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Infection Following Implant-based Breast Reconstruction: Salvage Rates and Predictors of Success
Richard Reish, MD, Branimir Damjanovic, M.D., William G. Austen, Jr., M.D., Jonathan Winograd, M.D., Eric Liao, M.D., Curtis L. Cetrulo, Jr., M.D., Amy S. Colwell, MD.
Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
PURPOSE: Few articles in the literature address salvage rates for infection in implant-based breast reconstruction and predictors of success. There remains controversy regarding indications for device explantation versus attempted salvage and optimal timing of secondary reconstruction following implant loss. An understanding of success rates and clinical predictors of failure may help guide management strategies.
METHODS: Retrospective analysis of multi-surgeon consecutive implant-based reconstructions from July 2004 to December 2010 was conducted at a single institution (MGH). Patient demographics, labs, and microbiology specimens if available were analyzed as potential predictors for infection and device loss.
RESULTS: One thousand nine hundred and fifty-two immediate implant-based reconstructions were performed in 1241 patients following mastectomy. Of the total breast prosthetic reconstructions, 99 of 1952 (5.1%) breasts developed erythema and were admitted for possible or definitive infection in 94 patients. These patients had a higher incidence of smoking (p<0.01), chemotherapy (p<0.01) and radiation (p<0.001) but no difference in age or BMI compared to patients without erythema. With intravenous antibiotics, 25 (25.3%) reconstructions improved and had no further evidence of infection while 74 (74.7%) reconstructions were taken to the OR for attempted salvage (18) or explant (56). On average, patients who failed to clear the infection medically had a higher admission WBC (p<0.002) and more patients with an admission WBC >10,000 (p<0.03). Of the attempted operative salvage group, 12 cleared the infection with immediate implant exchange (11) or flap salvage (1) and six eventually lost the implant. The total salvage rate was 37.3% (37/99). Patients who failed implant salvage with medication and/or operative exchange were more likely to have MRSA (p<0.006).
The total reconstruction explant rate was 3.2% (62/1952). Following explantation, 32 patients had delayed tissue expander insertion after an average of 150 days (range 22-305 days), 6 had delayed autologous flap reconstruction after an average of 139 days (range 93-213 days), 13 patients had no further attempt at reconstruction (average follow-up 817 days), and 5 patients were lost to follow-up. Of the delayed tissue expander insertions, 26 were successful and 6 had recurrent infection resulting in implant loss. There were no significant differences in patient demographics, labs, or time interval to delayed tissue expander insertion between successful and unsuccessful secondary surgeries.
CONCLUSION: Salvage of the infected breast prosthesis remains a challenging yet viable option for a subset of breast reconstruction patients. Implant salvage with intravenous antibiotics and/or implant exchange was successful in 37.3% of reconstructions. Smoking, radiation, and chemotherapy were significant predictors for developing infection. Patients with a WBC>10,000 and MRSA were more likely to fail implant salvage attempts. There was no association with time interval between delayed tissue expander insertion and secondary explant.
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