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Prevention and Treatment of Infections in Breast Reconstruction with Implants

  • Emannuel Filizola Cavalcante
  • Douglas de Miranda Pires
  • Régis Resende Paulinelli
  • Carolina Lamac Figueiredo
  • Carolina Nazareth Valadares
  • Mariana dos Santos Nascimento
Chapter
  • 639 Downloads

Abstract

Breast cancer is one of the main causes of deaths among women all over the world. Its treatment has been changed dramatically over the last decades with the paradigm change from radical mastectomy to conservative surgery associated with radiotherapy [1, 2]. Nonetheless, conservative surgeries could make deformities in the breast and better strategies needed to be used for better aesthetic results [3]. The oncoplastic surgery is the answer for this matter with greater benefits, including excellent cosmetic outcomes, better local control of the margins of the tumor, and greater satisfactions from patients and surgeons [4]. The skills of the breast surgeons have been improved in conservative techniques and also in reconstruction of the breast in cases of mastectomies, with a complication rate of 15–25% [5, 6].

Breast cancer is one of the main causes of deaths among women all over the world. Its treatment has been changed dramatically over the last decades with the paradigm change from radical mastectomy to conservative surgery associated with radiotherapy [1, 2]. Nonetheless, conservative surgeries could make deformities in the breast and better strategies needed to be used for better aesthetic results [3]. The oncoplastic surgery is the answer for this matter with greater benefits, including excellent cosmetic outcomes, better local control of the margins of the tumor, and greater satisfactions from patients and surgeons [4]. The skills of the breast surgeons have been improved in conservative techniques and also in reconstruction of the breast in cases of mastectomies, with a complication rate of 15–25% [5, 6].

In 1963, silicone implants were used for the first time, and since then they have been a great option for breast reconstruction. There are several researches looking for better materials, biocompatibility, resistance, durability, less deformability, ideal shape, and smooth touch more similar to the natural breast [7].

Most breast reconstructions are based on implants or tissue expanders [8]. Some of the surgeries using those devices may have complications, such as infections, capsular rupture or contracture, distortion, fibrosis, and chronic inflammation [9].

One of the worse complications in breast reconstruction using implants is infection. In some cases, the removal of the device is necessary, and the patient could stay for a long time hospitalized [10]. This could cause psychological damages and expensive costs and postpone the adjuvant treatment of the cancer.

In the United States, a surgical site infection after breast surgery can cost approximately 4000 dollars [11]. Infection in the breast pocket of the implant can cost even more. Infections and capsular contracture are the main cause of reoperations [12].

The authors of this article made a bibliographic review using the data of the Public Medical Literature Analysis and Retrieval System Online (Pubmed) and Cochrane Library in seven steps (Table 46.1) using the specific citations: infection; complications; reconstructive; risk factors; antibiotic prophylaxis, irrigation; implant; breast; salvage; capsular contracture.
Table 46.1

Steps on bibliographic review

Steps

Citations

Articles found

Selected articles

1

Infection and implant and breast

583

08

2

Complications and reconstructive and implant and breast

494

10

3

Risk factors and Infection and implant and breast

90

07

4

Capsular contracture and implant and breast

104

05

5

Antibiotic prophylaxis and implant and breast

29

04

6

Irrigation and implant and breast

46

03

7

Salvage and implant and breast

90

03

Total

 

1436

40

It was found that out of 1436 articles published until 2015, 40 of them were selected (39 from Pubmed and 1 from Cochrane Library) based on the topics: risk factors for complications in breast reconstructive surgery, surgical site infection in breast procedures, antibiotic prophylaxis in breast surgery, irrigation of breast implant pocket, and biofilm and capsular contracture. Articles about complications with autologous tissue reconstruction, case reports, and nonhuman procedures were excluded.

46.1 Infection Incidence Rates in Breast Surgery with or Without Implants

Breast surgeries are classified as clean according to the surgical wound classification, and infection rates are usually less than 2%. Comparing mastectomy to aesthetic procedures, the former has 4.4% and the latter 1.1% infection [13].

Reconstructive breast surgery can be exhausting for patients because it demands more interventions, such as the use of implants, immediate and delayed contralateral symmetrization, treatment of complications, and nipple reconstruction. In 2014, the median number of procedures was 2.37 by breast [14].

Complication incidence rates differ significantly between distinct institutions. In 134 studies with 42,146 patients (8.2% of these studies were randomized trials), there has been found less than 20% of complications. The author recommends more accurate methodological criteria to determine the exact rate of complication [15].

In breast reconstruction with implants or tissue expanders, infection rates vary in 1–30%, depending on definition of surgical site infection, type of procedure, patient’s comorbidities, follow-up, pre- and postoperative assessment and treatments, and proper registration in patient’s data [16].

46.2 Risk Factors for Breast Implants

There are multiple and complex variables associated with surgical site infection (SSI) rates and, as a severe consequence of it, extrusion of the implant. The definition of SSI from the Center Disease Control and Prevention (CDC) is based on those criteria [17]:
  • Purulent drainage, with or without laboratory confirmation, from the superficial incision

  • Organisms isolated from an aseptically obtained culture of fluid or tissue from the superficial incision

  • At least one of the following signs or symptoms of infection: pain or tenderness, localized swelling, redness, or heat

  • Diagnosis of superficial incisional SSI by the surgeon or attending physician

In 2009, a strong association was shown between infection and these variables: large breasts (p < 0.001), previous irradiation (p = 0.007), and repeated implant (p = 0.008). Additional significant covariates in this model included one surgical oncologist (p = 0.003) [11]. In 2012, another study with 195 women demonstrated cellulitis as an independent factor, raising more than 200 times the risk of infection [18].

In 2012, a meta-analysis with eight randomized trials described those following risk factors: increased age (OR 1.73), hypertension (OR 1.69), higher body mass index—BMI (OR 1.96), diabetes mellitus (OR 1.88), American Society of Anesthesiologist (ASA) 3 or 4 (OR 2.06), previous breast biopsy or surgery (OR 1.84), preoperative chemoradiation (OR 2.97), hematoma (OR 2.45), seroma (OR 1.65), intraoperative bleeding (OR 1.38), postoperative drain (2.84), longer drainage time (OR 2.95), and second drainage tube placed (OR 3.35) [16].

Another study with 981 Japanese women that were reconstructed with tissue expanders or implants was described: diabetes (OR 4.22), repeated expanders (OR 2.81), expanders larger than 400 cc (OR 2.52), postoperative hormone therapy (OR 2.50), preoperative chemotherapy (OR 2.36), nipple-sparing mastectomy (OR 2.30), and delayed reconstruction (OR 1.21) [19].

In a review with 14,585 patients, factors were age >55 years (OR 1.66, p = 0.013), class II obesity (OR 3.17, p < 0.001), active smoking (OR 2.95, p < 0.001), bilateral reconstruction (OR 1.69, p = 0.007), and direct-to-implant reconstruction (OR 1.69, p = 0.024) [20].

Using the ACS-NSQIP program in 12,163 patients from 250 institutions who made immediate reconstructions with expanders, researchers identified the following risk factors: age >55 years (OR 1.4), BMI > 30 (OR 3.4), operative time >4 h (OR 1.9), and acellular dermal matrix—ADM (4.5% versus 3.2% in the patients who didn’t use ADM) [21].

A recent publication described as predictors of complication: radiation (raising infection and capsular contracture 5–48%), smoking (37.9%), BMI >30 (seven times more reconstruction failure), hypertension (twice more), and previous conservative mastectomies with radiotherapy. The material of the implant, immediate reconstruction, and fat grafting can improve the aesthetic results [22].

Summarizing, Table 46.2 shows the risk factors for infection that was found in this review:
Table 46.2

Risk factors that increase the rates of infection in breast surgeries using implants

Patient characteristics

Surgery

Clinical treatment

Diabetes (OR 4.22)

Repeated implants (OR 2.81)

Preoperative chemotherapy

BMI > 30 (OR 3.1–3.4)

Expansor larger than 400 cc (OR 2.52)

Radiotherapy

Smoking (OR 2.95)

Nipple-sparing mastectomy (OR 2.3)

Postoperative hormone therapy

Age > 55 years (OR 1.4–1.66)

Operative time >4 h (OR 1.9)

 

Others: hypertension, previous breast biopsy or surgery, large breasts

Bilateral reconstruction (OR 1.69)

 
 

Direct-to-implant reconstruction (OR 1.69)

 
 

Delayed reconstruction (OR 1.21)

 
 

Others: drains, surgeon’s experience, the absence of antibiotic prophylaxis, acellular dermal matrix, intraoperative bleeding, hematoma, seroma, cellulitis

 

46.3 Capsular Contracture (CC) and Infection

Capsular contracture is the most common complication in augmentation mammoplasty. Usually aesthetic procedures have less CC than reconstruction (11% × 37.5% CC), but the rates can vary from 2% to 80% of CC in breast reconstruction with implants [23, 24].

The material and the pocket placement can influence those incidence rates. Smooth implant surfaces have higher incidence of CC than textured ones (statistical significance at 3.10; 95% CI, 2.23–4.33). Only the subglandular group had a statistically significant pooled result of 3.59 (95% CI, 2.43–5.30) [25]. Radiotherapy has an adverse impact in capsular contracture, well-described in articles and reviews. CC in patients with radiotherapy can reach 21.6% versus 3.3% in non-radiated patients [26].

Capsular contracture score is based on Baker classification (1975), which includes clinical firmness evaluation of the breast:
  • Grade I—the breast is normally soft and appears natural in size and shape

  • Grade II—the breast is a little firm but appears normal

  • Grade III—the breast is firm and appears abnormal

  • Grade IV—the breast is hard and painful to touch and appears abnormal

Capsular contracture can occur in days, months, or years after the surgery. The precise cause is still unknown, but there are theories about inflammatory and infectious etiology. Exaggerated inflammatory response was identified in patients with CC. The quantity of silicon particles associated with macrophages and myofibroblasts providing a contractile force seems to influence the severity of contracture [27].

The infectious hypothesis is based on biofilm, in which bacterial stimulus maintains inflammation and fibrosis. Some studies describe the incidence of CC four times higher with biofilm. Subclinical bacterial colonization can be found in up to 66.7% Baker III and IV CC. The microorganisms usually found in those cases are coagulase-negative staphylococcus species and Propionibacterium acnes, and capsular infection is more associated with Staphylococcus epidermidis [9].

The contamination can occur because of contaminated saline solution or implant, surgical room, skin microbiome, and mammary ducts besides bacterial invasion from other sites [26].

Some prophylactic methods can be used to diminish the probability of infection and CC, such as textured implants, submuscular pocket, inframammary incision, adequate hemostasis, and antibiotic prophylaxis [28].

46.4 Antibiotic Prophylaxis in Breast Implants

Despite of the use of antibiotic prophylaxis by surgeons in breast reconstruction, the rates of surgical site infections are still high and can reach 35% [29].

The use of antibiotic prophylaxis in breast surgery is not a consensus. Some surgeons select the cases they are going to use it, like high-risk patients for infection [30], while others use antibiotics for every patient for 7 days or during the drainage. The National Surgical Infection Prevention Project suggests that antibiotic prophylaxis should not last longer than 24 h, based on studies from plastic surgeries and not breast reconstructions with implants [31].

The discussion about the best option of antibiotic and for how long the surgeon should maintain the prophylaxis remains. In some institutions cephalexin is prescribed; for others vancomycin, azithromycin, clindamycin, ampicillin-sulbactam, or quinolones can be used. Craft indicated in his study the use of vancomycin, nasal swab evaluation to treat methicillin-sensitive and methicillin-resistant Staphylococcus aureus before surgery with mupirocin nasal ointment, chlorhexidine scrub to the surgical area, and breast pocket irrigation with povidone-iodine as well as a triple antibiotic solution [29].

In this review, three articles were selected to show the impact of antibiotic prophylaxis in aesthetic and reconstructive breast surgeries (Table 46.3).
Table 46.3

Impact of antibiotic prophylaxis in aesthetic and reconstructive breast surgeries

Article

Type of study

Year

Objective

Results

Once Is Not Enough: Withholding Postoperative Prophylactic Antibiotics in Prosthetic Breast Reconstruction Is Associated with an Increased Risk of Infection [32]

Retrospective

2012

• To determine whether the change in antibiotic prophylaxis regimen would affect rates of surgical site infections

• To compare preoperative and postoperative prophylactic antibiotics with only a single dose of preoperative antibiotic

• Breast pocket irrigation was used according to surgeon’s preference

• The overall rate of SSI increased from 18.1% to 34.3% (p = 0.004)

• 4.74 times more likely to develop a surgical site infection requiring reoperation in the preoperative antibiotic group

• Infections requiring reoperation increased from 4.3% to 16.4% (p = 0.002)

Prophylactic Antibiotics to Prevent Surgical Site Infection After Breast Cancer Surgery [33]

Systematic review

2014

• 2867 patients

• To determine the effects of prophylactic (pre- or perioperative) antibiotics on SSI after breast cancer surgery

• Prophylactic antibiotics used preoperatively reduce the risk of SSI in patients undergoing surgery for breast cancer

• Further studies with patients undergoing immediate breast reconstruction are needed

Antibiotic Prophylaxis in Prosthesis-Based Mammoplasty: A Systematic Review [34]

Systematic review

2015

• To compare systemic antibiotic prophylaxis more than 24 h postoperatively with antibiotic prophylaxis within 24 h

• 2438 patients

• Cephalosporin was the most commonly preferred antibiotic regimen, vancomycin or clindamycin in allergic patients

• Extended systemic antibiotic prophylaxis more than 24 h postoperatively could significantly decrease infection risk

• Extended antibiotic prophylaxis could significantly decrease SSI risk in implant reconstruction surgery, but not in aesthetic procedures

46.5 Pocket Irrigation in Breast Implants

Studies from 1986, 1994, and 1995 had already shown benefits of prosthesis pocket povidone-iodine irrigation in reducing capsular contracture. A review including 1244 augmentation mammoplasty patients whose surgeons prescribed intravenous cefuroxime during the procedure and have done irrigation of the pocket with a solution of cefuroxime 750 mg, gentamycin 80 mg, and povidone-iodine 10% found only 10 cases of Baker III and IV capsular contracture, which is 0.6% of the patients (p = 0.006) [35].

There is a 6-year prospective study with 335 aesthetic and reconstructive breast surgery patients who were submitted to pocket irrigation with povidone-iodine 50 mL, cefazolin 1 g, and gentamycin 80 mg diluted in 500 mL of saline solution. The follow-up of the study was 14 months. 1.8% of patients had Baker III and IV CC in aesthetic surgeries, no patient had it in breast augmentation and mastopexy, and 9.5% of patients had it in breast reconstruction. The researchers recommend triple solutions in breast augmentation and reconstruction [36].

A retrospective cohort study with 33 breast augmentation patients compared two different groups. The first one, group A, had a single dose of intravenous cefalotin 1.5 g intraoperatively plus cephalexin 750 mg orally for 7 days. The second one, group B, had a single dose of intravenous cefuroxime 750 mg intraoperatively and irrigation of the pocket with a solution of 25 mL of 10% povidone-iodine, cefuroxime 750 mg, and gentamycin 80 mg diluted in 150 mL of saline solution plus levofloxacin 500 mg for 5 days. The infection rates were 1.8% and 1.2%, and capsular contracture rates were 6% and 0.6%, respectively [37].

A recent systematic review of cosmetic breast augmentation analyzed three retrospective and one prospective studies. It compared the incidence of CC in a group with pocket irrigation and another one without it (control group). The median CC rate in the first group was 4.86% versus 6.81% of the control group. The odds ratio of CC was 0.472 (95% CI, 0.316–0.707, p < 0.001) in the irrigation group [34].

A 2015 meta-analysis of patients undergoing aesthetic breast augmentation evaluated nine studies with a total of 5153 women. Only three comparative studies achieved high methodological quality. The meta-analysis included four studies, with 1191 patients receiving povidone-iodine irrigation and 595 patients receiving saline irrigation. The meta-analysis indicates povidone-iodine irrigation for decreasing Baker class III/IV capsular contracture (2.7% versus 8.9%; OR, 0.30; 95% CI, 0.18–0.50; p < 0.00001; I = 0%). The reported implant rupture rates for both silicone and saline implants were less than 1% [35].

The most common germs found in implant infections are Staphylococcus epidermidis, methicillin-sensitive Staphylococcus aureus, Serratia mascescens, Pseudomonas aeruginosa, Enterococcus sp., Escherichia coli, Enterobacter sp., group B streptococcus, and Morganella morganii. In this analysis, 70% of bacteria were cefazolin-resistant and sensitive to gentamycin (86%), levaquin (80%), and ciprofloxacin (63%). In those cases with skin necrosis, the surgeon should consider Pseudomonas aeruginosa infection resistant to ciprofloxacin, and levofloxacin is a better choice. ADM was used in 70% of the reconstructions in this group [38].

The severity of periprosthetic infection and the presence of skin necrosis are important factors to evaluate when considering salvage of prosthesis. Some protocols can reach salvage rates of 76.7%; others describe 37.3% with the following interventions: culture of the capsule, exhaustive irrigation of the pocket with antibiotic solutions, capsulectomy and capsulotomy, removal of necrotic tissue, and positioning of a new implant [39, 40].

46.6 Conclusion

The infection incidence rates in breast reconstruction are higher than in aesthetic procedures. Many factors can influence these rates such as factors related to the patient, the procedure itself, and the treatment of the disease. In the implant infection/pathology, it is included inflammatory reaction and biofilm formation. Antibiotic prophylaxis, prosthesis pocket irrigation, and intraoperative cares are essentials to protection.

Notes

Conflict of Interest

There is no conflict of interest.

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Copyright information

© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  • Emannuel Filizola Cavalcante
    • 1
  • Douglas de Miranda Pires
    • 2
  • Régis Resende Paulinelli
    • 3
    • 4
  • Carolina Lamac Figueiredo
    • 5
  • Carolina Nazareth Valadares
    • 6
  • Mariana dos Santos Nascimento
    • 6
  1. 1.Hospital Santa Casa de MisericórdiaSobralBrazil
  2. 2.Oncoplastic and Reconstructive Surgery DepartmentSanta Casa de MisericórdiaBelo HorizonteBrazil
  3. 3.Mastology Program, Department of Gynecology and ObstetricsFederal University of Goiás, Service of Gynecology and Breast, Hospital Araújo Jorge, ACCG (Associação de Combate ao Câncer em Goiás)GoiâniaBrazil
  4. 4.Gynecologist and Breast Service of Araujo Jorge HospitalBreast Fighting Association in GoiásGoiásBrazil
  5. 5.Hospital Santa Casa de MisericórdiaBelo HorizonteBrazil
  6. 6.Santa Casa de MisericórdiaBelo HorizonteBrazil

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