UvA-DARE (Digital Academic Repository) Topics in plastic surgery of the breast Lapid, O. Link to publication

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1 UvA-DARE (Digital Academic Repository) Topics in plastic surgery of the breast Lapid, O. Link to publication Citation for published version (APA): Lapid, O. (20). Topics in plastic surgery of the breast General rights It is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), other than for strictly personal, individual use, unless the work is under an open content license (like Creative Commons). Disclaimer/Complaints regulations If you believe that digital publication of certain material infringes any of your rights or (privacy) interests, please let the Library know, stating your reasons. In case of a legitimate complaint, the Library will make the material inaccessible and/or remove it from the website. Please Ask the Library: or a letter to: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam, The Netherlands. You will be contacted as soon as possible. UvA-DARE is a service provided by the library of the University of Amsterdam ( Download date: 21 Apr 2018

2 USE OF GENTAMICIN COLLAGEN SPONGES FOR THE TREATMENT OF PERIPROSTHETIC BREAST IMPLANT INFECTION

3 Abstract The infection of a breast implant or tissue expander is a major complication with significant psychological and medical ramifications. The incidence has been reported to range from 1.1% in cosmetic augmentations to as high to 24% in a series of reconstructive cases. Gentamicin Surgical Implant is a surgical implant comprised of a lyophilised collagen matrix impregnated with a broad-spectrum antibiotic. When placed in the operative field, it achieves very high local concentrations of drug several fold above the minimal inhibitory concentrations; and the collagen carrier is absorbed. Its beneficial use has been reported in other fields of surgery. Gentamicin sponges were used in four cases of periprosthetic infections. The implants were removed, the pockets cleaned with pulse lavage and the implants were replaced, together with a gentamicin collagen implant. This was followed by a 6-week systemic antibiotic regimen. The patients had uneventful recovery and have not developed capsular contracture. Gentamicin collagen sponges may be used as an adjunct in the salvage of infected breast implants. Periprosthetic infections, as well as the use of gentamicin, are reviewed. Oren Lapid Journal of Plastic, Reconstructive & Aesthetic Surgery (2011) 64, e313ee

4 Introduction The infection of a breast implant or tissue expander is a major complication. The incidence has been reported to range from 1.1% in cosmetic augmentations [1] to as high as 24% in reconstructive cases [2]. The common strategy is to remove the infected implant and wait for 6 months before reinsertion. This approach is deleterious to the surgical result besides being psychological taxing. Patients with an infected implant are managed using the following protocol. Intravenous ciprofloxacin and clindamycin are started, the patients are operated as soon as possible, the pocket is cultured, the implant is removed and the pocket cleaned with pulse lavage using 6 l of saline followed by rinsing with Povidone-iodine. A new implant is inserted, together with a gentamicin-impregnated sponge. The sponge is cut in two; one-half is put at the upper pole of the pocket, whereas the second one is placed between the breast implant and the closure line. If there is no similar breast implant available, the old implant is also cleaned using the pulse lavage and rinsed in Povidone-iodine prior to reinsertion. Oral antibiotics are continued for 6 weeks postoperatively. This protocol was successfully used in four cases of secondary surgery complicated by periprosthetic infections; see Table 1. Table 1. Patient age HX Operation indication Time following surgery days Culture Implant f/u months outcome 1 47 Augmentation Mastectomy reconstruction 2 24 Augmentation Gestational hypertrophy mastectomy and reconstruction 3 48 mastectomy, delayed implant reconstruction, 3 revisions 4 47 Breast augmentation capsular contracture Infection after revision for asymmetry Infection after implant exchange for reconstruction Infection after revision for Infection after capsulectomy 13 Staphylococcus aureus 5 staphylococcus epidermis 180 Leucocytes Negative culture 60 Staph coagulase negative old 30 Baker I nl scar old 36 Soft minimal capsule contracture nl scar Old 20 Soft breast nl scar. New 30 Baker II nl scar 163

5 Case reports Patient 1 A 47-year-old patient underwent revision surgery due to asymmetry. She had a history of bilateral augmentation followed by a unilateral subcutaneous mastectomy and implant reconstruction due to DCIS. At surgery, the pockets and skin envelope were revised and the implants were exchanged. The patient received prophylactic Flucloxacilline; the pockets were irrigated with Povidone-iodine. Two weeks postoperatively, the patient had complaints of increasing fever, pain and redness and induration of the non-reconstructed breast, which had not improved despite 3 days of treatment with oral antibiotics administered by her general physician. The breast was red, swollen and indurated; the patient was febrile, and had leucocytosis and an increased C-reactive protein (CRP). The patient was treated according to the protocol, the pocket contained a cloudy fluid and the original implant was reinserted. The cultures were positive for Staphylococcus aureus (Figures 1 and 2). Oral ciprofloxacin and clindamycin were continued for a total of 6 weeks. On a follow-up of 30 months, the patient has had no further complications and no significant capsular contraction (Baker class 1). Patient 2 A 26-year-old patient with a history of subglandular breast augmentation developed gestational gigantomasty requiring bilateral mastectomies during her pregnancy. Figure 1. Patient 1 before surgery, the right breast is red, swollen and tense. 164

6 Delayed reconstruction was performed a year later with submuscular tissue expanders; this was complicated by an infection of the right tissue expander, requiring explantation. Cultures were positive for Staphylococcus epidermidis. Six months later, definitive reconstruction was performed with textured anatomic gel implants. As per protocol, the pockets were irrigated using Povidoneiodine and prophylactic Flucloxacilline was administered preoperatively. Five days postoperatively, the patient developed fever, swelling and redness of the right breast. Figure 2. Patient 1, Result at 30 months The patient was treated according to the following treatment of the infection protocol; the same implant was reinserted. following the presented protocol. (the The cultures were once again positive right breast has been augmented, the left breast has been reconstructed with for S. epidermidis. Oral ciprofloxacin and an implant following mastectomy). Clindamycin were continued for a total of 6 weeks. Over a 3-year follow-up, the patient has had no further complications and no significant capsular contracture. Discussion An infection of a breast implant is a major complication. Removal of the implant is deleterious for the surgical result and for the psychological well-being of the patient. In a review of 3002 patients with primary breast augmentations, Araco et al. reported a 1.1% rate of infection; the common pathogens were S. epidermidis and S. aureus [1]. The Danish registry for plastic surgery of the breast reported, in a series of 5373 women, a 1.5% incidence of infections, of which 23% required surgical intervention [3]. Armstrong et al. reported an infection rate of 24% in patients undergoing breast reconstruction [2]. There are many case reports of infections with atypical bacteria as well various species of mycobacteria. The common approach is to remove an infected breast implant and wait for 6 months after resolution of the infection before attempting reinsertion [4, 5]. However, there have been reports of successful salvage of infected breast implants. Courtiss et al. stated that infected implants may be salvaged [6]. De Lorenzi used pulse lavage [4]. Chun reported a protocol of intravenous antibiotics followed by drainage of fluid, manual debridement and curettage of the infected pocket, device exchange and postoperative antibiotics. Gentamicin, an aminoglycoside antibiotic, is rapidly bactericidal; the efficacy is concentration dependent. A post-antibiotic effect, that is, residual bactericidal activity persisting after the serum concentration has fallen below the minimum inhibitory 165

7 concentration (MIC), has also been reported. The microbiological spectrum of aminoglycosides is presented in Table 2. At high concentrations, gentamicin may also be effective against resistant bacteria [7]. However high concentrations may cause ototoxicity, nephrotoxicity and neuromuscular blockade. Gentamicin Surgical Implant is a perioperative surgical implant comprised of a collagen matrix impregnated with the broad-spectrum antibiotic. When placed in the operative field, it achieves very high local concentrations of drug several fold above the MIC. Such concentrations cannot be achieved with systemic parenteral administration due to the associated toxicity. At the local concentrations achieved, Table 2. Reported Microbiologic spectrum of aminoglycosides Sensitive Escherichia coli Klebsiella spp. Proteus mirabilis, Proteus vulgaris, Proteus penneri Providencia stuartii, Providencia alcalifaciens Enterobacter spp. Morganella morganii Salmonella spp. Shigella spp. Serratia marcescens Citrobacter spp. Aeromonas spp. Pseudomonas aeruginosa Acinetobacter baumannii, Acinetobacter Iwoffi Methicillin-susceptible Staph. aureus non-staph. aureus spp. (e.g. Staphylococcus epidermidis) Yersinia pestis Francisella tularensis Brucella spp. Haemophilus influenzae Mycobacterium tuberculosis, selective atypical mycobacteria (e.g. Mycobacterum fortuitum) Neisseria meningitidis, N. gonorrhoeae Moraxella catarrhalis Legionella spp. Resistant Streptococci Enterococci MRSA Methicillin-resistant Staph. aureus Anaerobes Stenotrophomonas maltophilia Burkholderia cepacia Flavobacterium spp. Mycoplasma spp. Mycobacterium kansasii Mycobacterium avium-intracellulare Burkholderia cepacia Rickettsiae Fungi Viruses 166

8 gentamicin may also be active against resistant bacteria [7]. The collagen carrier is absorbed by the body. The product is available as a sponge of equine collagen 10x 10 x 0.5 cm containing 130 mg of gentamicin (Garacol; Schering-Plough). The use of these implants has been reported in the treatment of bone and soft-tissue infections [7], for the salvage of infected hip prostheses [8], in the treatment of pilonidal sinus [9], hydradenitis, and in the management of sternal wounds [10]. It is possible that the treatment protocol presented could have salvaged the implants without the use of gentamycin implants. However, in three cases, the infections were managed despite the compromise that was made of implanting contaminated textured implants that were possibly still harbouring pathogens in a biofilm. The patients had a high risk for the development of capsular contractures, but did not develop any. This may be an additional benefit of this treatment; however, further investigation is warranted. Conclusion Periprosthetic infections can be successfully managed with aggressive lavage and antibiotic therapy. Gentamicin sponges may a useful adjunct in the management protocol and in the prevention of capsular contraction. References 1. Araco A, Gravante G, Araco F, Delogu D, Cervelli V, Walgenbach K: Infections of breast implants in aesthetic breast augmentations: a single-center review of 3,002 patients. Aesthetic Plast Surg 2007, 31(4): Armstrong RW, Berkowitz RL, Bolding F: Infection following breast reconstruction. Ann Plast Surg 1989, 23(4): Hvilsom GB, Holmich LR, Henriksen TF, Lipworth L, McLaughlin JK, Friis S: Local complications after cosmetic breast augmentation: results from the Danish Registry for Plastic Surgery of the breast. Plast Reconstr Surg 2009, 124(3): De Lorenzi C: Successful treatment of acute periprosthetic breast infection with curettage, pulse lavage, and immediate device exchange. Aesthetic Plast Surg 2005, 29(5): Chun JK, Schulman MR: The infected breast prosthesis after mastectomy reconstruction: successful salvage of nine implants in eight consecutive patients. Plast Reconstr Surg 2007, 120(3): Courtiss EH, Goldwyn RM, Anastasi GW: The fate of breast implants with infections around them. Plast Reconstr Surg 1979, 63(6): Stemberger A, Grimm H, Bader F, Rahn HD, Ascherl R: Local treatment of bone and soft tissue infections with the collagen-gentamicin sponge. Eur J Surg Suppl 1997(578): Swieringa AJ, Tulp NJ: Toxic serum gentamicin levels after the use of gentamicin-loaded sponges in infected total hip arthroplasty. Acta Orthop 2005, 76(1): Holzer B, Grussner U, Bruckner B, Houf M, Kiffner E, Schildberg FW, Vogel P, Rosen HR: Efficacy and tolerance of a new gentamicin collagen fleece (Septocoll) after surgical treatment of a pilonidal sinus. Colorectal disease : the official journal of the Association of Coloproctology of Great Britain and Ireland 2003, 5(3): Friberg O: Local collagen-gentamicin for prevention of sternal wound infections: the LOGIP trial. APMIS 2007, 115(9):