Correspondence and communications undergo contralateral symmetrising reduction mammaplasty (Figure 2). Based on limited reports in the literature, we conclude that this pattern of injury is associated with the triad of fat necrosis, clefting of the breast and associated tethering of skin (which may result in distortion of the NAC). Reconstruction is simple and involves excision of the cleft (þ/ seroma cavity), repositioning of the NAC and symmetrisation of the contralateral breast if necessary. Scarring on the visible cleavage area and residual defects in the upper pole can be minimised by the concomitant use of liposculpture.
Conflict of interest N/A.
Funding N/A.
Ethical approval N/A.
References 1. Teo I, Dujon D, Azmy I. Seat belt injury causing bisection of the breast: a case report. J Plastic Reconstr Aesthetic Surg JPRAS 2014;67(7):1008e9. 2. Scott PP, W. P. TRRL research report. 1985. p. 985. 3. Available from: hyperphysics.phy-astr.gsu.edu. 4. Paddle AM, Morrison WA. Seat belt injury to the female breast: review and discussion of its surgical management. ANZ J Surg 2010;80(1e2):71e4.
N.C. Petrie Consultant Plastic and Reconstructive Surgeon, Department of Plastic and Reconstructive Surgery, John Radcliffe Hospital, Oxford, UK DOI of original article: http://dx.doi.org/10.1016/j.bjps.2014. 01.024 ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2014.10.026
Rib osteomyelitis: An uncommon complication of breast implant infection Dear Sir, Rib osteomyelitis (RO) is a disease that is rarely reported.1 The purpose of this paper is to report on the first 3 cases of RO as a complication of breast implant infection (BII)
431 recorded in a cohort study of 37 cases of BI managed from January 2008 to June 2012 in an inter-regional referral center for bone/joint infections in the south of France. Our center is also a regional referral center for plastic/reconstructive surgery that managed 1350 breast implant (BI) included 217 definitive implants for reconstruction (DIR) and 1133 esthetic breast augmentations (EBA) during the study period. - 1st case: A 77-year-old woman was admitted for breast implant exchange nine years after EBA. The BI type was poly implant prostheses (PIP). After surgical resection, a peripherally located cutaneous siliconoma in the right breast was confirmed on histology. The patient presented a swelling, reddish and painful right breast 2 months after surgery. She also had a fistula until the 4th right rib, with purulent discharge and without fever. Deep-sample and bone biopsy cultures were positive for Staphylococcus aureus. She was treated with surgical debridement and discharged after 3 months of association of rifampicin and ofloxacin. - 2nd case: A 41-year-old woman underwent a mastectomy and radiotherapy for breast cancer. She had received BI for DIR. The patient had no other predisposing factor for infection. The postoperative evolution was characterized by intermittent local inflammation, resolved by short courses of antibiotic treatment. A perioperative diagnosis of RO related to BII by S. aureus was performed. The patient was discharged after prosthesis removal combined with surgical debridement and 3 months of association of rifampicin and ofloxacin. - 3rd case: A 60-year-old woman had received BI for EBA. She presented purulent discharge from the scar 2 weeks after the surgery. She was treated with repeated short courses of antibiotic treatment with amoxicillin and clavulanic acid for several months. A diagnosis of RO and BII was made during surgical breast implant removal. Deep samples and bone biopsies were positive for S. aureus and Pseudomonas aeruginosa. The patient was discharged after surgical debridement and 3 months of association of ceftazidime, ciprofloxacin and rifampicin. We herein report 3 cases of RO related to BII over 4.5 years of experience. For these patients, BI were made by experienced breast surgeons of private clinics in the region. We have supported these cases as inter-regional referral center for plastic/reconstructive surgery. In two of the cases of EBA, BI were inserted in the retro-muscular space at the level of the periosteum through inframammary fold. In one case, BI had been placed for DIR. Silicone implants were used in the 3 cases. RO is uncommon and usually occurs in patients with predisposing factors i.e. pneumonia, lung empyema, chest trauma, chronic granulomatous disease, neutropenia, sickle-cell disease, thalassemia or disseminated infections.1,2 Three cases of RO related to BII were caused by S. aureus and 1 case caused by P. aeruginosa. These bacteria were known as classical microorganism involved in chronic osteitis and BII.1,3e5 Among the 3 cases of chronic RO related to BII, the median age of the patients was 60 years (18 years, range 41e77). The mean time to the diagnosis of chronic RO after
432 the BI placement was 1620 days (1406 days, range 720e3240). Purulent flow was observed in 3 cases. We did not observe fever, hyperleukocytosis, or C-reactive protein levels 40 mg/ml. Symptoms were resembled to chronic osteitis. The diagnosis of all of 3 RO cases was made during the surgical BI removal. We realized fistulectomy with costalchondral resection of infected tissue. The necrotic tissues were removal by leaving only the tissues of good qualities. No purulent fluid coming out of the rib, but the removal rib was hypovascularized with necrotic appearance. The periosteum and perichondrium was later followed to avoid exposing the pleura and mediastinum. The decision of costal removal was made at the meeting of multidisciplinary team of interregional referral center for bone/joint infections, and adapted in intra-operatively finding. No any imaging study had been performed before the operation. All 3 patients were discharged after surgical BI removal, followed by 90 days of antibiotic treatment. No relapse was observed after 2-years of follow-up. Nonetheless, the nature of the BI was not reported as a risk factor for BII. Removal of the BI and appropriate antibiotic treatment fostered healing in all 37 cases in our study. To our knowledge, no previous case of RO as a complication of BII has been reported in the literature. This rare complication, which was present in 8% of BII, should be discussed and investigated in cases of chronic BII to adapt the management strategy, and the implant must be removed to control the infection. Surgical debridement, followed by at least 3 months of antibiotic treatment, is also required for RO treatment.
Ethics This study was approved by the institutional research ethics board, and a written informed consent form was signed by each patient.
Funding The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in this manuscript. No writing assistance was utilized in the production of this manuscript.
Conflict of interest The authors declare that they have no conflicts of interest.
Acknowledgments The authors thank Christine Leautier and Catherine Peruffo for their assistance with this study.
References 1. Bishara Jihad, Gartman-Israel Dina. Osteomyelitis of the Ribs in the Antibiotic Era. Scand J Infect Dis 2000 Jan;32(3):223e7.
Correspondence and communications 2. Gamaletsou MN, Kontoyiannis DP, Sipsas NV, et al. Candida osteomyelitis: analysis of 207 pediatric and adult cases (1970e2011). Clin Infect Dis 2012 Nov 15;55(10):1338e51. 3. Pittet B, Montandon D, Pittet D. Infection in breast implants. Lancet Infect Dis 2005 Feb;5(2):94e106. 4. Horch RE, Schultz G, Schubert DW, Schmitz M. Infectious complications in implant based breast surgery and implications for plastic surgeons. 20133Doc04 [Internet] GMS Ger Plast Reconstr Aesthet Surg 2013 Jul [cited 2014 Sep 21]; Available from:, http://www.egms.de/static/de/journals/gpras/20133/gpras000014.shtml. 5. Mlodinow AS, Ver Halen JP, Lim S, Nguyen KT, Gaido JA, Kim JYS. Predictors of readmission after breast reconstruction: a multi-institutional analysis of 5012 patients. Ann Plast Surg 2013 Oct;71(4):335e41.
Piseth Seng Service de Maladies Infectieuses et tropicales, CHU de la Conception, 147, boulevard Baille, Marseille, France Aix Marseille Universite´, URMITE, UM63, CNRS 7278, IRD 198, Inserm 1095, 13005 Marseille, France Institut Hospitalo-Universitaire Me´diterrane´e Infection, Poˆle des maladies infectieuses et tropicales cliniques et biologique, Assistance Publique des Hoˆpitaux de Marseille, 13005 Marseille, France E-mail address: [email protected] Sophie Bayle Mireille Vernier Service de Maladies Infectieuses et tropicales, CHU de la Conception, 147, boulevard Baille, Marseille, France Fanny Romain Service d’informatique me´dicale, CHU de la Conception, 147, boulevard Baille, Marseille, France Antoine Alliez Guy Magalon Dominique Casanova Service de chirurgie plastique reconstructrice et esthe´tique, CHU de la Conception, 147, boulevard Baille, Marseille, France Andreas Stein Service de Maladies Infectieuses et tropicales, CHU de la Conception, 147, boulevard Baille, Marseille, France Aix Marseille Universite´, URMITE, UM63, CNRS 7278, IRD 198, Inserm 1095, 13005 Marseille, France Institut Hospitalo-Universitaire Me´diterrane´e Infection, Poˆle des maladies infectieuses et tropicales cliniques et biologique, Assistance Publique des Hoˆpitaux de Marseille, 13005 Marseille, France ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2014.10.024
Conflict of interest N/A.
Funding N/A.
Ethical approval N/A.
References 1. Teo I, Dujon D, Azmy I. Seat belt injury causing bisection of the breast: a case report. J Plastic Reconstr Aesthetic Surg JPRAS 2014;67(7):1008e9. 2. Scott PP, W. P. TRRL research report. 1985. p. 985. 3. Available from: hyperphysics.phy-astr.gsu.edu. 4. Paddle AM, Morrison WA. Seat belt injury to the female breast: review and discussion of its surgical management. ANZ J Surg 2010;80(1e2):71e4.
N.C. Petrie Consultant Plastic and Reconstructive Surgeon, Department of Plastic and Reconstructive Surgery, John Radcliffe Hospital, Oxford, UK DOI of original article: http://dx.doi.org/10.1016/j.bjps.2014. 01.024 ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2014.10.026
Rib osteomyelitis: An uncommon complication of breast implant infection Dear Sir, Rib osteomyelitis (RO) is a disease that is rarely reported.1 The purpose of this paper is to report on the first 3 cases of RO as a complication of breast implant infection (BII)
431 recorded in a cohort study of 37 cases of BI managed from January 2008 to June 2012 in an inter-regional referral center for bone/joint infections in the south of France. Our center is also a regional referral center for plastic/reconstructive surgery that managed 1350 breast implant (BI) included 217 definitive implants for reconstruction (DIR) and 1133 esthetic breast augmentations (EBA) during the study period. - 1st case: A 77-year-old woman was admitted for breast implant exchange nine years after EBA. The BI type was poly implant prostheses (PIP). After surgical resection, a peripherally located cutaneous siliconoma in the right breast was confirmed on histology. The patient presented a swelling, reddish and painful right breast 2 months after surgery. She also had a fistula until the 4th right rib, with purulent discharge and without fever. Deep-sample and bone biopsy cultures were positive for Staphylococcus aureus. She was treated with surgical debridement and discharged after 3 months of association of rifampicin and ofloxacin. - 2nd case: A 41-year-old woman underwent a mastectomy and radiotherapy for breast cancer. She had received BI for DIR. The patient had no other predisposing factor for infection. The postoperative evolution was characterized by intermittent local inflammation, resolved by short courses of antibiotic treatment. A perioperative diagnosis of RO related to BII by S. aureus was performed. The patient was discharged after prosthesis removal combined with surgical debridement and 3 months of association of rifampicin and ofloxacin. - 3rd case: A 60-year-old woman had received BI for EBA. She presented purulent discharge from the scar 2 weeks after the surgery. She was treated with repeated short courses of antibiotic treatment with amoxicillin and clavulanic acid for several months. A diagnosis of RO and BII was made during surgical breast implant removal. Deep samples and bone biopsies were positive for S. aureus and Pseudomonas aeruginosa. The patient was discharged after surgical debridement and 3 months of association of ceftazidime, ciprofloxacin and rifampicin. We herein report 3 cases of RO related to BII over 4.5 years of experience. For these patients, BI were made by experienced breast surgeons of private clinics in the region. We have supported these cases as inter-regional referral center for plastic/reconstructive surgery. In two of the cases of EBA, BI were inserted in the retro-muscular space at the level of the periosteum through inframammary fold. In one case, BI had been placed for DIR. Silicone implants were used in the 3 cases. RO is uncommon and usually occurs in patients with predisposing factors i.e. pneumonia, lung empyema, chest trauma, chronic granulomatous disease, neutropenia, sickle-cell disease, thalassemia or disseminated infections.1,2 Three cases of RO related to BII were caused by S. aureus and 1 case caused by P. aeruginosa. These bacteria were known as classical microorganism involved in chronic osteitis and BII.1,3e5 Among the 3 cases of chronic RO related to BII, the median age of the patients was 60 years (18 years, range 41e77). The mean time to the diagnosis of chronic RO after
432 the BI placement was 1620 days (1406 days, range 720e3240). Purulent flow was observed in 3 cases. We did not observe fever, hyperleukocytosis, or C-reactive protein levels 40 mg/ml. Symptoms were resembled to chronic osteitis. The diagnosis of all of 3 RO cases was made during the surgical BI removal. We realized fistulectomy with costalchondral resection of infected tissue. The necrotic tissues were removal by leaving only the tissues of good qualities. No purulent fluid coming out of the rib, but the removal rib was hypovascularized with necrotic appearance. The periosteum and perichondrium was later followed to avoid exposing the pleura and mediastinum. The decision of costal removal was made at the meeting of multidisciplinary team of interregional referral center for bone/joint infections, and adapted in intra-operatively finding. No any imaging study had been performed before the operation. All 3 patients were discharged after surgical BI removal, followed by 90 days of antibiotic treatment. No relapse was observed after 2-years of follow-up. Nonetheless, the nature of the BI was not reported as a risk factor for BII. Removal of the BI and appropriate antibiotic treatment fostered healing in all 37 cases in our study. To our knowledge, no previous case of RO as a complication of BII has been reported in the literature. This rare complication, which was present in 8% of BII, should be discussed and investigated in cases of chronic BII to adapt the management strategy, and the implant must be removed to control the infection. Surgical debridement, followed by at least 3 months of antibiotic treatment, is also required for RO treatment.
Ethics This study was approved by the institutional research ethics board, and a written informed consent form was signed by each patient.
Funding The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in this manuscript. No writing assistance was utilized in the production of this manuscript.
Conflict of interest The authors declare that they have no conflicts of interest.
Acknowledgments The authors thank Christine Leautier and Catherine Peruffo for their assistance with this study.
References 1. Bishara Jihad, Gartman-Israel Dina. Osteomyelitis of the Ribs in the Antibiotic Era. Scand J Infect Dis 2000 Jan;32(3):223e7.
Correspondence and communications 2. Gamaletsou MN, Kontoyiannis DP, Sipsas NV, et al. Candida osteomyelitis: analysis of 207 pediatric and adult cases (1970e2011). Clin Infect Dis 2012 Nov 15;55(10):1338e51. 3. Pittet B, Montandon D, Pittet D. Infection in breast implants. Lancet Infect Dis 2005 Feb;5(2):94e106. 4. Horch RE, Schultz G, Schubert DW, Schmitz M. Infectious complications in implant based breast surgery and implications for plastic surgeons. 20133Doc04 [Internet] GMS Ger Plast Reconstr Aesthet Surg 2013 Jul [cited 2014 Sep 21]; Available from:, http://www.egms.de/static/de/journals/gpras/20133/gpras000014.shtml. 5. Mlodinow AS, Ver Halen JP, Lim S, Nguyen KT, Gaido JA, Kim JYS. Predictors of readmission after breast reconstruction: a multi-institutional analysis of 5012 patients. Ann Plast Surg 2013 Oct;71(4):335e41.
Piseth Seng Service de Maladies Infectieuses et tropicales, CHU de la Conception, 147, boulevard Baille, Marseille, France Aix Marseille Universite´, URMITE, UM63, CNRS 7278, IRD 198, Inserm 1095, 13005 Marseille, France Institut Hospitalo-Universitaire Me´diterrane´e Infection, Poˆle des maladies infectieuses et tropicales cliniques et biologique, Assistance Publique des Hoˆpitaux de Marseille, 13005 Marseille, France E-mail address: [email protected] Sophie Bayle Mireille Vernier Service de Maladies Infectieuses et tropicales, CHU de la Conception, 147, boulevard Baille, Marseille, France Fanny Romain Service d’informatique me´dicale, CHU de la Conception, 147, boulevard Baille, Marseille, France Antoine Alliez Guy Magalon Dominique Casanova Service de chirurgie plastique reconstructrice et esthe´tique, CHU de la Conception, 147, boulevard Baille, Marseille, France Andreas Stein Service de Maladies Infectieuses et tropicales, CHU de la Conception, 147, boulevard Baille, Marseille, France Aix Marseille Universite´, URMITE, UM63, CNRS 7278, IRD 198, Inserm 1095, 13005 Marseille, France Institut Hospitalo-Universitaire Me´diterrane´e Infection, Poˆle des maladies infectieuses et tropicales cliniques et biologique, Assistance Publique des Hoˆpitaux de Marseille, 13005 Marseille, France ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2014.10.024
