Hyperbaric Oxygen Therapy for Threatened Nipple-Sparing Mastectomy Flaps

Abstract

Background: Nipple-sparing mastectomy (NSM) is emerging as the standard of care for treatment of breast cancer because of its oncologic safety and superior aesthetic outcomes. However, ischemia or necrosis of the skin flap and/or nipple-areola complex remain frequent complications. Hyperbaric oxygen therapy (HBOT) has emerged as a potential adjunct for flap salvage, although it is not currently a widely accepted practice. Here we review our institution's experience using a protocol of HBOT in patients with signs of flap ischemia or necrosis after NSM. Methods: Retrospective review identified all patients treated with HBOT at our institution's hyperbaric and wound care center because of signs of ischemia after NSM. Treatment parameters consisted of 90-minute dives at 2.0 atmosphere once or twice daily. Patients unable to tolerate dives were considered a treatment failure, whereas those lost to follow-up were excluded from analysis. Patient demographics, surgical characteristics, and treatment indications were recorded. Primary outcomes assessed were flap salvage (no operative revision), need for revision procedures, and treatment complications. Results: A total of 17 patients and 25 breasts met the inclusion criteria. The mean ± SD time to initiation of HBOT was 9.47 ± 12.7 days. The mean ± SD age was 46.7 ± 10.4 years, and mean ± SD follow-up time was 36.5 ± 25.6 days. Indications for NSM included invasive cancer (41.2%), carcinoma in situ (29.4%), and breast cancer prophylaxis (29.4%). Initial reconstruction included tissue-expander placement (47.1%), autologous reconstruction with deep inferior epigastric flaps (29.4%), and direct-to-implant reconstruction (23.5%). Hyperbaric oxygen therapy indications included ischemia or venous congestion for 15 breasts (60.0%) and partial thickness necrosis for 10 breasts (40.0%). Flap salvage was achieved in 22 of 25 breasts (88.0%). Reoperation was required for 3 breasts (12.0%). Hyperbaric oxygen therapy-related complications were observed in 4 patients (23.5%), which included 3 patients with mild ear pain and 1 patient with severe sinus pressure leading to treatment abortion. Conclusions: Nipple-sparing mastectomy is an invaluable tool for breast and plastic surgeons to achieve oncologic and cosmetic goals. However, ischemia or necrosis of the nipple-areola complex or mastectomy skin flap remains frequent complications. Hyperbaric oxygen therapy has emerged as a possible intervention for threatened flaps. Our results demonstrate the utility of HBOT in this population to achieve excellent NSM flap salvage rates.

Minimizing Nipple-Areolar Complex Complications in Prepectoral Breast Reconstruction After Nipple-Sparing Mastectomy

“…This variance in outcomes after HBOT reflects a variety of factors, including differences in surgeon assessment of extent and thickness of NAC necrosis and time to detection of NAC ischemia and initiation of HBOT. Prior studies from our institution have demonstrated an 88% salvage rate for 25 breasts with mastectomy and NAC necrosis following breast reconstruction and NSM, and as such, it is a useful modality for this purpose 41,42 …”

“…Prior studies from our institution have demonstrated an 88% salvage rate for 25 breasts with mastectomy and NAC necrosis following breast reconstruction and NSM, and as such, it is a useful modality for this purpose. 41,42 Limitations of this study include the small, retrospective nature of our cohort, which precludes our ability to establish causality between variables. Further, a heterogeneous group of breast and plastic surgeons were included, each with slight variation in their operative technique.…”

“…Hyperbaric oxygen therapy is a noninvasive therapy that can mitigate NAC or mastectomy flap necrosis after NSM. 41,42 In HBOT, the patient is placed in a closed chamber with an elevated internal atmospheric pressure and oxygen concentration. In doing so, the tissue partial pressure of oxygen increases, which leads to generation of reactive oxygen and nitrogen species.…”

“…In our study, all 7 cases of partial NAC necrosis underwent local wound therapy, 3 (38%) underwent HBOT, 2 (25%) required outpatient excision and debridement, and 2 (25%) required operative debridement. Hyperbaric oxygen therapy is a noninvasive therapy that can mitigate NAC or mastectomy flap necrosis after NSM 41,42 . In HBOT, the patient is placed in a closed chamber with an elevated internal atmospheric pressure and oxygen concentration.…”