Total Capsulectomy and NPWT for Management of a Mycobacterium abscessus Breast Implant Infection Unresponsive to Antimicrobial Therapy: A Case Report and Literature Review

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Periprosthetic infection after breast augmentation remains one of the main concerns among plastic surgeons, since this type of complication often leads to implant explantation and a suboptimal cosmetic outcome. The reported overall incidence following augmentation mammaplasty is 1% to 2%.¹ The majority of these infections are caused by Gram-positive organisms such as Staphylococcus aureus and coagulase-negative Staphylococcus. Nevertheless, skin and soft tissue infections caused by NTM are increasing and should raise suspicion with a sterile culture in presence of clinical signs of infection, especially when a prosthesis is involved. 

A review of the literature shows a prevalence of RGM among NTM involved in post-cosmetic surgeries infections such as breast augmentations, especially in individuals who travel to developing countries for so-called “medical tourism.”² The most common are M. fortuitum,^3-9 which is responsible for half of RGM infections,¹⁰M. abscessus,^11-14 and M. chelonae.^15,16

More specifically, M. abscessus infections usually present as breast swelling and redness followed by the formation of subcutaneous abscesses and fistulas at the site of recent surgery. Patients are often misdiagnosed due to possible culture negativity on the most common stains and non-responsiveness to empirical antibiotic therapy. In almost all cases, treatment of these infections requires implant explantation, surgical debridement, and capsulectomy associated with targeted intravenous antibiotics, followed by a maintenance antibiotic therapy. A minimum of 3 to 6 months of antibiotic therapy is recommended, and breast re-implantation is not recommended until after at least 6 months of negative cultures.^7,17

In this case experience, the authors emphasize the importance of radical excision of the periprosthetic capsule (total capsulectomy) in association with implant removal. Moreover, to the authors’ knowledge this is the first case reporting the use of NPWT for NTM infected-based wound management after periprosthetic space debridement. PET-CT as a reliable diagnostic exam for excluding any infection process residuals is also stressed. The purpose was to obtain a faster and optimal space closure, shorten the healing time, and prepare for breast reconstruction, reducing patient psychological distress as well. 

Informed consent was obtained from the patient and her spouse for publication of this case report, including the images shown.

The patient was a 60-year-old female with history of recurrent bronchiectasis and bronchitis who underwent bilateral breast augmentation in 1995 and subsequent revision with bilateral breast implants replacement in 2015. 

In September 2021, the patient underwent left lower lobe apical segmentectomy surgery through an anterior mini-thoracotomy as a result of radiological finding of an excavated neoformation associated with repeated episodes of hemoptysis. 

Postoperative course was complicated by clinical-radiological evidence of surgical wound infection and left breast swelling (Figure 1A). 

Culture examination of the periprosthetic fluid resulted positive for M. abscessus, so the patient undertook intravenous antibiotic therapy of vancomycin and amikacin followed by home intravenous antibiotic therapy based on dalbavancin, amikacin, and cefotaxime.

Due to clinical and radiological findings of periprosthetic infection and clinical evidence of breast implant exposure (Figure 1B, 1C), in December 2021, a left breast implant removal and partial capsulectomy was performed. Afterwards, due to the lack of clinical benefit and the persistence of high levels of inflammatory indexes, antibiotic therapy was suspended and a new culture examination was performed, which again was positive for M. abscessus.

The patient presented to the authors’ department for consultation in January 2022. On examination, the patient presented with a dehiscence on the left inframammary fold of about 3 cm in size that was surrounded by an area of erythema and swelling and characterized by severe breast asymmetry, as seen in Figure 2. 

Based on the patient's medical history and clinical, radiological, and laboratory findings, the authors recommended radical debridement of the periprosthetic pocket, total capsulectomy of the periprosthetic capsule, and placement of an NPWT device for peri-implant space drainage and closure. The patient underwent debridement surgery and wound treatment by means of an NPWT device, followed by targeted hospital intravenous antibiotic therapy with linezolid, amikacin, and cefoxitin, administered for 2 weeks.

After discharge, the patient received advanced NPWT-based dressings weekly for 4 weeks using a pressure of -100 mm Hg, combined with home oral antibiotic therapy consisting of linezolid tablets. NPWT-based dressings were removed and replaced in the outpatient department during follow-up visits. 

After 1 month of NPWT, wound depth had consistently reduced to a nearly complete peri-implant closure, with a resulting clean and sharp-edged wound.

As the wound fundus became granule-like and bleeding, allowing the use of smaller, more superficial dressings, it was decided to switch to advanced alginate-based dressings on a biweekly basis. These dressings allowed the authors to achieve complete wound healing within 2 months after debridement surgery. 

Mild inferior pole retraction of the left breast occurred as a result of debridement and healing by second intention. Lack of lower quadrants and irregular breast profile compared with the contralateral breast were the main issues the patient was concerned about. 

Before breast implant replacement was performed, the authors waited for a complete resolution of the infection based on 3 negative wound cultures and further confirmed by PET/CT with 18-FDG that showed no residual uptake in the left breast region, as well as no inflammatory indexes beyond the upper limits.

In June 2022, 6 months after debridement, left breast implant replacement and right breast implant revision surgery was performed. Anatomical smooth breast implants were used. 

Moderate asymmetry of shape and volume persisted on objective examination due to scar retraction of the left breast from previous surgeries (Figure 3). As a result, 2 sessions of lipofilling associated with scar lysis were needed for the left breast at 6 months and 12 months after implant replacement, which enabled the achievement of a pleasing aesthetic outcome and breast symmetry, as shown in Figure 4. Key events are shown in Figure 5.

M. abscessus is a rare NTM classified among the RBM whose name reflects its capability of generating subacute cutaneous infections with the formation of fistulas and subcutaneous abscesses. According to the literature, breast augmentation is placed in third place among the most common cosmetic procedures complicated with an M. abscessus infection.¹³ Surgical re-intervention with or without implant reimplantation is required in almost all the cases, followed by a targeted antimicrobial therapy that needs to be protracted for an average of 4.6 months, as reported in a previous review.10 The infectious sources have been hypothesized to include contaminated instruments, skin disinfectant, gentian violet used for skin marking, and contaminated hospital water systems. Immunosuppression and alteration of host defenses by tissue damage likely act as conducive factors for the infection onset.⁷

In the case featured in the current study, periprosthetic infection arose from an operative wound dehiscence infection resulting from a previous left lower lobe apical segmentectomy, which was initially undertreated and led to a spreading skin and soft tissue infection that eventually reached the ipsilateral breast. In a certain way, this case source may be considered atypical compared to others reported in literature. Despite the source, when mycobacteria come to colonize solid surfaces such as external devices, infection is hard to eradicate and prosthesis explantation is mandatory. What the authors want to highlight in the current case experience is the possible key role of the peri-implant capsule in maintaining the mycobacterial infection by acting like a microbial source. This is suggested by the persistence of the infection even after breast implant removal and antimicrobial therapy and the subsequent complete resolution obtained only after a radical debridement including of the residual periprosthetic capsule.

Infected implant-based breast reconstruction is a real concern since tissue infection may cause skin envelope loss due to necrosis and consequent breast profile modification. Even in cases when the skin envelope remains intact, second intention healing causes several cicatricial retractions that are difficult to deal with during revision surgery after the infection is resolved. In the literature, there is an inconsistency and paucity of data about the optimal management of a threatened implant following augmentation mammaplasty, with most of the articles arguing for device removal and delayed reinsertion when extrusion occurs and in case of severe infections, even if promising implant salvage rates have been reported in some cases.^18,19 

Conventional management of periprosthesis infection consists of spontaneous wound closure followed by re-implantation after several months. In the current case, the authors proposed the use of NPWT, since its application in this type of complication has been associated with higher patient satisfaction, earlier re-implantation, and fewer readmissions and outpatient visits thanks to preserving more of the breast skin envelope.²⁰ NPWT causes wound edges to contract and removes inflammatory and infectious material, thereby reducing microbacterial charge and promoting angiogenesis and tissue granulation.²¹

Although PET/CT is a gold standard for detection of several inflammatory and infectious diseases,²² mycobacterial or other microbial periprosthetic infections of the breast are not mentioned in the literature. Since the case detailed in the current study required the ability to detect any inflammatory residual focus, the authors opted for PET/CT to safely ascertain absence of infection, as suggested by their institution’s infectiologist.

By means of NPWT for wound management and PET/CT for earlier detection of infection absence, the authors were able to achieve an earlier local resolution. Compared to the 10.5 months average interval between implant removal and reinsertion reported in the literature,10 the patient in the current study received a new breast implant only 6 months after debridement. Moreover, compared to other cases where antibiotic therapy has been prolonged for several months after explantation, the eradication of the infection in the current study—confirmed by both negative cultures and PET/CT—allowed the authors to safely suspend antibiotics and proceed to the replacement earlier, in agreement with the infectiology consultant. Furthermore, this approach reduced the number of outpatient medications needed and the associated patient stress.

It is ambitious to draw definitive conclusions regarding use of NPWT for wound management after infection-based breast implant removal and removal of the periprosthetic capsule because of the inherent limitations of case reports. 

Prospective and comparative studies involving a large sample size and comparing NPWT use to conventional management may be necessary, but it is challenging to undertake owing to the low incidence of NTM infections occurring after breast augmentations, which is reported to be under 0.1%.²³ Although this current report is a singular case, it offers valuable insights into the management of wounds secondary to breast implant mycobacterial infection by using NPWT for optimal drainage and cleansing of the peri-implant space, which could potentially maintain a mycobacterial source if not well-treated. In addition, the authors believe that the use of NPWT with a hypochlorite instillation would have resulted in a further reduction in healing time.

Atypical NTM periprosthetic infections after breast augmentation represent a rare eventuality that in most cases requires implant removal and delayed reconstruction followed by a specific long-term antibiotic therapy, and are a real burden for patient well-being. In this case report, the authors show the importance of associating a radical capsulectomy with the implant removal. Moreover, the use of NPWT for wound management may help to achieve a faster and optimal periprosthetic space drainage and closure, thus expediting the timing of culture negativity and breast reimplantation.  

Authors: Andrea Aniello Cimmino, MD; Giovanni Francesco Marangi, MD, PhD; Gianluca D’Onofrio, MD; Marco Gratteri, MD; Daniela Porso, MD; Fara Desiree Romano, MD; Carlo Mirra, MD; and Paolo Persichetti, MD, PhD

Affiliation: Department of Plastic, Reconstructive and Aesthetic Surgery, Università Campus Bio-Medico di Roma, Rome, Italy

Disclosure: The authors disclose no financial or other conflicts of interests. All equipment used in this article is the property of Fondazione Policlinico Campus Bio-Medico. 

Ethical Approval: Informed consent was obtained from the patient and her spouse for publication of this case report, including the images shown.

Correspondence: Andrea A. Cimmino, MD; Unit of Plastic and Reconstructive Surgery Campus Bio-Medico University of Rome, via Alvaro del Portillo 200, 00128 Rome, Italy; andrea.cimmino@unicampus.it

Manuscript Accepted: August 21, 2024