Management of Expander- and Implant-Associated Infections in Breast Reconstruction.

BACKGROUND: Periprosthetic infection remains the most common complication after implant-based breast reconstruction. Objectives of the study were to (1) describe our clinical approach and treatment protocol for managing patients with suspected periprosthetic infection, (2) identify the microorganisms causing periprosthetic infections at our institute, and (3) report on outcomes of implant salvage versus explantation. METHODS: A retrospective chart review of patients who were treated with parenteral antibiotics for periprosthetic infection was carried out. Patient characteristics, clinical and laboratory findings, outcomes, treatment modalities and complications were extracted from electronic medical records. Data were compared between patients whose implants were salvaged versus explanted. RESULTS: Fifty-nine patients with 67 tissue expander (TE)/implants underwent parenteral antibiotic treatment for suspected infection. Thirty-three (49%) of the TE/implants were salvaged. Mean follow-up was 14.3 months. The most commonly cultured organisms were P. aeruginosa followed by S. epidermidis. All suspected infections were treated with broad spectrum parenteral antibiotics with MRSA coverage. The most common combination was daptomycin 6 mg/kg combined with Zosyn 4.5 g. Explantations were significantly more common in patients with history of chemotherapy (p = 0.03), hypertension (p = 0.04) and those who underwent therapeutic mastectomy (p = 0.04). CONCLUSION: Risk factors for explantation due to postoperative periprosthetic infections following TE/implant-based breast reconstruction include chemotherapy, hypertension and therapeutic mastectomy. Prompt diagnosis and effective treatment of periprosthetic infection, particularly in these high-risk patients, are imperative to salvage the breast reconstruction. Gram-negative bacteria are increasingly found in breast implant infections and should be covered when employing empiric antibiotherapy. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The relationship of the marginal mandibular nerve to the mandibular osseocutaneous ligament and lesser ligaments of the lower face.

BACKGROUND: An in-depth understanding of the nuances of facial anatomy is the best means of preventing complications during facelift surgery. An appreciation of the operative details is complicated not only by the complexity of the anatomy but also by the variability in the nomenclature used. OBJECTIVES: The authors have attempted to clarify these issues by detailing the relationships of the ligaments of the lower face both to each other and to the marginal mandibular nerve. METHODS: The mandibular ligament, the platysma mandibular ligament, and the marginal mandibular nerve were identified in 22 cadaver halves. The gonial angle, and the lower mandibular border were used as perpendicular reference lines. RESULTS: The mean length, height, and depth of the mandibular ligament and the platysma mandibular ligament were calculated. The mean distance of the mandibular ligament from the gonial angle along the mandibular border was also noted:it was always located superior to the platysma mandibular ligament. The marginal mandibular "danger zone" was identified a quarter of the length of the mandibular body along the lower jaw border. Finally variability in nomenclature of the lower face ligaments was clarified. CONCLUSIONS: A topographic map of the structures of surgical importance in the lower face was constructed in the hope that this will prevent surgical errors during facelift surgery.