Aesthetic Plastic Surgery

, Volume 29, Issue 5, pp 400–403

Successful Treatment of Acute Periprosthetic Breast Infection with Curettage, Pulse Lavage, and Immediate Device Exchange

Authors

    • Claudio De Lorenzi
    • C. De Lorenzi
Article

DOI: 10.1007/s00266-004-0132-3

Cite this article as:
De Lorenzi, C. Aesth Plast Surg (2005) 29: 400. doi:10.1007/s00266-004-0132-3

Abstract

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.

Background

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 [16] but getting accurate data on incidence is difficult [7]. Finding positive culture reports is not unusual in patients who are not clinically infected but who may have capsule contracture [810] and may feel unwell [11], 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 [14] or more aggressive management [13,15]. There are numerous reports of unusual causal organisms [1629] that may require special management.

A 44-year-old woman presented to the clinic 30 days after bilateral subfascial breast augmentation with 355 cc textured Mentor Siltex® Contour Profile Gel-Filled Mammary Implants (Mentor Medical Systems B.V., Zernikedreef 2, 2333 CL Leiden, The Netherlands, REF 354*1308, Tel (31) 71 524-9600). She presented with a swollen reddish tender warm right breast, with the following metrics: 67” tall, 121 lbs, afebrile, normal neutrophil count (Figure 1). There was no drainage from the healed inframammary wound, and the patient felt systemically well. A periprosthetic wound infection was suspected with a differential diagnosis of bacterial mastitis. Wide antibiotic coverage (orally) was instituted immediately, and followup was arranged daily to assess her progress. By the second day, 32 days postaugmentation, a small amount of fluid was seen at the inframammary incision site. On the next day, light pressure with a cotton swab resulted in a sudden release of approximately 6 cc of cloudy serous yellowish fluid, which gave the patient some relief. The fluid tested positive for Staphylococcus aureus. A literature search revealed the article written by Spear [30] which indicated that most patients with this degree of infection could be salvaged with an aggressive intraoperative curettage, pulsed lavage, and then using a new clean setup in the operating room (fresh drapes, gowns, gloves and instruments) with a new device inserted into the same pocket with appropriate postoperative drainage. This was controversial, so the author contacted Dr. Spear and through telephone consultation decided to act upon this, and follow the advice given.
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Fig. 1

This 44-year-old patient presented with a tender, swollen, slightly erythematous right breast 32 days following cohesive gel breast augmentation.

Results

The patient was taken to the operating room on the 34th post augmentation day, and the old implant was removed and curettage performed of the implant pocket. Pulsed lavage (Stryker Interpulse®, 4100 East Milham Drive, Kalamazoo, MI, 91004 USA (800) 253-3210) was performed and then after switching to the other setup, a new device was placed. A Hemovac® drain was used (Zimmer Surgical, P.O. Box 708, 1800 West Center Street, Warsaw, IN 46581-0708, (800)-613-6131). The patient received one dose of antibiotics intravenously in the hospital and was discharged on oral Cephalexin 500 mg qid. The drainage stopped within 48 hours and her pain and redness were better within this time frame. The second intraoperative culture report confirmed the initial one. The drain was left in for 5 days. The patient was followed carefully daily for the first week, then biweekly, and finally monthly. By the third month, the author was finally convinced that the procedure had worked and that the result was indeed excellent. She remains asymptomatic with soft breasts and no evidence of capsule contracture at seven months following the initial procedure (Figures 2 and 3).
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Fig. 2

Preoperative views.

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Fig. 3

Seven months after treatment (8 months post initial augmentation) of right periprosthetic breast infection as described. Both breasts are soft (Baker Grade 1) with 355cc Mentor CPG implants in the (subfascial) submammary space. Breasts have a natural shape and no evidence of rippling or encapsulation.

Discussion

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 [30].

Conclusions

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.

Competing Interests

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.

Acknowledgments

Dr. De Lorenzi wishes to thank Dr. Scott Spear for generously assisting the author sharing his wisdom and experience.

Copyright information

© Springer Science+Business Media, Inc. 2005