Abstract
Implant exposure (IE) is a rare but devastating complication of aesthetic surgery owing to its psychological and economic implications for patients. In cases of IE, the most reliable strategy is implant removal; however, most patients do not prefer this option. In the absence of prosthetic contamination, salvage procedures are a viable option, with promising success rates.
Once IE is detected, the cutaneous defect cannot be treated with direct closure. If additional tissue is needed, the anterior intercostal artery perforator (AICAP) flap can be harvested, using the inframammary fold as a donor site, with minimal aesthetic implications. AICAP flaps can cover defects over the entire lower mammary pole and are useful as deep reinforcement for breast-slimmed flaps.
We report a case of augmentation mastopexy in a patient with grade I tuberous breasts. The undeveloped lower mammary pole led to delayed IE at 33 days after surgery. No signs of contamination were observed, and the cutaneous defect was covered with an AICAP flap. Antibiotic instillation was established for 24 h, and oral antibiotic therapy was administered for 3 weeks. Seven months later, a dog-ear deformity of the lateral inframammary fold and excess skin on the flap were excised, resulting in a good aesthetic outcome.
Keywords: Intercostal artery flap, Implant exposure, Implant salvage, Breast augmentation, Mastopexy
Introduction
Infection and prosthetic exposure are frequently encountered during breast reconstruction, with incidence rates ranging from 19 % to 35 %.1,2 In contrast, the rates are much lower in aesthetic surgery (2.8 % and 3.4 % respectively).1,3,4 These concerns are among the primary considerations for patients considering breast augmentation.5
Patients with tuberous breasts, particularly those with hypoplastic lower poles, who undergo combined breast implantation and mastopexy face a heightened risk of implant exposure (IE). Here, we report a case of aesthetic breast IE in which an implant salvage procedure was performed using an anterior intercostal artery perforator (AICAP) flap.
Case report
A 34-year-old female who was a previous smoker and without a medical history of interest presented to our clinic one year postpartum from her second pregnancy seeking correction of breast ptosis (Figure 1). She presented with moderate asymmetric ptosis, grade I tuberous breasts, and moderate-quality skin.
Figure 1.
Preoperative image of the patient.
An inverted-T mastopexy with a McKissock pedicle combined with breast augmentation using 325 cc Syltex moderate plus round breast implants (Mentor®) in the dual plane was performed. Thirty-three days after the surgery, the patient showed wound dehiscence at the junction of the two legs of the inverted-T pedicle in the left breast. A zone of extreme skin slimming was present at the vertical scar, with two minimal zones of IE. No exudation or other signs of infection were observed. Cultures were obtained, provisional closure was performed under local anaesthesia, and the wound was covered with an occlusive dressing. Oral antibiotic therapy was initiated with clindamycin (300 mg/6 h) and ciprofloxacin (500 mg/12 h). The revision surgery was delayed until negative culture results were obtained on day 37.
Different options were discussed with the patient, and a therapeutic strategy was chosen (see DISCUSSION). Under general anaesthesia, nonviable or uncertain skin of the lower breast pole was removed, resulting in a 4 × 2.5 cm2 defect vertically oriented along the midline, with prosthesis exposure. A necrotic area was observed in the lowest part of the McKissock pedicle. The implant was not removed. The perforator of the intercostal anterior artery was located in the sixth intercostal space at the midclavicular line. An incision was made in the lower breast scar, through the subfascial plane, from the defect to the anterior axillary line. A propeller AICA flap was designed using this line as its upper border, with a width of 4 cm at the base. The flap was rotated 90° and de-epidermized, except for a cutaneous island (4 × 2.5 cm2) coinciding with the defect (Figure 2). The de-epidermized portion was anchored to the posterior portion of the nipple-areola complex and used as a deep reinforcement for the cutaneous remnant flaps. A catheter was inserted into the breast for antibiotic irrigation for 24 h. The patient was discharged 48 h later, before a good vascular status of the flap was confirmed. Home rest was recommended for 5 days, and oral antibiotic therapy was administered for 3 weeks postoperatively. No signs of infection or exposure were observed after the salvage surgery. Seven months later, the dog-ear deformity was removed from the lateral end of the incision, and the cutaneous island was debulked under local anaesthesia. After two years of follow-up, the patient was pleased with the aesthetic results and underwent an inverted nipple correction at our centre (Figs. 3 and 4).
Figure 2.
Dehiscence with breast exposure and flap design. The flap perforator is marked.
Figure 3.
Frontal view of the patient one year and five months after surgery. The flap has been debulked, and the dog-ear deformity has been removed.
Figure 4.
Inferolateral view of the flap one year and five months after surgery. The cutaneous island is adapted to the form of the inframammary fold and lower pole of the breast.
Discussion
Explantation, antibiotic therapy, and implant repositioning 6 months later are the most effective and reliable strategies for exposed breast prostheses, regardless of reconstructive or aesthetic augmentation.2,6 However, when no periprosthetic signs of infection or contamination are observed (lack of exudation, negative cultures, and absence of biofilms), an implant salvage procedure may be performed, with an overall success rate of 80 %.7 This procedure usually involves changing the implant, capsulectomy, and breast pocket irrigation with antibiotic solutions before new implant repositioning.2,6,7 However, some successful rescue procedures in aesthetic surgery for uninsured patients salvage existing implants. Capsulectomy and direct closure without breast implant exchange and/or capsulectomy with postoperative antibiotic irrigation via percutaneous catheters have been proposed.2,7 In the present case, the patient desired implant preservation surgery, which was reasonable because of the absence of contamination. Capsulectomy was not performed due to the high risk of devascularization of the inferior mastopexy flaps.
Good skin coverage is necessary in the presence of cutaneous defects. The AICAP flap has traditionally been employed in oncoplastic breast surgery for partial or complete reconstruction of the lower pole of the breast. It has many advantages, including the presence of good perforators near the defect in the 5th and 6th intercostal spaces, from the sternum to the middle mammary line (usually 1–3 cm lateral to the sternal border). Flap dimensions can extend from the border of the sternum to the anterior axillary line without significant aesthetic disturbance of the inframammary fold whenever there is sufficient skin laxity at that level. The width of the flap is determined using the pinch test, with the inframammary fold serving as a cranial reference point (4–5 cm).3,8, 9, 10
Owing to these advantages, Mesa et al. reported 16 cases in which AICAP flaps were used to salvage the breast during reconstruction without implant removal, with a success rate of 100 % when infection was not present.2 To our knowledge, this is the first report on the use of this technique for an aesthetic procedure. We decided to perform a salvage procedure combined with an AICAP flap to reconstruct the lower pole with minimal aesthetic impairment and because the patient preferred preservation of the implant. Asymmetry in the fold could be greater in thinner patients.
Conclusion
Implant salvage surgery is a reliable procedure for patients with breast prosthesis exposure, particularly in the absence of contamination. Patients should be advised about the risk of periprosthetic infection and delayed explantation with this option. The AICAP flap is a reliable option with minimal aesthetic implications for cutaneous reconstruction of the lower pole.
Ethical approval
Not required.
Informed consent
The patient provided written consent for the use of her clinical data and images, and any data that could compromise her anonymity was removed.
Declaration of competing interest
The authors declare no conflicts of interest.
Funding
None.
Footnotes
This manuscript adheres to the STROBE guidelines.
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