Infection Following Implant-Based Breast Reconstruction: Salvage Rates and Predictors of Success

PURPOSE:  Few studies address salvage rates for infection in implant-based breast reconstruction and predictors of success. There remains controversy regarding indications for device explantation versus attempted salvage.

METHODS:  Retrospective analysis of multi-surgeon consecutive implant-based reconstructions from July 2004 to December 2010 was conducted at the Mass General Hospital. Patient demographics, labs, and microbiology specimens were analyzed as potential risk factors for infection and device loss.

RESULTS:  Immediate implant-based reconstruction was performed in 1241 patients and 1952 breasts following mastectomy. Of the reconstructions, 99 (5.1%) developed breast erythema and were admitted for possible infection in 94 patients. These patients had a higher incidence of smoking (p<0.01), chemotherapy (p<0.01) and radiation (p<0.001). With IV antibiotics, 25 (25.3%) reconstructions improved, while 74 (74.7%) reconstructions were taken to the OR for attempted salvage (18) or explant (56). Patients who failed to clear the infection medically had a higher average admission WBC, and the WBC was more likely to be >10,000 (p<0.03). Of the attempted salvage group, 12 cleared the infection with immediate implant exchange (11) or flap salvage (1) and six eventually lost the implant. Patients who failed implant salvage with medication and/or operative exchange were more likely to have MRSA (p<0.006). The total explant rate was 3.2%. Following explantation, 32 patients had delayed tissue expander insertion after an average of 150 days, 6 had delayed autologous reconstruction after an average of 139 days, 13 patients had no further attempt at reconstruction, and 5 patients were lost to follow-up. Of the delayed tissue expander insertions, 26 were successful and 6 had recurrent implant loss. There were no significant differences in patient demographics or time interval to delayed tissue expander insertion between successful and unsuccessful secondary surgeries.

CONCLUSION: Salvage of the infected breast prosthesis remains a challenging yet viable option for a subset of breast reconstruction patients.  Implant salvage with intravenous antibiotics and/or implant exchange was successful in 37.3% of patients. Smoking, radiation, and chemotherapy were significant predictors for developing infection. Patients with a WBC>10,000 and MRSA were more likely to fail implant salvage attempts.