Implant infection after augmentation mammaplasty: a review of the literature and report of a multidrug-resistant Candida albicans infection

A Systematic Review of Outcomes and Complications of Tuberous Breast Surgery

BACKGROUND

Tuberous breast is a complex congenital breast anomaly that can be challenging to correct surgically.

OBJECTIVES

The authors conducted a systematic review with pooled analysis of data, with the aim of determining the effectiveness and complications related to operative management of the deformity.

METHODS

Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were adopted in performing this systematic review. A simplified classification system for tuberous breast deformity was developed to accurately compare data and guide analysis.

RESULTS

The review identified 38 studies, reporting a total of 897 patients undergoing tuberous breast surgery. The mean age of patients was 24 years (range 13-53 years). Mean follow-up was 39 months. A combination of tissue rearrangement and implant augmentation was the most common technique (73% of patients) followed by fat transfer alone (9%). Breast implants were employed in 83% of patients. The mean implanted volume per breast was 263 cc. Fat grafting was performed in 13% of patients and mean volume of fat grafted per breast was 185 cc. An overall complication rate of 20% was reported. Subjective assessment of patient satisfaction was 99%, and the mean score on BREAST-Q for satisfaction with clinical outcome was 86.7. Future studies should focus on robust study designs including randomized and cohort studies, use of patient-reported outcome measures, and long-term follow-up.

CONCLUSIONS

The surgical techniques to correct tuberous breast deformity are safe, effective, and have a high satisfaction rate. Fat transfer has the capacity to provide promising results in treating tuberous breast deformity.

LEVEL OF EVIDENCE: 4

"Just Pulse it!" Introduction of a conservative implant salvage protocol to manage infection in pre-pectoral breast reconstruction: Case series and literature review

Post-operative implant infection is generally rare after breast augmentation, but it can occur in up to 35% of cases in post-mastectomy breast reconstruction. Standard treatment consists in the administration of antibiotics, implant removal, and delayed prosthesis replacement leading to multiple operations, with a negative impact on patient's clinical, economical, and psychological outcomes. There is little information published in the literature on the management of periprosthetic infection following pre-pectoral reconstructions. Capsule's removal from a pre-pectoral plane brings the risk of excessive tissue thinning and the compromise of skin flaps viability. In this preliminary multi-center case series, eight patients diagnosed with implant infection following oncological mastectomy and two-stage heterologous pre-pectoral breast reconstruction underwent the same protocol, consisting in tissue expander removal and conservative surgical revision supplemented by an antibiotate pulse lavage of the pocket surface. All patients achieved a successful infection resolution with immediate prosthesis replacement switching the temporary expander to definitive implant. No additional surgical revision was registered during follow-up. The intermittent irrigation is meant to disrupt the biofilm structure and restore antibiotic susceptibility. Moreover, pulse lavage allows the cleansing of the prosthetic capsule, thus avoiding the vascular stress associated with subcutaneous capsulectomy. To the best of our knowledge, this is the first series reporting on the use of Pulsavac in periprosthetic infection following pre-pectoral breast reconstruction, in an attempt to set the basis for an alternative conservative protocol to manage breast implant infection. A thorough literature review on pulse lavage in breast surgery was carried out.

Extended Latissimus Dorsi Kite Flap (ELD-K Flap): Revisiting an Old Place for a Total Autologous Breast Reconstruction in Patients with Medium to Large Breasts

BACKGROUND

The latissimus dorsi (LD) flap represents one of the most reliable methods for autologous breast reconstruction. However, in many patients, the exclusive use of this technique may not guarantee the restoration of an adequate volume and projection. We report our experience with the extended latissimus dorsi kite flap (ELD-K flap), an alternative surgical approach to maximize the volume of the fleur-de-lis pattern LD flap, for total autologous breast reconstruction.

METHODS

Between 2016 and 2018, 23 patients were subjected to mastectomy and immediate autologous reconstruction with "extended latissimus dorsi kite flap" (ELD-K flap), technique that employs an extended version of the LD musculocutaneous flap, based on the skeletonized thoracodorsal pedicle and a trilobate skin incision with an inferiorly based vertical branch. The BREAST-Q questionnaire was administered preoperatively, and one year after surgery to evaluate the quality of life results of the patients. BREAST-Q latissimus dorsi module was also provided.

RESULTS

Average body mass index was 29.7 kg/m² (range 25-40 kg/m²). Mild complications occurred in only six cases, and eight patients underwent treatment to improve the donor site scar outcome. Patients indicated high scores in quality of life measures with an increase in all BREAST domains from the preoperative to the postoperative period. A statistically significant increase (p < 0.05) was noted in: "overall satisfaction with breasts" (p < 0.05), "psychosocial well-being" (p < 0.05), "physical impact of the surgery" (p < 0.05). Within the LD module, participants reported a mean score of, respectively, 73.8 and 67.9 for "satisfaction with back" and "satisfaction with shoulder and back function" domains.

CONCLUSIONS

The extended incision allows the recruitment of additional tissue to provide enough volume to complete the reconstruction without implants. The isolation of the vascular pedicle allows for extreme freedom and mobilization of the flap, ensuring adequate filling of the breast. ELD-K flap may expand the indications for a total autologous LD immediate breast reconstruction, representing an additional and reliable alternative in selected cohorts of patients.

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 .

Dermatologic sequelae of breast cancer: From disease, surgery, and radiation

The care of breast cancer patients is important to dermatologists. Breast cancer's initial presentation, clinical progression, and its associated treatments can result in a variety of cutaneous complications. Dermatologists may be the first to identify a breast cancer diagnosis, as a subset of patients first present with direct extension of an underlying tumor or with a cutaneous metastasis. The surgical treatment of breast cancer also begets a variety of skin sequelae, including postoperative lymphedema, soft tissue infections, seromas, pyoderma gangrenosum, and scarring disorders. Moreover, breast cancer radiation treatment commonly results in skin changes, which can range from mild and temporary dermatoses to chronic and disfiguring skin ulceration, fibrosis, and necrosis. Radiation may also precipitate secondary malignancies, such as angiosarcoma, as well as rarer dermatologic diseases, such as radiation-induced morphea, lichen planus, and postirradiation pseudosclerodermatous panniculitis. Finally, breast cancer is also associated with an array of paraneoplastic phenomena, including Sweet's syndrome and the rarer intralymphatic histiocytosis. Herein, we review the dermatological manifestations of breast cancer, including conditions associated with its presentation, progression, and treatment sequelae. Chemotherapy-induced cutaneous side effects are beyond the scope of this review. This article provides a comprehensive review for dermatologist to be able to identify, diagnose, and manage breast cancer patients from initial presentation to treatment monitoring and subsequent follow-up.

Aspergillus fumigatus Spores Are Not Able to Penetrate Silicone Breast Implant Shells

INTRODUCTION

Bacterial contamination is hypothesized to be one reason for the development of capsular contracture after alloplastic breast reconstruction using silicone breast implants. The role of fungal colonization or infection in this context as well as the question if microorganisms can penetrate the shell of silicone breast implants remains an unresolved question to date. Therefore, the aim of this study was to assess whether fungal spores are able to penetrate the shell of silicone implants.

MATERIALS AND METHODS

In an experimental in vitro setup with different arrangements of growth compartments, silicone chambers were placed in culture dishes filled with Aspergillus minimal medium or liquid culture medium. Inoculation was performed with conidia of Aspergillus fumigatus and incubated for seven days. On a daily basis, plates were inspected for conidial germination and hyphal growth.

RESULTS

In none of the different experimental settings nutrients or hyphae of Aspergillus fumigatus were able to penetrate the silicone material.

CONCLUSIONS

Fungal spores and hyphae do not permeate through an intact silicone shell used in breast implants; thus, the silicone material serves as an impenetrable barrier.

The use of the Alexis(®) device in breast augmentation to improve outcomes: a comparative randomized case-control survey

BACKGROUND

We present our experience in using a disposable wound retractor commonly used in abdominal surgery named Alexis(®) (Applied Medical Resources Corporation, Rancho Santa Margarita, CA, USA), during breast augmentation in order to improve outcomes, particularly final scar length.

METHODS

Between January 2010 and November 2012, 40 patients undergoing breast augmentation with an inframammary approach were enrolled in the present study. Patients were randomly assigned to two groups: group 1 underwent breast augmentation with the standard technique; group 2 underwent breast augmentation by using the Alexis(®) (Applied Medical Resources Corporation) device. Patients were followed-up for a 12-month period. The time of surgery, the days of drain duration and the length of the incisions were recorded for both groups and statistical significance was evaluated with the Wilcoxon rank sum test. Also, final scar appearance was evaluated using a visual analogue scale (VAS).

RESULTS

Patients in group 2 reported a lower incidence of hematomas and had shorter drain duration. The difference in scar length between the two groups was statistically significant (P<0.05). Surgeons and patients were mostly satisfied with the final appearance of the scar.

CONCLUSIONS

The use of the Alexis(®) (Applied Medical Resources Corporation) device has proven useful in reducing the length of the inframammary incision. Interestingly, the increased visibility obtained with the use of the Alexis device allowed a better hemostasis, as suggested by the shorter drain duration and lower incidence of hematomas. However, its use prolongs the operative time, for which we recommend surgeons to allow themselves some time to become familiar with the device.

LEVEL OF EVIDENCE

level I, evidence obtained from at least one properly designed randomized controlled trial.

Application time for postoperative wound dressing following breast augmentation with implants: study protocol for a randomized controlled trial

Background

Breast augmentation with silicone implants is one of the most frequently performed cosmetic surgeries worldwide. Surgical site infection (SSI) remains an important complication of this procedure. One of the most important risk factors for SSI is the presence of microorganisms on the skin surrounding the wound. Guidelines by the Centers for Disease Control (CDC) recommend that surgical wounds be covered with a sterile dressing for 24 to 48 hours. However, a recent study showed that the application of a dressing for six days after breast reduction reduced wound colonization by coagulase-negative staphylococci.

Methods/Design

A randomized clinical trial was designed to assess two protocols of postoperative wound care to determine how the application duration of the postoperative dressing influences wound colonization in patients undergoing breast augmentation with silicone implants. Women aged between 18 and 60 years who are candidates for breast augmentation with silicone implants will be randomly allocated to group I (n = 48), in which the dressing will be removed on the first postoperative day, or group II (n = 48), in which the dressing will be removed on the sixth postoperative day. Cutaneous colonization will be assessed by cultures of samples of skin flora taken from the wound region. The incidence of SSI, using standardized CDC criteria, and the perceptions of patients towards the dressing will be secondary outcomes.

Discussion

An important component of SSI prevention is to minimize all possible risk factors, and the application of postoperative dressing plays a key role in this endeavor. The results of this clinical trial may help to standardize postoperative wound care after breast augmentation with silicone implants.

Trial registration

This trial was registered on 12 March 2012 with ClinicalTrials.gov (identifier: NCT01553604).

Bioceramic Materials Show Reduced Pathological Biofilm Formation

The aim of the present work was to assess the surface ability of three bioceramic materials (A: alumina BIOLOX®forte; B: Si3N4; C: alumina matrix composite BIOLOX®delta) to inhibit bacterial biofilm formation. For this purpose, ceramic disks at standardized roughness (Ra = 0,25 μm) were used as test materials while commercial polystyrene was considered as control. Two biofilm-producing bacterial strains (S. epidermidis ATCC14990, Escherichia coli ATCC25922) were used for experiments. The viable biomass was assessed by the metabolic MTT assay after 24h incubation. Morphological data regarding biofilms structure were obtained by scanning electron microscopy. In general, results revealed that all bioceramics materials were significantly less colonized compared to polystyrene. The degree of biofilm formation onto bioceramics ranged between about 30 to 60% less than the polystyrene control. Moreover, some differences were noticed by comparing the three bioceramics inhibition ratio: bioceramic A showed significanlty less S. epidermidis biofilm formation (p<0.005) compared to B and C that showed similar performance. Conversely, no difference were noted for E. coli biofilm amount for A, B and C. In conclusion, the tested materials showed capability to reduce biofilm formation to a different extent depending on the tested bacterial strains.

A rare fungal species, Quambalaria cyanescens, isolated from a patient after augmentation mammoplasty--environmental contaminant or pathogen?

Some emerging but less common human fungal pathogens are known environmental species and could be of low virulence. Meanwhile, some species have natural antifungal drug resistance, which may pose significant clinical diagnosis and treatment challenges. Implant breast augmentation is one of the most frequently performed surgical procedures in China, and fungal infection of breast implants is considered rare. Here we report the isolation of a rare human fungal species, Quambalaria cyanescens, from a female patient in China. The patient had undergone bilateral augmentation mammoplasty 11 years ago and was admitted to Peking Union Medical College Hospital on 15 September 2011 with primary diagnosis of breast infection. She underwent surgery to remove the implant and fully recovered thereafter. During surgery, implants and surrounding tissues were removed and sent for histopathology and microbiology examination. Our careful review showed that there was no solid histopathologic evidence of infection apart from inflammation. However, a fungal strain, which was initially misidentified as “Candida tropicalis” because of the similar appearance on CHROMagar Candida, was recovered. The organism was later on re-identified as Q. cyanescens, based on sequencing of the rDNA internal transcribed spacer region rather than the D1/D2 domain of 26S rDNA. It exhibited high MICs to 5-flucytosine and all echinocandins, but appeared more susceptible to amphotericin B and azoles tested. The possible pathogenic role of Q. cyanescens in breast implants is discussed in this case, and the increased potential for misidentification of the isolate is a cause for concern as it may lead to inappropriate antifungal treatment.

The root canal system: a channel through which we can seed cells into grafts

Bone tissue engineering is bringing hope to patients with jawbone defects, but this technology works well only for small- to moderate-sized jawbone defects. For large segmental jawbone defects, it is difficult to form the functional vascular networks within the graft due to limited diffusion of nutrition and uneven distribution of seed cells. From the standpoint of bionics, seed cells should be continuously transmitted into the graft to replace the necrotic cells during the entire process of bones regeneration. However, the existing one-time inoculation method (OIM) fails to achieve this goal because it is almost impossible to re-open the wound and inoculate cells into grafts that have already been implanted into the body. Inspired by the anatomical structure of jawbones, we hypothesize that the root canal in teeth of jawbones could be used as a channel through which seed cells could be delivered into the graft. Therefore, the multiple-times inoculation method (MIM) could be achieved via the root canal system if defects are located on the maxillofacial bones with teeth. Both osteogenesis and vascularization would be promoted to a large extent because the engineered construct has a limitless supply of seed cells and growth factors.