Use of Local Antibiotic Delivery Systems in Tissue Expander and Implant-Based Breast Reconstruction

A Systematic Review of the Literature

Nathan Makarewicz, BA; Kelsey Lipman, MD; Thomas Johnstone, BA; Mohammed Shaheen, JD; Jennifer Krupa Shah, BA; Rahim Nazerali, MD


ePlasty. 2023;23(e24) 

In This Article

Abstract and Introduction


Background: Periprosthetic infections are a debilitating complication of alloplastic breast reconstruction. Local antibiotic delivery for prophylaxis and infection clearance has been used by other surgical specialties but rarely in breast reconstruction. Because local delivery can maintain high antibiotic concentrations with lower toxicity risk, it may be valuable for infection prophylaxis or salvage in breast reconstruction.

Methods: A systematic search of the Embase, PubMed, and Cochrane databases was performed in January 2022. Primary literature studies examining local antibiotic delivery systems for either prophylaxis or salvage of periprosthetic infections were included. Study quality and bias were assessed using the validated MINORS criteria.

Results: Of 355 publications reviewed, 8 met the predetermined inclusion criteria; 5 papers investigated local antibiotic delivery for salvage, and 3 investigated infection prophylaxis. Implantable antibiotic delivery devices included polymethylmethacrylate, calcium sulfate, and collagen sponges impregnated with antibiotics. Non-implantable antibiotic delivery methods used irrigation with antibiotic solution into the breast pocket. All studies indicated that local antibiotic delivery was either comparable or superior to conventional methods in both the salvage and prophylaxis settings.

Conclusions: Despite varied sample sizes and methodologies, all papers endorsed local antibiotic delivery as a safe, effective method of preventing or treating periprosthetic infections in breast reconstruction.


Implant-based methods remain the most commonly performed type of postmastectomy breast reconstruction,[1] accounting for approximately 80% of reconstructions.[2] While autologous breast reconstruction is often rated higher than alloplastic reconstruction in terms of patient satisfaction,[3–6] increased surgical complexity, donor site morbidity, and requirement for microsurgical expertise remain limiting factors for many patients.[7] Despite their popularity, tissue expander and implant-based surgeries carry a higher risk of infection compared with that of autologous reconstruction,[2] which can lead to additional surgeries, significant patient morbidity, and even loss of the reconstructed breast pocket. The literature discussing infections in implant-based breast reconstructions (IBBRs) report infection rates ranging widely from 1% to 43%,[8] highlighting the importance of both effective infection prophylaxis and implant salvage protocols.

In an effort to mitigate this risk, antibiotics are a common tool used to prevent and treat surgical site infections. While there is currently no consensus regarding the prophylactic use of antibiotics,[9] their administration has been demonstrated to have some benefit[10] and is recommended for clean breast surgeries.[11] However, there is a lack of consistent evidence in support of antibiotic prophylaxis for other breast surgeries,[12] and adherence to guidelines among breast surgeons is poor.[13] Postoperative antibiotic use is another source of debate. Postoperative antibiotics are commonly prescribed following many surgical procedures, and some studies have identified a benefit from their use in prosthetic breast reconstruction.[14] However, on aggregate, there is limited evidence illustrating a benefit from postoperative antibiotic use;[15] in fact, the World Health Organization recommends against this practice.[16]

Once established, periprosthetic infections can be highly morbid and difficult to treat. Traditional methods for managing infected breast implants have previously included a trial of intravenous (IV) antibiotics, breast pocket washout with removal of the device, and consideration of delayed reconstruction several months later.[17,18] Reconstruction following infection and explantation is often abandoned by patients, especially when the primary reason for mastectomy is oncologic rather than prophylactic.[19,20] As a result of the morbidity posed by an infection following alloplastic breast reconstruction, many recent studies have investigated new modalities for preventing infection and salvaging infected implants. Local antibiotic delivery systems are of significant interest as they can greatly increase the concentration of antibiotics in the breast pocket without the same risk of complications that result from high systemic doses.

The use of local antibiotic delivery systems has been popularized in other surgical fields, such as orthopedic surgery, but their use within plastic surgery remains scarce. Antibiotic-infused bone cement has been used by orthopedic surgeons since the 1970s for the treatment and prevention of infections following joint arthroplasty.[21,22] More recently, the use of antibiotic-eluting devices like nonabsorbable polymethylmethacrylate (PMMA) or absorbable calcium sulfate have begun to appear in soft tissue surgeries, such as vascular surgeries[23–26] and hernia repair,[27,28] but their use is far from routine. Other proposed methods for local antibiotic delivery to surgical sites include continuous antibiotic infusion via catheterization[29] and antibiotic lavage.[30–32] Some authors even propose using materials like antibiotic-loaded collagen matrix[33,34] or antibiotic-infused surgical meshes[35–37] as a means of providing both local antibiotic delivery and soft tissue support; however, few publications have explored their efficacy in reconstructive surgery.

With breast cancer being the most common cancer among women worldwide, even a low incidence of surgical infection has the potential to affect a large number of patients.[38] Though novel, the use of local antibiotic delivery methods for infection prophylaxis and implant salvage may potentially offer better infection control than standard methods. Thus, the focus of this systematic review is to identify studies that use local antibiotic delivery as either a method of prophylaxis or salvage for IBBR and provide an evidence-based summary of their results.