Safe and Efficient Implant-Based Breast Reconstruction

Albert H. Chao, MD

Disclosures

Plast Reconstr Surg Glob Open. 2020;8(9):e3134 

In This Article

Avoiding and Managing Most-dangerous Complications

Infection

One of the most potentially impactful complications in implant-based breast reconstruction is infection. Since salvage is not always possible, infection can be a source of overall reconstructive failure. A key component of infection prevention is proper preparation of the surgical field and pocket before tissue expander and implant placement. Before insertion of the device, the pocket should be thoroughly irrigated, the skin cleansed with povidone-iodine solution, and new surgical gloves donned. The device should be minimally handled during placement, and at that juncture it is advisable to use only surgical instruments not used earlier in the case. Standardized protocols that incorporate these elements have been described and found to reduce the risk of infection.[23] Judicious drain placement is also recommended to prevent fluid collections that can serve as a nidus for infection. Existing evidence does not support the routine use of postoperative prophylactic antibiotics.[24,25]

Salvage of an infected prosthesis is possible in some cases. A multitude of management approaches have been described that include varying combinations of antibiotic therapy, radiologic drain placement, capsule curettage, capsulectomy, device exchange, and continuous antibiotic irrigation.[26] However, it is debated as to which of these interventions should be performed and precisely when to maximize the likelihood of successful salvage. Nevertheless, there are general principles that should be followed. First, the earlier infection is identified and addressed, the higher the likelihood of salvage. In this regard, it is important to educate patients on the signs and symptoms of infection. Second, initial management should consist of broad spectrum antibiotic therapy that covers the most common causative organisms, namely Staphylococcus epidermidis, S. aureus, Escherichia coli, Pseudomonas aeruginosa, Propionibacterium, and Corynebacterium.[27] Institutional antibiograms can aid antibiotic selection based on sensitivities of local microbiomes.[28] Patients should be followed closely to assess the response to antibiotic therapy, and if inadequate then surgical intervention is undertaken. Third, thorough evaluation (including intraoperative gram stain), irrigation, and debridement of involved tissues should be performed before making a decision about whether to attempt salvage of the reconstruction with device exchange. In patients who ultimately require tissue expander explantation, a second attempt at implant-based reconstruction is usually successful (79%).[29]

Exposure

Another potential source of reconstructive failure is device exposure. Like with infection, prevention is critical because once a prosthesis is exposed it is often unsalvageable. Exposure can occur both through sites of mastectomy flap necrosis or the incision itself. At the time of the breast reconstruction procedure, a thorough assessment of the thickness and perfusion of the flaps should be performed. Use of a tissue expander filled conservatively with air, or not at all, can help reduce pressure on the incision and mastectomy flaps when they may be marginal. If air is used, saline exchange is subsequently performed in the clinic at an appropriate time based on clinical assessment. Total submuscular reconstruction or delayed reconstruction should be considered when there are greater concerns about soft tissue coverage.

Breast Implant-associated Anaplastic Large Cell Lymphoma

Breast-implant–associated anaplastic large cell lymphoma (BIA-ALCL) is a form of lymphoma that can occur secondary to textured breast implants. The lifetime risk of developing BIA-ALCL is estimated to be approximately 1 in 2200 to 86,000.[30] Although rare, it is a potentially fatal condition, but readily treatable if identified and managed appropriately. Patients with BIA-ALCL most often present with breast asymmetry, mass, pain, or skin changes more than 1 year after placement of the implant. Patients with these signs and symptoms should be initially evaluated with ultrasound of the breast and regional lymph node basins.[31] If an effusion or mass is seen, fluid or tissue sampling should be performed, with cytology, histology, flow cytometry, and CD30 immunohistochemistry. A confirmed diagnosis of BIA-ALCL is most appropriately managed through a multidisciplinary approach. The surgical component of treatment generally consists of explantation and total capsulectomy. Immediate reconstruction should only be considered for disease that is confined to the capsule on preoperative positive emission tomography/computed tomography scan.[32]

There is currently no evidence that a difference in aesthetic outcome exists between textured anatomic implants and smooth round implants in breast reconstruction.[33,34] In this regard, and since a variety of cohesivity levels are widely available with smooth devices, it may be prudent for plastic surgeons to utilize implants with smooth shells, which can produce excellent aesthetic results while eliminating the potential risk for BIA-ALCL.

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