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BREAST Management of the Infected or Exposed Breast Prosthesis: A Single Surgeon’s 15-Year Experience with 69 Patients Scott L. Spear, M.D. Mitchel Seruya, M.D. Washington, D.C. Background: In 2004, the senior author (S.L.S.) published an algorithm for the management of breast device infection and/or exposure. The purpose of this study was to build on the authors’ prior experience by expanding the cohort of patients and to identify risk factors for failed breast device salvage and recurrent infection/exposure. Methods: A retrospective study was carried out on a single plastic surgeon’s experience between 1993 and 2008. Patients with infected and/or exposed breast devices were classified into one of seven groups and salvage rates were calculated. Patient demographics and wound culture pathogens were analyzed as possible risk factors for device loss and recurrent infection/ exposure. Results: Over a 15-year period, the senior author managed 69 patients with 87 events of breast device infection and/or exposure. The overall salvage rate was 64.4 percent. Failed device salvage was significantly associated with the presence of atypical pathogens, such as Gram-negative rods, methicillin- resistant Staphylococcus aureus, and Candida parapsilosis. Recurrent device infection and/or exposure was significantly associated with a history of radiotherapy or the presence of S. aureus on wound culture. Conclusions: Salvage of the infected and/or exposed breast prosthesis re- mains a challenging yet viable option for a subset of patients. Relative contraindications include atypical pathogens on wound culture, such as Gram-negative rods, methicillin-resistant S. aureus, and C. parapsilosis. Pa- tients with a prior device infection and/or exposure and a history of either radiotherapy or S. aureus on wound culture should be monitored closely for signs of recurrence and managed cautiously in the setting of elective breast surgery. (Plast. Reconstr. Surg. 125: 1074, 2010.) B reast implants continue to be a popular op- tion for both aesthetic and reconstructive plas- tic surgery patients. Augmentation mamma- plasty has seen a 64 percent increase in volume since the year 2000, and became the top cosmetic procedure performed in the United States in 2007, with 347,500 new cases. Furthermore, pros- thetic breast reconstruction has remained the most common procedure performed for women with acquired mastectomy defects, representing 75.5 percent of all breast reconstruction cases in 2007 in the United States. 1 Despite improvements in breast implant design and surgical technique, device infection and expo- sure remain real concerns. Rates of infection have ranged from 0.4 to 2.5 percent for augmentation mammaplasty 2–6 and from 1 to 35.4 percent for prosthetic breast reconstruction. 3,7–13 Further- more, rates of exposure have been reported From the Department of Plastic Surgery, Georgetown Uni- versity Hospital. Received for publication June 29, 2009; accepted October 22, 2009. Poster presented at the 88th Annual Meeting of the American Association of Plastic Surgeons, in Rancho Mirage, Cali- fornia, March 21 through 24, 2009. Copyright ©2010 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0b013e3181d17fff Disclosure: Dr. Spear is a paid consultant for LifeCell Corp. (Branchburg, N.J.) and Allergan, Inc. (Irvine, Calif.). Dr. Seruya has no financial interest in any of the products, devices, or drugs mentioned in this article. www.PRSJournal.com 1074

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BREAST
Management of the Infected or Exposed Breast Prosthesis: A Single Surgeon’s 15-Year Experience with 69 Patients
Scott L. Spear, M.D. Mitchel Seruya, M.D.
Washington, D.C.
Background: In 2004, the senior author (S.L.S.) published an algorithm for the management of breast device infection and/or exposure. The purpose of this study was to build on the authors’ prior experience by expanding the cohort of patients and to identify risk factors for failed breast device salvage and recurrent infection/exposure. Methods: A retrospective study was carried out on a single plastic surgeon’s experience between 1993 and 2008. Patients with infected and/or exposed breast devices were classified into one of seven groups and salvage rates were calculated. Patient demographics and wound culture pathogens were analyzed as possible risk factors for device loss and recurrent infection/ exposure. Results: Over a 15-year period, the senior author managed 69 patients with 87 events of breast device infection and/or exposure. The overall salvage rate was 64.4 percent. Failed device salvage was significantly associated with the presence of atypical pathogens, such as Gram-negative rods, methicillin- resistant Staphylococcus aureus, and Candida parapsilosis. Recurrent device infection and/or exposure was significantly associated with a history of radiotherapy or the presence of S. aureus on wound culture. Conclusions: Salvage of the infected and/or exposed breast prosthesis re- mains a challenging yet viable option for a subset of patients. Relative contraindications include atypical pathogens on wound culture, such as Gram-negative rods, methicillin-resistant S. aureus, and C. parapsilosis. Pa- tients with a prior device infection and/or exposure and a history of either radiotherapy or S. aureus on wound culture should be monitored closely for signs of recurrence and managed cautiously in the setting of elective breast surgery. (Plast. Reconstr. Surg. 125: 1074, 2010.)
Breast implants continue to be a popular op- tion for both aesthetic and reconstructive plas- tic surgery patients. Augmentation mamma-
plasty has seen a 64 percent increase in volume since the year 2000, and became the top cosmetic procedure performed in the United States in 2007, with 347,500 new cases. Furthermore, pros- thetic breast reconstruction has remained the most common procedure performed for women
with acquired mastectomy defects, representing 75.5 percent of all breast reconstruction cases in 2007 in the United States.1
Despite improvements in breast implant design and surgical technique, device infection and expo- sure remain real concerns. Rates of infection have ranged from 0.4 to 2.5 percent for augmentation mammaplasty2–6 and from 1 to 35.4 percent for prosthetic breast reconstruction.3,7–13 Further- more, rates of exposure have been reported
From the Department of Plastic Surgery, Georgetown Uni- versity Hospital. Received for publication June 29, 2009; accepted October 22, 2009. Poster presented at the 88th Annual Meeting of the American Association of Plastic Surgeons, in Rancho Mirage, Cali- fornia, March 21 through 24, 2009. Copyright ©2010 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0b013e3181d17fff
Disclosure: Dr. Spear is a paid consultant for LifeCell Corp. (Branchburg, N.J.) and Allergan, Inc. (Irvine, Calif.). Dr. Seruya has no financial interest in any of the products, devices, or drugs mentioned in this article.
www.PRSJournal.com1074
between 0.29 and 2 percent for breast augm- entation4,5 and between 0.25 and 8.3 percent for device-based breast reconstruction.10,14,15
In the past, common practice was the immediate removal of the infected or exposed breast prosthe- ses16,17; however, the more recent plastic surgery lit- erature has explored options for device salvage.3,18–32
Methods for salvaging an infected device have included systemic antibiotics combined with either conservative wound drainage,3 antibiotic lavage,33
capsulotomy and device exchange,29 capsule curettage and device exchange,18 antibiotic la- vage followed by capsule curettage and device exchange,28 or capsulotomy/curettage/device ex- change followed by postoperative continuous an- tibiotic irrigation.31,32 For exposed breast prosthe- ses, salvage techniques have included conservative wound care with systemic antibiotics,19 device ex- change with primary closure with or without pos- terior capsular flap coverage,25,26 and device ex- change combined with muscular coverage.24
Despite a number of reports focusing on man- agement of the infected or exposed breast pros- thesis, there is still disagreement regarding the wisdom of and indications for device salvage and the optimal timing, setting, or technique. It would be valuable for plastic surgeons to better define a set of clinical guidelines addressing these very is- sues, given the medical, legal, psychological, and economic issues associated with possible implant loss. Device explantation is a traumatic event and, for practical purposes, represents the loss of a breast. Successful device salvage offered to prop- erly selected patients with the greatest possibility of success would be a highly desirable alternative to loss of an implant.
In 2004, the senior author (S.L.S.) introduced an algorithm for the management of breast device infection and/or exposure. Patients were strati- fied into one of seven groups of infection/expo- sure, and a treatment strategy was based on the response of the infection to initial antibiotic ther- apy and on the availability of soft-tissue coverage.27
As an initial step, that recommendation deserves further review to validate its observations and to refine its analysis.
The purpose of the present study was to build on our prior experience by expanding the cohort of patients and to try to better identify risk factors for failed breast device salvage and recurrent in- fection/exposure. With this added information, patients and surgeons can make more informed decisions regarding the likelihood of saving a threatened breast prosthesis.
PATIENTS AND METHODS A retrospective study was carried out on a sin-
gle plastic surgeon’s experience between 1993 and 2008. Patients with infected and/or exposed breast devices were identified through a combi- nation of quality improvement records of compli- cations, office charts, and hospital records. Events of device infection and/or exposure were classi- fied into one of seven groups, as defined by Spear et al.27 as follows: group I, mild infection; group II, severe infection; group III, threatened exposure; group IV, threatened exposure with mild infec- tion; group V, threatened exposure with severe infection; group VI, actual exposure with no/mild infection; and group VII, actual exposure with severe infection. Mild infection was defined as warmth, swelling, cellulitis, or nonpurulent drain- age that was responsive to initial antibiotic ther- apy. Severe infection was defined as persistent or substantial warmth/erythema/swelling despite antibiotic therapy, purulent drainage, atypical organisms on wound culture (e.g., methicillin- resistant Staphylococcus aureus, Gram-negative rods, mycobacteria, or yeast), or serious signs and symptoms of systemic infection (e.g., high fever, hypotension).
Salvage rates for individual classes of breast prosthesis infection and/or exposure were calcu- lated. Salvage rates were reported on a per-event basis, given that a number of patients experienced more than one episode of infection and/or ex- posure. “Device salvage” was defined as the con- tinued presence of a prosthetic device after surgical intervention, though not necessarily reten- tion of the original device.27 Depending on the ini- tial response to antibiotics and the availability of soft-tissue coverage, different modalities of device salvage were used for the infected or exposed breast device, as described previously.27 These included sys- temic antibiotic therapy, wound edge debridement, capsule curettage, capsulectomy, pulse lavage, de- vice position change (e.g., subglandular to subpec- toral), device exchange, primary closure, and/or flap coverage.
Associated demographics, including patient age, body mass index, former or active tobacco use, history of chemotherapy, and exposure to radiotherapy, were assessed as possible risk factors for device loss and recurrent infection/exposure. Patient demographics were reported on a per- event basis for device loss and on a per-patient basis for recurrent infection/exposure. This en- sured comprehensive collection and analysis of all available data.
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Wound culture pathogens were also investi- gated as potential contributors to device loss and recurrent infection/exposure. Culture data were not available for every event of infection/expo- sure, as some patients presented without evidence of wound drainage. Pathogens were reported on a per-event basis for device loss and on a per- patient basis for recurrent infection/exposure.
For statistical analysis, the t test was used for comparison of continuous variables, given their normal distribution and equal variances. The Fish- er’s exact test was used for evaluation of percent- ages or frequencies. A value of p 0.05 was con- sidered statistically significant.
RESULTS Over a 15-year period, the senior author man-
aged 69 patients with 87 events of breast device in- fection and/or exposure. The mean patient age was 49.8 years (range, 17 to 75 years), and the average body mass index was 23.4. Smoking history revealed that 18.4 percent of events involved patients with former or active tobacco use. Furthermore, 35.6 per- cent of events were associated with a history of che- motherapy use and 23.0 percent of incidents in- volved patients with exposure to radiotherapy.
The mean postoperative time to breast prosthe- sis infection/exposure was 5.5 months, with an over- all device salvage rate of 64.4 percent. Salvage and explantation rates for individual classes of infection and/or exposure are listed in Table 1, with a mean follow-up of 24.7 months. Thirty-four events involved breast prostheses with mild infection, classified as group I, and were associated with a 100 percent salvage rate. Twenty-six events concerned devices with severe infection, categorized as group II, and resulted in a 30.8 percent salvage rate. Six events involved threatened device exposure without signs of infection, labeled as group III, and were associ- ated with a 100 percent salvage rate. Three events dealt with threatened device exposure with mild in- fection, classified as group IV, and were related to a 66.7 percent salvage rate. Five incidents involved
threatened prosthesis exposure with severe infec- tion, categorized as group V, and were associated with a 40.0 percent salvage rate. Six events concerned actual device exposure with no/mild infection, labeled as group VI, and were associated with a 66.7 percent salvage rate. Seven incidents involved actual device ex- posure with severe infection, classified as group VII, and resulted in a 0 percent salvage rate.
Rates of contracture, hematoma, and seroma were investigated for the 56 events of successful device salvage. There was a 1.8 percent rate of capsular contracture (Baker grade III/IV) and a 1.8 percent incidence of hematoma. There were no occurrences of seroma or patient death.
Patient demographics and wound pathogens were evaluated as possible risk factors for failed device salvage and as potential predictors for suc- cessful device salvage. As shown in Table 2, events of failed device salvage were associated with a sig- nificantly higher degree of atypical pathogens, such as Gram-negative rods, methicillin-resistant Staphylococcus aureus, and Candida parapsilosis, as compared with events of successful salvage (42.9 percent versus 11.5 percent, p 0.015). Events of failed device salvage trended with an older mean patient age, in contrast to events of successful sal- vage, yet these results were not statistically signif- icant (age 52.5 years compared with 48.3 years, p 0.069). Failed device salvage events had a higher percentage of patients with exposure to radiother- apy as compared with successful salvage events, yet these findings did not reach statistical significance (32.3 percent compared with 17.9 percent, p 0.18). Incidents of failed device salvage had a higher degree of Gram-negative rods and S. aureus on wound culture in relation to events of success- ful salvage, yet neither result was found to be sta- tistically significant (28.6 percent compare with 11.5 percent, p 0.18; and 25.0 percent compared with 7.7 percent, p 0.14, respectively). Events of successful prosthesis salvage were associated with a higher percentage of coagulase-negative Staph- ylococcus, in contrast to events of failed salvage;
Table 1. Salvage and Explantation Rates for Different Classes of Infected and/or Exposed Breast Prostheses*
Class of Infection and/or Exposure Successful Salvage
Rate (%) Explantation Rate without
Surgical Salvage Attempt (%)
Group I: Mild infection 34/34 (100) 0/34 (0) Group II: Severe infection 8/26 (30.8) 18/26 (69.2) Group III: Threatened exposure 6/6 (100.0) 0/6 (0) Group IV: Threatened exposure with mild infection 2/3 (66.7) 1/3 (33.3) Group V: Threatened exposure with severe infection 2/5 (40.0) 3/5 (60.0) Group VI: Actual exposure with mild infection 4/6 (66.7) 1/6 (16.7) Group VII: Actual exposure with severe infection 0/7 (0) 6/7 (85.7) *Analyzed per event.
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however, this too was not statistically significant (30.8 percent compared with 17.9 percent, p 0.35). No statistically significant effects on device salvage were noted for body mass index, history of tobacco use, exposure to chemotherapy, or ab- sence of growth on wound cultures.
Patient demographics and wound pathogens were also evaluated as possible risk factors for re- current device infection and/or exposure. As listed in Table 3, patients with recurrent device infection and/or exposure were significantly as- sociated with either a history of radiotherapy or the presence of S. aureus on wound culture as compared with patients with a one-time episode (46.2 percent compared with 16.1 percent, p 0.028; and 38.5 percent compared with 5.9 per- cent, p 0.012, respectively). Although patients with repeat episodes of infection and/or exposure
had a higher rate of tobacco and chemotherapy use in relation to patients with a single episode, these findings were not found to be statistically significant (30.8 percent compared with 14.3 per- cent, p 0.22; and 46.2 percent compared with 28.6 percent, p 0.32, respectively). Patients with recurrent episodes of device infection and/or ex- posure had a lower degree of Gram-negative rods on wound culture in contrast to patients with a one-time event, yet this was not found to be sta- tistically significant (7.7 percent compared with 29.4 percent, p 0.15). No statistically significant effects on recurrent device infection and/or ex- posure were noted for age, body mass index, pres- ence of either atypical pathogens or coagulase- negative Staphylococcus on wound culture, or absence of growth on wound cultures.
CASE REPORTS
Case 1: Group I (Mild Infection) A 35-year-old patient with a history of previous subglan-
dular augmentation mammaplasty underwent bilateral revi- sion breast augmentation and primary mastopexy to address breast asymmetry, ptosis, and distortion secondary to capsu- lar contracture (Fig. 1). Operative steps included bilateral total capsulectomies, pocket conversion to a dual plane, placement of silicone smooth implants (Allergan 15-371, 15-339; Allergan, Inc., Irvine, Calif.), and circumvertical mas- topexies. On postoperative day 4, the patient presented to the emergency room with right breast swelling, erythema, pain, and a low-grade fever. This was managed with a one- time dose of vancomycin intravenously, followed by a course of Augmentin (GlaxoSmithKline, Brentford, London, United Kingdom) on discharge. After 5 days of oral antibiotic therapy, the erythema was much improved and there was minimal breast swelling. Symptoms resolved completely following a 10-day course of Augmentin and the patient was without signs of in- fection or capsular contracture at 11-month follow-up.
Table 2. Risk Factors for Breast Device Loss*
Salvaged (n 56)
Failed (n 31) p
Mean age, years 48.3 52.5 0.069 Mean BMI, kg/m2 23.4 23.3 0.94 History of tobacco use, % 17.9 19.4 1.00 History of chemotherapy, % 32.1 41.9 0.48 History of radiotherapy, % 17.9 32.3 0.18 Pathogens†
Atypical flora‡, % 11.5 42.9 0.015 Gram-negative rods, % 11.5 28.6 0.18 Coagulase-negative
Staphylococcus, % 30.8 17.9 0.35 Staphylococcus aureus, % 7.7 25.0 0.14 No growth, % 42.3 35.7 0.78
BMI, body mass index. *Analyzed per event. †Analysis based on salvaged and failed events with available wound culture, n 26 and n 28, respectively. ‡Gram-negative rods, methicillin-resistant Staphylococcus aureus, and Candida parapsilosis.
Table 3. Risk Factors for Recurrent Breast Device Infection or Exposure*
One-Time Infection/ Exposure (n 56)
Recurrent Infection/ Exposure (n 13) p
Mean age, years 49.1 50.8 0.61 Mean BMI, kg/m2 23.8 23.0 0.59 History of tobacco use, % 14.3 30.8 0.22 History of chemotherapy, % 28.6 46.2 0.32 History of radiotherapy, % 16.1 46.2 0.028 Pathogens†, %
Atypical flora‡, % 32.4 30.8 1.00 Gram-negative rods, % 29.4 7.7 0.15 Coagulase-negative Staphylococcus, % 26.5 30.8 1.00 Staphylococcus aureus, % 5.9 38.5 0.012 No growth, % 29.4 38.5 0.73
BMI, body mass index. *Analyzed per patient. †Analysis based on one-time and recurrent infection patients with available wound culture, n 34 and n 13, respectively. ‡Gram-negative rods, methicillin-resistant Staphylococcus aureus, and Candida parapsilosis.
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Case 2: Group 2 (Severe Infection) A 58-year-old patient underwent bilateral nipple-sparing
mastectomies and tissue expander reconstruction (Fig. 2). Ap- proximately 4 years after bilateral implant exchange, the pa- tient presented with right breast warmth and superior pole erythema. This was managed with a 10-day course of oral cip- rofloxacin and resulted in resolution of symptoms 1 month later. A year and a half later, the erythema returned around the nipple-areola complex. Despite initiating a course of cipro- floxacin, the erythema waxed and waned and was accompanied by a low-grade fever. Given local symptom recurrence in the setting of antibiotic therapy, device salvage was undertaken. This consisted of pocket curettage, pulse lavage, device ex- change for smooth saline implants (Allergan 68HP-455), and primary closure. Intraoperative cultures were negative and the patient was continued on a course of ciprofloxacin postoper- atively. At 15 months postoperatively, the patient had remained symptom-free, without signs of infection. Case 3: Group 6 (Actual Exposure with Mild Infection)
A 52-year-old woman with a history of active tobacco use, tissue expander reconstruction of a right skin-sparing mastectomy de-
fect, and radiotherapy, presented for right revision breast recon- struction. Despite six revision procedures, the patient continued to have capsular contracture and delayed wound healing of the right reconstructed breast (Fig. 3). To address the complications, the patient underwent partial subpectoral placement of a textured silicone implant (Allergan 324-1051) supported by an acellular dermal matrix inferior sling. Two months postoperatively, the patient presented with right medial breast erythema and actual implant exposure with serosanguineous drainage. Cultures showed moderate coagulase-negative Staphylococcus and alpha-he- molytic Streptococcus. With actual implant exposure associated with common breast flora, a device salvage procedure was offered and accepted by the patient. Operative details included total capsu- lectomy, complete removal of the previously placed acellular der- mal matrix, pedicled latissimus flap coverage of the soft-tissue– deficient region, device exchange for a silicone smooth implant (Allergan 10-210), and site change to a sub–latissimus/prepectoral pocket. The patient received Ancef (GlaxoSmithKline, London, United Kingdom) intraoperatively and was discharge to home on a 10-day course of Duricef (Bristol-Myers Squibb, Princeton, N.J.) by mouth. The patient remained infection- free and healed uneventfully through her 7-month follow-up.
Fig. 1. Case 1. (Above, left) A 35-year-old patient with a history of previous subglandular augmentation mammaplasty underwent bilateral revision breast augmentation and primary mastopexy to address breast asymmetry, ptosis, and distortion secondary to capsular contracture. (Above, right) On postoperative day 4, the patient presented with right breast swelling, erythema, pain, and a low-grade fever. (Below, left) After 5 days of Augmentin, the erythema was much improved and there was minimal breast swelling. (Below, right) At 11-month of follow-up, the patient was without signs of infection or capsular contracture.
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Case 4: Group 7 (Actual Exposure with Severe Infection without Salvage Attempt)
A 67-year-old patient with a history of active tobacco use and pedicled transverse rectus abdominis musculocutaneous flap reconstruction of a left modified radical mastectomy defect presented for left revision breast reconstruction (Fig. 4). The patient’s concern centered on the left superior pole deficiency sustained after debridement of extensive flap fat necrosis. The patient underwent partial subpectoral placement of a textured saline tissue expander (Allergan 133MV-14) to address the soft- tissue deficiency. Six months later, implant exchange for a textured saline implant (Allergan 363LF), inferior capsulor- rhaphy, and nipple-areola complex reconstruction were per- formed. Two months postoperatively, the patient presented with a pin-size, medial area of actual implant exposure that was associated with serosanguineous drainage. Cultures were con- clusive for ciprofloxacin-sensitive and Zosyn (Wyeth, Madison, N.J.)-sensitive Pseudomonas aeruginosa. Despite a course of oral ciprofloxacin, the serosanguineous drainage persisted and the area of actual implant exposure increased in size. Given the worsening clinical course, the patient was counseled for and agreed to device explantation. The patient had an uneventful postoperative course once the device was removed.
Case 5: Group 7 (Actual Exposure with Severe Infection and Failed Salvage Attempt)
A 55-year-old patient with a history of bilateral mastectomies, tissue expander reconstruction, and left-sided radiation therapy underwent bilateral implant exchange and fat injection of the left reconstructed breast (Fig. 5). Operative steps included left inferior strip capsulectomy, left circumferential capsulotomy, bilateral partial subpectoral placement of smooth silicone (Al- lergan 20-500) implants, and 25 cc of fat injected into the superior pole of the left reconstructed breast. Six weeks post- operatively, the patient presented with a high-grade fever of 104°F, left-sided erythema, and left breast implant actual ex- posure with serous drainage. Results of culture specimens taken at the time were positive for methicillin-resistant S. aureus. The fever subsided and erythema was much improved following a 2-week course of intravenous daptomycin. Given the patient’s positive response to antibiotic therapy, the patient was offered and consented to a device salvage procedure. The patient un- derwent capsular curettage, pedicled latissimus flap coverage of the soft-tissue–deficient region, device exchange for a saline textured tissue expander (Allergan 133MV-14), and site change to a sub–latissimus/prepectoral pocket. Postoperatively, the pa- tient was managed with a 3-week course of intravenous vanco-
Fig. 2. Case 2. (Above, left) A 58-year-old patient underwent bilateral implant exchange following tissue expander reconstruction of bilateral nipple-sparing mastectomies. (Above, right) Approximately 4 years after bilateral implant exchange, the patient pre- sented with waxing and waning right breast warmth and erythema despite repeated courses of ciprofloxacin. (Below, left) Postop- erative photograph obtained 9 days after device salvage by means of pocket curettage, pulse lavage, device exchange for smooth saline implants (Allergan 68HP-455), and primary closure. (Below, right) At 15 months postoperatively, the patient remained symp- tom-free, without signs of infection.
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mycin. One month postoperatively, the patient presented with a low-grade fever, malaise, and return of left breast erythema. Despite restarting intravenous vancomycin, the erythema per- sisted. At this point, the patient decided to forgo further at- tempts at device salvage and underwent an uneventful device explantation.
DISCUSSION In 1965, Perras introduced the concept of “sal-
vage” of an infected breast implant by means of antibiotic lavage.33 His contribution challenged surgical dogma, which dictated foreign body re- moval in instances of infection,17 and sparked the evolution of device salvage. Relying on systemic antibiotic therapy and passive wound drainage, Courtiss et al. reported salvage rates of 44.8 and 50 percent for infected implants in the setting of breast augmentation and breast reconstruction, respectively.3 Like Perras, Toranto and Malow per-
formed antibiotic lavage but supplemented it with systemic antibiotic therapy, surgical curettage, and device exchange to salvage three of three implants infected with atypical mycobacteria.28 Toranto and Malow enhanced their aforementioned protocol, adding capsulotomies, local flap reinforcement of the suture line, and postoperative closed-system irrigation to salvage 62.5 percent of infected breast implants, as reported by Wilkinson et al.31
Silver extended device salvage to the manage- ment of exposed breast implants, advocating site change and the use of a posterior capsular flap to reinforce primary closure of the skin breakdown area.25 Investigating an alternative soft tissue cover, Rempel reported the use of a serratus anterior mus- cle flap to salvage a breast implant in the setting of recurrent exposure.24 Using a technique similar to that of Toranto and Malow,28 Weber and Hentz
Fig. 3. Case 3. (Above, left) A 52-year-old woman with a history of active tobacco use, radiotherapy, and seven right revision breast reconstructions presented with right medial breast erythema, actual implant exposure, and serosanguineous drainage 2 months postoperatively. Cultures showed moderate coagulase-negative Staphylococcus and alpha-hemolytic Streptococcus. (Above, right) Device salvage by means of total capsulectomy, pedicled latissimus flap coverage of the soft-tissue– deficient region, device ex- change for a silicone smooth implant (Allergan 10-210), and site change to a sub–latissimus/prepectoral pocket. (Below, left) Post- operative view, 3 months after device salvage. (Below, right) The patient remained infection-free and healed uneventfully through her 7-month follow-up.
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salvaged 100 percent of exposed breast implants using preoperative systemic antibiotic therapy and antibiotic lavage, followed by excisional debride- ment, open capsulotomy, wound irrigation, device exchange, and closed drain placement.29 Building on Rempel’s technique, Wilkinson reported a two- flap technique for soft-tissue coverage, consisting of a sling of serratus anterior and pectoralis mus- cle coupled with a Limberg skin flap.30 Furthering Snyder’s concept of site change, Planas and Car- bonell recommended switching to a subpectoral plane for exposed implants that were initially placed in a subglandular pocket.23
In 2004, the senior author codified the afore- mentioned techniques of device salvage into an
algorithm for the management of breast device infection and/or exposure.27 It helped move the topic from one of “do or do not” attempt device salvage to the next level, by shedding light on “how” and “when” instead. The “how” boiled down to aggressively treating infections with bacteria- specific antibiotics, delivered in reliable and suf- ficient doses. This approach resolved many mild infections and downgraded some of the more se- vere cases. All exposed devices were assumed to be infected to a degree and were treated accordingly. The second step was to eliminate or reduce the bacterial inoculum. This required a combination of device exchange, capsulectomy, capsule de- bridement, irrigation, drainage, and intraopera-
Fig. 4. Case 4. (Above, left) A 67-year-old patient with a history of active tobacco use and pedicled transverse rectus abdominis musculocutaneous flap reconstruction of a left modified radical mastectomy defect presented for left revision breast reconstruction for superior pole deficiency. (Above, right) Two months after implant exchange with a textured saline implant (Allergan 363LF), inferior capsulorrhaphy, and nipple-areola reconstruction, the patient presented with a pin-size, medial area of actual implant exposure that was associated with serosanguineous drainage. Cultures were conclusive for ciprofloxacin-sensitive Pseudomonas aeruginosa. (Below, left) Despite a 1-week course of oral ciprofloxacin, the serosan- guineous drainage persisted and the area of actual implant exposure increased in size. (Below, right) Given the worsening clinical course, the patient underwent device explantation and healed uneventfully.
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tive instrument change. The third element was viable and sufficient soft-tissue coverage. For some cases, this required adding a flap.
In the present study, we hoped to further ex- pound on the “when” aspect of device salvage. The overall salvage rate in the setting of mild or no infection was 93.9 percent (groups I, III, IV, and VI), which was significantly higher than the 26.3 percent salvage rate for severe infection (groups II, V, and VII), p 0.05 by the Fisher’s exact test. Therefore, severe infections, marked by insuffi- cient response of erythema, pain, drainage, or swell- ing to antibiotics, are not promising candidates for successful salvage. Mild infections or exposed im- plants, in contrast, have a high likelihood of success- ful salvage using the described principles.
Patients should be counseled that device sal- vage need not compromise the long-term aes-
thetic outcome following prosthetic breast sur- gery. In this study, there was a 1.8 percent capsular contracture rate. This compared favorably to prior studies reporting contracture rates ranging from 9.1 to 68.4 percent.3,18,27,29,32
Patient demographics and bacterial patho- gens were evaluated as risk factors for failed device salvage and as potential predictors for successful device salvage. Events of failed device salvage were associated with a significantly higher degree of atypical pathogens, such as Gram-negative rods, methicillin-resistant S. aureus, and C. parapsilosis, as compared with events of successful salvage. Therefore, in our practice, patients with atypical pathogens on culture are not routinely offered the option of device salvage.
No individual pathogen or patient comorbid- ity was a predictor of device salvage failure or
Fig. 5. Case 5. (Above, left) A 55-year-old patient with a history of bilateral mastectomies, tissue expander reconstruction, and left-sided radiation therapy presented 6 weeks after bilateral implant exchange and left breast fat grafting with a high-grade fever of 104°F, left-sided erythema, and left breast implant actual exposure with serous drainage. Results of culture specimens taken at the time were positive for methicillin-resistant Staphylococcus aureus. (Above, right) Given symptom improvement while on dap- tomycin, device salvage was performed by means of capsular curettage, pedicled latissimus flap coverage of the soft-tissue– defi- cient region, device exchange for a saline textured tissue expander (Allergan 133MV-14), and site change to a sub–latissimus/ prepectoral pocket. (Below, left) Three weeks postoperatively, the patient completed a 3-week course of vancomycin and was infection-free. (Below, right) Four weeks postoperatively, the patient presented with a low-grade fever, malaise, and return of left breast erythema. She decided to forgo further attempts at device salvage and underwent an uneventful device explantation.
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success. Similar to the findings of Yii and Khoo, a history of radiotherapy did not affect the salvage outcome.32 In contrast to Yii and Khoo, growth of S. aureus on cultures was not found to be a risk factor for failed device salvage. To explain the discrepancy, all cases of device loss with S. aureus in the study by Yii and Khoo were in the setting of unattempted device salvage secondary to patient preference and not attributable to failed salvage procedures.
We also found that the absence of bacterial growth on culture did not impact the likelihood of device salvage. No growth of bacteria may signify a true reduction in colonies versus ster- ilization without elimination of bacterial patho- gens. The variability of bacterial clearance as- sociated with “no growth” may explain why it does not serve as a predictor of device salvage failure or success.
Although a history of radiotherapy or the pres- ence of S. aureus on wound culture did not affect the success of device salvage, they both were sig- nificantly associated with recurrent device infec- tion and/or exposure. In practice, patients with either of these risk factors should be monitored closely for signs of recurrent breast prosthesis in- fection/exposure. In the setting of elective breast surgery, these patients need to be managed cau- tiously and covered with historically effective peri- operative antibiotics.
This study addresses the “when” aspect of breast device salvage, but it does have several lim- itations. First, the lack of statistical significance for specific comorbidities or pathogens as risk factors for breast device loss or recurrent infection/ex- posure may stem from the small sample size for subgroup analysis rather than the true absence of a statistical difference. Second, our reported sal- vage rates seemingly underestimate the success of device salvage in situations of true attempts. Of the 31 events of device explantation, 29 incidents were in the setting of unattempted device salvage, whereas only two events were secondary to failed device salvage. Therefore, one needs to under- stand the distinction between failed salvage versus unattempted salvage when interpreting the afore- mentioned salvage rates. Lastly, because of the retrospective collection of data, it is possible that events of infection and/or exposure may have been misclassified or unidentified. All efforts were made to identify incidents of breast device infec- tion and/or exposure and correlate the events with documented patient signs, symptoms, and culture data.
CONCLUSIONS Salvage of the infected and/or exposed breast
prosthesis remains a challenging but viable option for a subset of patients. Keys to success include culture-directed antibiotics, capsulectomy, device exchange, and adequate soft-tissue coverage. Rel- ative contraindications to breast device salvage in- clude atypical pathogens on wound culture, such as Gram-negative rods, methicillin-resistant S. au- reus, and C. parapsilosis. Patients with a prior device infection and/or exposure and a history of either radiotherapy or S, aureus on wound culture should be closely monitored for signs of recurrent breast prosthesis infection/exposure and managed cau- tiously in the setting of elective breast surgery.
Scott L. Spear, M.D. Georgetown University Hospital
3800 Reservoir Road, NW PHC Building, 1st Floor Washington, D.C. 20007
[email protected]
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