Implant salvage in breast reconstruction with severe peri‐prosthetic infection

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Excerpt

Implant loss is a complication of implant‐based breast reconstruction associated with significant psychological and aesthetic morbidity. High levels of patient dissatisfaction as well as increased rates of depressive symptoms and anxiety have been reported.1 A major cause of implant loss is peri‐prosthetic infection, especially when the infection does not resolve with oral or intravenous antibiotics.3 It has been reported that more than half of patients who suffer implant loss secondary to peri‐prosthetic infection will not proceed to have delayed reconstruction.5 In addition, patients who do proceed with a delayed reconstruction risk having an inferior aesthetic outcome due to contraction or loss of the skin envelope. The treatment of peri‐prosthetic infection, therefore, aims to prevent implant loss in order to reduce the associated morbidity experienced by patients.
A number of implant salvage techniques have demonstrated high success rates in the setting of mild peri‐prosthetic infection. These techniques generally include a combination of a course of intravenous/oral antibiotics; debridement/curettage of the breast pocket with or without partial or total capsulectomy; copious lavage/washout of the breast pocket using a combination of normal saline, chlorhexidine, hydrogen peroxide, povidone‐iodine and/or antibiotic wash; implant exchange with or without implant position change; and finally, primary closure or flap coverage of the breast pocket.5 These methods, however, have demonstrated lower success rates with severe peri‐prosthetic infection.10 Furthermore, certain characteristics of infection such as less common pathogens on wound culture (for example, gram‐negative rods), concurrent infection with exposure or threatened exposure of the breast prosthesis and/or the presence of frank pus with liquefied capsular tissue on exploration or severe inflammatory rind have been listed as contraindications to attempting salvage.5
A case report by Kendrick and Chase 2008, however, demonstrated successful implant salvage in a patient with severe peri‐prosthetic infection involving methicillin‐resistant Staphylococcus aureus (MRSA) utilizing negative pressure wound therapy (NPWT).14 There has been relatively little description and investigation of the use of NPWT in achieving implant salvage. To the authors' knowledge, there have been three case reports.14 These cases have included peri‐prosthetic infection following augmentation as well as breast reconstruction. All three reports demonstrated success, with the advantage of not only treatment of the infected breast pocket, but also maintenance of breast shape without evidence of capsular contracture on follow‐up.14 A novel wound therapy that combines NPWT with instillation (NPWTi) may be an important addition to existing implant salvage methods in the setting of severe peri‐prosthetic infection. This study will present the experience of the authors with an implant salvage protocol, which uses NPWTi, for patients with severe peri‐prosthetic infection following breast reconstruction.

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