DOI: 10.1097/01.prs.0000214738.97424.ff
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PMID: 16652010
Issn Print: 0032-1052
Publication Date: 2006/05/01
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Excerpt
Exposure of silicone breast implants is a major complication of mammary augmentation. Although removal of the implant is usually recommended, some series of successful salvage of the exposed implant have been reported in the literature.1,2 We report a case of salvage of a repetitively exposed implant in a patient with no obvious cause of dehiscence. We finally found that the patient was using topical cutaneous corticosteroids for a localized psoriasis in such an important quantity that it was responsible for systemic side effects equivalent to those of chronically high doses of corticotherapy.
A 32-year-old woman came to the emergency department for wound dehiscence with exposure of a breast implant. She had undergone breast augmentation 6 weeks earlier in which an inframammary approach was used. Three weeks postoperatively, a wound dehiscence appeared and her surgeon reoperated immediately, closing the wound in a two-layer suture. The wound reopened and the patient came to our hospital. Clinically, there was no infection. Previous medical history included appendicectomy, conization, and psoriasis. She did not take any medication and smoked 20 cigarettes. We decided to excise the tissue alongside the dehiscence, remove the implant, explore and wash the cavity with povidone-iodine (Betadine), install a two-way continuous washing device, place back the same implant, and perform a 3-layer closure of the wound using the periprosthetic capsule to reinforce the closure. Bacteriological samplings were all negative, and clinical evolution was satisfactory, allowing us to remove the washing device on the fifth postoperative day. The patient was discharged with oral antibiotics to be continued for 7 more days.
On postoperative day 30, the patient presented with extreme thinning of her scar and on day 45, a very small new opening was present, justifying a new procedure. Once again, bacteriological samplings were all negative. The borders of the wound were not inflammatory but instead were atonic. The same surgical procedure was performed, with the wound closed in three layers and advancement of the periprosthetic capsule (Figs. 1 and 2).
When we interrogated the patient for the fifth time, she said that she used a topical cream for her psoriasis. One tube of this cream contained 19.2 mg of betamethasone per 30 g of cream. Betamethasone is a very powerful fifth-generation corticosteroid; 0.75 mg of betamethasone is equivalent to 25 mg of cortisone. The cream had been prescribed by her dermatologist to be applied during short periods of psoriasis exacerbation. One tube of cream was prescribed for a period of one whole year. Instead, our patient had used it for 14 years on the basis of one tube per week, with the prescription renewal being provided by her general practitioner! This is equivalent to high-dose systemic corticotherapy. Withdrawal of this intensive topical treatment allowed good wound healing after the last procedure. Care was taken not to produce an Addison syndrome.
This case emphasizes three important points. First, as has described by several authors,3–5 chronic topical corticotherapy may have systemic side effects equivalent to those of high doses of oral corticotherapy. Second, iterative exposure of a breast implant does not contraindicate salvage procedure. Third, when interrogating a patient, we must be aware that he or she may hide important elements either voluntarily or simply because he or she thinks these elements are not relevant to the procedure. We have to actively evaluate each aspect of the past and present medical history of our patients.
