We read the December 2009 article by Dr. Nahabedian in which an observation of inferior pole erythema (refractory to antibiotic therapy) after the use of AlloDerm (LifeCell Corp., Branchburg, N.J.) for breast reconstruction is noted.1 We have made similar observations using a variety of allograft/xenografts for breast reconstruction. By discussions with colleagues, we have learned that this is a widely observed phenomenon referred to as the “red breast syndrome.” However, the literature appears to be lacking as to reliable explanations for its cause, course, and treatment options.
In our practice, and as reported to us anecdotally by our colleagues, the red breast syndrome appears to affect some patients, but not others. It may appear days to weeks after surgery and manifests as erythema of the skin overlying the allograft/xenograft, often the entire inferior hemisphere of the neobreast complex. Like cellulitis, the erythema appears to have a blanching character; however, there is no pain, elevated skin temperature, or induration appreciated. Also absent are elevations of serum markers seen in the face of infection such as white blood cell count, C-reactive protein, erythrocyte sedimentation rate, and neutrophil count.
The cause of the red breast syndrome is unknown. Dr. Nahabedian suggests it may be a response to preservatives used in the preparation and processing of AlloDerm. However, we have observed “red breasts” following the placement of allografts/xenografts prepared differently. Possible causes for the red breast have resonated at meetings and discussions with our colleagues. Although these theories are anecdotal in nature, they may provide impetus for future investigation. Theories include dependant erythema, interruption of lymphatic flow, response to an unknown factor retained in the mesh, a generalized histamine release, a previously unidentified histocompatability factor, and hyperemia of the overlying skin secondary to the dilation of cutaneous vascular network as the underlying graft material experiences vascular ingrowth.
Left untreated, the red breast appears to resolve without sequelae in a self-limited fashion, usually within a few weeks or months. Nevertheless, we do not support simple observation alone. Should an underlying infectious cause be responsible, doing “nothing” may allow a simple low-grade cellulitis to progress to a scenario necessitating tissue expander or breast implant removal. Therefore, it is helpful if the surgeon can rule out an infectious cause expeditiously to avoid long courses of antibiotics or removal of the prosthetic unnecessarily.
Our management of suspected red breast syndrome is the following: after onset, the involved skin is marked with a skin marker to facilitate accuracy in serial examinations and, if present, drains are cultured and laboratory tests are performed. The patient is started on antibiotics and reevaluated by clinical examination and repeat laboratory tests 24 to 48 hours later. If there has been no extension of the erythema and initial laboratory values were normal and remain normal, an infections cause is less likely. Antibiotics are discontinued and observation is initiated. If a significant response to antibiotics is appreciated—by improvement in erythema or a decrease in previously elevated serum markers—an infectious cause is more likely and treatment should proceed accordingly.
Further investigation into this phenomenon may help to reach a diagnosis sooner and more efficiently and may provide insight into the interaction between allografts/xenografts and the human host.
Dr. Newman and Dr. Samson are both speakers for Synovis Surgical Innovations; Ethicon, Inc.; Mentor Corp.; and Johnson & Johnson. They have received honoraria for discussing the use of their products in presentations. This communication was created independently of the companies listed above.
Martin I. Newman, M.D.
Enrique Hanabergh, M.D.
Michel C. Samson, M.D.
Cleveland Clinic Florida
1.Nahabedian MY. AlloDerm performance in the setting of prosthetic breast surgery, infection, and irradiation. Plast Reconstr Surg.
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