Keywords leech - infection - nipple–areola complex - venous congestion - reduction mammaplasty
Introduction
Nipple–areola complex (NAC) necrosis secondary to reduction mammaplasty/mastopexy
represents a serious complication with a massive impact on patient satisfaction and
well-being. Complete or partial NAC necrosis has been reported in 2 to 6% of breast
reductions, respectively, and more frequently in patients with risk factors such as
smoking, diabetes, and obesity. The most common cause is inadequate venous drainage
with the typical blueish color of the NAC, dark blood at the pinprick, and increased
edema.[1 ]
[2 ]
Historically, leeches have been used for a variety of medical conditions, with a specific
application in Plastic and Reconstructive Surgery on venous congestions since the
1980s. In case of mild venous drainage impairment, leeches can be applied directly
to the affected area; the number of leeches and the frequency of treatment are quite
variable. Despite the uncontested benefits of hirudotherapy, several complications
have been described such as anemia, localized infection, and sepsis, with a reported
incidence of infection ranging from 2 to 20%.[3 ]
We present a single case of breast infection related to leech therapy in a patient
with NAC venous congestion after a reduction mammaplasty.
Case
A 45-year-old woman candidate for body-contouring procedures after massive weight
loss was admitted to our department with large and ptotic breasts. The patient underwent
bilateral Wise-Pattern Reduction Mammaplasty using a superolateral pedicle and an
inferior dermoglandular Ribeiro flap for autoaugmentation. Standard preoperative antibiotic
prophylaxis with cefazolin (2 g) was used. On the first postoperative day, the right
NAC displayed venous congestion which was managed conservatively with multiple leech
applications ([Fig. 1 ]). Leech therapy was continued until a visible improvement in NAC perfusion was obtained,
and the patient was discharged 5 days postoperatively. On the eighth postoperative
day, the patient was readmitted to our hospital for fever (40°C) and clinical presentation
of septicemia. Physical examination showed swelling, tenderness, redness, and pus
discharge from the wounds on the right breast ([Fig. 2 ]). Blood test findings revealed leukocytosis (white blood cells: 21.7 × 109 /L) and high levels of C-Reactive Protein (8.8 mg/dL). Surgical treatment consisted
of abscess drainage, wound irrigations, and surgical debridement of the necrotic tissues
resulting from the colliquated abscess, and reshaping of the remaining breast parenchyma
([Fig. 3 ]). Aeromonas veronii was isolated in the wound cultures, and intravenous antibiotic therapy was started
including meropenem (3 g/d) for 4 days, followed by oral ciprofloxacin (1 g/d) for
8 days. The patient was then discharged 11 days postoperatively and complete wound
healing was achieved after 1 month. A 6-month follow-up visit showed an overall satisfactory
shape of the breast, and a largely preserved NAC ([Fig. 4 ]).
Fig. 1 Venous congestion of the nipple–areola complex following reduction mammaplasty.
Fig. 2 Breast infection after leech therapy on day 8 postoperatively, with wound dehiscence
and pus discharge from the wounds.
Fig. 3 Intraoperative picture showing the surgical debridement of the necrotic tissues and
abscess drainage.
Fig. 4 Six-month follow-up visit showing complete healing and partial preservation of the
nipple–areola complex.
Discussion
Partial or full-thickness necrosis of the NAC represents a critical complication in
terms of aesthetic and functional results after a reduction mammaplasty. Rather than
arterial insufficiency, the more common cause is related to venous congestion. In
fact, at the basis of the NAC loss, there could be an extremely tight inset of the
reshaped breast with a consequent constriction of the pedicle, inadequate preservation
of the venous drainage, and/or hematoma. Once detected, the treatment options for
NAC congestion are various: from removing any tension created during closure or delayed
inset of the pedicle (if torsion is the causal factor) to the more recent use of vacuum-assisted
closure therapy, to the “ancient” application of leeches.[4 ] Each of these methods has pros and cons. The removal of periareolar sutures with
delayed wound closure, as well as the delayed inset of the pedicle, is a safe and
reliable alternative for the management of NAC congestion. Nevertheless, leaving the
wound open may represent a theoretical risk of wound infection or pathological scarring
with consequent poor cosmetic outcomes. Moreover, it requires more outpatient visits
and an adequate patient compliance.
Further resection of breast parenchyma or resection of deepithelialized keyhole platform
represents another alternative by reducing the tension which causes venous congestion.
However, a loss of nipple or breast projection could occur.
The negative pressure wound therapy is a simple and reliable option in cases of suffering
venous NAC. It demonstrated to reduce significantly perilesional tissue edema. Nevertheless,
it may not always be easily accessible and it is a relatively expensive device.
Hirudotherapy for treatment of NAC congestion has been widely reported in the literature.[5 ]
[6 ]
[7 ] However, several cases of infection related to leech therapy have been reported,
and Aeromonas spp. has the most participation in infections. Clinical manifestations usually start
in the following 10 days after leeching, even though the timing is quite variable.[8 ] Our patient started manifesting signs and symptoms of infection 8 days after leech
therapy. A prompt diagnosis of infection is essential to avoid more potentially severe
complications. In our experience, in addition to conventional practice consisting
of local bacteriological samples and broad-spectrum antibiotic, an extensive and early
surgical debridement of all necrotic and infected tissues lead to a dramatic improvement
in clinical conditions. The fever ceased on the first postoperative day and the patient
remained apyretic even after discontinuation of targeted antibiotic therapy, and a
fast improvement of blood tests was observed.
Antibiotic prophylaxis is routinely recommended during medical leech therapy in order
to reduce the risk of Aeromonas infection, although many units did not use prophylaxis or used inappropriate agents
until a few years ago.[8 ] The most commonly used antibiotics for prophylaxis are fluoroquinolones, trimethoprim–sulfamethoxazole,
and third-generation cephalosporins, even though emerging multidrug resistance has
been reported. Therefore, algorithms for the prevention and control of Aeromonas infections associated with hirudotherapy should be further implemented. Among these,
new leech culture protocols[9 ] or regular environmental surveillance culture of leech water have been proposed,
even though a standardized practice has not yet been established.[10 ]
The present case would serve as an alert for the possibility of infection transmission
when using leech therapy for NAC salvage even in those patients undergoing aesthetic
procedures. To date, leech-related breast infections have only been reported in cases
of postmastectomy autologous breast reconstruction.[11 ] Nevertheless, it is known that patients with a history of breast cancer surgery
are more prone to surgical site infection due to chemotherapy and/or radiotherapy
to which the tissues are subjected.[12 ] Moreover, it has been observed that oncologic and immunocompromised patients can
have severe infections due to Aeromonas .[13 ]
The aim of our paper was to report a new case of Aeromonas breast infection in a healthy patient with no risk factors who underwent a cosmetic
surgery procedure. In this regard, we discourage the use of hirudotherapy in cases
where breast implants are used (e.g. augmentation mastopexy with implants) due to
the potentially devastating consequences of a soft tissues infection with breast implant
involvement.
If on one hand hirudotherapy represents a valid alternative for the management of
NAC venous congestion; on the other hand, the potential of soft tissue infections
should be carefully considered. When using hirudotherapy for the management of venous
congestion after cosmetic breast surgery procedures, both the surgeon and the patients
should be aware of these potential complications, and their use should be adequately
weighted.
