The majority of incisions (50%, n=13) were inframammary, although a variety of approaches were used (Table 1). Regarding the anatomical plane for the implant pocket, details were available for 22 of 26 patients. Custom prostheses in were placed in the submuscular plane, or supra- or sub-fascial. In all four cases with simultaneous bilateral breast augmentation, the mammary prostheses were placed in a subglandular plane. Most patients had a short hospital stay, and 81% (n=21) were discharged by the second post-operative day.

Mean follow-up time was 641 days (range 13 days to 8.1 years). 15% (n=4) had less than 30 days follow-up, due to failure to attend clinic appointments. 62% (n=16) developed one or more complications; excluding seromas and hypertrophic scars the complication rate was 31% (n=8). Post-operative complications are outlined in Table 1. The incidence of seroma was 27% (n=7) ((n=5) in pectus excavatum (n=2) in Poland syndrome). 12% (n=3) had seromas which required serial aspiration, and 15% (n=4) had seromas which resolved spontaneously.

A second admission for surgery was required in 23% (n=6) patients. 4% (n=1) developed generalised reactive lymphadenopathy within days of implant insertion which required urgent removal of the implant. Symmastia of breast prostheses and communication with the custom prosthesis pocket occurred in 4% (n=1), requiring implant repositioning and refashioning of the suprasternal pocket in pectus excavatum. 4% (n=1) underwent insertion of an additional prosthesis to correct asymmetry. 4% (n=1) underwent staged exchange of implants for asymmetry and serial seroma, and 8% (n=2) required autologous fat grafting following the customised prosthesis to improve contour or symmetry, one of whom required serial fat graft procedures. 8% (n=2) developed implant migration, of whom one required elective trimming of the implant, and the other settled spontaneously. In total, asymmetry was noted in 15% (n=4). One patient with asymmetry did not require intervention. No direct cardiorespiratory or rib complications were observed in this series, nor was silicone leakage noted.

Intravenous antibiotic prophylaxis was used in most cases (Table 2), although some received additional post-operative oral prophylaxis. A suspected superficial surgical site infection was noted in 4% (n=1), following perioperative prophylactic intravenous and oral prophylactic antibiotics, and a course of post-operative oral flucloxacillin and phenoxymethylpenicillin was prescribed.

Surgical drains (closed-suction) were used in 42% (n=11), not used in 46% (n=12), and drain status was unrecorded in 12% (n=3). Of those with drains, a higher proportion developed seroma, 36% (n=4), compared with 17% (n=2) of the 12 patients without drains, although this was not statistically significantly different on Fisher’s exact test (p=0.08).

A subjective assessment of patient satisfaction was obtained at completion of follow-up from the clinical records of outpatient reviews for 22 of the 26 patients. 77% (n=17) were satisfied with the outcome, 19% (n=5) had some ongoing concerns recorded including 8% (n=2) regarding residual asymmetry, 8% (n=2) reported some discomfort or pain, and 4% (n=1) with implant migration.

A retrospective review of antibiotic prophylaxis in prosthetic augmentation of 3256 breasts17 found a lower incidence of superficial and periprosthetic infections in patients who had received a single dose of intravenous antibiotics, compared with those who had received a combination of intravenous and oral antibiotics. Antibiotic prophylaxis according to the published antimicrobial guidelines for our institution18,19 for implants in plastic surgery patients are a single dose of 1.5 grams of intravenous cefuroxime at induction of anaesthesia, without prophylactic oral antibiotics. The absence of infective complications in this series, and the low rate of infection in published series2,9,15,20, suggests that post-operative oral antibiotic prophylaxis is not necessary for this cohort. Margulis et al. (2006) from Israel reported good outcomes from seven patients with custom implants for pectus excavatum, and used cefazolin 1 gram at induction, and two suction drains for each patient20. Drain use in prosthetic breast augmentation to reduce the incidence of haematoma formation or early capsule formation, has shown no association with infection, at least with cohesive gel implants21.

It is possible that other superficial infections and minor seromas may have occurred and been under-reported. Regarding drains, selection bias may account for the increased seroma rate in those with drains: the more extensive procedures may have necessitated surgical drains. The duration of follow-up for some participants may not be sufficient to detect incidences of capsular contracture or leakage, and future studies should aim to report long term outcomes.