Purpose: In 2004, the senior author published an algorithm for the management of breast device infection and/or exposure. The purpose of this study was to build on our prior experience with an additional cohort of patients, in an effort to identify risk factors for either breast device loss or recurrent infection/exposure and to better measure outcomes in terms of salvage rates.
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 identified and classified into one of seven groups. Salvage rates for individual classes were calculated. Patient specific data and wound culture pathogens were analyzed as possible risk factors for device loss or recurrent infection/exposure. Student’s t and Fisher’s exact tests were used in statistical analysis.
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%, with a mean follow-up of 24.7 months. Salvage and explantation rates for individual classes can be found in Table I. As shown in Table II, breast device loss was significantly associated with the presence of atypical pathogens, such as gram-negative rods, methicillin-resistant Staphylococcus aureus, and Candida parapsilosis (p = 0.015). Breast device loss trended with an older mean patient age, though this result was not statistically significant (p = 0.069). Furthermore, as found in Table III, recurrent device infection and/or exposure was significantly associated with either a history of radiotherapy or the presence of Staphylococcus aureus on wound culture (p = 0.028 and p = 0.012, respectively).
Conclusions: Salvage of the infected and/or exposed breast prosthesis remains a challenging but viable option for a subset of patients. Relative contraindications to device salvage include atypical pathogens on wound culture, such as gram-negative rods, methicillin-resistant Staphylococcus aureus, and Candida parapsilosis. Patients with a prior device infection and/or exposure and a history of either radiotherapy or Staphylococcus aureus on wound culture should be closely monitored for signs of recurrent breast prosthesis infection/exposure and cautiously managed in the setting of elective breast surgery.

Table I Salvage and Explantation Rates for Different Classes of Infected and/or Exposed Breast Prostheses‡
Class of infection and/or exposure	Successful salvage rate	Explantation rate w/out surgical salvage attempt
Group I: Mild infection	100.0% (34 / 34)	0.0% (0 / 34)
Group II: Severe infection	30.8% (8 / 26)	69.2% (18 / 26)
Group III: Threatened exposure	100.0% (6 / 6)	0.0% (0 / 6)
Group IV: Threatened exposure w/ mild infection	66.7% (2 / 3)	33.3% (1 / 3)
Group V: Threatened exposure w/ severe infection	40.0% (2 / 5)	60.0% (3 / 5)
Group VI: Actual exposure w/ mild infection	66.7% (4 / 6)	16.7% (1 / 6)
Group VII: Actual exposure w/ severe infection	0.0% (0 / 7)	85.7% (6 / 7)

‡Analyzed per event

Table II Risk Factors for Breast Device Loss‡
	Salvaged (N=56)	Failed (N=31)	p value
Mean age (years)	48.3	52.5	0.069
Mean BMI (kg/m2)	23.4	23.3	0.94
History of tobacco use	17.9%	19.4%	1.00
History of chemotherapy	32.1%	41.9%	0.48
History of radiotherapy	17.9%	32.3%	0.18
Pathogens†
Atypical flora#	11.5% (3/ 26)	42.9% (12 / 28)	0.015*
Coagulase-negative Staphylococcus	30.8% (8/ 26)	17.9% (5 / 28)	0.35
Staphylococcus aureus	7.7% (2 / 26)	25.0% (7 / 28)	0.14
No Growth	42.3% (11 / 26)	35.7% (10 / 28)	0.78

‡Analyzed per event
†Analysis based on salvaged and failed events with available wound culture, N=26 and N=28, respectively
#Atypical flora = Gram-negative rods, methicillin-resistant Staphylococcus aureus, and Candida parapsilosis
*Statistically significant result on Fisher’s exact test

Table III Risk Factors for Recurrent Breast Device Infection and/or Exposure‡
	Non-recurrent infection/exposure (N=56)	Recurrent infection/exposure (N=13)	p value
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% (11 / 34)	30.8% (4 / 13)	1.00
Coagulase-negative Staphylococcus	26.5% (9 / 34)	30.8% (4 / 13)	1.00
Staphylococcus aureus	5.9% (2 / 34)	38.5% (5 / 13)	0.012*
No Growth	29.4% (10 / 34)	38.5% (5 / 13)	0.73

‡Analyzed per patient
†Analysis based on non-recurrent and recurrent infection/exposure patients with available wound culture, N=34 and N=13, respectively
#Atypical flora = Gram-negative rods, methicillin-resistant Staphylococcus aureus, and Candida parapsilosis
*Statistically significant result on Fisher’s exact test