Exposed Implant after Immediate Breast Reconstruction – Presentation and Analysis of a Clinical Management Protocol

 

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Abstract

Objective Infection and exposure of the implant are some of the most common and concerning complications after implant-based breast reconstruction. Currently, there is no consensus on the management of these complications. The aim of the present study was to review our cases and to present a clinical protocol.

Methods We conducted a retrospective review of consecutive patients submitted to implant-based breast reconstruction between 2014 and 2016. All patients were managed according to a specific and structured protocol.

Results Implant exposure occurred in 33 out of 277 (11.9%) implant-based reconstructions. Among these, two patients had history of radiotherapy and had their implant removed; Delayed reconstruction with a myocutaneous flap was performed in both cases. Signs of severe local infection were observed in 12 patients, and another 5 presented with extensive tissue necrosis, and they were all submitted to implant removal; of them, 8 underwent reconstruction with a tissue expander, and 2, with a myocutaneous flap. The remaining 14 patients had no signs of severe infection, previous irradiation or extensive tissue necrosis, and were submitted to primary suture as an attempt to salvage the implant. Of these, 8 cases (57.1%) managed to keep the original implant.

Conclusion Our clinical protocol is based on three key points: history of radiotherapy, severe infection, and extensive tissue necrosis. It is a practical and potentially-reproducible method of managing one of the most common complications of implant-based breast reconstruction.

Resumo

Objectivo Infecção e exposição da prótese são algumas das complicações mais comuns e preocupantes após reconstrução da mama com implantes. Atualmente, ainda não há consenso quanto ao manejo destas complicações. O objetivo deste estudo foi o de revisar os casos da nossa instituição e apresentar um protocolo clínico.

Métodos Realizou-se uma revisão retrospectiva de todos os casos consecutivos submetidos a reconstrução mamária imediata com prótese entre 2014 e 2016. Todos os casos foram conduzidos de acordo com um protocolo específico e estruturado.

Resultados A exposição do implante ocorreu em 33 de 227 reconstruções (11,9%). Dentre estas, duas pacientes tinham histórico de radioterapia, e foram submetidas a remoção da prótese e posterior reconstrução com retalho miocutâneo. Sinais de infecção local grave foram observados em 12 pacientes, e, em 5, necrose extensa de tecido, e todas foram submetidas a remoção dos implantes; destas, 8 foram reconstruídas com expansor, e 2, com retalho miocutâneo. As 14 pacientes remanecentes não haviam sido submetidas previamente à radioterapia, não tinham sinais de infecção, nem necrose extensa; portanto, foram submetidas a sutura primária em uma tentativa de salvar a prótese. Dessas, 8 pacientes (57,1%) conseguiram manter os implantes originais.

Conclusão Nosso protocolo clínico é baseado em três pontos principais: histórico de radioterapia, infecção grave, e necrose extensa de tecido. Ele constitui um método prático e potencialmente reprodutível de manejo de uma das complicações mais comuns da reconstrução mamária com implantes.

Contributions

All authors participated in the concept and design of the study; analysis and interpretation of data; and draft or revision of the manuscript. All authors have approved the manuscript as submitted, and are responsible for the reported research.

Publication History

Received: 28 September 2020

Accepted: 05 August 2021

Article published online:
20 October 2021

© 2021. Federação Brasileira de Ginecologia e Obstetrícia. This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

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• References

• 1 Albornoz CR, Bach PB, Mehrara BJ, Disa JJ, Pusic AL, McCarthy CM. et al. A paradigm shift in U.S. Breast reconstruction: increasing implant rates. Plast Reconstr Surg 2013; 131 (01) 15-23 DOI: 10.1097/PRS.0b013e3182729cde.
  CrossrefPubMedGoogle Scholar
• 2 Alderman A, Gutowski K, Ahuja A, Gray D. Postmastectomy ExpanderImplant Breast Reconstruction Guideline Work Group. ASPS clinical practice guideline summary on breast reconstruction with expanders and implants. Plast Reconstr Surg 2014; 134 (04) 648e-655e DOI: 10.1097/PRS.0000000000000541.
  CrossrefPubMedGoogle Scholar
• 3 Freitas-Júnior R, Gagliato DM, Moura Filho JW, Gouveia PA, Rahal RM, Paulinelli RR. et al. Trends in breast cancer surgery at Brazil's public health system. J Surg Oncol 2017; 115 (05) 544-549 DOI: 10.1002/jso.24572.
  CrossrefPubMedGoogle Scholar
• 4 Karunanayake M, Bortoluzzi P, Chollet A, Lin JC. Factors influencing the rate of post-mastectomy breast reconstruction in a Canadian Teaching Hospital. Plast Surg (Oakv) 2017; 25 (04) 242-248 DOI: 10.1177/2292550317728034.
  CrossrefPubMedGoogle Scholar
• 5 Ng YY, Tan VK, Goh TL, Yong WS, Wong CY, Ho GH. et al. Trends in post-mastectomy reconstruction in an Asian population: a 12-year institutional review. Breast J 2017; 23 (01) 59-66 DOI: 10.1111/tbj.12682.
  CrossrefPubMedGoogle Scholar
• 6 American Society of Plastic Surgeons. 2017 reconstructive plastic surgery statistics [Internet]. 2017 [cited 2018 Jul 28]. Available from: https://www.plasticsurgery.org/documents/News/Statistics/2017/reconstructive-procedure-trends-2017.pdf
  PubMedGoogle Scholar
• 7 Alderman AK, Wilkins EG, Lowery JC, Kim M, Davis JA. Determinants of patient satisfaction in postmastectomy breast reconstruction. Plast Reconstr Surg 2000; 106 (04) 769-776 DOI: 10.1097/00006534-200009040-0000.
  CrossrefPubMedGoogle Scholar
• 8 McCarthy CM, Klassen AF, Cano SJ, Scott A, Vanlaeken N, Lennox PA. et al. Patient satisfaction with postmastectomy breast reconstruction: a comparison of saline and silicone implants. Cancer 2010; 116 (24) 5584-5591 DOI: 10.1002/cncr.25552.
  CrossrefPubMedGoogle Scholar
• 9 Kuroda F, Urban C, Zucca-Matthes G, de Oliveira VM, Arana GH, Iera M. et al. Evaluation of aesthetic and quality-of-life results after immediate breast reconstruction with definitive form-stable anatomical implants. Plast Reconstr Surg 2016; 137 (02) 278e-286e DOI: 10.1097/01.prs.0000475746.17968.f4.
  CrossrefPubMedGoogle Scholar
• 10 Susarla SM, Ganske I, Helliwell L, Morris D, Eriksson E, Chun YS. Comparison of clinical outcomes and patient satisfaction in immediate single-stage versus two-stage implant-based breast reconstruction. Plast Reconstr Surg 2015; 135 (01) 1e-8e DOI: 10.1097/PRS.0000000000000803.
  CrossrefPubMedGoogle Scholar
• 11 Franchelli S, Pesce M, Baldelli I, Marchese A, Santi P, De Maria A. Analysis of clinical management of infected breast implants and of factors associated to successful breast pocket salvage in infections occurring after breast reconstruction. Int J Infect Dis 2018; 71: 67-72 DOI: 10.1016/j.ijid.2018.03.019.
  CrossrefPubMedGoogle Scholar
• 12 Baker JL, Mailey B, Tokin CA, Blair SL, Wallace AM. Postmastectomy reconstruction is associated with improved survival in patients with invasive breast cancer: a single-institution study. Am Surg 2013; 79 (10) 977-981
  CrossrefPubMedGoogle Scholar
• 13 Petit JY, Gentilini O, Rotmensz N, Rey P, Rietjens M, Garusi C. et al. Oncological results of immediate breast reconstruction: long term follow-up of a large series at a single institution. Breast Cancer Res Treat 2008; 112 (03) 545-549 DOI: 10.1007/s10549-008-9891-x.
  CrossrefPubMedGoogle Scholar
• 14 Masoomi H, Paydar KZ, Evans GR, Tan E, Lane KT, Wirth GA. Does immediate tissue expander placement increase immediate postoperative complications in patients with breast cancer?. Am Surg 2015; 81 (02) 143-149
  CrossrefPubMedGoogle Scholar
• 15 Fischer JP, Wes AM, Tuggle CT, Nelson JA, Tchou JC, Serletti JM. et al. Mastectomy with or without immediate implant reconstruction has similar 30-day perioperative outcomes. J Plast Reconstr Aesthet Surg 2014; 67 (11) 1515-1522 DOI: 10.1016/j.bjps.2014.07.021.
  CrossrefPubMedGoogle Scholar
• 16 Petersen A, Eftekhari AL, Damsgaard TE. Immediate breast reconstruction: a retrospective study with emphasis on complications and risk factors. J Plast Surg Hand Surg 2012; 46 (05) 344-348 DOI: 10.3109/2000656X.2012.700025.
  CrossrefPubMedGoogle Scholar
• 17 Fischer JP, Nelson JA, Serletti JM, Wu LC. Peri-operative risk factors associated with early tissue expander (TE) loss following immediate breast reconstruction (IBR): a review of 9305 patients from the 2005-2010 ACS-NSQIP datasets. J Plast Reconstr Aesthet Surg 2013; 66 (11) 1504-1512 DOI: 10.1016/j.bjps.2013.06.030.
  CrossrefPubMedGoogle Scholar
• 18 Radovanovic Z, Radovanovic D, Golubovic A, Ivkovic-Kapicl T, Bokorov B, Mandic A. Early complications after nipple-sparing mastectomy and immediate breast reconstruction with silicone prosthesis: results of 214 procedures. Scand J Surg 2010; 99 (03) 115-118 DOI: 10.1177/145749691009900302.
  CrossrefPubMedGoogle Scholar
• 19 Alderman AK, Wilkins EG, Kim HM, Lowery JC. Complications in postmastectomy breast reconstruction: two-year results of the Michigan Breast Reconstruction Outcome Study. Plast Reconstr Surg 2002; 109 (07) 2265-2274 DOI: 10.1097/00006534-200206000-00015.
  CrossrefPubMedGoogle Scholar
• 20 Cordeiro PG, McCarthy CM. A single surgeon's 12-year experience with tissue expander/implant breast reconstruction: part II. An analysis of long-term complications, aesthetic outcomes, and patient satisfaction. Plast Reconstr Surg 2006; 118 (04) 832-839 DOI: 10.1097/01.prs.0000232397.14818.0.
  CrossrefPubMedGoogle Scholar
• 21 Nahabedian MY, Tsangaris T, Momen B, Manson PN. Infectious complications following breast reconstruction with expanders and implants. Plast Reconstr Surg 2003; 112 (02) 467-476 DOI: 10.1097/01.PRS.0000070727.02992.54.
  CrossrefPubMedGoogle Scholar
• 22 Franchelli S, Pesce M, Savaia S, Marchese A, Barbieri R, Baldelli I. et al. Clinical and microbiological characterization of late breast implant infections after reconstructive breast cancer surgery. Surg Infect (Larchmt) 2015; 16 (05) 636-644 DOI: 10.1089/sur.2014.146.
  CrossrefPubMedGoogle Scholar
• 23 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 (06) 1634-1644 DOI: 10.1097/01.prs.0000117194.21748.02.
  CrossrefPubMedGoogle Scholar
• 24 Hughes K, Brown C, Perez V, Ting JWC, Rozen WM, Whitaker IS. et al. The effect of radiotherapy on implant-based breast reconstruction in the setting of skin-sparing mastectomy: clinical series and review of complications. Anticancer Res 2012; 32 (02) 553-557 https://ar.iiarjournals.org/content/32/2/553.long cited2018Jul7 [Internet]
  PubMedGoogle Scholar
• 25 Cowen D, Gross E, Rouannet P, Teissier E, Ellis S, Resbeut M. et al. Immediate post-mastectomy breast reconstruction followed by radiotherapy: risk factors for complications. Breast Cancer Res Treat 2010; 121 (03) 627-634 DOI: 10.1007/s10549-010-0791-5.
  CrossrefPubMedGoogle Scholar
• 26 Spear SL, Seruya M. Management of the infected or exposed breast prosthesis: a single surgeon's 15-year experience with 69 patients. Plast Reconstr Surg 2010; 125 (04) 1074-1084 DOI: 10.1097/PRS.0b013e3181d17fff.
  CrossrefPubMedGoogle Scholar
• 27 Forman DL, Chiu J, Restifo RJ, Ward BA, Haffty B, Ariyan S. Breast reconstruction in previously irradiated patients using tissue expanders and implants: a potentially unfavorable result. Ann Plast Surg 1998; 40 (04) 360-363 , discussion 363–364. DOI: 10.1097/00000637-199804000-00007.
  CrossrefPubMedGoogle Scholar
• 28 Behranwala KA, Dua RS, Ross GM, Ward A, A'hern R, Gui GP. The influence of radiotherapy on capsule formation and aesthetic outcome after immediate breast reconstruction using biodimensional anatomical expander implants. J Plast Reconstr Aesthet Surg 2006; 59 (10) 1043-1051 DOI: 10.1016/j.bjps.2006.01.051.
  CrossrefPubMedGoogle Scholar
• 29 Chun JK, Schulman MR. The infected breast prosthesis after mastectomy reconstruction: successful salvage of nine implants in eight consecutive patients. Plast Reconstr Surg 2007; 120 (03) 581-589 DOI: 10.1097/01.prs.0000270296.61765.28.
  CrossrefPubMedGoogle Scholar
• 30 Yii NW, Khoo CT. Salvage of infected expander prostheses in breast reconstruction. Plast Reconstr Surg 2003; 111 (03) 1087-1092 DOI: 10.1097/01.PRS.0000046490.02212.BA.
  CrossrefPubMedGoogle Scholar
• 31 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 Aesthet Surg 2011; 64 (10) 1270-1277 DOI: 10.1016/j.bjps.2011.05.009.
  CrossrefPubMedGoogle Scholar
• 32 Prince MD, Suber JS, Aya-Ay ML, Cone Jr JD, Greene JN, Smith Jr DJ. et al. Prosthesis salvage in breast reconstruction patients with periprosthetic infection and exposure. Plast Reconstr Surg 2012; 129 (01) 42-48 DOI: 10.1097/PRS.0b013e3182361fbd.
  CrossrefPubMedGoogle Scholar
• 33 Brandstetter M, Schoeller T, Pülzl P, Schubert H, Wechselberger G. Capsular flap for coverage of an exposed implant after skin-sparing mastectomy and immediate breast reconstruction. J Plast Reconstr Aesthet Surg 2010; 63 (08) 1388-1390 DOI: 10.1016/j.bjps.2009.11.054.
  CrossrefPubMedGoogle Scholar
• 34 Varga J, Mohos G, Varga Á, Erős G, Bende B, Németh IB. et al. A Possible technique for the complex reconstruction of exposed breast implant: applicability and microcirculation of the capsule flap. J Invest Surg 2019; 32 (06) 530-535 DOI: 10.1080/08941939.2018.1442532.
  CrossrefPubMedGoogle Scholar
• 35 Woerdeman LA, Hage JJ, Smeulders MJ, Rutgers EJ, van der Horst CM. Skin-sparing mastectomy and immediate breast reconstruction by use of implants: an assessment of risk factors for complications and cancer control in 120 patients. Plast Reconstr Surg 2006; 118 (02) 321-330 , discussion 331–332. DOI: 10.1097/01.prs.0000234049.91710.ba.
  CrossrefPubMedGoogle Scholar