Dominykas Markevičius1, Nerijus Jakutis2,3
1 Faculty of Medicine, Vilnius University, Vilnius, Lithuania.
2 Clinic of Rheumatology, Orthopedics – Traumatology and Reconstructive Surgery, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania.
3 Center of Plastic Reconstructive Surgery, Vilnius University Hospital “Santaros Klinikos”, Vilnius, Lithuania.
Abstract
Introduction: Breast implant infection is the most common complication after breast reconstruction surgeries. A lot of different implant infection management protocols exist, and they are still debatable which is the best. We present the case of a patient with breast implant infection after risk-reducing bilateral mastectomy with immediate direct-to-implant reconstruction.
Case presentation: A 45-year-old woman underwent bilateral prophylactic mastectomy with immediate implant reconstruction. 31 days after the discharge she was administered to an emergency department with painful, erythematous non-healing wound in left breast. During the examination, a 2 cm wound covered with necrotic masses was observed. During the debridement surgery, a deeper implant-reaching necrosis was revealed. Immediate surgery involving debridement, lavage with antiseptics, defect closure was performed. A day after, the patient complained of left breast redness and enlargement. Despite no leukocytosis or elevated CRP, breast implant infection was diagnosed. Implant salvage procedure was indicated, during which partial capsulectomy and temporal explantation were performed, a swab for microbiological culture taken. The implant was irrigated with saline and povidone – iodine solution, then placed in a povidone – iodine-based solution with gentamicin (80.0 g) and cefazoline (1.0 g) 1.5 hours. After thorough debridement and implant pocket irrigation with 50 % povidone – iodine and antibiotic solution the same implant was reimplanted. Cefuroxime was administered and the drain was taken out after 5 days. 7 days after the surgery the patient was discharged without any signs of infection.
Conclusions: Breast implant infection remains one of the most dreaded complications after breast reconstruction surgery. We could not find any publication about the reimplantation of the same implant during the implant salvage procedure. Our case shows that a new breast implant salvage protocol could be used successfully in order to salvage the infected breast implant.
Keywords: Breast implant infection, breast reconstruction, implant salvage procedure.
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Medical Sciences 2020 Vol. 8 (17), p. 205-210
New protocol for treating breast implant infection: Case report
Dominykas Markevičius
1
, Nerijus Jakutis
2,3
1
Faculty of Medicine, Vilnius University, Vilnius, Lithuania.
2
Clinic of Rheumatology, Orthopedics - Traumatology and Reconstructive Surgery, Institute of
Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania.
3
Center of Plastic Reconstructive Surgery, Vilnius University Hospital “Santaros Klinikos”,
Vilnius, Lithuania.
Abstract
Introduction: Breast implant infection is the most common complication after breast reconstruction
surgeries. A lot of different implant infection management protocols exist, and they are still debatable which is
the best. We present the case of a patient with breast implant infection after risk-reducing bilateral mastectomy
with immediate direct-to-implant reconstruction.
Case presentation: A 45-year-old woman underwent bilateral prophylactic mastectomy with
immediate implant reconstruction. 31 days after the discharge she was administered to an emergency
department with painful, erythematous non-healing wound in left breast. During the examination, a 2 cm wound
covered with necrotic masses was observed. During the debridement surgery, a deeper implant-reaching
necrosis was revealed. Immediate surgery involving debridement, lavage with antiseptics, defect closure was
performed. A day after, the patient complained of left breast redness and enlargement. Despite no leukocytosis
or elevated CRP, breast implant infection was diagnosed. Implant salvage procedure was indicated, during
which partial capsulectomy and temporal explantation were performed, a swab for microbiological culture
taken. The implant was irrigated with saline and povidone – iodine solution, then placed in a povidone – iodine-
based solution with gentamicin (80.0 g) and cefazoline (1.0 g) 1.5 hours. After thorough debridement and
implant pocket irrigation with 50 % povidone – iodine and antibiotic solution the same implant was reimplanted.
Cefuroxime was administered and the drain was taken out after 5 days. 7 days after the surgery the patient was
discharged without any signs of infection.
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Conclusions: Breast implant infection remains one of the most dreaded complications after breast
reconstruction surgery. We could not find any publication about the reimplantation of the same implant during
the implant salvage procedure. Our case shows that a new breast implant salvage protocol could be used
successfully in order to salvage the infected breast implant.
Keywords: Breast implant infection, breast reconstruction, implant salvage procedure.
1. INTRODUCTION
The majority of breast reconstruction
procedures after mastectomy are implant based. It
reaches up to 80% of all breast reconstructions(1).
Every time a foreign body is implanted the risk of
postoperative complication increases. There are
many possible postoperative complications after
breast reconstruction surgeries, but breast implant
infection is one of the most common with mean rate
reaching from 1% to 35%(2).
Many different implant infection
management protocols have been discussed
throughout history, yet there has never been an
agreement which protocol is the best. Nevertheless,
a general agreement exists that antibiotic therapy
should be administered and any attempt in
salvaging the breast implant should be made(3).
Breast implant removal and systemic antibiotic
administration followed by delayed new implant
positioning within months has been the standard
management of breast implant infection. However,
this protocol has always been associated with
multiple surgical procedures that have their own
risks(4). Recently the new protocol was created for
salvaging an infected breast implant, which not
only allows to save the primary implant, but also
increases women psychological satisfaction. This
new protocol has an increasing popularity as it
potentially increases the rate of implant salvage.
In this paper we report one out of several
successful cases of implant salvage procedure
using new protocol and present the literature
review of different methods used in salvaging
infected breast implant.
2. CASE REPORT
A 45-year-old woman underwent a
successful risk reducing bilateral nipple spearing
mastectomy with immediate implant
reconstruction. Because of BRCA1 gene mutation.
In the past, cancer of her right breast was diagnosed
and treated by oncologists-mammologists with
quadrantectomy. Intravenous cefazoline (1g
3g/day) was administered before and after surgery.
Epidermolysis had been seen on the lateral pole of
the left breast; hence povidone - iodine solution
applications were prescribed for treatment. Thirty
– one days after the patient was discharged home,
she was administered to an emergency department
with painful erythematous non-healing wound in
her left breast. On examination, a 2 cm wound,
covered with necrotic tissue was observed and
debridement procedure was indicated.
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During the procedure, a deeper-implant-
reaching necrosis was diagnosed and immediate
surgery involving necrectomy, antiseptic lavage
and defect closure was chosen for treatment.
Necrectomy was performed and the implant
became exposed. Therefore, the pocket was
irrigated with povidone – iodine solution and
integrity of the implant was kept. Intravenous
cefuroxime (3g) was administered. Next day, the
patient started complaining about her left breast
red, hot, and enlarged. Upon examination, there
were typical clinical signs of breast implant
infection, despite no leukocytosis and CRP being
normal, and immediate implant salvage procedure
was chosen for treatment.
During the surgery, partial capsulectomy
and temporary explantation of the implant was
performed, a swab for microbiological culture
taken, although no pus has been detected
macroscopically. Irrigation of the implant with
saline and later with povidone – iodine solution
followed, and the implant was placed in a povidone
– iodine-based solution with gentamicin (80.0 g)
and cefazoline (1.0 g) for 1.5 hours. Thorough
necrectomy until no necrotic masses were seen and
implant pocket irrigation with 50 % povidone –
iodine and antibiotic solution were performed. The
surgical field and sterile gloved were changed and
reimplantation of the same implant followed. The
wound was then closed in 3 layers, and active drain
was placed. The microbiological analysis showed
no bacterial growth. Cefuroxime (1.5 mg 3
times/daily) was prescribed and the drain was taken
out 5 days after the surgery. 7 days after the surgery
the patient was discharged without any signs of
infection and symptom – free.
3. DISCUSSION
Breast implant infection in one of the
most dreaded complication after breast
reconstruction surgery(2). It could manifest in the
early postoperative period (up to first 6 weeks) or
in late postoperative period (more than 6 weeks
after surgery)(5). Most of the infections are caused
by Staphylococcus spp. (more specifically S.
aureus). Early complications (during first 6 weeks
after the surgery) can cause fever, breast pain or
discomfort, sense of tension feeling in the breast,
erythema, or purulent discharge from the surgery
wound. In the case we took for analysis, the woman
presented with a typical clinical manifestation of
the early postoperative infection of the breast(6,7).
Even though infections can manifest differently, it
is important to find and understand what bacteria
could be involved in the pathogenesis of the
infection to choose an optimal infection treatment
plan.
The first breast implant infection
treatment protocol was proposed by Courtiss et al
and involved tissue debridement and new implant
replacement during the same surgery involving
systemic antibiotic therapy and wound drainage(8).
Later Weber et al suggested perioperative
antibiotic therapy with wound irrigation and
implant replacement(9). Several other groups have
introduced implant pocket irrigation with saline
solution combined with antibiotic therapy and
implant exchange with or without
capsulectomy(10).
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In 2004 Spear et al introduced an implant
salvage algorithm, which has become a gold
standard for treating implant related infections. He
categorized patients into 7 groups depending on the
severity of infection and implant exposure risk. The
first group included patients with a mild infection
without the risk of implant exposure whereas the
seventh group included patients with severe
infection and breast implant exposure. During the
salvage procedure capsulectomy, implant pocket
curettage, pulse lavage, new implant placement and
closure was performed. Success ratio reached
95%(11).
Adams Jr. et al researched the
effectiveness of triple antibiotic solution (50,000 U
bacitracin, 80 mg gentamicin, 1 g cefazolin in 500
mL normal saline) in breast implant infection
management. The infection rate was 9.5% in
comparison to a higher rate of other methods that
have been used in history. In addition, they
proposed alternatives for allergic patients(12).
Yalanis et al found the povidone – iodine solution
to be effective in reducing risk of capsule
contractures(13).
In 2016 during “London breast meeting”
conference Adams W. Jr. introduced a technique
that involved Reimplantation of the same implant
after preparation of the implant mound and implant
itself for the reimplantation. During the procedure,
if pus was present around the implant, explantation
and delayed implantation of a new implant was
chosen. If pus was not present around the implant,
poor quality skin was removed, a swab for
microbiological culture was taken and implant
temporarily removed. The removed implant was
cleaned and placed in triple antibiotic solution.
Further steps included granulation curettage, saline
irrigation, triple antibiotic (betadine containing)
irrigation, implant reimplantation, layered closure,
closed suction drain placement and postoperative
antibiotic therapy for 1 – 2 weeks. This method was
also used for our patient. As we can see, using this
method the implant was salvaged and no
postoperative complications were seen. There is no
literature describing this new method and its
success rate.
Even though there are many different
implant infection management protocols in the
literature, there has never been an agreement which
protocol is the best. In recent years we are faced
with the increasing necessity to preserve the initial
implant not only because it is cost effective, but
also reduces the rate of future infections. Although
the new protocol seems to have wonderful results,
further investigations and clinical trials should be
performed to identify the breast implant salvage
rate using the new method.
4. CONCLUSIONS
Breast implant infection remains one of
the most dreaded complication after breast
reconstruction surgery. Even though there are
many different possible protocols for breast
implant salvage, there is none in which the same
implant could be saved and reimplanted. Our case
shows that a new breast implant salvage protocol
could be used in cases when no pus is not visible
around the implant during the surgery.
Nevertheless, further research involving this
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method should be conducted to identify the rate of
breast implant salvage.
5. DECLARATION
The authors have no conflict of interest to
declare in relation to the content of this article. No
external funding was received for this article.
Patient consent was obtained for sharing this case
information.
6. REFERENCES
1. Cemal Y, Albornoz CR, Disa JJ, McCarthy CM,
Mehrara BJ, Pusic AL, et al. A paradigm shift in
U.S. breast reconstruction: Part 2. The influence
of changing mastectomy patterns on
reconstructive rate and method. Plast Reconstr
Surg. 2013 Mar;131(3):320e–6e.
2. Colwell AS, Damjanovic B, Zahedi B, Medford-
Davis L, Hertl C, Austen WG. Retrospective
review of 331 consecutive immediate single-
stage implant reconstructions with acellular
dermal matrix: indications, complications,
trends, and costs. Plast Reconstr Surg. 2011
Dec;128(6):1170–8.
3. Franchelli S, Pesce M, Baldelli I, Marchese A,
Santi P, De Maria A. Analysis of clinical
management of infected breast implants and of
factors associated to successful breast pocket
salvage in infections occurring after breast
reconstruction. Int J Infect Dis IJID Off Publ Int
Soc Infect Dis. 2018 Jun;71:67–72.
4. Ooi AS, Song DH. Reducing infection risk in
implant-based breast-reconstruction surgery:
challenges and solutions. Breast Cancer Targets
Ther. 2016 Sep 1;8:161–72.
5. Cohen JB, Carroll C, Tenenbaum MM,
Myckatyn TM. Breast Implant-Associated
Infections: The Role of the National Surgical
Quality Improvement Program and the Local
Microbiome. Plast Reconstr Surg. 2015
Nov;136(5):921–9.
6. Netscher DT, Weizer G, Wigoda P, Walker LE,
Thornby J, Bowen D. Clinical Relevance of
Positive Breast Periprosthetic Cultures Without
Overt Infection. Plast Reconstr Surg. 1995
Oct;96(5):1125–1129.
7. Pajkos A, Deva AK, Vickery K, Cope C, Chang
L, Cossart YE. Detection of subclinical infection
in significant breast implant capsules. Plast
Reconstr Surg. 2003 Apr 15;111(5):1605–11.
8. Courtiss EH, Goldwyn RM, Anastasi GW. The
fate of breast implants with infections around
them. Plast Reconstr Surg. 1979 Jun;63(6):812–
6.
9. Weber J, Hentz RV. Salvage of the exposed
breast implant. Ann Plast Surg. 1986
Feb;16(2):106–10.
10. Reish RG, Damjanovic B, Austen WG,
Winograd J, Liao EC, Cetrulo CL, et al.
Infection following implant-based
reconstruction in 1952 consecutive breast
reconstructions: salvage rates and predictors of
success. Plast Reconstr Surg. 2013
Jun;131(6):1223–30.
Journal of Medical Sciences. May 25, 2020 - Volume 8 | Issue 17. Electronic-ISSN: 2345-0592
210
11. Spear SL, Howard MA, Boehmler JH, Ducic I,
Low M, Abbruzzesse MR. The infected or
exposed breast implant: management and
treatment strategies. Plast Reconstr Surg. 2004
May;113(6):1634–44.
12. Adams WP, Rios JL, Smith SJ. Enhancing
patient outcomes in aesthetic and reconstructive
breast surgery using triple antibiotic breast
irrigation: six-year prospective clinical study.
Plast Reconstr Surg. 2006 Dec;118(7
Suppl):46S-52S.
13. Yalanis GC, Liu E-W, Cheng H-T. Efficacy and
Safety of Povidone-Iodine Irrigation in
Reducing the Risk of Capsular Contracture in
Aesthetic Breast Augmentation: A Systematic
Review and Meta-Analysis. Plast Reconstr Surg.
2015 Oct;136(4):687–98.