Complications of Methylene Blue Dye in Breast Surgery: Case Reports and Review of the Literature

Abstract

Introduction: Methylene blue dye has been used worldwide successfully with few complications in breast surgery. We present two different complications involving methylene blue: 1) skin and parenchymal necrosis when dye was injected in a subdermal fashion and 2) Mycoplasma infection caused by contaminated methylene blue in breast reduction surgery. Methods: We present two cases seen at the University of Arizona during 2008 and referred to a breast surgeon for management. We evaluated and managed complications of methylene blue dye injected by 2 referring surgeons for different indications. A review of the literature was performed. Results: The first case is a 67 year old female diagnosed with infiltrating ductal carcinoma o f the left breast for which she was treated by her initial surgeon with left segmental mastectomy and sentinel node biopsy. The operating surgeon injected methylene blue in a subareolar subdermal fashion (distant from the primary tumor); unfortunately the patient suffered skin and breast necrosis requiring multiple surgical debridements and finally achieving delayed primary closure. The second case is a 45 year old female with infiltrating lobular carcinoma with a history of Mycoplasma infection secondary to methylene blue injected for breast reduction surgery. She required multiple debridements and had granulomas masquerading as cancer on MRI that confounded her extent of disease. Conclusions: The use of methylene blue dye in breast surgery is not without risk. In both cases methylene blue was responsible for complications requiring surgical debridement for local wound problems. In each case severe necrosis and infection were present. Methylene blue may cause not only significant morbidity, but may also produce cosmetically unsatisfactory results.

A prospective randomized trial comparing patent blue and methylene blue for the detection of the sentinel lymph node in breast cancer patients

“…There have been reports of a few cases of skin necrosis and fat necrosis following injection of different dyes; however, no complication of this type was found in the present study. 27,28 In our study, the sentinel lymph node detection rate was 68.1% in the patent blue group and 60.6% in the methylene blue group, with no statistically significant difference between the two groups. This detection rate may appear low, but this can be explained by the large number of locally advanced tumors, of cases in which axillary involvement was present and of cases in which neoadjuvant chemotherapy had been performed.…”

Optimizing Safety, Predictability, and Aesthetics in Direct to Implant Immediate Breast Reconstruction

“…One recent adjustment we have made in our coordinated surgical protocol with our oncologic surgeons is to rely solely an radionucleotide and discourage the use of methylene blue in the identification of sentinel nodes, because the use of methylene blue has been associated with a higher risk of wound skin edge necrosis, [31][32][33][34] and this indeed played a role in our series.…”

Using Color to Guide Debridement

“…45,46 These complications have been reported only when the dye was injected via a needle into the subdermal space and not when it was placed on wounds. Studies have demonstrated increased rates of skin necrosis, infection, and skin graft failure when methylene blue dye was used to help identify sentinel lymph nodes.…”