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Proposed Etiology of Red Breast Syndrome

Danino, Alain M. MD, PhD, FRCSC; Khatib, Arij El MD; Paek, Laurence MD; Nelea, Monica Iliescu PhD; Gagnon, Alain MD; Bernier, Christina MD; Bou-Merhi, Joseph MD

Plastic and Reconstructive Surgery - Global Open: August 2019 - Volume 7 - Issue 8S-1 - p 20-21
doi: 10.1097/01.GOX.0000584304.75993.5c
Breast Abstracts

University of Montreal Hospital Center, Montreal, QC, Canada

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

INTRODUCTION: Despite the well-established benefits of acellular dermal matrices, a poorly defined entity referred to as red breast syndrome has emerged with an incidence of 1.7–14.3%. It is commonly described as a delayed erythema localized on the skin over the acellular dermal matrix (ADM) appearing days to weeks after reconstructive breast surgery without systemic signs of infection. The aim of our study is to clarify the etiology of this phenomenon.1–4

METHODS: Patients presenting with RBS without infectious signs following 1- or 2-stage breast reconstruction with implants using ADMs were recruited prospectively between April 2017 and June 2018 as a case series. All reconstructions consisted of subpectoral prosthesis placement with the ADM acting as an inferolateral hammock. We started broad-spectrum antibiotics, admitted for observation and operated for washout of pocket and implant when no clinical improvement was observed in 24 hours of antibiotic therapy. A control group constituted of asymptomatic patients undergoing 2-stage expander with ADM to permanent implant exchange. During surgery, two 1 cm2 pieces were collected from the ADMs, one sent for bacterial cultures and the other for scanning electron microscopy. Image analysis of specimens was performed at 3,000× and 6,000× magnifications, including bacterial count and Van Heerden’s semiquantitative biofilm scale.

RESULTS: Study group: 9 breasts in 8 patients presented with red breast syndrome. All 9 ADMs utilized were AlloDerm Ready-to-Use (LifeCell Corporation, N.J.) with a size of 16 × 8 cm. The mean time-to-onset of RBS was 2.5 weeks in 7 patients and 4 years in 1 patient, whereas the mean time from symptoms to surgical exploration was 4 days. Postoperative cultures revealed commonly found bacteria from skin flora and gastrointestinal tract. Furthermore, biofilm from different bacterial populations was found on all samples on scanning electron microscopy pictures. Control group: 8 breasts were reconstructed with Allergan Biocell expanders. The average size was 490 cm3, and all procedures were done with submuscular insertion assisted by AlloDerm (16 × 8 cm). Definitive expander-to-implant exchange occurred between 4 and 16 months after the first stage. Specimens from the implant–ADM interface with Biocell expansion had no clinically identifiable “Velcro-effect” or macrotexturing ingrowth but showed a rate of 100% (n = 8) for biofilm formation under electron microscopy.

CONCLUSION: The presence of bacterial biofilm was demonstrated on ADMs in all cases. This suggests that biofilm on ADMs is not always symptomatic. We postulate that bacterial biofilm could be a causative agent of red breast syndrome, but we do not have enough data to propose a “tipping point” which would ultimately cause the syndrome to start.


1. Pittman TA, Fan KL, Knapp A, et al. Comparison of different acellular dermal matrices in breast reconstruction: the 50/50 study. Plast Reconstr Surg. 2017;139:521–528.

2. Zenn M, Venturi M, Pittman T, et al. Optimizing outcomes of postmastectomy breast reconstruction with acellular dermal matrix: a review of recent clinical data. Eplasty. 2017;17:e18.

3. Kim JY, Davila AA, Persing S, et al. A meta-analysis of human acellular dermis and submuscular tissue expander breast reconstruction. Plast Reconstr Surg. 2012;129:28–41.

4. Hunsicker LM, Ashikari AY, Berry C, et al. Short-term complications associated with acellular dermal matrix-assisted direct-to-implant breast reconstruction. Ann Plast Surg. 2017;78:35–40.

Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons. All rights reserved.