Management of Expander- and Implant-Associated Infections in Breast Reconstruction

Management of the Infected Tissue Expander

BACKGROUND

Tissue expander (TE) infection is a critical postoperative complication in 2-stage implant-based breast reconstruction (IBBR). The authors assessed risk factors associated with TE infection and reconstructive loss and examined reconstructive salvage rates.

METHODS

The authors retrospectively reviewed patients who underwent IBBR with TE placement from 2017 to 2022. Included were patients with TE infection treated with admission and intravenous antibiotics, interventional radiology (IR) drainage, and/or operative management (washout with or without TE removal and TE replacement, TE removal and replacement with implant, and/or TE removal without replacement). Reconstructive success was defined as maintenance of breast reconstruction for 1 year after TE placement.

RESULTS

Of 4498 patients who underwent IBBR, 305 (338 TEs) met the inclusion criteria. Cox modeling showed that higher body mass index, hypertension, radiation therapy, bilateral TEs, acellular dermal matrix use, increasing mastectomy weight, and nipple-sparing mastectomy were associated with increased hazard of TE infection. Patients with TE infection had a 54% reconstructive failure rate within 1 year; Cox modeling showed that Black race and Gram-negative cultures were associated with increased hazard of reconstructive failure within 1 year. Patients who underwent TE replacement with an implant had the most favorable success rate following infection.

CONCLUSIONS

Overall, 46% of patients admitted with a periprosthetic infection had successful salvage. Patients with TE infection should be started on intravenous antibiotics with a low threshold for operative intervention based on examination and culture data. Although IR can guide operative intervention of periprosthetic infections, our practice has shifted away from IR drainage toward definitive operative management.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Effect of Prepectoral Versus Subpectoral Implant-Based Reconstruction on Post-Mastectomy Radiation Dosimetry

BACKGROUND

The placement of breast implants in a prepectoral plane has become increasingly popular in breast reconstruction, although data on how this affects radiation delivery in women with breast cancer are limited. This study aimed to assess the dosimetric differences in radiation plans for immediate breast reconstruction between prepectoral and subpectoral implants.

METHODS

In this study, a retrospective review and dosimetric analysis of patients with breast cancer who underwent immediate implant-based reconstruction and postmastectomy radiation therapy (PMRT) were performed. Patients with pre- or subpectoral implants were matched 1:1 by use of boost and radiation field. Demographics and complications were compared using the Mann-Whitney U test for continuous variables and the chi-square test for categorical variables. Dosimetric data were analyzed to compare doses to the target, heart, lungs, and pectoralis major using a Mann-Whitney U test.

RESULTS

The study identified 42 patients who met the inclusion criteria. Planning target volume (PTV) coverage was better in the prepectoral group (PTV D95%, 45.61 vs. 43.38 Gy; p = 0.04). The heart and lung doses did not differ. The patients with subpectoral implants had a lower absolute volume of pectoralis major receiving 20 to 45 Gy.

CONCLUSION

This assessment of radiation dosimetry for patients undergoing immediate breast reconstruction found that the primary dosimetric difference between prepectoral and subpectoral implants was the dose to the pectoralis major. Otherwise, no significant difference in target coverage was found. These data suggest that implant placement can be selected to optimize reconstructive outcomes, with less concern for compromise to the oncologic quality of PMRT.

Monitoring and Management of Infection following Prepectoral Implant-based Breast Reconstruction: Retrospective Analysis of Conservative Treatment Versus Implant Removal

Background

Infection following implant-based breast reconstruction (IBBR) represents a major complication, potentially leading to prosthesis removal. However, no clear protocol for its prevention and management exists. This study aimed to evaluate the efficacy of conservative treatment methods in preventing implant removal and analyze factors responsible for implant loss in the context of prepectoral IBBR.

Methods

A single-institution retrospective review chart of patients undergoing immediate prepectoral IBBR for breast cancer between October 2020 and January 2024 was performed. The inclusion criteria were the presence of at least one of the following postoperative complications: seromas, cellulitis, clinically suspected prosthesis infection, and confirmed periprosthetic infection. A comparative analysis between patients with successful conservative treatment (ultrasound-guided aspiration and antibiotic therapy) and patients undergoing implant removal was performed.

Results

A total of 219 immediate prepectoral IBBR cases were identified, 38 of which met inclusion criteria. Implant removal was required in 11 cases, whereas implant retention was achieved in 27 patients with conservative treatment. Implants were invariably removed when bacterial cultures were positive (P < 0.05). Conversely, when pathogens were not identified, the likelihood of implant removal decreased significantly (P < 0.05). Conservative treatment allowed implant salvage in all patients presenting with postoperative seroma alone, without other associated complications (P < 0.05).

Conclusions

This study suggests that when bacterial cultures are positive, implant removal is unavoidable. Conversely, noninfected seromas correlated with implant salvage. Infections from Bacillus pumilus and Corynebacterium pseudodiphtheriticum are reported for the first time.

Negative Pressure Wound Therapy with Instillation for Periprosthetic Infection after Breast Reconstruction: A Systematic Review

Background

Periprosthetic infection after breast reconstruction is not uncommon and can result in loss of the implant pocket and negative patient outcomes. Management of these infections typically involves removal of the prosthesis, treatment with antibiotics, and delayed reconstruction upon infection resolution. The impact of adjunctive use of negative pressure wound therapy with instillation and dwell (NPWTi-d) on breast pocket salvage rates, time to implant reinsertion, and related outcomes was examined.

Methods

A systematic literature search using PubMed, Cochrane, OVID, Scopus, and Embase was conducted to identify peer-reviewed articles written in English and published between January 2004 and April 2023 that examined NPWTi-d use in the breast pocket with a history of periprosthetic infection after breast reconstruction.

Results

Of the 1703 publications, 6 studies met inclusion criteria, representing 115 patients and 122 breasts. The overall breast pocket salvage rate with NPWTi-d across studies was approximately 92%. In the 6 studies that included prosthesis type and radiation history, overall salvage rates were 97.8% (45 of 46) for pockets containing implants and 93.8% (15 of 16) for pockets containing tissue expanders. Salvage rates were 85.7% (12 of 14) and 91.7% (53 of 58) for irradiated and nonirradiated breasts, respectively. Mean time to implant reinsertion ranged from 2.3 to 10.3 days.

Conclusions

In this review, antibiotic therapy along with adjunctive use of NPWTi-d for periprosthetic infections after breast reconstructions was associated with high rates of breast pocket salvage and reduced time to implant reinsertion. Larger prospective and randomized trials are needed to better understand and optimize the effectiveness of NPWTi-d in this population.

Microbiology of periprosthetic infections following implant-based breast reconstruction surgery: a multicentric retrospective study

Introduction

Implant-based breast reconstruction (IBR) is the predominant breast reconstruction technique post-mastectomy, with bacterial infections being a significant complication affecting patient recovery and quality of life. The following study aimed to determine the microbiological features of the causative agents responsible for breast implant infections, with more attention paid to the comparative analysis of Gram-positive and Gram-negative bacteria and their presentation.

Methods

We conducted a retrospective analysis of 214 patients who presented with periprosthetic infection and underwent implant removal following implant-based breast reconstruction at Humanitas Research Hospital and Istituto Europeo di Oncologia between January 2018 and March 2024.

Results

The study revealed that Gram-positive bacteria were more prevalent, with Staphylococcus species, particularly Staphylococcus aureus, being the most isolated pathogen in both institutions (∼39.96%). In contrast, Gram-negative bacteria were less frequent, with a higher proportion of these pathogens being multi-resistant strains. A significant difference was observed (p = 0.007), indicating that individuals with normal BMI have a higher prevalence of Gram-positive infections (88.46%), whereas obese and overweight patients had higher proportions of Gram-negative infections (23.53% and 28.89%, respectively). In addition, smoking status was also significantly associated with pathogen distribution (p = 0.032), with active and past smokers being related to higher percentages of polymicrobial infections. Furthermore, positive prophylactic MSSA/MRSA swabs were significantly more associated with Staphylococcus aureus infections compared to those with negative results (p = <0.001).

Conclusions

Gram-positive bacteria, especially Staphylococcus species, dominate the microbiological landscape of implant-based breast reconstruction (IBR) infections. Our findings provide insights into this critical issue, facilitating a more precise choice of empiric antibiotic treatment and prevention strategies. This analysis underscores the necessity for prophylactic protocols and therapeutic approaches tailored to the predominant bacterial groups. Further research is needed to explore long-term trends and resistance mechanisms to improve patient management.

Reconstructive breast implant-related infections: Prevention, diagnosis, treatment, and pearls of wisdom

Implant-based reconstructions are increasingly utilized following mastectomy in the prevention and treatment of breast cancer. However, these implants are associated with a high rate of infection, which is a major complication that can lead to implant removal, delay in adjuvant radiation and chemotherapy, and increase in health care costs. Early clinical signs and symptoms of infection, such as erythema, warmth, and tenderness, are challenging to discern from expected postsurgical responses. Furthermore, when atypical features are present or the patient's condition does not improve on adequate antimicrobials, the clinician should be prompted to consider an alternative noninfectious etiology. Herein we highlight the key elements of the preventive, diagnostic, and multidisciplinary therapeutic approach to salvaging the infected breast implant; review several infectious disease mimickers; and provide many pearls of wisdom that the practicing clinician must be familiar with and be able to manage in an effective and successful manner.

Prepectoral versus Submuscular Implant-Based Breast Reconstruction: A Matched-Pair Comparison of Outcomes

BACKGROUND

Implant-based breast reconstruction is the most common reconstructive approach after mastectomy. Prepectoral implants offer advantages over submuscular implants, such as less animation deformity, pain, weakness, and postradiation capsular contracture. However, clinical outcomes after prepectoral reconstruction are debated. The authors performed a matched-cohort analysis of outcomes after prepectoral and submuscular reconstruction at a large academic medical center.

METHODS

Patients treated with implant-based breast reconstruction after mastectomy from January of 2018 through October of 2021 were retrospectively reviewed. Patients were propensity score exact matched to control demographic, preoperative, intraoperative, and postoperative differences. Outcomes assessed included surgical-site occurrences, capsular contracture, and explantation of either expander or implant. Subanalysis was done on infections and secondary reconstructions.

RESULTS

A total of 634 breasts were included (prepectoral, 197; submuscular, 437). A total of 292 breasts were matched (146 prepectoral:146 submuscular) and analyzed for clinical outcomes. Prepectoral reconstructions were associated with greater rates of SSI (prepectoral, 15.8%; submuscular, 3.4%; P < 0.001), seroma (prepectoral, 26.0%; submuscular, 10.3%; P < 0.001), and explantation (prepectoral, 23.3%; submuscular, 4.8%; P < 0.001). Subanalysis of infections revealed that prepectoral implants have shorter time to infection, deeper infections, and more Gram-negative infections, and are more often treated surgically (all P < 0.05). There have been no failures of secondary reconstructions after explantation in the entire population at a mean follow-up of 20.1 months.

CONCLUSIONS

Prepectoral implant-based breast reconstruction is associated with higher rates of infection, seroma, and explantation compared with submuscular reconstructions. Infections of prepectoral implants may need different antibiotic management to avoid explantation. Secondary reconstruction after explantation can result in long-term success.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Minimally Invasive and Innovative Management of Prosthesis Infections in Endoscopic-Assisted Breast Reconstruction

BACKGROUND

Implant infection continues to be the most common complication of breast reconstruction, and it can lead to serious consequences of implant loss. Recently, endoscopic-assisted nipple-sparing mastectomy with direct-to-implant breast reconstruction is being performed more frequently, with similar prosthetic infection incidence compared to conventional techniques. But there is little information published in the literature on the management of periprosthetic infection in endoscopic-assisted breast reconstruction.

METHODS

A retrospective review was performed of patients who underwent endoscope-assisted breast reconstruction and developed periprosthetic infection between January 2020 and December 2022. Prosthesis infection was defined as any case where antibiotics were given, beyond the surgeon's standard perioperative period, in response to clinical signs such as swelling, pain, erythema, increased temperature, fever, etc. We summarized our clinical approach and treatment protocol for periprosthetic infection patients. Collected data include preoperative basic information, surgical details, postoperative data, and outcomes.

RESULTS

A total of 580 patients (713 reconstructions) underwent endoscopic-assisted immediate breast reconstruction. There were 58 patients developed periprosthetic infection, 14 of whom had bilateral prosthesis reconstruction with unilateral prosthesis infection. The incidence of infection was 10.0%. Average follow-up was 17.3 ± 8.9 months (range = 2-37 months). Of the 58 patients, 53 (91.4%) patients successful salvaged implant and 5(8.6%) patients removed prosthesis. During follow-up, Baker III capsular contracture occurred in 2 patients (3.8%) who had radiotherapy.

CONCLUSION

Our management of prosthesis infections in endoscopic-assisted breast reconstruction is easy, minimally invasive, and inexpensive. This method can be repeated if the implant infection does not improve after the first drainage. What's more, our data suggest that our prosthesis salvage of periprosthetic infection is effective.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Artificial Intelligence Modeling to Predict Periprosthetic Infection and Explantation following Implant-Based Reconstruction

BACKGROUND

Despite improvements in prosthesis design and surgical techniques, periprosthetic infection and explantation rates following implant-based reconstruction (IBR) remain relatively high. Artificial intelligence is an extremely powerful predictive tool that involves machine learning (ML) algorithms. We sought to develop, validate, and evaluate the use of ML algorithms to predict complications of IBR.

METHODS

A comprehensive review of patients who underwent IBR from January of 2018 to December of 2019 was conducted. Nine supervised ML algorithms were developed to predict periprosthetic infection and explantation. Patient data were randomly divided into training (80%) and testing (20%) sets.

RESULTS

The authors identified 481 patients (694 reconstructions) with a mean ± SD age of 50.0 ± 11.5 years, mean ± SD body mass index of 26.7 ± 4.8 kg/m 2 , and median follow-up time of 16.1 months (range, 11.9 to 3.2 months). Periprosthetic infection developed in 113 of the reconstructions (16.3%), and explantation was required with 82 (11.8%) of them. ML demonstrated good discriminatory performance in predicting periprosthetic infection and explantation (area under the receiver operating characteristic curve, 0.73 and 0.78, respectively), and identified nine and 12 significant predictors of periprosthetic infection and explantation, respectively.

CONCLUSIONS

ML algorithms trained using readily available perioperative clinical data accurately predict periprosthetic infection and explantation following IBR. The authors' findings support incorporating ML models into perioperative assessment of patients undergoing IBR to provide data-driven, patient-specific risk assessment to aid individualized patient counseling, shared decision-making, and presurgical optimization.

Evaluating the Efficacy of Povidone-Iodine Solution Infection Prophylaxis in Immediate Tissue Expander-Based Breast Reconstruction: A Controlled Retrospective Analysis

Background: There is currently no consensus among plastic surgeons regarding the optimal infection prophylaxis for immediate tissue expander placement following mastectomy. The goal of this study was to determine whether irrigation with 1 L of standard triple antibiotic solution (TAS) can achieve similar infection rates compared to a regimen of 180 mL of TAS with povidone-iodine solution (Betadine) painted on the field immediately prior to the placement of the expander. Methods: The 2 regimens were compared via retrospective propensity matching of all patients of the 2 senior authors who underwent bilateral tissue expander placement immediately following mastectomy with one of 3 mastectomy surgeons from January 2013 to December 2019 (n = 281). Groups were controlled for mastectomy surgeon, mastectomy type, mastectomy weight, age, race, body mass index, diabetes, hypertension, smoking, smoking status, prepectoral/subpectoral placement, use of acellular dermal matrix, operating room time, and duration of postoperative antibiotics. Results: Compared to the Betadine cohort (n = 65), the non-Betadine cohort (n = 65) experienced a similar rate of infections (13.8% vs 12.3%, P = 1.00), including major injections requiring intravenous antibiotic treatment (10.8% vs 9.2%, P = 1.00), after propensity matching. Infections in the non-Betadine cohort did not grow different bacteria on culture, require different antibiotic coverage, or result in prolonged duration of average antibiotic therapy (12.0 days vs 19.3 days, P = .19). Rates of subsequent expander washout and exchange (P = 1.00) and overall complications that required return to the operating room (P = .826) were similar between groups. Conclusion: The addition of Betadine solution to TAS added no benefit to infection prophylaxis or reduction of surgical complications in immediate tissue expander placement procedures.

Analysis of pathogen distribution and antimicrobial resistance at infected sites in plastic surgery

OBJECTIVE

By analyzing the distribution and drug resistance of common pathogen in different sites in plastic surgery to provide reference for clinicians to choose the best antibacterial treatment plan.

METHODS

Pathogens of postoperative infection in plastic surgery from January 2011 to December 2021 were retrospectively analyzed to determine the species and quantity, and to access the trend of each pathogen's detection rate. The antibiotic sensitivity and distribution characteristics of common pathogens were studied in conjunction with the site of infection.

RESULTS

A total of 1709 bacterial strains were detected, including 1244 gram-positive bacterial strains and 465 gram-negative bacterial strains. The main pathogen of perineum was Escherichia coli (E. coli) and Pseudomonas aeruginosa (P. aeruginosa), while Staphylococcus aureus (S. aureus) was the most common pathogen in the other infected sites. The detection rate of methicillin-resistant S. aureus (MRSA) and methicillin-resistant coagulase-negative staphylococcus (MRCNS) was on the rise from 2011 to 2021. No S. aureus and coagulase-negative staphylococcus (CoNS) strains were resistant to vancomycin. The sensitive rate of S. aureus from all parts and CoNS from all sites except lower limbs and mandible was higher than 80% to linezolid. The resistance rate of S. aureus and CoNS in all parts to penicillin, clindamycin, and erythromycin was high. The susceptibility rate of CoNS in lower mandible was high to gentamicin.

CONCLUSIONS

Staphylococcus aureus was the primary pathogen of gram-positive bacteria in all site of plastic surgery except perineum, followed by CoNS. The distribution and drug resistance of pathogen in different infection sites were different. We should formulate more accurate and reasonable antibacterial programs according to drug resistance results of various parts to reduce the emergence of resistant strains and effectively prevent and control infection.

Shared Decision-Making in Breast Reconstruction for Breast Cancer Patients: A Scoping Review

For most breast cancer (BC) patients who have undergone a mastectomy, the decision whether to proceed with breast reconstruction (BR) is complicated and requires deliberation. Shared decision-making (SDM) helps to address those needs and promote informed value-based decisions. However, little is known about the SDM status for BR in BC patients. This scoping review describes: 1) basic characteristics of studies on BR SDM in BC patients; 2) factors influencing BR SDM in BC patients; 3) experience and perception of BR SDM in BC patients; and 4) outcome measures reported. This review was performed in accordance with the Arksey and O'Malley methodology. A total of 5 English and 4 Chinese databases were searched, as well as different sources from grey literature. The data extraction form was developed by referring to the objectives and the Ottawa Decision Support Framework (ODSF). Data was analyzed using thematic analysis, framework analysis and descriptive statistics, with findings presented in the tables and diagrams. A total of 1481 records were retrieved and 42 of these included after screening. In 21 (21/42, 50%) of the studies, patient decision aids (PDAs) were utilized, and in 17 (17/42, 40.48%) of the studies, the factors influencing the implementation of SDM were explored. Of these 17 studies, the factors influencing the implementation of SDM were categorized into the following: the patient level (17/17, 100%), the healthcare level (2/17, 11.76%) and the organizational and system level (7/17, 41.18%). A total of 8 (19.05%) of the 42 studies focused on patients' experiences and perceptions of SDM, and all studies used qualitative research methods. Of these 8 studies, a total of 7 (7/8, 87.50%) focused on patients' experiences of SDM participation, and 4 (4/8, 50.00%) focused on patients' perceptions of SDM. A total of 24 studies (24/42, 57.14%) involved quantitative outcome measures, where 49 items were divided into three classifications according to the outcomes of ODSF: the quality of the decision (17/24, 70.83%), the quality of the decision-making process (20/24, 83.33%), and impact (13/24, 54.17%). Although researchers have paid less attention to other research points in the field of SDM, compared to the design and application of SDM interventional tools, the research team still presents some equally noteworthy points through scoping review. For instance, the various factors influencing BC patients' participation in SDM for BR (especially at the healthcare provider level and at the organizational system level), patients' experiences and perceptions. Systematic reviews (SRs) should be conducted to quantify the impact of these different factors on BR SDM. Implementation of scientific theories and methods can inform the exploration and integration of these factors.

Successful salvage of an infected breast prothesis by changing from continuous to intermittent suction under continuous irrigation

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Continuous irrigation does not always salvage infected breast implants.

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It is unclear whether continuous or intermittent suction is more effective.

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We salvaged a breast implant by changing from continuous to intermittent suction.

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Intermittent suction worked well in this patient and it is worthy of further studies.

Introduction

Implant-based breast reconstruction is a widely performed procedure. However, prostheses are susceptible to infection and there are currently no established guidelines on treatment. In the present case, a prosthesis was salvaged by changing from continuous irrigation and suction to continuous irrigation and intermittent suction. This case report has been reported in line with the SCARE criteria [1].

Presentation of case

A 50-year-old female patient underwent implant-based breast reconstruction following surgery for breast cancer. One month later, the left breast prosthesis was infected with abscesses. Surgical treatment and continuous irrigation were performed as postoperative therapy. However, recurrent infection was detected a few days after surgery. Continuous irrigation was changed to continuous irrigation with intermittent aspiration, which successfully controlled the infection.

Discussion

Factors that limit the effectiveness of continuous irrigation and aspiration have not yet been identified. Inflow/discharge shunt routes may be established in continuous aspiration, and, thus, sufficient cleaning may not be possible. On the other hand, the storage of water throughout the wound in intermittent aspiration may facilitate cleaning.

Conclusion

Intermittent suction worked well in this patient and, thus, warrants further study.

Protocol for Prevention and Monitoring of Surgical Site Infections in Implant-Based Breast Reconstruction: Preliminary Results

Surgical site infection in implant-based breast reconstruction is a complication with variable incidence reported in the literature. Due to potential loss of implant and reconstruction, it can have a strong psychological impact on patients. Background and objectives: This study aimed primarily at analyzing the current status of the surgical site infection (SSI), (type, time of onset, clinical presentation, pathogens and management) in patients who underwent implant-based breast reconstruction at our Breast Unit. Secondarily, we wanted to establish whether introduction of a new, updated evidence-based protocol for infection prevention can reduce SSI in implant-based breast reconstruction. Materials and Methods: A single-center retrospective study was performed primarily to evaluate the incidence and features of SSI after implant-based breast reconstruction from 2007 to 2020. In June 2020, a protocol for prevention of SSI in implant-based breast reconstruction was introduced in clinical practice. Secondarily, a data analysis of all patients who underwent implant-based breast reconstruction in compliance with this protocol was performed after preliminarily assessing its efficacy. Results: 756 women were evaluated after mastectomy and implant-based breast reconstruction for breast cancer. A total of 26 surgical site infections were detected. The annual incidence of SSI decreased over time (range 0-11.76%). Data relating to infections' features, involved pathogens and implemented treatments were obtained. Since the introduction of the protocol, 22 patients have been evaluated, for a total of 29 implants. No early infections occurred. Conclusions: Surgical site infection rates at our Breast Unit are comparable to those reported in the literature. The SSI rates have shown a decreasing trend over the years. No SSI has occurred since the introduction of the prevention protocol for surgical site infection in June 2020.

Invited Discussion on: Management of Expander and Implant Associated Infections in Breast Reconstruction

The author presents an objective review on "Management of Expander and Implant Associated Infections in Breast Reconstruction," discussing different points related to this subject, such as infection definition, identification of risk factors, related microorganisms, surgical techniques, preventive measures, antibiotic prophylaxis and therapy. Flaws in methodologies are identified and points of discrepancy in data and treatment results from previously published studies are pointed out, with discussion of possible causes for these inconsistencies. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.