1. Salvage of infected breast implants with continuous
peri-prosthetic antibiotic irrigation: A retrospective audit.
J.E. Kelsall 1, E. Gutteridge 1, L. Whisker 1
1. Nottingham Breast Institute, Nottingham City Hospital, UK
Introduction
Infection in the setting of prosthetic breast reconstruction is a much feared complication as it may result in implant loss; causing psychological distress, poor cosmesis, further surgical procedures, and additional health care costs. Explantation in this setting has traditionally been the standard of care.
Prosthesis salvage has been successfully described in selected situations,1-3 including using antibiotic irrigation and drainage.4,5
Our institution has developed a protocol utilising intra-operative lavage, +/- exchange of the prosthesis, followed by continuous peri-prosthetic antibiotic irrigation for at least 48hrs; in order to attempt implant salvage in selected patients.
Results
20 patients who had undergone irrigation for periprosthetic infection were identified. 15 of 20 (75%) were successfully salvaged.
Post-operative periprosthetic irrigation was undertaken for at least 48 hrs (range 2-6 days, median = 3 days). Irrigation drains were removed once irrigation ceased, with outflow drains remaining for 5-7 days.
14 patients had undergone immediate reconstruction, 2 delayed reconstructions, and 4 revision procedures.
18 patients presented with infection and required intervention within 2 months of their reconstructive or revisional surgery.
Most patients had already had a course of oral antibiotics prior to admission, all had IV antibiotics on admission. 9 grew sensitive S.aureus, 2 grew Propionibacterium, one grew Coag negative Staph and E. coli; and another grew Pseudomonas in addition to S. aureus. In 9 patients, no organism was cultured.
The most common risk factor for infection was obesity: with 14 of 20 patients overweight or obese; others included smoking (4/20), concurrent fat grafting (4/20), previous irradiation (3/20); and diabetes (2/20). 12 had either an acellular dermal matrix or synthetic mesh in situ. One had undergone axillary clearance, and 3 sentinel lymph node biopsy.
Of the 15 successfully salvaged, 8 were happy with the outcome and have not required further surgery. One has had exchange of TE for implant with good outcome, another needed a single session of fat grafting only; and three have had or are due to have fat grafting and exchange for of TE to implant. One patient opted for a local flap at the time of exchange of TE to implant; and one opted for explant and LD flap.
Age
Procedure undertaken at return to theatre:
Prosthesis in situ (days)
Organism grown
Salvage successful
Follow-up
(months)
Outcome 56
Exchange of implant for TE, debridement necrotic wound 35
Staph. aureus
Yes 27
Exchange TE for implant 14 months later, TDAP flap to cover thin lower pole 51
Exchange of TE, removal non-integrated mesh 28
Coag neg Staph. + E. coli No 23
Explant 1 month later due to ongoing infection.
Plan for delayed DIEP pending weight loss. 54
Exchange for new implant 22
Nil growth 8
Good outcome. 31 14 70
Exchange implant for TE, removal non-integrated mesh 33 6
Expanded and awaiting exchange and fat grafting at 6 months 68
Implant reinserted 5 65 7
Staph. Aureus + Pseudomonas
4 yrs 5 mo
Explant day 8.
Previous LD and failed DIEP prior to implant revision surgery. Has undergone 5 x fat grafting procedures with good effect. 66
Exchange implant for TE
5 yrs 9 mo
Exchange TE for implant 4 months later, good outcome at 14 months. 17 4
Minor rippling, patient happy, not wanting further surgery.
Exchange for new implant, wound debridement 58 20
Explant at 1 month due to ongoing infection. Secondary reconstruction discussed pending smoking cessation. 44 29 46
4 yrs 4 mo 45 3
Propionibacterium 15
Fat grafting at 4 months, good outcome at 15 months.
Successful salvage, however opted for elective LD reconstruction 5 months later, and subsequent fat grafting. 62
Exchange for new implant, removal non-integrated ADM 26
Exchange of implant for TE 13
3 x fat grafting to improve skin flaps prior to exchange of TE to implant
Exchange for new TE, removal non-integrated mesh 78
Explant at 1 month. Insertion of TE and fat graft at 23 months.
TE reinserted
Explant at 2 months for recurrent infection.
TE inserted at 4 months, fully expanded and fat grafted at 8 months. 40
Exchange for new TE, debridement of wound 16 38
Fat grafting at 4 months, exchange TE for implant at 11 months, good outcome at 38 months. 10 24
AIM
We have audited the results of breast prosthesis salvage using antibiotic irrigation and drainage at our institution; and present our technique and outcomes.
Method
Retrospective audit of all infected breast prosthesis irrigation cases over the preceding 5 yrs at our institution.
Included immediate and delayed reconstructions; and revision surgery with either implants or tissue expanders.
Cases identified from prospectively collected database; unit morbidity and mortality data; hospital admission and operating data.
Patient demographics, surgical and perioperative data, and final outcomes following irrigation were collected.
Salvage was defined as successful retention of a prosthetic device, although not always the original prosthesis.
All patients were admitted and commenced on IV antibiotics
Patients underwent GA, pocket lavage with copious normal saline +/- povidone-iodine, debridement of wound edges if required, and re-insertion or exchange of the original prosthesis at the surgeon’s discretion. Peri-prosthetic fluid samples taken intra-operatively for culture.
Two drains inserted into pocket around prosthesis
10 Fr drain located superiorly to instill antibiotic solution into the cavity
15 Fr drain inferiorly attached to suction drain bottle
Irrigation solution - a continuous post-operative infusion of:
2g Vancomycin in 1L of Normal Saline over 10 hrs is our standard protocol (other antibiotics as per sensitivities)
No need to measure systemic vancomycin levels
Irrigation duration to be as brief as possible to avoid selection of resistant organisms – usually hrs
Conclusions
Our protocol using intra-operative lavage and post-operative peri-prosthetic antibiotic irrigation and drainage is a simple and effective technique. We have demonstrated a 75% successful salvage rate with this technique, providing an opportunity to salvage infected implant reconstructions in selected patients. This offers a good alternative to implant removal followed by delayed reconstruction.
References
Spear SL, Seruya M. Management of the infected or exposed breast prosthesis: A single surgeon’s 15-year experience with 69 patients. Aesthetic Plast Surg. 1985; 9 (2):
Spear SL, Howard MA, Boehmler JH, Ducic I, Low M, Abbruzzesse MR. The infected or exposed breast implant: management and treatment strategies. Plast Reconstr Surg. 2004; 113 (6):
Bennett SP, Fitoussi AD, Berry MG, Couturaud B, Salmon RJ. Management of exposed, infected implant-based breast reconstruction and strategies for salvage. J Plast Reconstr Aesth Surg. 2011; 64 (10):
Wilkinson TS, Swartz BE, Toranto IR. Resolution of late developing periprosthetic breast infections without prosthesis removal. Aesthetic Plast Surg. 1985; 9:
Yii NW, Khoo CT. Salvage of infected expander prostheses in breast reconstruction. Plast Reconstr Surg. 2003; 111:
Disclosures: The authors have nothing to disclose.
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