The Intraluminal Use of Methylene Blue in Breast Expander Devices – A Word of Caution

Abstract

In this technique, the authors inject methylene blue dye inside the lumen of the breast tissue expander in conjunction with saline so that the colour of the content turns blue for the easy identification in further injections. Although this provides an easy way to identify the port of entry of the breast tissue expander and make certain of the intraluminal placement of saline solution in future inflation sessions, the technique should not be taken lightly and a few points of caution should be raised before its universal use. Methylene blue is a tetramethylthionine chloride that belongs to a group of thiazide dyes with close chemical resemblance to phenothiazines.1 It is a potent inhibitor of guanylate, a target enzyme acted upon by nitric oxide in order to produce endothelium-dependent relaxation effect in shock condition.2 The medicinal use of methylene blue is well known. It is administered as an intravenous infusion for the intra-operative identification of parathyroid glands due to the selective uptake of the dye by the gland.3 In a small doses (1–2 mg/kg), methylene blue can be used for the treatment of methaemoglobinaemia, although in larger doses it can have the reverse effect and introduce the formation of methaemoglobin.4 Methylene blue is also used to reverse the adverse effect of nitric oxide and treat patients with anaphylactic or septic shock.2,5 In addition, methylene blue is commonly used in sentinel lymph node identification and biopsy in different types of cancer.6 Like all chemicals, there is an associated risk of developing adverse effects with the use of methylene blue. It was found in one study that when 3–5 ml of 1% methylene blue was injected intradermally for sentinel lymph node identification in breast cancer, there was a 21% incidence of developing either superficial ulceration or intense erythema at the injection site; therefore, it was recommended the dye be injected deeper in the peritumoural area to avoid such adverse effect.7,8 There are also three documented cases in the English medical literature of generalised toxicity effects when the dye is infused intravenously for the identification and localisation of parathyroid adenomas. These systemic effects were in the form of expressive aphasia, confusion, nystagmus, and myoclonic jerks. All three patients made complete recovery within 24–48 h.9–11 The use of breast expanders is associated with the risk of device leakage or complete deflation with the release of the expander contents into the breast pocket. In a 6-year follow-up study of breast reconstruction using saline-filled implants, the incidence of gradual leakage with loss of volume was 38%, while the incidence of sudden deflation that prompted re-operation was 16%.12 With the development of more modern devices, the incidence may be less but the risk is always there. The potential release of methylene blue solution inside a body cavity may be associated with a theoretical risk of local and systemic adverse effects. Keeping the amount of the used methylene blue at or below 4 mg/kg (recommended by the UK National Poisons Information Service11 as a maximum safe dose) may be a way to prevent the potential systemic hazard in case of fluid release. One last point of interest is that we believe the manufacturer device guarantee does not cover the intraluminal use of methylene blue in breast expanders in case of device failure or malfunction. In general, the benefits of using a technique should always be balanced against its potential risks and, in all cases, patients should be fully counselled to obtain their informed consent.