Nontuberculous Mycobacterial Infection of Facial Implant Following Cosmetic Surgery Abroad

An 82-year-old female presented with an orocutaneous fistula extending from the left maxillary buccal first molar to the left pretragus (Figure 1). She underwent malar augmentation 6 months prior in South America. Medical comorbidities included hypertension, diabetes, atrial fibrillation, and a remote history of facial burn. Magnetic resonance imaging demonstrated osteomyelitis of the left maxillary first molar and 2 curvilinear implants lateral to the left maxilla (Figure 2). The patient underwent debridement and explantation, revealing a MEDPOR implant (Stryker) and silastic implant over the left maxilla (Figure 3). Intraoperative cultures identified the presence of Mycobacterium abscessus. The patient was treated with Levaquin and doxycycline with improvement and a planned course of 3 months. She expired 10 weeks postoperatively from natural causes.

Nontuberculous mycobacteria (NTM) are common in the environment on dust particles, in the soil, and in water reservoirs. In the United States, NTM are most prevalent in the southern coastal states from Texas to Maryland. In humans, NTM are taken up by macrophages. NTM infections are more prevalent than tuberculous mycobacterial infections in developed countries.¹Mycobacterium abscessus is a subtype of NTM first isolated in 1953.² It is found in both smooth and rough variants. Rough variants are pathogenic and lack a specific glycopeptidolipid within the cell wall that allows them to resist phagocytosis, cluster within the phagosome, and cause local tissue damage. M. abscessus has the potential to transform from smooth to rough variants via a yet unknown stimuli, an attribute which may explain the variability in clinical presentation between immunocompetent and immunocompromised hosts.¹

NTM surgical site infection (NTM SSI) is a devastating complication of plastic surgery. Most reported cases have followed breast augmentation; however, they have also been described following cosmetic facial surgery including ablative laser therapy, rhytidectomy, and blepharoplasty. They occur more frequently in patients undergoing cosmetic surgery abroad.^3,4 NTM SSI are associated with trauma, foreign bodies, contaminated marking solutions, needles, syringes, injectables, and the improper reuse and sterilization of instruments. Nasolacrimal duct obstruction or lacrimal duct probing also increases the risk.⁵ In our case, risk factors included the malar augmentation abroad and history of facial burn that may have resulted in a degree of nasolacrimal duct dysfunction.

The typical presentation of NTM SSI is subacute beginning 2 to 4 weeks postoperatively but may occur up to 16 weeks postoperatively. Symptoms include erythema, tenderness, firm violaceous cutaneous nodules, and discharge at the surgical site.⁶ If untreated, sequelae of facial infections include orocutaneous fistula as seen in this case, disfiguring scars, ectropion, and cavernous sinus thrombosis. Diagnosis requires a tissue culture or biopsy with deoxyribonucleic acid analysis. Acid fast staining, though useful, is often negative. Immunocompromise should be ruled out with a T-cell panel and serologic studies.^7,8 Standard treatment begins with debridement and removal of any foreign body followed by combination antibiotic therapy. A core antibiotic used to treat NTM infections is clarithromycin, a macrolide and 6-O-methyl derivative of erythromycin, which accumulates in tissues and phagocytes at up to 10 times the serum concentration.⁹ Other antibiotics used in combination with clarithromycin include ciprofloxacin, doxycycline, imipenem, amikacin, and/or rifampin. A review of the patient’s current medications will ensure no interactions that may alter the pharmacokinetic and pharmacodynamic parameters of therapy and lead to ineffective treatment.¹⁰ Resistance is common, making sensitivity testing, close follow-up, and antimicrobial stewardship a must. The standard course of antimicrobial treatment is 3 to 9 months, similar to other mycobacterial infections including tuberculosis.

A few select cases of NTM SSI have been resolved with debridement and explantation alone without prolonged antimicrobial therapy. A study by Rahav et al in 2006 described a case-control study of 15 patients who developed infections with Mycobacterium jacuzzii following breast augmentation. All underwent explantation and debridement. Two experienced a clinical recovery without additional antibiotics.¹¹ Jhaveri et al in 2020 described a case of a 36-year-old female with a clarithromycin-resistant Mycobacterium chelonae infection following breast augmentation who also underwent explantation and debridement with clinical improvement. The patient was noncompliant with initial therapy of linezolid and azithromycin due to side effects and then refused alternative antibiotics after becoming pregnant. She remained asymptomatic with no recurrence of the infection.¹² Taking these reports into consideration, explantation without prolonged antibiotics is a potential course of action in a patient with relative contraindications to antimicrobial therapy and a favorable response to surgical treatment. The patient in this case may have benefitted from a trial of explantation alone given her age, frailty, and underlying comorbidities.