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Photos 22.22 Grade 1 Gynaecomastia treated by only gland excision. Before and after 6mont gynaecomastia surgery
H. Nurein
Photos 22.23 Grade 2 Gynaecomastia treated by liposuction and gland excision. Before and after 2months gynaecomastia surgery
on how one feels, more men are resorting to aesthetic surgery. To get a good outcome, like in any other cosmetic
surgery, the surgeon must acknowledge the primary concern and goal of the patient and then decide if he or she can
achieve their expectations as well as establish whether the
patient understands and accepts the potential side effects
and limitations of proposed gynecomastia treatment espe-
cially for the more severe cases where skin may not be taut
enough after the surgery or when the procedure is to be
staged.
Ultrasound-assisted liposuction as an adjunct tool is
increasingly popular in liposculpture; thus, more patients
are looking for a more dened athletic male chest look. One
must respect the need for the right balance between the tis-
22 Gynaecomastia
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Photos 22.24 Grade 3 Gynaecomastia, treated with liposuction, gland excision and skin tightening modality. Example 1, Before and 2months
and 1year after gynaecomastia surgery
Example 2. Before and 2months after gynaecomastia surgery
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Example 3. Before and 10days after gynaecomastia surgery
Example 4. Before and 2weeks after gynaecomastia surgery
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Photo 22.25 Grade 4 Gynaecomastia example 1 treated by horizontal incision with inferior dermal pedicle for nipple areola translocation.
Before and 4 days after surgery. Grade 4 Gynaecomastia example 2 treated by double incision with free nipple graft method. Before and 1 year
after surgery
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H. Nurein
sue excised, and that is left behind to achieve the desired
goals.
To achieve the desired results, fat deposits that cause
unwanted contours such as pre axillary fat and lateral chest
skin roll must be treated. This may also involve addressing
the excess skin where present and avoid over excision to
avoid poor scarring.
Over-resection is more difcult to correct than underresection, and if the procedure is staged for severe cases,
there is a possibility that this risk is reduced. When a correction is required, it is best offered after 6months, at least after
the initial surgery.
References
Alagaratnam TT. Idiopathic gynecomastia treated with tamoxifen: a
preliminary report. Clin Ther. 1987;9(5):483–7.
Bannayan GA, Hajdu SI.Gynecomastia: clinicopathologic study of 351
cases. Am J Clin Pathol. 1972;57(4):431–7.
Blau M, Hazani R, Hekmat D. Plastic and reconstructive surgery.
Global Open. 2016;4(8):e854.
Cuhaci N, Polat SB, Evranos B, Ersoy R, Cakir B. Gynecomastia:
clinical evaluation and management. Indian J Endocrinol Metab.
2014;18(2):150–8.
Hood K, Ganesh Kumar N, Kaoutzanis C, Higdon KK.Hematomas in
aesthetic surgery. Aesthet Surg J. 2018;38(9):1013–25. https://doi.
org/10.1093/asj/sjx236.
Kaoutzanis C, Winocour J, Gupta V, etal. Incidence and risk factors for
major hematomas in aesthetic surgery: analysis of 129,007 patients.
Aesthet Surg J. 2017;37(10):1175–85. https://doi.org/10.1093/asj/
sjx062.
Kornstein AN, Cinelli PB. Inferior pedicle reduction tech-
nique for larger forms of gynecomastia. Aesthet Plast Surg.
1992;16(4):331–5.
Mannu GS, Sudul M, Bettencourt-Silva JH, Tsoti SM, Cunnick G,
Ahmed SF. Role of tamoxifen in idiopathic gynecomastia: a
10-year prospective cohort study. Breast J. 2018;24:1043. https://
doi.org/10.1111/tbj.13080.
Munavalli GS, Panchaprateep R.Cryolipolysis for targeted fat reduc-
tion and improved appearance of the enlarged male breast.
Dermatol Surg. 2015;41(9):1043–51. https://doi.org/10.1097/
DSS.0000000000000415.
Niewoehner CB, Nuttall FQ.Gynecomastia in a hospitalized male pop-
ulation. Am J Med. 1984;77(4):633–8.
Rosen H, Webb ML, DiVasta AD, Greene AK, Weldon CB, Kozakewich
H, Perez-Atayde AR, Labow BI. Adolescent gynecomastia: not
only an obesity issue. Ann Plast Surg. 2010;64:688–90.
Simon BE, Hoffman S, Kahn S.Classication and surgical correction
of gynecomastia. Plast Reconstr Surg. 1973;51(1):48–52.
Yue D, Cooper LRL, Ctein R, Charman SC, Kang NV.Dening normal
parameters for the male nipple-areola complex: a prospective observational study and recommendations for placement on the chest
wall. Aesthet Surg J. 2018;38(7):742–8.
Part V
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Complications and Their Treatment
Breast Implant Infections
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MohanThomas andJamesD’silva
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23.1 Introduction
Breast augmentation using a prosthesis is one of the commonest surgical procedures undertaken as part of body
enhancement surgery for people having small breasts, asymmetric breasts, as part of gender re-assignment as well as for
reconstruction after mastectomy. Two types of breast prostheses are currently available: silicone gel implants and
saline implants. These are further classied into smooth, textured, and silk textured based on the implant surface and
round and anatomic based on their shape. Silicone implants,
consisting of a silicone polymer shell lled with silicone gel,
are preferred for augmentation because they provide a more
natural appearance and feel and there are no chances of sudden deation. Saline implants, however, offer the advantage
of a smaller incision, can be placed remotely (TUBA) as well
as have no risk of silicone leak because they are inserted as
empty silicone shells and inated using sterile saline.
Breast implants as part of aesthetic surgery can be placed
through an inframammary, periareolar, axillary, or a remote
umbilical incision. Pockets for breast implant are dissected
through these incisions so that the implant can be placed in
the subglandular or sub-muscular plane. When implants are
used for breast reconstruction, they are usually placed in the
sub-muscular plane so as to have sufcient tissue for implant
coverage. Sometimes an expander may be required to enlarge
the surrounding tissue (post-mastectomy or congenital amastia) followed by the implant placement. An acellular dermal
matrix, composed of extracellular matrix structures of
bovine, porcine, or human cadaveric origin, or synthetic
mesh can be used as an adjunct to tissue expanders for shaping the reconstructive breast and anchoring the implant to the
chest wall. Common complications associated with implantbased breast augmentation or reconstruction include prosthetic implant infections, capsular contractures (10-year
incidence: 9.2% for augmentation and 14.5% for reconstruction), implant rupture (10-year incidence: 9%), implant malposition, asymmetry, wrinkling, or seromas (<5%). Periodic
MRIs of breast implants are recommended to determine if
implant rupture has occurred (Lalani 2018).
Implant infection following breast reconstruction is not
an uncommon event; rates cited in the literature range from
2.5% to 16.5%. Implant infection following breast augmentation is much less common with rates of 1–2.5% (Cordeiro
and McCarthy 2006).
Historically, the commonest causative organism has been
the staphylococcal bacteria, but recent publications have
shown an increase in Gram-negative infections, atypical
mycobacteria and at times anaerobic microorganisms as
well. A better understanding of the most common causative
species involved allows cosmetic and reconstructive surgeons to approach the treatment of these patients in a rational
and evidence-based manner.
The management of implant-associated infection varies
depending on severity. Less severe cases can be treated with
outpatient oral antibiotics, while more severe cases necessitate inpatient admission and intravenous antibiotics. The
most severe cases result in an implant loss and a failure of
implant-based reconstruction after cancer surgery. Attempts
for reconstructive salvage, dened as the ability to keep an
implant after infection, have also become more popular in
recent years. Our overall goal is to devise a rational and
evidence- based approach to the treatment of these patients
(Boustany etal. 2018).
M. Thomas (*) · J. D’silva
Aesthetic Surgery, The Cosmetic Surgery Institute
and D. Y. Patil University, Mumbai, India
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
M. Thomas, J. D‘silva (eds.), Manual of Cosmetic Medicine and Surgery, https://doi.org/10.1007/978-981-99-3726-4_23
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23.2 Epidemiology andRisk Factors
Infections associated with breast implant surgery are possible anytime during the healing period. Implant-associated
infections after breast augmentation or implant-based reconstruction has been found to be in the range of 1.1–2.5%
(Washer and Gutowski 2012). These infections are predominantly present in a bimodal fashion:
1. Infections during the early postoperative period (up to
6weeks): This is primarily caused due to the pathogen
seeding during surgery. The factors causing the infection
may be host, procedure or facility related.
2. Subacute or late onset infections (any time after 6weeks):
This is usually caused due to host related factors such as
reduced immunity with hematogenous spread (such as
from dental procedures without antibiotic prophylaxis) or
slow growing atypical infections.
23.2.1 Risk Factors forBreast Implant
Infections Include
23.2.1.1 Host Factors
1. Comorbidities of the patient such as obesity, diabetes,
liver and kidney diseases, smoking, and low
haemoglobin.
2. Women undergoing breast augmentation as part of breast
reconstruction following mastectomy. Extensiveness of
the surgery as well as deciency of healthy tissues and
use of aps/mesh to provide support to the breast implant
as well as use of a drain.
3. Ladies requiring axillary dissection, chemotherapy, and/
or radiation therapy have a ten times higher risk than
women going in for cosmetic breast enlargement (Pittet
etal. 2005). The increased risk is due to ischemia of the
tissues, prior scarring causing a delay in wound healing
or a breakdown.
23.2.1.2 Procedure Factors
1. Surgical factors: Periareolar or a transareolar approach
has a higher potential of infection of the implants due to
the contamination by the endogenous ora present in
the nipple and breast ducts. Appearance of a hematoma
in the periprosthetic area increases the risk of infection.
Use of a 2 stage breast reconstruction procedure after
mastectomy helps clear the contaminated ora from the
surgical bed. Use of acellular dermal matrix (ADM)
whether of human, porcine, or bovine origin was associated with increased infections especially in people who
underwent breast reconstruction. The use of ADM very
close to the skin surface causes erythema of the overlying skin called as the “red breast syndrome” which is
not an infection and is rather due to increased vascularity as well as interruption of lymphatic ow. This should
not be confused with cellulitis of infective origin as it is
self-limiting and gets resolved in a few months (Newman
etal. 2011).
2. Operation theatre factors: Operation theatres with laminar airow, ltered air exchange, and positive pressure
reduce the chances of surgical site contamination from
the circulating air. Increased human movement in and out
of the operation theatre can increase the chances of bacterial infections as a result trafc in the OT should be limited (Ooi and Song 2016).
23.3 Microbiology andPathogenesis
The breast implant can be infected internally from endogenous skin bacteria which are present in the nipple and can
enter through the surgical incision or through the alveolar
ducts. Infection can also enter due to contamination of the
implant from the environment, body piercings or spread
from a distant site through a hematogenous route. A direct
open injury to the chest area can also cause infection of the
breast implant.
The endogenous ora of the breast includes Gram-positive
organisms such as Staph. Aureus, Streptococci, and
Propionibacterium spp. are the common pathogens associated with early post implant infection. Other less common
infections in the early postoperative period are caused by
Gram-negative bacteria as well as atypical bacteria.
Once colonized in the implant pocket, the infective organisms form a biolm. Bacterial biolms are complex surfaces
in which large bacterial colonies are gelled by a polymer
matrix containing proteins, polysaccharides, and extracellular DNA which is produced by the bacteria. Biolm formation is composed of the following phases (Fig.23.1):
1. Reversible attachment phase: Non-specic bacterial
attachment to implant surfaces.
2. Irreversible attachment phase: Bacteria attached using
adhesions through lipopolysaccharide and mbriae.
3. Growth and differentiation of the colony: Bacteria now
produces extracellular polymeric substances which initiate the maturation phase of the biolm in which these
bacteria attract to each other and form a microcolony.
4. Dissemination phase: The bacterial cells depart biolms
and start all over again.
Reversible
Irreversible
Growth and
Dissemination
23 Breast Implant Infections
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attachment
Bacterial cells Biofilm Surface of implant
Fig. 23.1 Phases of biolm formation
attachment
differentiation
Bacteria present in the biolms have an altered metabolism and as a result they are resistant to antibiotics even
though culture sensitivity may show otherwise hence the
only method to completely eradicate the biolm once formed
is removal of the implant (Costerton etal. 2005). The lack of
a microcirculation in the implanted material and impaired
neutrophil function further enhance the susceptibility to
infection.
Atypical mycobacterial infections following breast augmentation with implants have increased with M. fortuitum
and M. chelonei as the commonest culprits. Water is being
considered as the possible source of atypical mycobacteria.
M. fortuitum and M. chelonei have been reported to be resistant to routine disinfectants such as povidone iodine, formalin, and glutaraldehyde. Gas sterilization of instruments for
circumventing this possible source of infection is most recommended. The presence of lipid coating in the mycobacterial cell walls is proven to be the culprit in biolm formation
over the surface of implants.
23.4 Classication ofBreast Implant
Related Infection
Spear et al (Spear et al. 2004). Classied implant related
breast infections as follows:
Group I, mild infection;
Group II, severe infection;
Group III, threatened exposure;
Group IV, threatened exposure with mild infection;
Group V, threatened exposure with severe infection;
Group VI, actual exposure with no/mild infection; and
Group VII, actual exposure with severe infection.
Mild infection is categorized as swelling of the breast on
the affected side, signs of cellulitis, and inammation with or
without non-purulent discharge. This type of early infection
is usually responsive to antibiotic therapy (Fig.23.2a, b).
Severe infection includes substantial increase in the signs
of inammation which includes pain, increased local temperature, redness, and increased size in spite of antibiotic
therapy. There may also be frank purulent discharge with or
without culture of organisms such as methicillin resistant
Staphylococcus aureus, Gram-negative bacilli, atypical
mycobacteria, or yeast (Fig.23.2c–e). Drainage of the periimplant collection either spontaneously or secondary to a
surgical incision can cause exposure of the implant
(Fig.23.2f).
Serious signs and symptoms of systemic infection also
known as “toxic shock syndrome” may be present. These
include pyrexia, hypotension, a diffuse rash, multisystem
involvement such as diarrhoea and vomiting, myalgia, hyperaemia of mucous membranes, increased creatinine levels,
low platelets, and altered sensorium.
Late infections present months and years after surgery
and usually present with only vague breast pain with minimal signs of skin inammation. The implicating microorganism usually comes through the hematogenous route from a
distant site (dental).
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a b
c d
M. Thomas and J. D’silva
e f
Fig. 23.2 Breast implant infections can present as redness (a), cellulitis along the incision line (b), increased swelling (c), acute abscess (d),
chronic draining sinus (e), or obvious implant exposure (f)
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