 2506
consecutive penile implant procedures has achieved an unprece-
dented low infection rate of 0.44%. This is currently the lowest
infection rate reported in the literature.
Corresponding Author: J. Francois Eid, MD, 435 East 63rd
Street, New York, NY 10065. Phone: (212) 535-6690; Fax:
(212) 535-7025; E-mail: jfeid@advancedurologicalcare.com
Conflict of interest: Dr Eid receives or has received research
support/grants from American Medical Systems (AMS), Colo-
plast Corporation, Lilly ICOS LLC, Bayer, Vivus, Pharmacia-
Upjohn, and Pfizer Inc. He is or was a consultant and on the
speakers bureau for Coloplast, AMS, Lilly ICOS LLC, Bayer,
and Pfizer In.
Funding: None.
Sex Med Rev 2016;-:1e7
Penile Implant: No-Touch Technique 7

STATEMENT OF AUTHORSHIP 6. Kanev PM, Sheehan JM. Reflections on shunt infection.

Pediatr Neurosurg 2003;39:285-290.
Category 1
7. Brand RA. Sir william arbuthnot lane, 1856-1943. Clin Orthop
(a) Conception and Design Relat Res 2009;467:1939-1943.
J. Francois Eid
(b) Acquisition of Data 8. Mostofi S, ed. Who’s who in orthopedics. London: Springer-
J. Francois Eid; Djibril Diallo; Nathalie Ba; Jeanine Quillard; Verlag; 2005. http://dx.doi.org/10.1007/b138248.
Rodrigue Sètchéou Allodji 9. Fairbank HA. Non-touch technique for simple fractures. Br
(c) Analysis and Interpretation of Data Med J 1942;2:388-389.
J. Francois Eid
10. Ashpole RD. New instrumentation for the assembly of shunt
Category 2 systems by a non touch technique. Br J Neurosurg 1992;
6:237-242.
(a) Drafting the Article
J. Francois Eid 11. Faillace WJ. A no-touch technique protocol to diminish cere-
(b) Revising It for Intellectual Content brospinal fluid shunt infection. Surg Neurol 1995;43:344-350.
J. Francois Eid 12. Mladick RA. “No-touch” submuscular saline breast augmen-
tation technique. Aesthetic Plast Surg 1993;17:183-192.
Category 3
13. Zhang S, Blanchet NP. An easy and cost-effective method to
(a) Final Approval of the Completed Article
perform the “no-touch” technique in saline breast augmen-
J. Francois Eid
tation. Aesthet Surg J 2015;35:NP176-NP178.

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