Salvage of an Infected and Exposed Breast Device with Implant Retention and Delayed Exchange

Abstract

Sir: A 35-year-old white woman with a history of penicillin allergy underwent bilateral subpectoral augmentation mammaplasty in March of 2008. Intramuscular (Roche Pharmaceuticals, Basel, Switzerland) (1 vial/24 hours for 2 days) and oral ceftriaxone (500 mg/24 hours for the other 5 days) was administered after the intervention. Thirty-five days after she was discharged to home, the patient was referred to us because a 0.5-cm region of inframammary fold overlying the device broke down and the implant became exposed. She was afebrile and without signs of infection. Thus, we débrided all compromised tissue, opting for simple closure of the wound because sufficient viable soft tissue remained. Although oral antibiotics were administered, unfortunately, 10 days later, the patient presented with fever (40°C) and erythema on the left side, purulent material drainage, and left implant exposure. Pus culture grew Staphylococcus aureus. The abscess was drained (Fig. 1) and the patient placed on intravenous teicoplanin (Targocid; Sanofi-Aventis, Bridgewater, N.J.), 400 mg/24 hours for 5 days. Because the patient desired an attempt at implant salvage, refusing device explantation, she was started on saline, povidone-iodine (Betadine; Purdue Pharma, Stamford, Conn.), and antibiotic (Targocid) irrigations of the submuscular pocket three times per week. In addition, she was treated with 10 cycles of hyperbaric oxygen therapy (2 to 3 atm for 90 minutes each) and oral antibiotics. The patient was readmitted at the end of May by our unit and underwent capsulotomy, implant exchange, and definitive pocket closure with a closed-suction drainage catheter. After the infectious disease unit was consulted, the patient was started on intravenous daptomycin (Cubicin; Cubist Pharmaceuticals, Lexington, Mass.), 350 mg/24 hours for 5 days. At 2 months, the patient was symptom-free, without signs of infection or capsular contracture, and achieved a satisfactory result (Fig. 2).Fig. 1.: Drainage of the abscess through the small exposed region.Fig. 2.: Final cosmetic outcome after left breast implant salvage.Among the potential complications associated with the use of breast prostheses are the risks of periimplant infection and device extrusion, with an infection rate following breast augmentation ranging from 1 to 2 percent.1,2 Traditional recommendations for these problems dictate antibiotic treatment alone and/or device removal, with delayed replacement of the implant. Few reports have described successful techniques for salvage of an infected breast tissue device or salvage of an exposed but not infected implant, whereas no case exists reporting successful management for salvage of an infected and exposed breast implant after cosmetic augmentation. Yii and Khoo3 proposed a combination of capsulectomy and continuous irrigation with saline and intermittent antibiotic instillation to salvage infected expanders in breast reconstruction. Spear and colleagues4 developed treatment guidelines for implant infections, threatened device exposure, and actual device exposure. They submitted patients with severe implant infection and actual exposure (both reconstructive mammoplasties) to device removal posing a 0 percent salvage rate (without a real attempt at salvage). Chun and Schulman5 described the successful salvage of nine consecutive severely infected breast prostheses after mastectomy reconstruction, adopting a technique of immediate intravenous antibiotics followed by early device exchange and a long course of postoperative antibiotics. Salvage of an infected and exposed breast cosmetic implant must achieve two main goals: resolution of the infection and maintenance of the aesthetic outcomes, principally by avoiding device explantation. The described approach provides a means of achieving these objectives and was successful in our patient. DISCLOSURE There are no financial conflicts or interests to report in association with the contents of this article. Gian Luca Gatti, M.D. Davide Lazzeri, M.D. Marco Stabile, M.D. Gianfranco Romeo, M.D. Alessandro Massei, M.D. Plastic and Reconstructive Surgery and Burn Center Unit; Hospital of Pisa; Pisa, Italy