Innovative Management of Implant Exposure in ADM/Implant-Based Breast Reconstruction with Negative Pressure Wound Therapy

Implant-based Breast Reconstruction Salvage with Negative Pressure Wound Therapy with Instillation: An Evaluation of Outcomes

Background

Implant infection is problematic in breast reconstruction. Traditionally, infected tissue expanders (TE)/implants are removed for several months before replacement, resulting in breast reconstruction delay. Salvage involving device removal, negative pressure wound therapy with instillation and dwell (NPWTi-d) placement, and early staged TE/implant replacement within a few days has been described. The purpose of this study was to compare outcomes of the NPWTi-d salvage pathway with traditional implant removal.

Methods

A retrospective review was performed on patients who underwent implant-based reconstruction and developed TE/implant infection/exposure requiring removal. Patients were divided into two groups. Group 1 had TE/implant removal, NPWTi-d placement, and TE/implant replacement 1-4 days later. Group 2 (control) underwent standard TE/implant removal and no NPWTi-d. Reinfection after TE/implant salvage, TE/implant-free days, and time to final reconstruction were assessed.

Results

The study included 47 patients (76 TE/implants) in group 1 (13 patients, 16 TE/implants) and group 2 (34 patients, 60 TE/implants). The success rate (no surgical-site infection within 90 days) of implant salvage was 81.3% in group 1. No group 1 patients abandoned completing reconstruction after TE/implant loss versus 38.2% (13 of 34) in group 2 (P = 0.0094). Mean implant-free days was 2.5 ± 1.2 in group 1 versus 134.6 ± 78.5 in group 2 (P = 0.0001). The interval to final implant-based reconstruction was 69.0 ± 69.7 days in group 1 versus 225.6 ± 93.6 days in group 2 (P = 0.0001).

Conclusions

A breast implant salvage pathway with infected device removal, NPWTi-d placement, and early TE/implant replacement was successful in 81.3%. Patients experienced 132 less implant-free days and faster time to final reconstruction.

Is Instillational Topical Negative Pressure Wound Therapy in Peri-Prosthetic Infections of the Breast Effective? A Pilot Study

Peri-prosthetic breast infections pose a risk of severe complications after breast implant surgery. The need to remove the breast implant, control the infection and perform additional surgical procedures are the consequences. Reimplantation of an alloplastic implant is only appropriate after an infection-free interval. In this retrospective cohort study, we investigated the effectiveness of negative pressure wound treatment with instillation and dwell time (NPWTi-d) on peri-prosthetic breast infections in combination with implant removal and antibiotic therapy. Twelve patients treated with NPWTi-d due to breast implant infection were included in the study. The bacterial burden was analyzed using wound swabs before and after NPWTi-d. Additionally, laboratory values were determined before NPWTi-d and immediately before wound closure. A total of 13 peri-prosthetic breast infections in 12 patients were treated using implant removal and NPWTi-d. In 76.9% (n = 10) of the cases, the patients had undergone alloplastic breast reconstruction following cancer-related mastectomy, whereas 23.1% (n = 3) of the patients had undergone breast augmentation for cosmetic reasons. The bacterial burden in the breast pocket decreased statistically significant after implant removal and NPWTi-d. No shift from Gram-positive to Gram-negative bacteria was observed. Inflammatory markers rapidly decreased following treatment. NPWTi-d had a positive impact on the healing process after peri-prosthetic breast infections, leading to a decrease in bacterial burden within the wounds and contributing to uneventful healing. Therefore, secondary reimplantation of breast prostheses might be positively influenced when compared to conventional implant removal and simple secondary closure. Further studies are required to conclusively establish the beneficial long-term effects of using NPWTi-d for the treatment of peri-prosthetic breast infections.

Rinse But Don't Repeat: Single Application V.A.C. VERAFLO Salvages Infected Breast Prostheses

Introduction

Existing salvage protocols for infected breast prostheses using negative pressure wound therapy with instillation and dwell (NPWTi-d) require multiple returns to the operating room and prolonged length of stay. We present our expedited salvage protocol and discuss outcomes and associated costs savings.

Methods

Using a retrospective review, we identified 25 consecutive patients (27 breasts) with peri-prosthetic breast infection. Nine patients (10 breasts) underwent removal of infected breast prostheses followed by autologous or staged implant-based reconstruction. Sixteen patients (17 breasts) underwent our single application salvage protocol. A cost analysis was performed comparing the two groups, and an economic model was used to project the cost savings associated with using single application NPWTi-d protocol.

Results

Fifteen of the 16 patients (94%) who underwent single application NPWTi-d had successful implant salvage. Average duration of NPWTi-d was 2 days, 7 hours, and average length of stay was 4.43 days. Compared to control, patients who received the single application protocol required significantly fewer hospitalizations and office visits. A total savings of $58,275 could have been achieved by using the single application NPWTi-d protocol in the patients who did not undergo NPWTi-d.

Conclusions

Single application of NPWTi-d is a simple, safe, and cost-effective technique for salvage of breast prostheses, with 94% success rate, even in immunocompromised patients and severe infection. Compared to previous protocols, ours requires fewer trips to the operating room, shorter length of stay, and more permanent implants placed during salvage. Our protocol is also associated with fewer office visits and fewer returns to the operating room.

Negative-Pressure Wound Therapy in the Prevention and Management of Complications From Prosthetic Breast Reconstruction: A Systematic Review and Meta-analysis

BACKGROUND

Complications from prosthetic breast reconstruction are distressing for patients, and their management is challenging. For decades, negative-pressure wound therapy (NPWT) has been successfully used for the closure of complex wounds. This study analyzes the outcomes of NPWT use in the prevention and management of complications from prosthetic breast reconstruction.

METHOD

A systematic search of studies published until August 2020 was conducted using the PubMed/MEDLINE, EMBASE, and Ebscohost/CINAHL databases and using the following key words: "negative-pressure wound therapy," "breast reconstruction," and "prosthesis" (including breast implants and tissue expanders). Analyzed endpoints were outcomes of NPWT use in prosthetic breast reconstruction compared with conventional dressings. The methodological quality of included studies was assessed independently. Comparative studies were further meta-analyzed to obtain pooled odds ratios (ORs) describing the effectiveness of NPWT in prosthetic breast reconstruction.

RESULTS/DISCUSSION

Ten studies were included with a total of 787 patients (1230 breasts) undergoing prosthetic breast reconstruction with breast implants or tissue expanders. Three case-control studies focused on preventing breast wound complications. The meta-analysis of the 3 studies included 502 breasts receiving NPWT and 698 breasts receiving conventional wound care. The meta-analysis favored NPWT for less mastectomy flap necrosis (5.6% vs 14.3%; OR, 0.46; 95% confidence interval, 0.27 -0.77; P = 0.004; I2 = 0%) and less overall wound complications (10.6% vs 21.1%; OR, 0.49; 95% confidence interval, 0.35-0.70; P < 0.00001; I2 = 0%). In the management of nipple-areolar complex venous congestion, 1 case report demonstrated 85% rescue of nipple-areolar complex after using NPWT (-75 mm Hg) for a total of 12 days. In the management of periprosthetic infections, 2 case series used NPWT with instillation. It accelerated the treatment of infection and maintained the breast cavity for future reconstruction. Conventional NPWT also showed good salvage outcome in four studies.

CONCLUSIONS

Current evidence suggests that prophylactic use of NPWT in prosthetic breast reconstruction reduces the rate of overall wound complications and mastectomy flap necrosis. In the management of complications from prosthetic breast reconstructions, NPWT may be a promising option showing beneficial results. Additional high-quality trials are warranted to corroborate the findings of this systematic review.

Oncoplastic breast surgery: the role of negative pressure wound therapy

Wound-related problems following breast surgery are common. Delayed wound healing can lead to poor cosmesis and, among breast cancer patients, can result in delays in receiving adjuvant treatment. The aim of our review was to look at the literature in relation to the role of negative pressure wound therapy in oncoplastic breast surgery, as at the time of writing, there is no consensus on the use of prophylactic negative pressure dressings in closed wounds following breast surgery.

Salvaging the Unsalvageable: Negative Pressure Wound Therapy for Severe Infection of Prosthetic Breast Reconstruction

Background:

Severe infections of implant-based breast reconstruction are challenging to treat. Traditional management is removal of the implant with a further attempt at reconstruction months later once the infection has settled. This study evaluates an alternative management protocol using negative pressure wound therapy with instillation (NPWTi).

Methods:

Consecutive patients with severe peri-prosthetic infection following breast reconstruction were managed using the Implant Salvage Protocol: removal of the prosthesis with application of a NPWTi dressing, changed every 3 days until a negative culture was obtained. A new prosthesis was then placed in the pocket. Data were collected on patient demographics, microbiological, hospital/operative information, and overall success of salvage. Descriptive statistics were used for analysis.

Results:

In total, 30 breast prostheses in 28 patients were treated for severe peri-prosthetic infection. Twenty-five (83%) implants were salvaged. Mean time from initial reconstruction surgery to presentation was 49.5 days (median 23, range 7–420). Mean hospital stay was 11.5 days (median 12.0, range 6–22), mean number of returns to the operating theater was 3.7 (median 3.0, range 2–7), and mean number of days to negative culture was 5.2 (median 4.0, range 1–14). The most common organisms were methicillin-sensitive Staphylococcus aureus (n = 9) and Serratia marcescens (n = 4). Most had a tissue expander (n = 24, 80%) or implant (n = 5, 16.7%) placed at the completion of therapy. There was no record of capsular contracture nor recurrent infection during follow-up (mean 39.4 months, range 6–74 months).

Conclusion:

An estimated 83% of prosthetic breast reconstructions with severe infection were successfully salvaged using NPWTi.

Nipple-sparing mastectomy with immediate breast reconstruction - early complications and outcomes of the treatment

AIM OF THE STUDY

To assess the early complications and outcomes of the treatment of patients undergoing nipple-sparing mastectomy (NSM) with immediate breast reconstruction.

MATERIAL AND METHODS

A retrospective study was performed on 120 patients who underwent 130 NSM (10 bilateral) procedures between 1.01.2015 and 31.12.2017 in two oncology centers in Poland. In 80 patients a breast cancer was recognized. Sixteen patients underwent operations on the basis of being carriers of the BRCA1 mutation. The follow-up period ranged from 10 to 34 months. The NSM procedures were performed with or without skin reduction and a free nipple-areola complex (NAC) transplant, with 130 prosthetic devices inserted subpectorally. Breast cancer patients followed the standard protocol for adjuvant therapy.

RESULTS

The patients for risk-reducing mastectomies were younger. Prevalent histology was no special type (NST) in 60 out of 80 patients, mean tumor - NAC distance was 43.3 mm. The prevalent biological subtype was Luminal B HER2-negative. Adjuvant management consisted of chemotherapy in 61 and radiotherapy in 35 patients. We noted 14 cases of complications, 13 in the cancer group, and 1 in the non-cancer group. Skin necrosis was the most common. The mean time for the appearance of the complications was 2.8 months. No local recurrences were observed.

CONCLUSIONS

NSM is a safe and effective surgical option for qualified patients with breast cancer and in risk-reducing mastectomies.

Negative Pressure Wound Therapy With Chymotrypsin Irrigation: A Maximal Implant Retention Procedure Treating the Exposure/Infection of Titanium Mesh in Cranioplasty

This preliminary study aims to investigate the effects of a maximal implant retention procedure. The authors retrospectively reviewed the use of negative pressure wound therapy with chymotrypsin irrigation treating implant infection/exposure in titanium mesh cranioplasty by comparing patients with titanium mesh totally retained, partially removed, or totally removed according to the evaluation during the surgery. Negative pressure wound therapy with chymotrypsin irrigation was applied 5 days after the surgery. The negative pressure was set at -125 to -150 mmHg. A total of 21 patients were included, 4 patients treated with titanium mesh totally removed; 3 patients treated with titanium mesh partially removed; and 14 patients treated with U-shape debridement with titanium mesh preserved completely. However, 1 patient in the U-shape group required a second debridement to remove all implant. Negative pressure wound therapy with chymotrypsin irrigation is a novel procedure and could be used to treat implant-related infection without the exchange of implant.

Comparison of Volume Retention and Biocompatibility of Acellular Dermal Matrix/Hyaluronic Acid Filler to Autologous Fat Grafts in a Mouse Model

BACKGROUND

Although fat grafting has become a widely used technique in aesthetic and reconstructive surgeries, resorption is still a challenge. Micronized acellular dermal matrix (ADM) has been considered as a stable, biocompatible soft tissue coverage material that can be used as a volume filler. Here, we compared the bioacceptance and sustainability of ADM hyaluronic acid (HA) filler with human fat graft in a mouse model.

METHODS

Harvested human fat and ADM/HA filler were injected randomly on the dorsal side of mice. Thirty-two mice were analyzed over a 7-week period with respect to volume, weight and microscopic evaluations with hematoxylin and eosin (H&E), epidermal growth factor (EGF) and vascular endothelial growth factor (VEGF) staining.

RESULTS

The volume and weight were maintained at 80% and 83%, respectively, in the ADM/HA filler group and 56.5% and 49.7%, respectively, in the fat-grafted group by the 7th week. There were no significant microscopic differences in inflammatory changes and granulation via H&E staining. At 1 and 2 weeks, EGF and VEGF immunostaining intensity scores were lower in the ADM/HA filler group. At 7 weeks, there were no significant differences in immunostaining intensity scores between the two groups.

CONCLUSIONS

During the 7-week experimental period, the ADM/HA filler showed no foreign body reaction and the proper volume was well maintained. This suggests that the ADM/HA filler can possibly be used in small amounts as an alternative to autologous fat grafts.

NO LEVEL ASSIGNED

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In Vitro Characterization of a Novel Human Acellular Dermal Matrix (BellaCell HD) for Breast Reconstruction

In the past, acellular dermal matrices (ADMs) have been used in implant-based breast reconstruction. Various factors affect the clinical performance of ADMs since there is a lack of systematic characterization of ADM tissues. This study used BellaCell HD and compared it to two commercially available ADMs—AlloDerm Ready to Use (RTU) and DermACELL—under in vitro settings. Every ADM was characterized to examine compatibility through cell cytotoxicity, proliferation, and physical features like tensile strength, stiffness, and the suture tensile strength. The BellaCell HD displayed complete decellularization in comparison with the other two ADMs. Several fibroblasts grew in the BellaCell HD with no cytotoxicity. The proliferation level of fibroblasts in the BellaCell HD was higher, compared to the AlloDerm RTU and DermACELL, after 7 and 14 days. The BellaCell HD had a load value of 444.94 N, 22.44 tensile strength, and 118.41% elongation ratio, and they were higher than in the other two ADMs. There was no significant discrepancy in the findings of stiffness evaluation and suture retention strength test. The study had some limitations because there were many other more factors useful in ADM’s testing. In the study, BellaCell HD showed complete decellularization, high biocompatibility, low cytotoxicity, high tensile strength, high elongation, and high suture retention strengths. These characteristics make BellaCell HD a suitable tissue for adequate and safe use in implant-based breast reconstruction in humans.

Is negative-pressure wound therapy beneficial in modern-day breast surgery?

Negative-pressure wound therapy (NPWT) is used to treat many different types of wounds, but there is still a lack of large studies describing its effectiveness in breast surgery. Enhanced recovery, reduction of complications, and good scar quality might be improved by the application of NPWT. Existing data show that vacuumassisted closure (VAC) application after expander-based breast reconstruction may be beneficial because of decreasing overall complications in comparison with standard wound treatment. There are few cases in which the use of negative pressure resulted in healing of complicated breast wounds after implant insertion - most breasts achieved healing, wherein duration of NPWT ranged from seven to 21 days. The use of NPWT leads to a decrease of seroma formation (from 70% to 15%), the mean percutaneous aspirated volume (from 193 ml to 26 ml) and the numbers of percutaneous aspirations (from three to one) in latissimus dorsi flap reconstruction. Furthermore, a prospective, within-patient, randomised study with 200 participants showed that treating closed incisional wounds after reduction mammoplasty with a VAC system resulted in a decrease of overall complications and protected against wound dehiscence. In the literature, there are cases showing that NPWT may be useful for the successful treatment of chronic and non-healing wounds, included non-puerperal mastitis and surgical sites affected by radiation therapy due to breast cancer. There is still a need for evidence confirming the effectiveness of NPWT in breast surgery because of the deficiency of large prospective studies that compare NPWT with standard treatment.

Fat grafting for resurfacing an exposed implant in lower extremity: A case report

RATIONALE

Although numerous reconstruction protocols have been reported for lower leg trauma, those for distal leg trauma remain few. We present the case of a woman with an implant exposure wound, who was successfully treated through fat grafting, without major flap surgery.

PATIENT CONCERNS

An 83-year-old woman with an exposed implant in lower extremity received reconstruction surgery once and the surgery failed. She refused additional major surgery and negative pressure wound therapy.

DIAGNOSES

The diagnosis of a tibia and fibula shaft open fracture (type IIIA) complicated with an exposed implant was made.

INTERVENTIONS

The procedure was performed by deploying purified and emulsified fat with a Micro-Autologous Fat Transplantation gun. The required lipoaspirate amount was grossly estimated using a standard formula: 0.5 cc of a lipoaspirate per square centimeter of wound. We prepared the lipoaspirate simply through centrifugation followed by physical emulsification. The endpoint of fat grafting was when lipoaspirate began to flow out of the wound. The initial dressing after the procedure included the topical usage of biomycin ointment with AQUACEL Foam (ConvaTec Inc., NC, USA) coverage, which was later changed to INTRASITE gel (Smith & Nephew, London, UK) with a gauze dressing for 4 weeks. After 4 weeks, dressing components were changed to Mepilex (Mölnlycke Health Care, Gothenburg, Sweden) alone.

OUTCOMES

The wound healed completely without requiring major flap surgery by 18 weeks after surgery.

LESSONS

Fat grafting is one kind of cell therapy and potentially has regenerative effects during wound healing. Fat grafting is critical in the healing processes of complicated wounds and might be considered a step in reconstruction surgery.