The incidence of mastectomy skin flap necrosis is reported to be up to 15.8%.1–9 The necrosis can require the need for long-term local wound care, lead to unsightly scars that deform the breast, and delay adjuvant treatment (chemotherapy and/or radiation). Unlike implant-based breast reconstruction, autologous reconstruction has viable tissue underneath the mastectomy skin necrosis. The underlying healthy tissue allows for different wound care options. In most cases, local wound care with minimal debridement is appropriate. However, in certain cases, this results in a long time to wound closure, which is not optimal for the patient.9 Literature from burn management shows that wounds left to heal by secondary intention beyond 3 weeks increases the risk for cicatricial deformities.10 The development of scar has the potential to lead to an unaesthetically pleasing result by deforming the shape of the breast reconstruction. Therefore, we believe, operative intervention is the optimal treatment for wounds that require more than 3 weeks to heal. The treatment can be either primary closure or skin grafting. The choice of closure is dependent on the size of the wound. Patients with tumors requiring further adjuvant chemotherapy and radiation, we believe, should also be managed in similar fashion. Wound closure is expedited and, thus, the time until initiation of adjuvant therapy is decreased.
We performed a retrospective chart review of all patients undergoing autologous breast reconstruction in the past 5 years to examine our incidence and treatment of mastectomy skin flap necrosis. We then used these data to create a management algorithm for mastectomy skin flap necrosis (Fig. 1). The goals of this algorithm were as follows: (1) to not delay further oncologic treatment, (2) to expedite the healing time while minimizing patient risk, and (3)to create an aesthetically pleasing breast reconstruction.
After institutional review board approval, we performed a retrospective chart review of all autologous breast reconstruction by the senior author (G.K.L.) from 2008 to 2013. We then created a database of the patients. We recorded all relevant patient comorbidities for wound care. We defined “history of tobacco use” as those patients who had quit for greater than 2 weeks before surgery; and “active tobacco use” as those who smoked within 2-week preoperatively. We defined mastectomy skin necrosis as any loss of mastectomy skin in the postoperative period. The wound size was determined from both patient records and pictures. A qualitative classification was used when the specific wound dimensions were not available. The qualitative classifications were small, medium, large, and massive. These were defined as less than 5%, 5% to 15%, 15% to 30%, and greater than 30% of the total unilateral breast surface area, respectively.
The postoperative course was evaluated from the medical record and specific patient photographs. The type of wound treatment was classified into 4 major categories, namely, patients who received only local wound care in the clinic, patients who needed moderate debridement which was performed in the clinic, patients who required operative debridement with closure, and those patients who underwent operative debridement with skin grafting. Essentially, we sought to classify mastectomy skin necrosis as wounds that could be handled in the clinic, wounds that would need to be operated on to heal, and those wounds that needed operative debridement but could not be primarily closed due to size. We defined a healed wound as a wound with epidermis covering the entire wound.
We then used our data to stratify the wounds based on patient comorbidities, size, depth, treatment, and time to heal. After evaluation of our wound stratification, we created a management algorithm for mastectomy skin necrosis. Our algorithm had the overall goals of not to delay further oncologic treatment, to expedite healing while minimizing patient risk, and to create an aesthetically pleasing breast reconstruction.
During the 5-year period at Stanford University, our hospital performed a total of 944 breast reconstructions with autologous tissue (latissimus dorsi flaps, pedicled TRAMS, and free flaps). Two hundred four patients underwent free flap breast reconstructions performed by the senior author (G.K.L.). Of the 204 patients, 107 were delayed reconstruction(s), 91 were immediate reconstruction(s), and 6 were a combination of 1 side performed as an immediate and the contralateral side a delayed breast reconstruction. Table 1 lists the demographics for the patients in this study.
Table 2 compared patients who developed mastectomy skin necrosis versus those who had not developed any wound healing problems. Our overall incidence of mastectomy skin necrosis was 30% (62 patients). Body mass index (BMI; P = 0.01), active tobacco use (P = 0.04), and diabetes (P = 0.03) were found to be statistically significant for the development of mastectomy skin necrosis. A history of breast radiotherapy was not found to be statistically significant (P = 0.35). The type of mastectomy (skin sparing vs nipple sparing) was not statistically significant (P = 0.98 and P = 0.83, respectively) for the development of mastectomy wounds.
Table 3 shows those 62 patients with mastectomy skin necrosis categorized by their type of wound treatment. Most patients were managed in the clinic setting (n = 44). Operative intervention was used in 18 patients. Skin grafting was required in 6 patients. The average wound size requiring skin grafting was 89 cm2. The overall average wound healing time was 39 (20) days. None of the treatment groups had a healing time less than or equal to 21 days.
Table 4 displays those patients who had a healing time of greater than 3 weeks for their mastectomy skin wounds. The patients were categorized by their specific wound treatment and as an aggregate total. The P value compared the aggregate total (of patients who exceeded 3 weeks healing time) versus those patients who healed their wounds in 3 weeks or less. Body mass index (P = 0.04) and wound size (0.01) were found to be statistically significant for exceeding a 21-day healing time.
Mastectomy skin necrosis is a source of frustration for the reconstructive surgeon. The development of skin necrosis may create cicatricial defects that distort the shape of the reconstructed breast. This can necessitate further operations and/or revisions. The incidence of this is reported in the literature to be up to 15.8%. Prior studies have been published advocating only local wound care and office wound debridement. However, average time to wound healing in those studies was 120.6 days with average revision surgery occurring 8.9 months after the initial surgery.1–9 Although this is viable treatment option, it does decrease the patients quality of life. Studies have been performed to examine the impact on a patient’s quality of life in the presence of open wounds requiring local wound care. These studies have shown a decrease in quality of life and an increase in social isolation.11–13 Also, this approach to treatment for mastectomy skin necrosis is costly. Prior studies have shown that the incurred wound care cost until the wound is healed is $11.90 to $30.92/cm3 per dressing change.14,15 Furthermore, patients requiring adjuvant treatment would benefit from a more aggressive wound closure treatment.
At our institution, the total incidence of mastectomy skin flap necrosis is 30% (62 patients). Our rate of skin necrosis is significantly higher than previously reported in the literature. A reason for this could be that we had an extremely low threshold; and we documented all breakdowns in mastectomy skin. In addition, the development of skin necrosis is dependent on the blood supply left to the skin flaps after the mastectomy. Unfortunately, the thickness of the mastectomy skin flaps we have to reconstruct the breast(s) with is not in our control. We would trim the skin flaps back until we observed bright red bleeding. There were instances where an extremely large portion of the skin flaps viability was in question. In these instances, we would trim as much mastectomy skin as we could and still be able to close the mastectomy skin to the abdominal flap. We would then allow the tissue to fully demarcate in the postoperative period. In extreme cases where most/all of the mastectomy skin flap seemed nonviable, we performed a delayed flap inset/closure. We banked the abdominal flaps (untrimmed) under the mastectomy skin flaps. This allowed the skin flaps to demarcate postoperatively. We then performed a second operation where the flaps were inset and the mastectomy skin was trimmed.
The use of fluorescent angiography has been described to assess the viability of the mastectomy skin flaps.16,17 At our institution, we did not use fluorescent angiography to predict the viability of the skin flaps. The use of this technology could certainly be investigated to observe the possible impact on the incidence of skin necrosis.
Body mass index, current tobacco use, and diabetes were statistically significant for the development of mastectomy skin necrosis (Table 2). We defined “current tobacco use” as the use of tobacco within 2 weeks before surgery. These findings are consistent with prior studies that show BMI, tobacco use, and diabetes are associated with an increased risk of the development of wounds.2,8,18 Interestingly, a history of prior irradiation to the specific breast did not seem to be statistically significant for the development of mastectomy skin necrosis (P = 0.35). A history of radiation is typically associated with the development of wounds and difficulty in wound healing.1–9,18 A possible reason for this is that our incidence of mastectomy skin flap necrosis rate was so high that it masked the impact of prior radiation.
Table 3 categorized the patients who developed mastectomy skin necrosis by the wound treatment. The mean healing time for all patients with mastectomy skin necrosis was 39 (19) days. When we retrospectively examined our data, none of the categories of wound treatment had a mean wound healing time within 21 days. In the “operative group,” this finding was not completely surprising. Most of these patients had wounds with a prolonged healing time. It was this prolonged healing time that was the impetus for the more aggressive wound care. In addition, at our institution, it would logistically take 1 week to get the person on the operating schedule. This was not “the reason” for our patients having a longer mean wound healing time, but it was a factor. The remaining patients in the operative group who had a short healing time (<21 days) were those that needed adjuvant treatment (chemotherapy/radiation). Overall, none of our patients experienced a delay in adjuvant therapy due to wound-related issues.
We compared patients who took longer than 21 days to heal their mastectomy skin necrosis versus those who did not. We wanted to observe, retrospectively, if we could identify those patients who would take longer to heal; and thus, in the future we would know which patients to treat more aggressively (sooner operative debridement, etc). Table 4 displays these data. Our number of patients in each treatment group (local wound care, clinic debridement, operative treatment) was small and therefore we also combined these patients into an aggregate total. We statistically analyzed this aggregate total versus the patients who healed within 21 days. Not surprisingly, wound size was statistically significant (P = 0.01). Body mass index was statistically significant (P = 0.04) for those patients with healing greater than 21 days. Active tobacco use (P = 0.04) and diabetes (P = 0.03) were significant factors for the development of mastectomy skin necrosis; but neither were statistically significant (P = 0.06 and P = 0.4, respectively) in the group with healing greater than 21 days. Interestingly, again, a history of prior irradiation was not statistically significant for increasing wound healing.
Intuitively, wound size was found to be statistically significant for healing time. Therefore, we wanted to find a wound size threshold that would suggest a more aggressive (operative closure or skin grafting) treatment. A regression analysis showed that full-thickness wound greater than 6 cm2 took longer than 21 days to heal without operative intervention. In addition, partial-thickness wounds greater than 5 cm2 took longer than 21 days to heal without clinic debridement/closure.
The retrospective data were then used to create a management algorithm for mastectomy skin necrosis. The goals of the algorithm were as follows: (1) to not delay further oncologic treatment, (2) to expedite the healing time while minimizing patient risk, and (3) to create an aesthetically pleasing breast reconstruction (by reduction of cicatricial deformity). When we consider that one of our primary goals was to heal all wounds in 21 days or less, the patients in the “clinic debridement/closure” group were an area for improvement, as shown in Table 3. On the basis of our data, high BMI patients and those with full-thickness wounds greater than 6 cm2 would benefit from operative closure or skin grafting. If a skin graft is necessary, we advocate a full-thickness skin graft from the lateral flank. Often, there is “dog-ear” present from the abdominal flap harvest; and the existing abdominal scar can simply be extended laterally. The data analysis also showed that we should be more stringent on our patients receiving only local wound care. Patients with a high BMI and/or a partial-thickness wound greater than 5 cm2 would benefit from a more aggressive debridement or closure. This debridement and/or could be performed in the clinic.
In summary, our retrospective review showed that our incidence of mastectomy skin necrosis was 30%. Despite our high incidence of mastectomy skin necrosis, we had no delays in adjuvant oncologic treatment. Body mass index, current tobacco use, and diabetes were statistically significant for the development of skin necrosis. Prolonged wound healing was statistically significant with wound size and BMI.
Retrospective data analysis allowed us to then develop a management algorithm for mastectomy skin necrosis. We feel it is advantageous to the patient and the reconstructive outcome to heal the breast wounds in the acute phase (within 3 weeks); and with regression analysis, we found full-thickness wounds greater than 6 cm2 benefit from operative intervention. Patients requiring adjuvant oncologic treatment should be healed as quickly as possible so they may continue on with their oncologic care.
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