BREAST

Management of the Infected or Exposed Breast

Prosthesis: A Single Surgeon’s 15-Year
Experience with 69 Patients
Scott L. Spear, M.D.
Background: In 2004, the senior author (S.L.S.) published an algorithm for the
Mitchel Seruya, M.D. management of breast device infection and/or exposure. The purpose of this
Washington, D.C. study was to build on the authors’ prior experience by expanding the cohort of
patients and to identify risk factors for failed breast device salvage and recurrent
infection/exposure.
Methods: A retrospective study was carried out on a single plastic surgeon’s
experience between 1993 and 2008. Patients with infected and/or exposed
breast devices were classified into one of seven groups and salvage rates were
calculated. Patient demographics and wound culture pathogens were
analyzed as possible risk factors for device loss and recurrent infection/
exposure.
Results: Over a 15-year period, the senior author managed 69 patients with
87 events of breast device infection and/or exposure. The overall salvage rate
was 64.4 percent. Failed device salvage was significantly associated with the
presence of atypical pathogens, such as Gram-negative rods, methicillin-
resistant Staphylococcus aureus, and Candida parapsilosis. Recurrent device
infection and/or exposure was significantly associated with a history of
radiotherapy or the presence of S. aureus on wound culture.
Conclusions: Salvage of the infected and/or exposed breast prosthesis re-
mains a challenging yet viable option for a subset of patients. Relative
contraindications include atypical pathogens on wound culture, such as
Gram-negative rods, methicillin-resistant S. aureus, and C. parapsilosis. Pa-
tients with a prior device infection and/or exposure and a history of either
radiotherapy or S. aureus on wound culture should be monitored closely for
signs of recurrence and managed cautiously in the setting of elective breast
surgery. (Plast. Reconstr. Surg. 125: 1074, 2010.)

B
reast implants continue to be a popular op-
tion for both aesthetic and reconstructive plas-
tic surgery patients. Augmentation mamma-
plasty has seen a 64 percent increase in volume
since the year 2000, and became the top cosmetic
procedure performed in the United States in
2007, with 347,500 new cases. Furthermore, pros-
thetic breast reconstruction has remained the
most common procedure performed for women
From the Department of Plastic Surgery, Georgetown Uni-
versity Hospital.
Received for publication June 29, 2009; accepted October 22,
2009.
Poster presented at the 88th Annual Meeting of the American
Association of Plastic Surgeons, in Rancho Mirage, Cali-
fornia, March 21 through 24, 2009.
Copyright ©2010 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0b013e3181d17fff
with acquired mastectomy defects, representing
75.5 percent of all breast reconstruction cases in
2007 in the United States.1
Despite improvements in breast implant design
and surgical technique, device infection and expo-
sure remain real concerns. Rates of infection have
ranged from 0.4 to 2.5 percent for augmentation
mammaplasty2– 6 and from 1 to 35.4 percent for
prosthetic breast reconstruction.3,7–13 Further-
more, rates of exposure have been reported
Disclosure: Dr. Spear is a paid consultant for
LifeCell Corp. (Branchburg, N.J.) and Allergan,
Inc. (Irvine, Calif.). Dr. Seruya has no financial
interest in any of the products, devices, or drugs
mentioned in this article.

1074 www.PRSJournal.com
Volume 125, Number 4 • Infected or Exposed Breast Prosthesis
between 0.29 and 2 percent for breast augm-
entation4,5 and between 0.25 and 8.3 percent for
device-based breast reconstruction.10,14,15
In the past, common practice was the immediate
removal of the infected or exposed breast prosthe-
ses16,17; however, the more recent plastic surgery lit-
erature has explored options for device salvage.3,18 –32
Methods for salvaging an infected device have
included systemic antibiotics combined with either
conservative wound drainage,3 antibiotic lavage,33
capsulotomy and device exchange,29 capsule
curettage and device exchange,18 antibiotic la-
vage followed by capsule curettage and device
exchange,28 or capsulotomy/curettage/device ex-
change followed by postoperative continuous an-
tibiotic irrigation.31,32 For exposed breast prosthe-
ses, salvage techniques have included conservative
wound care with systemic antibiotics,19 device ex-
change with primary closure with or without pos-
terior capsular flap coverage,25,26 and device ex-
change combined with muscular coverage.24
Despite a number of reports focusing on man-
agement of the infected or exposed breast pros-
thesis, there is still disagreement regarding the
wisdom of and indications for device salvage and
the optimal timing, setting, or technique. It would
be valuable for plastic surgeons to better define a
set of clinical guidelines addressing these very is-
sues, given the medical, legal, psychological, and
economic issues associated with possible implant
loss. Device explantation is a traumatic event and,
for practical purposes, represents the loss of a
breast. Successful device salvage offered to prop-
erly selected patients with the greatest possibility
of success would be a highly desirable alternative
to loss of an implant.
In 2004, the senior author (S.L.S.) introduced
an algorithm for the management of breast device
infection and/or exposure. Patients were strati-
fied into one of seven groups of infection/expo-
sure, and a treatment strategy was based on the
response of the infection to initial antibiotic ther-
apy and on the availability of soft-tissue coverage.27
As an initial step, that recommendation deserves
further review to validate its observations and to
refine its analysis.
The purpose of the present study was to build
on our prior experience by expanding the cohort
of patients and to try to better identify risk factors
for failed breast device salvage and recurrent in-
fection/exposure. With this added information,
patients and surgeons can make more informed
decisions regarding the likelihood of saving a
threatened breast prosthesis.
PATIENTS AND METHODS
A retrospective study was carried out on a sin-
gle plastic surgeon’s experience between 1993 and
2008. Patients with infected and/or exposed
breast devices were identified through a combi-
nation of quality improvement records of compli-
cations, office charts, and hospital records. Events
of device infection and/or exposure were classi-
fied into one of seven groups, as defined by Spear
et al.27 as follows: group I, mild infection; group II,
severe infection; group III, threatened exposure;
group IV, threatened exposure with mild infec-
tion; group V, threatened exposure with severe
infection; group VI, actual exposure with no/mild
infection; and group VII, actual exposure with
severe infection. Mild infection was defined as
warmth, swelling, cellulitis, or nonpurulent drain-
age that was responsive to initial antibiotic ther-
apy. Severe infection was defined as persistent or
substantial warmth/erythema/swelling despite
antibiotic therapy, purulent drainage, atypical
organisms on wound culture (e.g., methicillin-
resistant Staphylococcus aureus, Gram-negative
rods, mycobacteria, or yeast), or serious signs
and symptoms of systemic infection (e.g., high
fever, hypotension).
Salvage rates for individual classes of breast
prosthesis infection and/or exposure were calcu-
lated. Salvage rates were reported on a per-event
basis, given that a number of patients experienced
more than one episode of infection and/or ex-
posure. “Device salvage” was defined as the con-
tinued presence of a prosthetic device after
surgical intervention, though not necessarily reten-
tion of the original device.27 Depending on the ini-
tial response to antibiotics and the availability of
soft-tissue coverage, different modalities of device
salvage were used for the infected or exposed breast
device, as described previously.27 These included sys-
temic antibiotic therapy, wound edge débridement,
capsule curettage, capsulectomy, pulse lavage, de-
vice position change (e.g., subglandular to subpec-
toral), device exchange, primary closure, and/or
flap coverage.
Associated demographics, including patient
age, body mass index, former or active tobacco
use, history of chemotherapy, and exposure to
radiotherapy, were assessed as possible risk factors
for device loss and recurrent infection/exposure.
Patient demographics were reported on a per-
event basis for device loss and on a per-patient
basis for recurrent infection/exposure. This en-
sured comprehensive collection and analysis of all
available data.
1075

Wound culture pathogens were also investi-
gated as potential contributors to device loss and
recurrent infection/exposure. Culture data were
not available for every event of infection/expo-
sure, as some patients presented without evidence
of wound drainage. Pathogens were reported on
a per-event basis for device loss and on a per-
patient basis for recurrent infection/exposure.
For statistical analysis, the t test was used for
comparison of continuous variables, given their
normal distribution and equal variances. The Fish-
er’s exact test was used for evaluation of percent-
ages or frequencies. A value of p ⬍ 0.05 was con-
sidered statistically significant.
RESULTS
Over a 15-year period, the senior author man-
aged 69 patients with 87 events of breast device in-
fection and/or exposure. The mean patient age was
49.8 years (range, 17 to 75 years), and the average
body mass index was 23.4. Smoking history revealed
that 18.4 percent of events involved patients with
former or active tobacco use. Furthermore, 35.6 per-
cent of events were associated with a history of che-
motherapy use and 23.0 percent of incidents in-
volved patients with exposure to radiotherapy.
The mean postoperative time to breast prosthe-
sis infection/exposure was 5.5 months, with an over-
all device salvage rate of 64.4 percent. Salvage and
explantation rates for individual classes of infection
and/or exposure are listed in Table 1, with a mean
follow-up of 24.7 months. Thirty-four events involved
breast prostheses with mild infection, classified as
group I, and were associated with a 100 percent
salvage rate. Twenty-six events concerned devices
with severe infection, categorized as group II, and
resulted in a 30.8 percent salvage rate. Six events
involved threatened device exposure without signs
of infection, labeled as group III, and were associ-
ated with a 100 percent salvage rate. Three events
dealt with threatened device exposure with mild in-
fection, classified as group IV, and were related to a
66.7 percent salvage rate. Five incidents involved
Table 1. Salvage and Explantation Rates for Different Classes of Infected and/or Exposed Breast Prostheses*
Class of Infection and/or Exposure
Group I: Mild infection
Group II: Severe infection
Group III: Threatened exposure
Group IV: Threatened exposure with mild infection
Group V: Threatened exposure with severe infection
Group VI: Actual exposure with mild infection
Group VII: Actual exposure with severe infection
*Analyzed per event.
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Plastic and Reconstructive Surgery • April 2010
threatened prosthesis exposure with severe infec-
tion, categorized as group V, and were associated
with a 40.0 percent salvage rate. Six events concerned
actual device exposure with no/mild infection, labeled
as group VI, and were associated with a 66.7 percent
salvage rate. Seven incidents involved actual device ex-
posure with severe infection, classified as group VII,
and resulted in a 0 percent salvage rate.
Rates of contracture, hematoma, and seroma
were investigated for the 56 events of successful
device salvage. There was a 1.8 percent rate of
capsular contracture (Baker grade III/IV) and a
1.8 percent incidence of hematoma. There were
no occurrences of seroma or patient death.
Patient demographics and wound pathogens
were evaluated as possible risk factors for failed
device salvage and as potential predictors for suc-
cessful device salvage. As shown in Table 2, events
of failed device salvage were associated with a sig-
nificantly higher degree of atypical pathogens,
such as Gram-negative rods, methicillin-resistant
Staphylococcus aureus, and Candida parapsilosis, as
compared with events of successful salvage (42.9
percent versus 11.5 percent, p ⫽ 0.015). Events of
failed device salvage trended with an older mean
patient age, in contrast to events of successful sal-
vage, yet these results were not statistically signif-
icant (age 52.5 years compared with 48.3 years, p ⫽
0.069). Failed device salvage events had a higher
percentage of patients with exposure to radiother-
apy as compared with successful salvage events, yet
these findings did not reach statistical significance
(32.3 percent compared with 17.9 percent, p ⫽
0.18). Incidents of failed device salvage had a
higher degree of Gram-negative rods and S. aureus
on wound culture in relation to events of success-
ful salvage, yet neither result was found to be sta-
tistically significant (28.6 percent compare with
11.5 percent, p ⫽ 0.18; and 25.0 percent compared
with 7.7 percent, p ⫽ 0.14, respectively). Events of
successful prosthesis salvage were associated with
a higher percentage of coagulase-negative Staph-
ylococcus, in contrast to events of failed salvage;
Successful Salvage Explantation Rate without
Rate (%) Surgical Salvage Attempt (%)
34/34 (100) 0/34 (0)
8/26 (30.8) 18/26 (69.2)
6/6 (100.0) 0/6 (0)
2/3 (66.7) 1/3 (33.3)
2/5 (40.0) 3/5 (60.0)
4/6 (66.7) 1/6 (16.7)
0/7 (0) 6/7 (85.7)
Volume 125, Number 4 • Infected or Exposed Breast Prosthesis

Table 2. Risk Factors for Breast Device Loss* had a higher rate of tobacco and chemotherapy
Salvaged Failed use in relation to patients with a single episode,
(n ⴝ 56) (n ⴝ 31) p these findings were not found to be statistically
Mean age, years 48.3 52.5 0.069 significant (30.8 percent compared with 14.3 per-
Mean BMI, kg/m2 23.4 23.3 0.94 cent, p ⫽ 0.22; and 46.2 percent compared with
History of tobacco use, % 17.9 19.4 1.00 28.6 percent, p ⫽ 0.32, respectively). Patients with
History of chemotherapy, % 32.1 41.9 0.48
History of radiotherapy, % 17.9 32.3 0.18 recurrent episodes of device infection and/or ex-
Pathogens† posure had a lower degree of Gram-negative rods
Atypical flora‡, % 11.5 42.9 0.015 on wound culture in contrast to patients with a
Gram-negative rods, % 11.5 28.6 0.18
Coagulase-negative one-time event, yet this was not found to be sta-
Staphylococcus, % 30.8 17.9 0.35 tistically significant (7.7 percent compared with
Staphylococcus aureus, % 7.7 25.0 0.14 29.4 percent, p ⫽ 0.15). No statistically significant
No growth, % 42.3 35.7 0.78
effects on recurrent device infection and/or ex-
BMI, body mass index.
*Analyzed per event. posure were noted for age, body mass index, pres-
†Analysis based on salvaged and failed events with available wound ence of either atypical pathogens or coagulase-
culture, n ⫽ 26 and n ⫽ 28, respectively. negative Staphylococcus on wound culture, or
‡Gram-negative rods, methicillin-resistant Staphylococcus aureus, and
Candida parapsilosis. absence of growth on wound cultures.

however, this too was not statistically significant CASE REPORTS

(30.8 percent compared with 17.9 percent, p ⫽
0.35). No statistically significant effects on device
salvage were noted for body mass index, history of
tobacco use, exposure to chemotherapy, or ab-
sence of growth on wound cultures.
Patient demographics and wound pathogens
were also evaluated as possible risk factors for re-
current device infection and/or exposure. As
listed in Table 3, patients with recurrent device
infection and/or exposure were significantly as-
sociated with either a history of radiotherapy or
the presence of S. aureus on wound culture as
compared with patients with a one-time episode
(46.2 percent compared with 16.1 percent, p ⫽
0.028; and 38.5 percent compared with 5.9 per-
cent, p ⫽ 0.012, respectively). Although patients
with repeat episodes of infection and/or exposure
Case 1: Group I (Mild Infection)
A 35-year-old patient with a history of previous subglan-
dular augmentation mammaplasty underwent bilateral revi-
sion breast augmentation and primary mastopexy to address
breast asymmetry, ptosis, and distortion secondary to capsu-
lar contracture (Fig. 1). Operative steps included bilateral
total capsulectomies, pocket conversion to a dual plane,
placement of silicone smooth implants (Allergan 15-371,
15-339; Allergan, Inc., Irvine, Calif.), and circumvertical mas-
topexies. On postoperative day 4, the patient presented to
the emergency room with right breast swelling, erythema,
pain, and a low-grade fever. This was managed with a one-
time dose of vancomycin intravenously, followed by a course
of Augmentin (GlaxoSmithKline, Brentford, London, United
Kingdom) on discharge. After 5 days of oral antibiotic therapy,
the erythema was much improved and there was minimal breast
swelling. Symptoms resolved completely following a 10-day
course of Augmentin and the patient was without signs of in-
fection or capsular contracture at 11-month follow-up.

Table 3. Risk Factors for Recurrent Breast Device Infection or Exposure*

One-Time Infection/ Recurrent Infection/
Exposure (n ⴝ 56) Exposure (n ⴝ 13) p
Mean age, years 49.1 50.8 0.61
Mean BMI, kg/m2 23.8 23.0 0.59
History of tobacco use, % 14.3 30.8 0.22
History of chemotherapy, % 28.6 46.2 0.32
History of radiotherapy, % 16.1 46.2 0.028
Pathogens†, %
Atypical flora‡, % 32.4 30.8 1.00
Gram-negative rods, % 29.4 7.7 0.15
Coagulase-negative Staphylococcus, % 26.5 30.8 1.00
Staphylococcus aureus, % 5.9 38.5 0.012
No growth, % 29.4 38.5 0.73
BMI, body mass index.
*Analyzed per patient.
†Analysis based on one-time and recurrent infection patients with available wound culture, n ⫽ 34 and n ⫽ 13, respectively.
‡Gram-negative rods, methicillin-resistant Staphylococcus aureus, and Candida parapsilosis.

1077
 Plastic and Reconstructive Surgery • April 2010

Fig. 1. Case 1. (Above, left) A 35-year-old patient with a history of previous subglandular augmentation mammaplasty underwent
bilateral revision breast augmentation and primary mastopexy to address breast asymmetry, ptosis, and distortion secondary to
capsular contracture. (Above, right) On postoperative day 4, the patient presented with right breast swelling, erythema, pain, and
a low-grade fever. (Below, left) After 5 days of Augmentin, the erythema was much improved and there was minimal
breast swelling. (Below, right) At 11-month of follow-up, the patient was without signs of infection or capsular contracture.

Case 2: Group 2 (Severe Infection)
A 58-year-old patient underwent bilateral nipple-sparing
mastectomies and tissue expander reconstruction (Fig. 2). Ap-
proximately 4 years after bilateral implant exchange, the pa-
tient presented with right breast warmth and superior pole
erythema. This was managed with a 10-day course of oral cip-
rofloxacin and resulted in resolution of symptoms 1 month
later. A year and a half later, the erythema returned around the
nipple-areola complex. Despite initiating a course of cipro-
floxacin, the erythema waxed and waned and was accompanied
by a low-grade fever. Given local symptom recurrence in the
setting of antibiotic therapy, device salvage was undertaken.
This consisted of pocket curettage, pulse lavage, device ex-
change for smooth saline implants (Allergan 68HP-455), and
primary closure. Intraoperative cultures were negative and the
patient was continued on a course of ciprofloxacin postoper-
atively. At 15 months postoperatively, the patient had remained
symptom-free, without signs of infection.
Case 3: Group 6 (Actual Exposure with Mild
Infection)
A 52-year-old woman with a history of active tobacco use, tissue
expander reconstruction of a right skin-sparing mastectomy de-
fect, and radiotherapy, presented for right revision breast recon-
struction. Despite six revision procedures, the patient continued
to have capsular contracture and delayed wound healing of the
right reconstructed breast (Fig. 3). To address the complications,
the patient underwent partial subpectoral placement of a textured
silicone implant (Allergan 324-1051) supported by an acellular
dermal matrix inferior sling. Two months postoperatively, the
patient presented with right medial breast erythema and actual
implant exposure with serosanguineous drainage. Cultures
showed moderate coagulase-negative Staphylococcus and alpha-he-
molytic Streptococcus. With actual implant exposure associated with
common breast flora, a device salvage procedure was offered and
accepted by the patient. Operative details included total capsu-
lectomy, complete removal of the previously placed acellular der-
mal matrix, pedicled latissimus flap coverage of the soft-tissue–
deficient region, device exchange for a silicone smooth implant
(Allergan 10-210), and site change to a sub–latissimus/prepectoral
pocket. The patient received Ancef (GlaxoSmithKline, London,
United Kingdom) intraoperatively and was discharge to
home on a 10-day course of Duricef (Bristol-Myers Squibb,
Princeton, N.J.) by mouth. The patient remained infection-
free and healed uneventfully through her 7-month follow-up.

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Volume 125, Number 4 • Infected or Exposed Breast Prosthesis

Fig. 2. Case 2. (Above, left) A 58-year-old patient underwent bilateral implant exchange following tissue expander reconstruction
of bilateral nipple-sparing mastectomies. (Above, right) Approximately 4 years after bilateral implant exchange, the patient pre-
sented with waxing and waning right breast warmth and erythema despite repeated courses of ciprofloxacin. (Below, left) Postop-
erative photograph obtained 9 days after device salvage by means of pocket curettage, pulse lavage, device exchange for smooth
saline implants (Allergan 68HP-455), and primary closure. (Below, right) At 15 months postoperatively, the patient remained symp-
tom-free, without signs of infection.

Case 4: Group 7 (Actual Exposure with Severe
Infection without Salvage Attempt)
A 67-year-old patient with a history of active tobacco use and
pedicled transverse rectus abdominis musculocutaneous flap
reconstruction of a left modified radical mastectomy defect
presented for left revision breast reconstruction (Fig. 4). The
patient’s concern centered on the left superior pole deficiency
sustained after débridement of extensive flap fat necrosis. The
patient underwent partial subpectoral placement of a textured
saline tissue expander (Allergan 133MV-14) to address the soft-
tissue deficiency. Six months later, implant exchange for a
textured saline implant (Allergan 363LF), inferior capsulor-
rhaphy, and nipple-areola complex reconstruction were per-
formed. Two months postoperatively, the patient presented
with a pin-size, medial area of actual implant exposure that was
associated with serosanguineous drainage. Cultures were con-
clusive for ciprofloxacin-sensitive and Zosyn (Wyeth, Madison,
N.J.)-sensitive Pseudomonas aeruginosa. Despite a course of oral
ciprofloxacin, the serosanguineous drainage persisted and the
area of actual implant exposure increased in size. Given the
worsening clinical course, the patient was counseled for and
agreed to device explantation. The patient had an uneventful
postoperative course once the device was removed.
Case 5: Group 7 (Actual Exposure with Severe
Infection and Failed Salvage Attempt)
A 55-year-old patient with a history of bilateral mastectomies,
tissue expander reconstruction, and left-sided radiation therapy
underwent bilateral implant exchange and fat injection of the
left reconstructed breast (Fig. 5). Operative steps included left
inferior strip capsulectomy, left circumferential capsulotomy,
bilateral partial subpectoral placement of smooth silicone (Al-
lergan 20-500) implants, and 25 cc of fat injected into the
superior pole of the left reconstructed breast. Six weeks post-
operatively, the patient presented with a high-grade fever of
104°F, left-sided erythema, and left breast implant actual ex-
posure with serous drainage. Results of culture specimens taken
at the time were positive for methicillin-resistant S. aureus. The
fever subsided and erythema was much improved following a
2-week course of intravenous daptomycin. Given the patient’s
positive response to antibiotic therapy, the patient was offered
and consented to a device salvage procedure. The patient un-
derwent capsular curettage, pedicled latissimus flap coverage of
the soft-tissue– deficient region, device exchange for a saline
textured tissue expander (Allergan 133MV-14), and site change
to a sub–latissimus/prepectoral pocket. Postoperatively, the pa-
tient was managed with a 3-week course of intravenous vanco-

1079
 Plastic and Reconstructive Surgery • April 2010

Fig. 3. Case 3. (Above, left) A 52-year-old woman with a history of active tobacco use, radiotherapy, and seven right revision breast
reconstructions presented with right medial breast erythema, actual implant exposure, and serosanguineous drainage 2 months
postoperatively. Cultures showed moderate coagulase-negative Staphylococcus and alpha-hemolytic Streptococcus. (Above, right)
Device salvage by means of total capsulectomy, pedicled latissimus flap coverage of the soft-tissue– deficient region, device ex-
change for a silicone smooth implant (Allergan 10-210), and site change to a sub–latissimus/prepectoral pocket. (Below, left) Post-
operative view, 3 months after device salvage. (Below, right) The patient remained infection-free and healed uneventfully through
her 7-month follow-up.

mycin. One month postoperatively, the patient presented with
a low-grade fever, malaise, and return of left breast erythema.
Despite restarting intravenous vancomycin, the erythema per-
sisted. At this point, the patient decided to forgo further at-
tempts at device salvage and underwent an uneventful device
explantation.
DISCUSSION
In 1965, Perras introduced the concept of “sal-
vage” of an infected breast implant by means of
antibiotic lavage.33 His contribution challenged
surgical dogma, which dictated foreign body re-
moval in instances of infection,17 and sparked the
evolution of device salvage. Relying on systemic
antibiotic therapy and passive wound drainage,
Courtiss et al. reported salvage rates of 44.8 and 50
percent for infected implants in the setting of
breast augmentation and breast reconstruction,
respectively.3 Like Perras, Toranto and Malow per-
formed antibiotic lavage but supplemented it with
systemic antibiotic therapy, surgical curettage, and
device exchange to salvage three of three implants
infected with atypical mycobacteria.28 Toranto and
Malow enhanced their aforementioned protocol,
adding capsulotomies, local flap reinforcement of
the suture line, and postoperative closed-system
irrigation to salvage 62.5 percent of infected breast
implants, as reported by Wilkinson et al.31
Silver extended device salvage to the manage-
ment of exposed breast implants, advocating site
change and the use of a posterior capsular flap to
reinforce primary closure of the skin breakdown
area.25 Investigating an alternative soft tissue cover,
Rempel reported the use of a serratus anterior mus-
cle flap to salvage a breast implant in the setting of
recurrent exposure.24 Using a technique similar to
that of Toranto and Malow,28 Weber and Hentz

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Volume 125, Number 4 • Infected or Exposed Breast Prosthesis

Fig. 4. Case 4. (Above, left) A 67-year-old patient with a history of active tobacco use and pedicled transverse rectus
abdominis musculocutaneous flap reconstruction of a left modified radical mastectomy defect presented for left revision
breast reconstruction for superior pole deficiency. (Above, right) Two months after implant exchange with a textured saline
implant (Allergan 363LF), inferior capsulorrhaphy, and nipple-areola reconstruction, the patient presented with a pin-size,
medial area of actual implant exposure that was associated with serosanguineous drainage. Cultures were conclusive for
ciprofloxacin-sensitive Pseudomonas aeruginosa. (Below, left) Despite a 1-week course of oral ciprofloxacin, the serosan-
guineous drainage persisted and the area of actual implant exposure increased in size. (Below, right) Given the worsening
clinical course, the patient underwent device explantation and healed uneventfully.

salvaged 100 percent of exposed breast implants
using preoperative systemic antibiotic therapy and
antibiotic lavage, followed by excisional débride-
ment, open capsulotomy, wound irrigation, device
exchange, and closed drain placement.29 Building
on Rempel’s technique, Wilkinson reported a two-
flap technique for soft-tissue coverage, consisting
of a sling of serratus anterior and pectoralis mus-
cle coupled with a Limberg skin flap.30 Furthering
Snyder’s concept of site change, Planas and Car-
bonell recommended switching to a subpectoral
plane for exposed implants that were initially
placed in a subglandular pocket.23
In 2004, the senior author codified the afore-
mentioned techniques of device salvage into an
algorithm for the management of breast device
infection and/or exposure.27 It helped move the
topic from one of “do or do not” attempt device
salvage to the next level, by shedding light on
“how” and “when” instead. The “how” boiled down
to aggressively treating infections with bacteria-
specific antibiotics, delivered in reliable and suf-
ficient doses. This approach resolved many mild
infections and downgraded some of the more se-
vere cases. All exposed devices were assumed to be
infected to a degree and were treated accordingly.
The second step was to eliminate or reduce the
bacterial inoculum. This required a combination
of device exchange, capsulectomy, capsule dé-
bridement, irrigation, drainage, and intraopera-

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 Plastic and Reconstructive Surgery • April 2010

Fig. 5. Case 5. (Above, left) A 55-year-old patient with a history of bilateral mastectomies, tissue expander reconstruction, and
left-sided radiation therapy presented 6 weeks after bilateral implant exchange and left breast fat grafting with a high-grade fever
of 104°F, left-sided erythema, and left breast implant actual exposure with serous drainage. Results of culture specimens taken at
the time were positive for methicillin-resistant Staphylococcus aureus. (Above, right) Given symptom improvement while on dap-
tomycin, device salvage was performed by means of capsular curettage, pedicled latissimus flap coverage of the soft-tissue– defi-
cient region, device exchange for a saline textured tissue expander (Allergan 133MV-14), and site change to a sub–latissimus/
prepectoral pocket. (Below, left) Three weeks postoperatively, the patient completed a 3-week course of vancomycin and was
infection-free. (Below, right) Four weeks postoperatively, the patient presented with a low-grade fever, malaise, and return of left
breast erythema. She decided to forgo further attempts at device salvage and underwent an uneventful device explantation.

tive instrument change. The third element was
viable and sufficient soft-tissue coverage. For some
cases, this required adding a flap.
In the present study, we hoped to further ex-
pound on the “when” aspect of device salvage. The
overall salvage rate in the setting of mild or no
infection was 93.9 percent (groups I, III, IV, and
VI), which was significantly higher than the 26.3
percent salvage rate for severe infection (groups
II, V, and VII), p ⬍⬍ 0.05 by the Fisher’s exact test.
Therefore, severe infections, marked by insuffi-
cient response of erythema, pain, drainage, or swell-
ing to antibiotics, are not promising candidates for
successful salvage. Mild infections or exposed im-
plants, in contrast, have a high likelihood of success-
ful salvage using the described principles.
Patients should be counseled that device sal-
vage need not compromise the long-term aes-
thetic outcome following prosthetic breast sur-
gery. In this study, there was a 1.8 percent capsular
contracture rate. This compared favorably to prior
studies reporting contracture rates ranging from
9.1 to 68.4 percent.3,18,27,29,32
Patient demographics and bacterial patho-
gens were evaluated as risk factors for failed device
salvage and as potential predictors for successful
device salvage. Events of failed device salvage were
associated with a significantly higher degree of
atypical pathogens, such as Gram-negative rods,
methicillin-resistant S. aureus, and C. parapsilosis,
as compared with events of successful salvage.
Therefore, in our practice, patients with atypical
pathogens on culture are not routinely offered the
option of device salvage.
No individual pathogen or patient comorbid-
ity was a predictor of device salvage failure or

1082
Volume 125, Number 4 • Infected or Exposed Breast Prosthesis
success. Similar to the findings of Yii and Khoo, a
history of radiotherapy did not affect the salvage
outcome.32 In contrast to Yii and Khoo, growth of
S. aureus on cultures was not found to be a risk
factor for failed device salvage. To explain the
discrepancy, all cases of device loss with S. aureus
in the study by Yii and Khoo were in the setting of
unattempted device salvage secondary to patient
preference and not attributable to failed salvage
procedures.
We also found that the absence of bacterial
growth on culture did not impact the likelihood
of device salvage. No growth of bacteria may
signify a true reduction in colonies versus ster-
ilization without elimination of bacterial patho-
gens. The variability of bacterial clearance as-
sociated with “no growth” may explain why it
does not serve as a predictor of device salvage
failure or success.
Although a history of radiotherapy or the pres-
ence of S. aureus on wound culture did not affect
the success of device salvage, they both were sig-
nificantly associated with recurrent device infec-
tion and/or exposure. In practice, patients with
either of these risk factors should be monitored
closely for signs of recurrent breast prosthesis in-
fection/exposure. In the setting of elective breast
surgery, these patients need to be managed cau-
tiously and covered with historically effective peri-
operative antibiotics.
This study addresses the “when” aspect of
breast device salvage, but it does have several lim-
itations. First, the lack of statistical significance for
specific comorbidities or pathogens as risk factors
for breast device loss or recurrent infection/ex-
posure may stem from the small sample size for
subgroup analysis rather than the true absence of
a statistical difference. Second, our reported sal-
vage rates seemingly underestimate the success of
device salvage in situations of true attempts. Of the
31 events of device explantation, 29 incidents were
in the setting of unattempted device salvage,
whereas only two events were secondary to failed
device salvage. Therefore, one needs to under-
stand the distinction between failed salvage versus
unattempted salvage when interpreting the afore-
mentioned salvage rates. Lastly, because of the
retrospective collection of data, it is possible that
events of infection and/or exposure may have
been misclassified or unidentified. All efforts were
made to identify incidents of breast device infec-
tion and/or exposure and correlate the events
with documented patient signs, symptoms, and
culture data.
CONCLUSIONS
Salvage of the infected and/or exposed breast
prosthesis remains a challenging but viable option
for a subset of patients. Keys to success include
culture-directed antibiotics, capsulectomy, device
exchange, and adequate soft-tissue coverage. Rel-
ative contraindications to breast device salvage in-
clude atypical pathogens on wound culture, such
as Gram-negative rods, methicillin-resistant S. au-
reus, and C. parapsilosis. Patients with a prior device
infection and/or exposure and a history of either
radiotherapy or S, aureus on wound culture should
be closely monitored for signs of recurrent breast
prosthesis infection/exposure and managed cau-
tiously in the setting of elective breast surgery.
Scott L. Spear, M.D.
Georgetown University Hospital
3800 Reservoir Road, NW
PHC Building, 1st Floor
Washington, D.C. 20007
spears@gunet.georgetown.edu
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