Infectious Complications Following Breast Reconstruction With Implants

Maurice Nahabedian, MD
Director: Center for Reconstructive and Aesthetic Surgery of the Breast
Johns Hopkins Hospital

The role of tissue expanders and implants in breast reconstruction following mastectomy is well established. In general, implant reconstruction is a two-stage process in which the temporary tissue expander is positioned followed a few months later by removal of the expander and insertion of a permanent implant. This procedure can be performed immediately following mastectomy or on a delayed basis. This form of breast reconstruction is usually well tolerated with high patient satisfaction; however, premature removal of the tissue expander or permanent implant has been demonstrated to occur in 2 to 10 percent of cases. A variety of etiologies have been reported that include infection, implant deflation, skin loss, hematoma, implant exposure, pain, and patient dissatisfaction. This review will focus on the infectious complications.

Infectious complications following breast reconstruction using implants have been reported to occur in 2 to 5 percent of patients. Infections can occur as a post surgical complication and manifest a few days following insertion or on a delayed basis manifesting months following insertion. Common signs and symptoms include pain, redness, fever, and swelling of the breast. At initial presentation, hospital admission is required for administration of intravenous antibiotics. If after 24 to 48 hours there is no significant improvement, operative exploration is required. In the majority of cases (90% in my experience) the implant has to be removed, however the implant can occasionally be salvaged. Following removal of the implant, the wound is irrigated, debrided, and closed over a drain. The drain is removed after 3 to 7 days, and oral antibiotics are administered for 7 to 10 days. Placement of a second implant or reconstruction using autologous tissue is considered after 6 months.

At the Johns Hopkins Hospital, the majority of our reconstructions (65%) utilize autologous tissue. However, over the past 5 years, we have performed 209 breast reconstructions using tissue expanders and implants. Infectious complications have occurred in 7 women (3.3%). The average time from expander/implant insertion to expander/implant removal was 122 days (range 20 to 278 days). Chemotherapy (adjuvant and palliative) was administered in 5 of these 7 women (71%) and appears to be a risk factor in the development of infection. Chemotherapy may temporarily weaken the immune system that can increase the incidence of infection via bacterial seeding of the implant. There were no implant infections related to radiation therapy.

Review of the literature demonstrates a paucity of information on this subject. In a recent article from Memorial-Sloan Kettering spanning a 10-year interval, the premature removal of the tissue expander was required in 14 of 771 patients (1.8%). The primary reason for removal of the expander was infection in 7 women followed by exposure, skin necrosis, patient dissatisfaction, and persistent cancer. The infected tissue expanders were removed at a mean of 3.2 months (range, 1 to 8 months) following insertion. Approximately 50% of the women were receiving adjuvant chemotherapy at the onset of the infection and one patient reported tobacco use. Diabetes mellitus, obesity, other concomitant medical illnesses, and prior mantle irradiation were not associated with expander removal.

In conclusion, the incidence of infectious complications following tissue expander/implant reconstruction following mastectomy is low (2-4%). The only factor that may predispose to late onset infection appears to be chemotherapy. In the event of expander or implant removal because of infection, reconstructive options for breast reconstruction are available and include insertion of a second expander/implant a few months later or use of autologous tissue.