Removal of exposed intact silicone implant

PREOPERATIVE DIAGNOSES:

1.  Exposed right breast implant.

2.  Right breast carcinoma.

3.  Status post chemotherapy.

4.  Status post radiation therapy to right breast.

POSTOPERATIVE DIAGNOSES:

1.  Exposed right breast implant.

2.  Right breast carcinoma.

3.  Status post chemotherapy.

4.  Status post radiation therapy to right breast.

OPERATIONS PERFORMED:

1.  Removal of exposed intact silicone implant.

2.  Irrigation of pocket and debridement of skin edges.

3.  Replacement of implant using Mentor 350-4001 BC implant, serial #5768292-147.

ANESTHESIA:  IV sedation.                    

INDICATIONS:  The patient is a 55-year-old nurse who underwent right mastectomy on 12/05/2007.  Postoperatively, she required chemotherapy as well as radiation therapy.  Chemotherapy ended in 04/08.  Radiation therapy ended in 06/11/08.  Of note, during the first procedure, she underwent placement of a tissue expander.  The patient underwent second stage reconstruction three months after completing radiation therapy.  At that time, her skin was relatively soft and pliable.  She underwent replacement of the tissue expander using the same exact volume as was previously placed on the tissue expander.  She did well after surgery without any complications.  She does not have any evidence of infection or delayed healing.  However, she called me in the evening of 11/04/08 informing me that her implant suddenly was exposed.  That was roughly six weeks since the second procedure.  She denies any bouts of infection.  She denies fever.  She denies any strenuous activity.  Unfortunately, the patient was out of town visiting with family in Kentucky.  Through a lengthy phone conversation, we discussed her findings as well as her options.  Obviously, one option is to have the implant removed and wound closed there in Kentucky, or she can return home, and I would schedule the surgery as soon as possible, and in fact, the next day as soon as she arrived.  The patient was immediately placed on prophylactic antibiotics, which were called in to her.  She denied any fevers or cellulitic changes as stated.  The patient is fairly well versed in medicine as she was a former ICU nurse.  She and her husband opted for returning home to have the surgery performed here in Florida.  The patient arrived this afternoon, and I met her in the preoperative setting as surgery was scheduled on the evening of 11/05/08.  In the preoperative setting, findings revealed no evidence of infection.  She had no fever, and her white count was normal at 5.1.  The clinical exam revealed no cellulitic changes.  She had no fluctuance.  There was no drainage.  The wound, in fact, was quite dry.  Exposed silicone implant was identified, previously covered by the patient with sterile gauze and tape.  The patient had been receiving p.o. Keflex since last evening.  In the preoperative setting with her husband present, I had a rather lengthy discussion with the patient lasting at least 45 minutes.  We went over, again, what her options were as I discussed the previous evening.  I discussed removal of the implant, closure of the wound with a drain, and waiting at least 3 months for further procedures, which include the possibility of autogenous tissue with implant or implant alone or autogenous tissue including a TRAM flap alone as well.  Pros and cons of the various options were discussed.  The patient informed me that as before she really was not interested on those other procedures predominantly, either the latissimus or the TRAM.  I informed her that another option might be entertained in light of the fact that the wound was quite clean without any signs of infection.  This option would include removal of the implant, washout of the pocket, and replacement with another implant.  However, I would recommend an even smaller implant.  Interestingly, on examination in the preoperative holding area, the wound could easily be closed overlying the existing implant.  Despite this, however, I did recommend going down in size to minimize any tension whatsoever.  The patient understands that with this second option she may have slightly increased risk for infection, and for this reason, she will be watched fairly closely regarding this.  The advantage of this, however, is that since she is not interested in autogenous tissue reconstruction that even with a smaller implant the pocket could be maintained minimizing contraction of the skin seen with radiation therapy.  She understands that, again, she does have a high risk of infection.  I also informed her that the standard would be latissimus flap and implant in the future.  As stated, she was not interested in that particularly at this point.  In light of the fact that she is a nurse and in light of the fact that she can be followed closely, I believe that the second option is a viable option as long as close followup can be provided.  Should any signs of infection occur whatsoever, then it is in fact a relatively simple procedure to remove the implant, which is where we would have been anyway at this point.  She and her husband considered their options, understood the above, and as stated a lengthy informed consent process took place.  Completing this, she and her husband wish that I proceed with washout of the pocket and replacement of the implant if possible.  I informed them she will have a drain which will likely be in place for a short period of time and as well will be maintained on prophylactic antibiotics.  At this point, all questions were answered and she wished that I proceed.  The patient received prophylactic antibiotics prior to skin incisions consisting of Ancef 2 g IV.               

PROCEDURE IN DETAIL:  The patient was taken to the main operating room and placed supine on the operating table.  Both arms were placed on well-padded arm boards and secured in a non-constricting fashion to prevent neuropraxic injuries.  Standard prepping and draping carried out in the anterior truncal region.  The patient received IV sedation.  She did not have much sensation in the skin flaps, and therefore, this procedure was quite well tolerated.  The implant was removed without difficulty.  As stated, the overlying skin flaps were in fact rather pliable and certainly far from tight.  In fact, the appearance of the wound basically looked as if she was on just prior to closure of a normal second stage operation.  The wound edges were in fact intact.  Operative findings revealed that the suture knots were in fact intact, and it appears that the suture tore through the surrounding tissue incision site.  In any case, after removal of the implant, new gloves were placed per my routine, and cultures were obtained from the pocket.  Simple pressure irrigation consisting of 3 L of triple antibiotic solution was then carried out, again, per my routine.  Completing this, the pocket was irrigated with Betadine solution and was subsequently immediately evacuated with remainder of the triple antibiotic solution.  A sizer was placed within the pocket with operative findings revealing that a 400 mL implant would not be too small.  A drain, 7-mm French, was placed through the base of the wound and directed on the most lateral portion of the incision.  A Mentor 350-401 BC implant was chosen, serial #5768292-147.  It was bathed in antibiotic solution.  No Betadine used overlying the implant.  As stated, the pocket was irrigated completely one final time with triple antibiotic solution.  A 10-20 drape placed overlying the skin incision so that no contact of the permanent implant of the skin would occur.  New gloves were again placed per my routine prior to handling of this new implant.  Through the _____ 10-20 drape and after assuring perfect hemostasis, the implant was placed within the pocket created.  There was no tension whatsoever with respect to closure of the skin incision.  In fact, as stated with the previous implant, skin could easily be closed without undue tension.  This resulted, therefore, in a fairly loose skin incision.  Closure was then performed in a meticulous fashion using interrupted 3-0 Vicryl suture.  Dermal layer was closed using interrupted 4-0 antibacterial Vicryl suture.  The skin itself closed using running over-and-over 4-0 Prolene suture.  The drain was secured and placed the bulb suction.  The drain was secured to the most lateral portion of the skin incision using 3-0 nylon suture.  Mastisol and Steri-Strips were applied, and occlusive dressing applied over the drain site.  As stated, the wound incision was not under any tension whatsoever.  The patient was transferred back to recovery in good condition.  She awoke easily.  She appeared to be comfortable without pain.  All sponge, instrument, and needle counts correct x2.  Instructions provided to both the patient and her husband.  I will follow the patient closely, and we will see her again in my office in two days.  She will be maintained on prophylactic antibiotics.