Successful Treatment of Acute Periprosthetic Breast Infection with Curettage, Pulse Lavage, and Immediate Device Exchange
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- De Lorenzi, C. Aesth Plast Surg (2005) 29: 400. doi:10.1007/s00266-004-0132-3
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Acute periprosthetic breast infection in aesthetic surgical patients is a rare event. These patients would be expected to be less tolerant of the standard option of removing the infected implant and waiting 6 months (or possibly more) for tissue conditions to become favourable prior to reinsertion. This report provides confirmatory evidence of a controversial method of management that involves removal of the infected implant, curettage of granulation tissue within the breast implant pocket, pulsed lavage, then switching to a “clean” setup (including gloves, gowns, drapes and instruments) and reinsertion of a new device with suction drainage. The technique allows for immediate replacement of the implant and if successful, obviates the need for any waiting period. Surgeons are encouraged to consider this management option in specific cases where tissue vascularity and patient health are satisfactory.
Arguably one of the most dreaded complications following aesthetic augmentation of the breast is periprosthetic infection. As a complication, breast periprosthetic infection is relatively uncommon [1–6] but getting accurate data on incidence is difficult . Finding positive culture reports is not unusual in patients who are not clinically infected but who may have capsule contracture [8–10] and may feel unwell , but this is fundamentally different from the situation discussed here in which classical clinical signs (calor, rubor, tumor, dolor, functio lessae) of infection are definitely present. The standard of care typically consists of implant removal, debridement if necessary, antibiotics, and drainage until complete tissue resolution, after which implant replacement may be considered [12,13]. If an implant is exposed, but not clinically infected, evidence suggests that some may be saved by conservative management  or more aggressive management [13,15]. There are numerous reports of unusual causal organisms [16–29] that may require special management.
Although as surgeons we aim to achieve a zero complication rate in all of our patients, the author would argue that in cases of breast reconstruction or more complex procedures, an occasional infection is more tolerable than infections occurring in our otherwise completely healthy aesthetic patients. This case illustrates that in selected healthy patients with acute periprosthetic infections, aggressive management with device removal, curettage of granulation tissue within the implant pocket, followed by pulsed lavage irrigation with normal saline or ringer’s lactate solution may reduce the bacterial load within the wound to such a point that immediate device replacement (with a completely fresh setup in the OR) may salvage cases that otherwise would need to wait 6 months with a significant breast asymmetry. Patients who are seeking breast enhancement surgery would apriori be expected to be much less tolerant of the breast asymmetry of this type. Spear has shown that aggressive management sometimes saves the day .
The standard common wisdom that all implants with periprosthetic infection require removal and waiting for 6 months or more has been challenged. In selected cases, a salvage procedure may provide for excellent results and reduce the need for nursing an unhappy patient through six months of iatrogenic asymmetry.
Dr. Claudio De Lorenzi has received research funding, products, and/or teaching preceptorship honorariums from Q-Med AB (Uppsala, Sweden) , Canderm Pharma (Saint Laurent, Quebec, Canada), Allergan (Markham, Ontario, Canada), Coherent-AMT (Kitchener, Ontario, Canada), Medicis Aesthetics (Scottsdale, AZ, USA), Surgical Specialties Inc. (Reading, PA, USA), Mentor Corporation (Oshawa, Ontario, Canada, and Santa Barbara, USA) and Inamed Corporation (Oakville, Ontario, Canada). No funding or resources were made available for this report.
Dr. De Lorenzi wishes to thank Dr. Scott Spear for generously assisting the author sharing his wisdom and experience.