Managing Complicated Nontuberculous Mycobacteria Infections in Plastic Surgery

Abstract

Nontuberculous mycobacteria (NTM) infections after cosmetic surgery have become an increasing concern. These infections are often initially misdiagnosed and treated with standard antibiotic regimens, which fail to resolve the underlying infection, leading to prolonged patient suffering. In this case study, we describe a chronic wound infection caused by Mycobacterium abscessus subsp. bolletii after a muscle-repair abdominoplasty. This case illustrates the diagnostic and therapeutic challenges plastic surgeons face in successfully treating such infections. Initial obstacles included the isolation of co-contaminating bacteria that masked the NTM infection, the use of antibiotics ineffective against the specific NTM species, and the failure to identify the infection source. In this instance, contaminated skin marker ink used to mark the rectus muscle, combined with a nonabsorbable (permanent) suture for muscle repair, led to the development of a biofilm that acted as a persistent reservoir for the infection, resistant to antibiotic treatments. Complete resolution was achieved only after evaluation by a plastic surgeon experienced in treating NTM infections and the subsequent removal of the permanent suture. The delayed suture removal contributed to a 15-month recovery period. This case underscores the importance of early recognition of NTM infections after cosmetic procedures. By sharing this case, we aim to raise awareness of NTM infections and help prevent future cases of misdiagnosis and prolonged antibiotic treatments. Key points regarding the diagnosis, sources of infection, and treatment options for NTM infections are highlighted in this article using "text boxes" to emphasize the most important information and provide concise summaries of critical insights.

Fig. 1.

NTM infection post-abdominoplasty: clinical features and diagnostic insights. A, Patient just before the first plastic surgery procedure, and (B) 4 months after the muscle-repair abdominoplasty procedure, showing wound dehiscence and a fistula. C, The application of the contaminated marker ink delineating the surgical site and the application of permanent sutures for tightening lax abdominal muscles during an abdominoplasty procedure. D, The sinus tract due to the M. abscessus infection, indicated with the point of the tweezers, and draining from the abdomen, near the permanent suture, to the skin. E, The suture culture, performed on L-J medium. The area where the suture encountered the L-J medium (depicted by the green color in the photograph due to the presence of Malachite green in this solid egg-based medium) showed the growth of an M. abscessus colony, which became visible after 5 days of incubation at 37°C.

Fig. 2.

Diagnoses of NTM infections.

Fig. 3.

Treatment of NTM infections

Fig. 4.

The source of NTM infections.