Salvage of an Infected Breast Tissue Expander with an Implant Sizer and Negative Pressure Wound Management

Abstract

Sir: A 38-year-old nurse underwent bilateral subcutaneous mastectomies for severe fibrocystic mastopathy with immediate placement of bilateral tissue expanders. One week before planned removal of the expanders and permanent implant placement, the patient presented with fever and erythema on the right side (Fig. 1). Faced with an obviously infected expander, the patient was counseled regarding treatment options.Fig. 1.: Temporary implant sizer in affected right breast with tissue expander in left breast.After hospital admission, the infectious disease unit was consulted for antibiotic therapy against methicillin-resistant Staphylococcus aureus. At the first operation, the tissue expander was removed and the pocket was debrided. A 325-ml implant sizer was sandwiched between two layers of vacuum-assisted closure (KCI, San Antonio, Texas) polyethylene sponges, and the wound was sealed. The sizer access port was externalized in case postoperative adjustment was needed. The sizer was filled to 325 ml, and the vacuum device was connected to 125 mmHg of continuous wall suction. On hospital days 4 and 7, the procedure was repeated and wound cultures were obtained. Results of the cultures from hospital day 7 debridement were negative. On hospital day 10, the wound was once again irrigated and debrided and a temporary Mentor (Santa Barbara, Calif.) high-profile implant (no. 350-3380) was placed and filled to 380 ml. The patient was discharged the following day with a drain in place. She was prescribed oral linezolid for 6 weeks. Ten weeks after presentation of infection, she returned to the operating room. The right temporary implant and left tissue expander were removed and exchanged for permanent implants. The patient has remained free of infection and is satisfied with her aesthetic result (Fig. 2).Fig. 2.: Final cosmetic result after implant salvage.Infection is one of the most common complications of tissue expanders and implants during breast reconstruction, with an infection rate ranging from 1 to 24 percent.1 This expensive and time-consuming complication is traditionally treated with intravenous antibiotics and removal of the device. Once the expander is removed, the soft tissue retracts rapidly to close the expanded pocket. Due to this phenomenon, the opportunity for immediate reconstruction is lost and a second attempt is usually considered at a later date. The majority of cases reported identify Staphylococcus epidermidis, S. aureus, or Serratia marcescens as the bacterium responsible for implant infection. In 1999, Disa et al. demonstrated that infection was the most common complication (50 percent) necessitating operative intervention for expander removal.2 Few reports have described successful techniques for salvage of an infected breast tissue expander or implant. In 2004, Spear et al.3 evaluated treatment strategies for implant infections. Patients with severe implant infection posed a 28.5 percent salvage rate (p = 0.0017). In 2002, Yii and Khoo4 conducted a study on salvage of infected expanders in breast reconstruction. Implant infections were managed through a process of capsulectomy and continuous irrigation with saline and intermittent antibiotic instillation. Only one in four patients with methicillin-resistant S. aureus infection was salvaged using their technique. Salvage of an infected tissue expander reconstruction must achieve two main objectives: resolution of the infection and maintenance of the expanded soft-tissue pocket for the implant. The described technique provides a means of achieving these goals and was successful in our patient. Aaron S. Kendrick, D.O. Department of Surgery University of Tennessee College of Medicine Christopher W. Chase, M.D. Plastic Surgery Chattanooga, Tenn. DISCLOSURE There are no financial conflicts or interests to report in association with the contents of this communication.