The Infected or Exposed Breast Implant:
Management and Treatment Strategies
Scott L. Spear, M.D., Michael A. Howard, M.D., James H. Boehmler, M.D., Ivica Ducic, M.D.,
Merv Low, M.D., and Mark R. Abbruzzesse, M.D.
Washington, D.C.
pletely required no further treatment. For persistent mild
infection or threatened or actual exposure, operative intervention was required, including some or all of the
following steps: implant removal, pocket curettage, partial
or total capsulectomy, débridement, site change, placement of a new implant, and/or flap coverage; the menu
of options varied with the precise circumstances. No immediate salvage was attempted in five cases, due to either
severe infection, nonresponding infection with gross purulence, marginal tissues, or lack of options for healthy
tissue coverage. Based on the authors’ experience, salvage
attempts for periprosthetic infection and prosthesis exposure may be successful, except in cases of overwhelming
infection or deficient soft-tissue coverage. Although an
attempt at implant salvage may be offered to a patient,
device removal and delayed reinsertion will always remain
a more conservative and predictable option. (Plast. Reconstr. Surg. 113: 1634, 2004.)
Among the potential complications associated with the
use of breast implants are the risks of periprosthetic infection and device extrusion. There is little published
information about the effective management of these situations. Conservative recommendations include antibiotic therapy and removal of the implant until resolution
of the infection or until the wound has healed. A retrospective review identified patients with periprosthetic infection or threatened or actual device exposure treated by
the senior author. Twenty-four patients encompassing 26
affected prostheses were available for review and were
classified into seven groups based on initial presentation
as follows: group 1, mild infection (n ⫽ 8); group 2, severe
infection (n ⫽ 4); group 3, threatened exposure without
infection (n ⫽ 3); group 4, threatened exposure with mild
infection (n ⫽ 3); group 5, threatened exposure with
severe infection (n ⫽ 1); group 6, actual exposure without
clinical infection (n ⫽ 5); and group 7, actual exposure
with infection (n ⫽ 2). To salvage the prosthesis in these
patients, various treatment strategies were utilized. All
patients with a suspected infection or device exposure
were started immediately on appropriate antibiotic therapy (oral antibiotics for mild infections and parenteral
antibiotics for severe infections). Salvage methods included one or more of the following: antibiotic therapy,
débridement, curettage, pulse lavage, capsulectomy, device exchange, primary closure, and/or flap coverage.
Twenty (76.9 percent) of 26 threatened implants with
infection or threatened or actual prosthesis exposure were
salvaged after aggressive intervention. The presence of
severe infection adversely affected the salvage rate in this
series. A statistically significant difference exists among
those patients without infection or with mild infection
only (groups 1, 3, 4, and 6); successful salvage was achieved
in 18 (94.7 percent) of 19 patients, whereas only two of
seven of those implants with severe infection (groups 2, 5,
and 7) were salvaged (p ⫽ 0.0017). Ten (90.9 percent) of
11 devices with threatened or actual exposure, not complicated by severe infection (groups 3, 4, and 6), were
salvaged. Several treatment strategies were developed for
periprosthetic infection and for threatened or actual implant exposure. Patients with infection were placed on
oral or intravenous antibiotics; those who responded com-
The use of breast implants for cosmetic and
reconstructive procedures is increasingly common today. Approximately 219,000 augmentation mammaplasties and 82,000 breast reconstructions were performed in the year 2001
alone.1 Common complications associated with
the use of breast implants include capsular
contracture, device failure, and implant malposition. Less frequent but more serious are the
risks of infection and device extrusion.
Although virtually all studies2–21 report a low
incidence of infection or breast implant exposure, there is little published information on
the management of these two complications.
Early recommendations for these problems included antibiotic treatment alone and/or device removal with delayed replacement of the
device.17 Courtiss et al.7 reported that 45 per-
From the Division of Plastic Surgery, Georgetown University Hospital. Received for publication February 24, 2003; revised June 18, 2003.
Presented at the 71st Annual Meeting of the American Society of Plastic Surgeons, in San Antonio, Texas, November of 2002.
DOI: 10.1097/01.PRS.0000117194.21748.02
1634
Vol. 113, No. 6 /
1635
THE INFECTED OR EXPOSED BREAST IMPLANT
cent of patients with a periprosthetic infection
characterized by drainage, erythema, swelling,
and/or pain may be treated successfully with
antibiotics, passive wound drainage, and healing by secondary intention. In their series, 68
percent of the salvaged implants developed
symptomatic capsular contracture.
To provide further understanding of the
management of these situations, the authors
reviewed their experience with threatened
prosthetic breast devices.
PATIENTS
AND
METHODS
A retrospective review of patients with prosthetic breast devices between 1990 and 2002
was conducted. Patients with infection or
threatened/actual device exposure were identified. Demographic, treatment, and outcome
data were collected and analyzed.
Patients presenting with clinical evidence of
infection were classified as having either mild
or severe infection. A mild infection was defined as warmth, swelling, or cellulitis without
drainage that was responsive to initial antibiotic therapy. A severe infection was defined
when one or more of the following were
present: persistent, substantial swelling despite
antibiotic therapy, purulent drainage with or
without cellulitis, aggressive or atypical organ-
isms on culture (e.g., Pseudomonas, mycobacteria, or Gram-negative rods), or serious signs
and symptoms of systemic infection (e.g., hypotension or high fever).
Patients were classified into seven groups according to initial presentation (Table I) as follows: group 1—mild infection (n ⫽ 8), minimal, localized erythema at the surgical site or
in the skin overlying the implant; group 2—severe infection (n ⫽ 4), significant generalized
erythema, purulent drainage, and/or systemic
signs of infection; group 3, threatened implant
exposure without infection (n ⫽ 3); group 4,
threatened implant exposure with mild infection (n ⫽ 3); group 5, threatened devices with
concurrent severe infection (n ⫽ 1); group 6,
actual implant exposure with no or mild signs
of infection (n ⫽ 5); group 7, actual device
exposure with significant or severe infection (n
⫽ 2).
For purposes of this study, “implant salvage”
was defined as continued presence of a prosthetic device after surgical intervention. Rather
than actual retention of the original device, the
goal was to maintain the results of the original
procedure. If the device was exposed or
periprosthetic infection was present, a new device was inserted at the time of the surgical
intervention.
TABLE I
Options and Guidelines for Implant Salvage
No Exposure Risk
No infection
No treatment necessary
Minor infection
Group 1
Antibiotics alone
Severe infection
Group 2
Antibiotics—downstage to group 1
or 4
Capsulectomy and exchange
implant
(or)
Remove implant
N/A, not applicable.
Threatened Exposure
Actual Exposure
Group 3
Antibiotics
Local tissue rearrangement
(and/or)
Flap coverage
Group 4
Antibiotics
Capsulectomy
Debridement
Pulse lavage
Device exchange
(then)
⫹/⫺ Site change
Local tissue coverage and closure
(and/or)
Flap coverage
N/A; exposure assumes a minimum low
grade contamination
Group 5
Antibiotics
Downstage to group 4
(or)
Remove implant
⫹/⫺ Delayed reconstruction
Group 6
Antibiotics
Capsulectomy
Debridement
Pulse lavage
Device exchange
(then)
⫹/⫺ Site change
Local tissue coverage and closure
(and/or)
Flap coverage
(or)
Remove implant
⫹/⫺ Delayed reconstruction
Group 7
Antibiotics
Remove implant
⫹/⫺ Delayed reconstruction
1636
PLASTIC AND RECONSTRUCTIVE SURGERY,
To achieve successful, primary implant salvage, various modalities were utilized, depending on the findings (Table I). Modalities included systemic antibiotic therapy, wound
edge débridement, curettage, pulse lavage,
capsulectomy, device position change (i.e.,
subglandular to subpectoral), device exchange, primary closure, and/or flap coverage.
The outcome of each patient group was
tabulated.
CASE REPORTS
Case 1: Group 2, Severe Infection
An 18-year-old patient underwent left augmentation mammaplasty and right mastopexy for congenital breast asymmetry (Fig. 1). Unbeknownst to the surgeon, the patient began
postoperative acupuncture therapy to the augmented breast
for pain control. On postoperative day 9, the patient developed erythema, clear fluid drainage, and slight dehiscence of
the left periareolar incision. Over the next 4 months, the
infection waxed and waned and was determined to involve
May 2004
the periprosthetic space. Antibiotic therapy was initiated to
treat intermittent episodes of breast swelling and erythema
and her indolent infection became quiescent. Six months
after the original presentation, the patient underwent left
capsulectomy and pulse lavage of the implant site. The surgical instruments were changed, the operative field re-prepared, and drapes, gloves, and gowns were changed. A new
implant was inserted in the same, partially subpectoral site.
Although intraoperative cultures were negative, antibiotic
therapy continued for 3 weeks postoperatively. At 6 months,
the patient was symptom-free without signs of infection or
capsular contracture and achieved a satisfactory result.
Case 2: Group 3, Threatened Exposure without
Infection
A 53-year-old patient underwent bilateral prophylactic
mastectomies using Wise pattern incisions and immediate
tissue expander placement in a partially submuscular space.
During the week after surgery, bilateral partial flap loss was
noted at the “T” junction of both breasts in an area without
underlying muscle coverage (Fig. 2). Although no obvious
infection was noted, the patient was started on antibiotic
therapy. On postoperative day 8, the patient underwent bilateral flap revision. After débridement of all compromised
FIG. 1. Preoperative (left) and postoperative (right) photographs of a patient who underwent left breast augmentation for a
congenital deformity. She was classified as group 2, as she developed a periprosthetic infection treated with a prolonged course
of antibiotics, capsulectomy, and implant exchange.
Vol. 113, No. 6 /
1637
THE INFECTED OR EXPOSED BREAST IMPLANT
FIG. 2. (Above, left) Preoperative view of a patient who underwent bilateral subcutaneous mastectomy and immediate reconstruction with tissue expanders. (Above, right) Postoperatively, partial flap loss occurred with threatened implant exposure.
She was classified as group 3, and her treatment included local flap revisions (below, left). (Below, right) Final result at 18 months.
tissue, the devices were covered with clean, healthy, and viable
soft tissue. Sufficient skin flaps remained to allow for simple
closure of the wounds. The patient healed uneventfully and
her expanders were exchanged to permanent implants 5
months later. She went on to heal with a satisfactory result,
without capsular contracture.
Case 3: Group 4, Threatened Exposure with Mild
Infection
A 55-year-old patient underwent bilateral subcutaneous
mastectomies and immediate expander reconstruction (Fig.
3). In the immediate postoperative period, bilateral necrosis
of the inferior portion of the breast skin flaps associated with
mild erythema was noted. The patient was started on oral
antibiotic therapy. Two weeks after the mastectomies, the
patient underwent a bilateral transverse rectus abdominis
musculocutaneous (TRAM) flap salvage procedure to replace
the breast skin loss. The expanders were left in place and were
exchanged to permanent implants 4 months later. The patient achieved a satisfactory result without further infection or
capsular contracture.
Case 4: Group 6, Actual Implant Exposure without
Clinical Infection
A 36-year-old with a history of previous subglandular augmentation mammaplasty underwent three subsequent operations to correct capsular contracture and implant malposition. Ultimately, the patient was referred to the senior author
when a 2-cm region of areola overlying the implant broke
down and the implant became exposed (Fig. 4). The patient
desired an attempt at implant salvage; therefore, device removal, capsulectomy, and pulse lavage of the implant pocket
were performed. A subpectoral pocket was created and a new
device was inserted. The patient healed uneventfully through
her 2-year follow-up.
RESULTS
Forty implants in 38 patients that were
treated for infection, threatened device exposure, or actual device exposure were identified.
Fourteen were excluded because of unavailable or incomplete records. Twenty-four patients’ charts encompassing 26 affected pros-
1638
PLASTIC AND RECONSTRUCTIVE SURGERY,
May 2004
FIG. 3. (Above, left) Preoperative view of a patient who underwent bilateral subcutaneous mastectomies and immediate
expander reconstruction. Bilateral flap necrosis associated with minor, localized infection occurred (above, right). She was
classified as group 4, and was treated with immediate salvage with bilateral pedicled TRAM flaps. (Below, left) Final postoperative
result at 1 year. (Below, right) Final postoperative result at 2 years.
theses were available for review (Table II). Two
patients had bilateral implant salvage. Five
(19.2 percent) of 26 devices were utilized for
breast augmentation, whereas 21 (80.8 percent) of 26 devices were used for breast reconstruction. Nine (42.9 percent) of the 21 threatened reconstruction devices were in patients
who received prior radiation therapy.
The eight patients who presented with minor or localized infection without exposure
(group 1) were treated solely with oral or intravenous antibiotic therapy. All of these patients were successfully treated and retained
their implants for an overall success rate of 100
percent.
In the four patients who had isolated severe
infection without exposure (group 2), two augmentation patients were offered implant salvage that was ultimately successful. One patient’s implant was salvaged with intravenous
antibiotics, capsulectomy, device exchange,
and site change. The other implant was salvaged by antibiotic therapy, capsulectomy, and
device exchange, but without site change. As a
result of overwhelming infection, two breast
reconstruction patients were not offered an
attempt at salvage and their implants were removed. The salvage rate among all patients
with severe infection was only 50 percent.
Among the two breast reconstruction patients who presented with three threatened implant exposures without evidence of infection
(group 3), one patient had bilateral threatened exposures in which the local soft tissues
were adequate to allow for a successful local
revision. In the other patient, a threatened
device with inadequate local soft tissue was successfully salvaged with a latissimus dorsi flap.
The overall salvage rate for threatened devices
without infection was 100 percent.
Vol. 113, No. 6 /
1639
THE INFECTED OR EXPOSED BREAST IMPLANT
FIG. 4. (Above) Preoperative photographs of a patient who presented with an implant exposure after a previous subglandular
breast augmentation. She was classified as group 6. The device was removed and capsulectomy was performed. A subpectoral
pocket was created, and a new device was inserted. (Below) Postoperative result at 2 years.
TABLE II
Procedures and Results by Group
No Exposure Risk
No infection
N/A
Minor infection
Group 1 (n ⫽ 8)
Antibiotics alone (8) (1 delayed
flap)
Severe infection
Group 2 (n ⫽ 4)
Capsulectomy, implant location
change, device change (1)
Capsulectomy, device change (1)
Elective explantation (2)
N/A, not applicable.
Threatened Exposure
Group 3 (n ⫽ 3)
(2) Local, primary tissue revision
(bilateral)
(1) Latissimus dorsi flap
Group 4 (n ⫽ 3)
Capsulectomy with flap closure (3)
(1) Bilateral TRAM
(1) Latissimus dorsi
Group 5 (n ⫽ 1)
Elective explantation (1)
Actual Exposure
N/A
Group 6 (n ⫽ 5)
Local revision and primary closure (2)
Capsulectomy and primary closure (1)
Change implant location (1)
Primary closure 3 failure 3 explant 3
delayed reconstruction (1)
Group 7 (n ⫽ 2)
Elective explantation 3 delayed
reconstruction (1)
Elective explanation 3 lost to follow-up (1)
1640
In the case of the three patients who presented with threatened exposure and minor
infection (group 4), each patient was successfully treated with antibiotic therapy, capsulectomy, device exchange, and immediate distant
flap coverage. One latissimus dorsi and one
bilateral TRAM flap were utilized for implant
salvage. The overall success rate was 100
percent.
The one patient who presented with threatened implant exposure and severe infection
(group 5) had undergone prior two-stage expander/implant reconstruction and subsequent radiation therapy. To supplement the
soft-tissue envelope, a TRAM flap was performed. There was partial flap loss and overwhelming infection with the obvious threat of
implant exposure. This was treated by explantation without a salvage attempt. The overall
salvage was 0 percent.
Among the five patients who presented with
actual implant exposure without clinical evidence of active infection (group 6), two of the
five had undergone breast augmentation. One
of these was treated with capsulectomy, implant site change, and primary closure. Another was treated by implant pocket irrigation
and simple wound closure. Of the three reconstruction patients, two reconstruction implants
were successfully salvaged. One was treated
with local skin flap revision and primary closure, and another with capsulotomy, irrigation,
and primary closure. Primary closure was attempted in a third reconstruction patient, but
this failed. The implant was subsequently removed and delayed reconstruction was performed. Overall, successful implant salvage was
80 percent in the setting of exposure without
infection.
For the two patients (group 7) who experienced prosthesis exposure with severe infection, the implant was removed without an attempt at salvage. One patient sought delayed
reconstruction, and a second was lost to followup. Thus, the success rate for implant salvage
for exposure with severe infection was zero
percent.
Of the 26 implants with infection or exposure, immediate salvage with either the original device or a new device was achieved in 20
cases (76.9 percent). In five of six failures, no
significant effort had been made to save the
implant given the overwhelming nature of the
infection. Augmentation patients’ devices were
salvaged in five of five cases. In the setting of
PLASTIC AND RECONSTRUCTIVE SURGERY,
May 2004
breast reconstruction, threatened devices were
salvaged in 15 of 21 cases (71.4 percent).
Ultimately, only two of the six failures underwent delayed reconstruction, both with twostage expander/implant reconstruction.
Among the 15 successful salvage attempts, subsequent revision surgery was required in four
(26.7 percent). Three salvaged implants, all for
breast reconstruction, subsequently required
capsulectomy to treat capsular contracture,
and one required a latissimus dorsi flap to
augment the soft-tissue envelope.
Overall success rates were as follows: salvage
of mild infections (group 1) was eight of eight,
threatened exposure (group 3) was three of
three, threatened exposure with mild infection
(group 4) was three of three, and actual exposure (group 6) was four of five. Hence, overall
success rate in the setting of mild or no infection was 18 of 19 (94.7 percent), whereas salvage in the severely infected groups (groups 2,
5, and 7) was two of seven. This difference was
significant (p ⫽ 0.0017) by two-sided Fisher’s
exact test. Both successes in the severely infected groups were in augmentation patients.
DISCUSSION
The senior author’s interest in this subject
originated with his 1998 publication18 describing 171 expander and implant breast reconstructions. In that study, two expanders (1.2
percent) were prematurely removed because
of infection. Disa et al.8 subsequently reported
a 1.4 percent premature removal rate resulting
from infection, exposure, or skin necrosis.
Others note that the rate of periprosthetic infection during augmentation mammaplasty
ranges from 1.7 percent to 2.5 percent.6
In the past, teaching held that infection in
the setting of a breast prosthesis required implant removal and delayed reinsertion.17 During the past 20 years, there has been a growing
awareness that a periprosthetic infection or
exposure does not necessarily condemn an implant to removal.7,19 Courtiss et al.7 reported
that in the setting of periprosthetic infection,
successful implant salvage was achieved in 13 of
29 implants by passive wound drainage and
antibiotic therapy. Courtiss et al.7 subsequently
recommended that active intervention is necessary to save implants with periprosthetic infection13 and that capsulotomy and dissection
should be performed to avoid skin tension during treatment of threatened implant exposure.15 Others have discussed salvage as an op-
Vol. 113, No. 6 /
THE INFECTED OR EXPOSED BREAST IMPLANT
tion, although some authors suggest that the
management of such situations is a clinical
judgment with few additional established
guidelines.2
In a rodent model, Marsh et al.13 studied the
effect of timing on implant reinsertion in the
face of infection. They found that in the presence of infection, device removal, pocket irrigation, and immediate reaugmentation with a
new device resulted in a 100 percent rate of
reinfection and dehiscence. A reinsertion delay of two or more hours reduced the failure
rate to 8.6 percent. Concomitant antibiotic
therapy did not affect the outcome. In that
study, the authors did not perform a capsulectomy, which arguably should be performed as
part of an adequate wound débridement.
There was also question as to the applicability
of this model to humans.13 There has been no
further consensus as to the application of these
findings to humans, and no subsequent recommendations have been published for delayed
implant reinsertion based on these findings.
The literature contains several reports describing atypical infection and device exposure
management on a case-by-case basis.2,9,10 Recommendations include device removal and
capsulectomy only,12 removal of the implant
with retention of capsule,9 explantation with
delayed reinsertion,10,11 implant retention with
local pocket irrigation catheters,19 –21 local revision with implant retention or immediate
reaugmentation,11 local muscle flaps,15 and fascia lata grafts.15
Admittedly, there has been, and continues to
be, an evolution in the authors’ treatment strategies for the clinical scenarios reported in this
series. Because of the small number of patients
in this study and the lack of a control group,
the authors’ treatment strategies do not benefit from statistical significance. The authors
also recognize that their experience in managing these patients does not rise to the level of a
definitive treatment algorithm. Although this
study lacked an ideal amount of scientific
rigor, the authors felt it important to share
strategies for the successful management of
these patients without sacrifice of their surgical
results (Figs. 5 and 6).
On critical evaluation, each presentation
usually involved one of three scenarios: infection, inadequate soft-tissue coverage, or both.
Initial treatment was directed by accurate diagnosis of the primary underlying problem. The
choice of treatment modality furthermore de-
1641
pended on the adequacy of local tissues, the
severity of infection and exposure, the willingness of the surgeon, and most importantly, the
wishes of the patient. Implant salvage was not
indicated in patients who were noncompliant
or not motivated to pursue salvage.
Initially, if infection was suspected, treatment commenced with wound or fluid culture
(if possible) and empiric antibiotic therapy.
The initial response to antibiotic therapy was
important. In some instances, early antibiotic
intervention cured or quieted the infection,
thereby “down-staging” the severity and avoiding surgical intervention altogether or permitting an attempt at salvage with surgical intervention in cases where a severe infection
became mild, localized, or indolent.
In the setting of persistent mild infection
(either de novo or after antibiotic therapy),
further reduction of the bacterial level through
surgical methods was successful. The affected
site required further “débridement,” which included partial or total capsulectomy, implant
exchange, device location change, pocket curettage, pulse lavage, change of instruments to
a clean setup after débridement, and eventual
pocket closure, usually with a closed-suction
drainage catheter.
In the setting of severe infection alone, antibiotic therapy often down-staged the problem
to a mild or localized indolent infection, with
or without threatened device exposure (group
1 or 4, Table I) amenable to the above treatment strategies. If the situation did not improve, device removal was indicated. The nature of the actual infection may influence the
ultimate outcome as well. Organisms such as
common skin flora (e.g., Staphylococcus aureus)
may be treated with a high success rate, but
organisms such as Pseudomonas species or
Gram-negative rods may not be as easily treated
and device removal is more likely indicated.
Moreover, if overwhelming localized infection
or systemic signs of infection persist, one
should likely forgo further salvage attempts.
In cases of threatened or actual exposure, if
sufficient local tissue is present, local tissue
rearrangement may be adequate. If local tissue
is not adequate, a distant flap should be used
for coverage. This is obviously more easily done
in reconstruction patients as compared with
augmentation patients. Furthermore, in the
setting of actual device exposure, the assumption is made that contamination or mild infection is present even though there may be no
1642
PLASTIC AND RECONSTRUCTIVE SURGERY,
May 2004
FIG. 5. Possible pathways for the treatment of periprosthetic infections.
clinical evidence of infection. Thus, initially,
the patient is covered with antibiotics, the device is removed, a capsulectomy is performed,
the pocket is curetted, the instrument set is
changed to a clean set, a new device is placed,
and closure is performed with local or distant
tissue. If a flap was utilized in the initial operation
before implant exposure and this distant tissue is
unavailable for a salvage procedure, the implant
is removed in favor of a delayed reinsertion.
Those patients with concurrent infection
and threatened or actual device exposure
present the greatest management challenges.
If the infection is mild from the outset or is
“down-staged” or controlled with antibiotic
therapy, salvage attempts may be attempted by
simultaneously solving the soft-tissue deficit. If
initial infection is overwhelming or antibiotic
therapy is unable to “down-stage” the infection,
the authors recommend foregoing further salvage attempts and removal of the implant. Delayed reconstruction is usually possible.
In the current series, patients at the extremes of clinical presentation involved few
Vol. 113, No. 6 /
1643
THE INFECTED OR EXPOSED BREAST IMPLANT
FIG. 6. Possible pathways for the treatment of implant exposures.
diagnostic or treatment dilemmas. Group 1
patients with mild infections were treated
solely with antibiotic therapy with good results.
The group 5 and 7 patients (n ⫽ 3), those with
severe infections in the setting of threatened or
actual exposure, were not offered a salvage
procedure and had their implant removed.
Patients with mild infection alone or patients
with threatened or actual exposure with mild
or no infection (groups 1, 3, 4, and 6) had a
high likelihood of successful implant salvage
(18 of 19, 95 percent). In reality, several of
those patients in our series whose implant was
not salvaged were not true failures, as salvage
attempts were not offered.
In this current study, six patients ultimately
required removal of their prosthesis. After explantation, two patients underwent successful
delayed reconstruction with a two-stage implant procedure. As in prior studies,2 we found
that after explantation, delayed reinsertion of a
breast prosthesis did not adversely affect the
ultimate aesthetic outcome. With this knowledge, immediate salvage attempts, even if unsuccessful, may not adversely affect future reconstruction should initial attempts fail.
CONCLUSIONS
Through review of this series of patients, the
authors have developed treatment guidelines
for implant salvage in the setting of infection
or device exposure. Although device removal
and delayed reinsertion remains the most conservative, safe, and predictable strategy, immediate salvage may often be possible. The degree
of infection, response of the infection to initial
antibiotic therapy, and availability of adequate
soft-tissue coverage are important factors when
making decisions and planning strategy in the
management of these patients. Aggressive salvage
measures also require a willingness to attempt
salvage on the part of both the patient and the
surgeon. Finally, because there are choices available, it is important to clearly communicate to
the patient the relative risks and alternatives.
Scott L. Spear, M.D.
Division of Plastic and Reconstructive Surgery,
1-PHC
Georgetown University Medical Center
3800 Reservoir Road, NW
Washington, D.C. 20007
[email protected]
1644
PLASTIC AND RECONSTRUCTIVE SURGERY,
ACKNOWLEDGMENT
We thank Joanie Douglas for her assistance with the
photography.
12.
REFERENCES
1. American Society of Plastic Surgeons. www.plasticsurgery.org.
2. Ablaza, V. J., and LaTrenta, G. S. Late infection of a
breast prosthesis with Enterococcus avium. Plast. Reconstr. Surg. 102: 227, 1998.
3. Ahn, C. Y., Ko, C. Y., Wagar, E. A., Wong, R. S., and Shaw,
W. W. Clinical significance of intracapsular fluid in
patients’ breast implants. Ann. Plast. Surg. 35: 455,
1995.
4. Ahn, C. Y., Ko, C. Y., Wagar, E. A., Wong, R. S., and Shaw,
W. W. Microbial evaluation: 139 implants removed
from symptomatic patients. Plast. Reconstr. Surg. 98:
1225, 1996.
5. Burkhardt, B. R., Fried, M., Schnur, P. L., and Tofield, J. J.
Capsules, infection, and intraluminal antibiotics.
Plast. Reconstr. Surg. 68: 43, 1981.
6. Cholnoky, T. Augmentation mammaplasty: Survey of
complications in 10,941 patients by 265 surgeons.
Plast. Reconstr. Surg. 45: 573, 1970.
7. Courtiss, E. H., Goldwyn, R. M., and Anastasi, G. W. The
fate of breast implants with infections around them.
Plast. Reconstr. Surg. 63: 812, 1979.
8. Disa, J. J., Ad-El, D. D., Cohen, S. M., Cordeiro, P. G., and
Hidalgo, D. A. The premature removal of tissue expanders in breast reconstruction. Plast. Reconstr. Surg.
104: 1662, 1999.
9. Gruver, D. Managing the patient with infection around
a polyurethane implant. Plast. Reconstr. Surg. 83: 927,
1989.
10. Heistein, J. B., Mangino, J. E., Ruberg, R. L., and Gergese,
J. J. A prosthetic breast implant infected with Mycobacterium fortuitum. Ann. Plast. Surg. 44: 330, 2000.
11. Kanhai, R. C. J., Hage, J. J., Darim, R. B., and Mulder, J. W.
13.
14.
15.
16.
17.
18.
19.
20.
21.
May 2004
Exceptional presenting condition and outcome of
augmentation mammaplasty in male-to-female transsexuals. Ann. Plast. Surg. 43: 476, 1999.
Lee, D., Goldstein, E. J., and Zarem, H. A. Localize
Mycobacterium avium-intracellulare mastitis in an immunocompetent woman with silicone breast implants.
Plast. Reconstr. Surg. 95: 142, 1995.
Marsh, J. S., Stevens, W. G., Smith, G. L., and Krogstad,
D. J. Reinsertability after breast prosthesis pocket
infection: An experimental study. Plast. Reconstr. Surg.
69: 234, 1982.
Netscher, D. T., Weizer, G., Wigoda, P., Walker, L. E.,
Thornby, J., and Bowen, D. Clinical relevance of positive breast periprosthetic culture without overt infection. Plast. Reconstr. Surg. 96: 1125, 1995.
Rempel, J. H. Treatment of an exposed breast implant
by muscle flap and by fascia graft. Ann. Plast. Surg. 1:
229, 1978.
Schlenker, J. D., Bueno, R. A., Ricketson, G., and Lynch,
J. B. Loss of silicone implants after subcutaneous
mastectomy and reconstruction. Plast. Reconstr. Surg.
62: 853, 1978.
Snyderman, R. K. Breast augmentation. In Symposium on
Neoplastic and Reconstructive Problems of the Female Brest.
St. Louis, Mo.: Mosby, 1973. Pp. 32-37.
Spear, S. L., and Majidian, A. Immediate breast reconstruction in two stages using textured, integrated-valve
tissue expanders and breast implants: A retrospective
review of 171 consecutive breast reconstructions from
1989 to 1996. Plast. Reconstr. Surg. 101: 53, 1998.
Toranto, I. R., and Malow, J. B. Atypical mycobacteria
periprosthetic infections: Diagnosis and treatment.
Plast. Reconstr. Surg. 66: 226, 1980.
Weber, J., Jr., and Hentz, R. V. Salvage of the exposed
breast implant. Ann. Plast. Surg. 16: 106, 1986.
Yii, N., and Khoo, C. T. K. Salvage of infected expander
prostheses in breast reconstruction. Plast. Reconstr.
Surg. 111: 1087, 2003.