Negative Pressure Therapy With Instillation for Salvage of Infected Breast Prostheses: A Technique Video

This educational video article is intended as a practical guide to the operative steps of negative pressure wound therapy with instillation and dwell (NPWTi-d) for prosthesis salvage. Full clinical outcomes, including salvage rates, microbiological profiles, complications, and antibiotic-irrigant comparisons, have been previously published in our multicenter outcomes study and are not repeated here to maintain focus on surgical technique. 1 Periprosthetic infection remains one of the most challenging complications in implant-based breast reconstruction. Traditionally, these infections have been managed by removing the prosthesis and delaying reconstruction, a process that often leads to long treatment courses, significant patient distress, and in many cases, failure to complete reconstruction. 2 Recent evidence, including a multi-institutional study, supports the use of NPWTi-d as an effective single-stage solution for immediate salvage. 1, 3, 4 This video presented a step-by-step demonstration of the NPWTi-d salvage technique, which can be highly effective, reproducible, and easy to incorporate into routine reconstructive practice. The aim of this submission was to support plastics surgeons by providing a step-by-step explanation and to encourage NPWTi-d as a first-line salvage option when faced with tissue expander or implant infection. TECHNIQUE OVERVIEW The procedure begins with an initial operative washout if a patient presents with clinical signs of periprosthetic infection (fever, laboratories indicating infection, erythema, pain, induration, drainage, wound dehiscence, or implant exposure). The breast pocket is opened, and the infected prosthesis and any nonintegrated acellular dermal matrix or mesh are explanted. A thorough debridement is performed to remove all devitalized tissue and inflammatory debris. Sharp excision is used to clean the mastectomy flaps and capsule. Cultures are taken from the pocket to guide postoperative antibiotic management. Following debridement, a significant volume of foam dressing is packed into the breast pocket. Significant emphasis is placed on fully packing the pocket with foam dressing. (See Video 1 online, which demonstrates removal of the infected prosthesis and application of the negative pressure wound therapy foam dressing. ) This is a critical step to preserve pocket domain, prevent collapse or contracture, and facilitate later prosthesis reimplantation. The breast skin will appear tight, and the pocket should be packed firmly with as much foam as will fit. This maintains the breast pocket domain and allows for reliable reimplantation of a tissue expander or implant when returning to the operating room (OR). After explanation, given the significant improvements in tissue compliance resulting from resolutions in induration and tissue edema, replacement of prior device volume is possible. "href": "Single Video Player", "role": "media-player-id", "content-type": "play-in-place", "position": "float", "orientation": "portrait", "label": "Video 1. ", "caption": "This video demonstrates removal of the infected prosthesis and application of the instillation negative pressure wound therapy foam dressing. ", "object-id": {"pub-id-type": "doi", "id": "", "pub-id-type": "other", "content-type": "media-stream-id", "id": "1ₙaz2wk1w", "pub-id-type": "other", "content-type": "media-source", "id": "Kaltura"} Once the foam dressing is secured, the site is sealed with an occlusive dressing and connected to the NPWTi-d unit. The system is programmed with the following standard settings. (See Video 2 online, which demonstrates NPWTi-d system setup, including the specific device settings used in the protocol. ) "href": "Single Video Player", "role": "media-player-id", "content-type": "play-in-place", "position": "float", "orientation": "portrait", "label": "Video 2. ", "caption": "This video demonstrates NPWTi-d system setup including specific device settings used in the protocol. ", "object-id": {"pub-id-type": "doi", "id": "", "pub-id-type": "other", "content-type": "media-stream-id", "id": "1ₘh58pgs6", "pub-id-type": "other", "content-type": "media-source", "id": "Kaltura"} Instillation solution: Normal saline or Irrisept (0. 05% chlorhexidine gluconate) Volume: 150–400 mL depending on pocket size Cycle frequency: every 2–4 hours Dwell time: 10–20 minutes Negative pressure: −125 mm Hg Patients remain hospitalized during therapy and receive intravenous antibiotics based on culture results. The NPWTi-d dressing is typically left in place for 24–72 hours without changes. Once clinical signs of infection resolve and inflammatory markers improve, the patient returns to the OR for NPWTi-d removal and prosthesis reimplantation. (See Video 3 online, which demonstrates removal of the NPWTi-d dressing, pocket preparation, and reimplantation of the breast prosthesis. ) Either a new tissue expander or permanent implant is used based on intraoperative assessment. To note, before prosthesis reimplantation, the incision is reprepared, the pocket is irrigated with an antiseptic solution (most commonly Irrisept), sterile towels are placed to isolate the wound edges, and a fresh set of gloves is donned to minimize implant handling contamination. These steps are part of our standard no-touch precautions, although not all are fully depicted in the video due to camera positioning and its focus on NPWTi-d application. "href": "Single Video Player", "role": "media-player-id", "content-type": "play-in-place", "position": "float", "orientation": "portrait", "label": "Video 3. ", "caption": "Demonstrating removal of the NPWTi-d dressing, pocket preparation, and re-implantation of the breast prosthesis. ", "object-id": {"pub-id-type": "doi", "id": "", "pub-id-type": "other", "content-type": "media-stream-id", "id": "1ₕg23yjyy", "pub-id-type": "other", "content-type": "media-source", "id": "Kaltura"} DISCUSSION This technique is based on the largest multi-institutional study to date evaluating single-application NPWTi-d for prosthesis salvage, which demonstrated an 85% success rate across 4 academic institutions. This approach avoids multiple return trips to the OR, prolonged hospitalizations, and extended antibiotic regimens. By preserving the existing breast pocket and enabling immediate reimplantation, this strategy reduces surgical morbidity and minimizes the physical, emotional, and financial burden associated with delayed reconstruction. Maximally filling the pocket is a critical technical step, as it helps maintain 3-dimensional pocket geometry and prevent soft-tissue collapse under negative pressure. In our clinical experience, insufficient foam dressing volume can result in measurable domain loss within as little as 24 hours, often necessitating additional capsulotomies or pocket revision during the second stage. Importantly, we have not observed any detrimental impact on mastectomy flap perfusion with overpacking, likely because the application of negative pressure redistributes tension away from the skin envelope, reducing ischemic strain. Instillation solution selection should be guided by the underlying bacterial culture, institutional protocols, and surgeon preference. Commonly used solutions include normal saline and Irrisept (0. 05% chlorhexidine gluconate). Our multicenter outcomes study found no statistically significant differences in salvage success or complication rates among these irrigants, including at a center using normal saline exclusively. This is consistent with what has been previously published in the NPWTi-d literature. 5 A larger cohort will be required to determine whether 1 irrigant confers superior benefit; however, our findings support that effective source control and operative technique are the primary drivers of successful salvage, even in the absence of antimicrobial properties in the irrigation solution. In addition, this protocol avoids prolonged postoperative antibiotic use (≤14 d), supporting antimicrobial stewardship principles. Although not every patient is a candidate for this approach—particularly those with severely compromised skin integrity, marked radiation-associated soft-tissue injury, or extensive necrosis requiring delayed reconstruction—the majority of patients presenting with early prosthetic infection can be successfully managed using this streamlined, 2-stage NPWTi-d salvage protocol. CONCLUSIONS This video demonstrates a practical and streamlined technique for salvaging infected breast prostheses using single-application NPWTi-d. By combining thorough debridement, foam overpacking for domain preservation, and short-duration instillation therapy, this method provides an effective and accessible option for implant salvage. We hope this video encourages broader adoption of NPWTi-d in breast reconstruction. DISCLOSURES Dr. Singh serves as a consultant for Solventum and IC Surgical. Dr. Holton is a speaker for Solventum. These relationships are unrelated to the present work. The other authors have no financial interest to declare in relation to the content of this article.