Wednesday, September 1, 2010

Infected or Exposed Breast Prosthesis

This is a tough situation for both patient and surgeon.  Dr. Scott Spear has published an article in the April issue of the Journal of Plastic and Reconstructive Surgery which reviews his management of this issue  (full reference below).

Rates of infection have ranged from 0.4 to 2.5 percent for augmentation mammaplasty and from 1 to 35.4 percent for prosthetic breast reconstruction. Furthermore, rates of exposure have been reported between 0.29 and 2 percent for breast augmentation and between 0.25 and 8.3 percent for device-based breast reconstruction.

Dr. Spear published an algorithm for the management of breast device infection and/or exposure in 2004.   The current article is a retrospective study of his experience with infected or exposed breast prosthesis between 1993 and 2008.   During this 15 year period, he managed 69 patients with 87 events of breast device infection and/or exposure.

The mean patient age was 49.8 years.  The average BMI was 23.4.   Other key traits:  smoking history 18.4%, history of chemotherapy use 35.6%, history of radiation therapy 23%.

Events of device infection and/or exposure were classified into one of seven groups using the published algorithm: 

group I, mild infection; group II, severe infection; group III, threatened exposure; group IV, threatened exposure with mild infection; 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 drainage that was responsive to initial antibiotic therapy.

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).

“Device salvage” was defined as the continued presence of a prosthetic device after surgical intervention, though not necessarily retention of the original device.

Dr. Spear reports that the mean postoperative time to breast prosthesis infection/exposure was 5.5 months.  He managed to obtain an overall device salvage rate of 64.4%.

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.

He concludes:

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.

Relative contraindications to breast device salvage include atypical pathogens on wound culture, such as Gram-negative rods, methicillin-resistant S. aureus, 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 cautiously in the setting of elective breast surgery.

 

 

REFERENCES

Management of the Infected or Exposed Breast Prosthesis: A Single Surgeon's 15-Year Experience with 69 Patients; Spear, Scott L.; Seruya, Mitchel; Plast Reconstr Surg 125(4):1074-1084, April 2010; doi: 10.1097/PRS.0b013e3181d17fff

Discussion: Management of the Infected or Exposed Breast Prosthesis: A Single Surgeon's 15-Year Experience with 69 Patients; Hammond, Dennis C.; Plast Reconstr Surg.125(4):1085-1086, April 2010; doi: 10.1097/PRS.0b013e3181d18289

The infected or exposed breast implant: Management and treatment strategies; Spear SL, Howard MA, Boehmler JH, Ducic I, Low M, Abbruzzesse MR.;  Plast Reconstr Surg. 2004;113:1634–1644.

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