Hyperbaric oxygen treatment for mastectomy flap ischaemia: A case series of 50 breasts

Introduction: Hyperbaric oxygen treatment (HBOT) has been suggested as an effective intervention to limit necrosis of ischaemic skin flaps after mastectomy. The purpose of this study was to evaluate outcomes of HBOT in the largest series of patients to date with mastectomy flap ischaemia. Methods: A retrospective analysis was performed of 50 breasts requiring HBOT for mastectomy flap ischaemia. The severity of the ischaemia or necrosis was evaluated by four independent observers using the skin ischaemia necrosis (SKIN) score. Multivariate logistic regression analyses were used to assess associations between risk factors and re-operation. Results: HBOT was started a median of 3 days (range 1–23) after surgery and continued for a median of 12 sessions (range 6–22). The breast SKIN surface area scores (n = 175 observations by the independent observers) improved in 34% (of observations) and the depth scores deteriorated in 42% (both P < 0.01). Both the surface area and depth scores were associated with the need for re-operation: higher scores, reflecting more severe necrosis of the mastectomy flap, were associated with increased need for re-operation. Twenty-nine breasts (58%) recovered without additional operation. Pre-operative radiotherapy (OR 7.2, 95% CI 1.4–37.3) and postoperative infection (OR 15.4, 95% CI 2.6–89.7) were risk factors for re-operation in multivariate analyses. Conclusions: In this case series, the surface area of the breast affected by ischaemia decreased during HBOT, and most breasts (58%) did not undergo an additional operation. A randomised control trial is needed to confirm or refute the possibility that HBOT improves outcome in patients with mastectomy flap ischaemia.

Optimizing the Mastectomy Flap to Improve Aesthetic Outcomes

The aesthetics of breast reconstruction inherently rely on both the ablative and reconstructive procedures. Mastectomy flap quality remains one of the most critical factors in determining the success of a reconstruction and its aesthetic outcome. Maintaining the segmental perfusion to the nipple and skin envelope during mastectomy requires preserving the subcutaneous tissue superficial to the breast capsule. Because this layer of tissue varies in thickness among different patients and within each breast, anatomic dissection along the appropriate planes is required rather than a “one-size-fits-all” mentality. A team-based approach between the breast surgeon and plastic surgeon will optimize both the ablative and reconstructive procedures while engaging in a process of shared decision-making with the patient. Preoperative clinical analysis and utilization of imaging to assess individual breast anatomy will help guide mastectomies as well as decisions on reconstructive modalities. Critical assessment of mastectomy flaps is paramount and requires flexibility to adapt reconstructive paradigms intraoperatively to minimize the risk of complications and provide the best aesthetic result.