The search identified 329 papers (Figure 3). Only articles published in English were included. A total of 292 articles were excluded, as they were not relevant to the aims of the review. Abstracts or reports from meetings not included in peer-reviewed publications were also not included. In all, 69 additional potentially important articles known to the authors, or cited within relevant papers, were included, giving a total of 106 articles used for the review. The results of this MSFN review are presented in the following sections.
MSFN and wound breakdown produce a range of challenges, including but not limited to immediate and long-term wound management problems, delays to adjuvant therapy, esthetic penalties through scarring and distortion, risk of infection and implant extrusion, psychological morbidity to the patient (through anxiety and distress) and increased financial expenditure. These are illustrated in Figure 2and outlined in more detail in the following.
MSFN may present as partial- or full-thickness necrosis. One of the difficulties in reviewing the literature is the inconsistency in the definition of MSFN, as superficial wound breakdown may be managed very differently (eg, with local wound care) than full-thickness necrosis (which may require surgical debridement). Management options for MSFN are discussed further later, but whichever option is chosen, there is oncological importance to start adjuvant chemotherapy or radiotherapy as soon as clinically possible. This is commensurate with National Institute for Health and Care Excellence (NICE) guidance to start adjuvant therapy within 31 days of completion of surgery (NICE guideline CG80 section 1.6.8) and the European Society of Medical Oncology guidelines indicating that treatment should ideally start within 2–6 weeks of surgery. Several papers have shown that SSM and NSM do not lead to significant delays to the start of adjuvant therapy, even when reoperation for skin flap complications is required.21,22 However, oncologists may be understandably reluctant to administer chemotherapy or radiotherapy during compromised or delayed wound healing. More light may be shed upon the possibility of delay to adjuvant therapy following immediate breast reconstruction, when the results from the National UK Immediate Breast Reconstruction and Adjuvant Therapy Audit (iBRA-2) are published (http://ibrastudy.com/iBRA2.php).
Scarring and distortion from MSFN can and will lead to esthetic penalty, whether that is a thicker, wider or distorted scar following a simple mastectomy without reconstruction, through to distortion of the skin envelope in SSM or NSM, or even implant extrusion in implant-based reconstruction. Implant-based reconstruction accounts for approximately a third of all breast reconstructions in the UK2 and around three-quarters of all reconstructions in the US.23 Complications can occur in up to 40% of cases,24 and 40% of patients may require revisional surgery.25 Over the last decade, implant-based reconstruction techniques have evolved from traditional two-stage procedures through to a single-stage procedure. Two-stage procedures involve initial placement of an expander (often with total submuscular coverage in a subpectoral pocket) followed by a second procedure to replace this with a definitive implant. Single-stage procedures involve the placement of a definitive implant usually in a subpectoral pocket, with either a dermal sling or a biological or synthetic mesh to provide inferolateral implant coverage.26,27 Immediate implant-based breast reconstruction is now usually combined with an SSM or NSM technique. However, there is still relatively little high-quality evidence comparing the benefits and complication rates of these new procedures, and so the UK Implant Breast Reconstruction evAluation (iBRA) study is currently prospectively investigating and evaluating these outcomes (http://ibrastudy.com/Home.php).
Patients experiencing visible necrosis of the skin, wound breakdown or discharge, may encounter psychological morbidity such as anxiety and depression, with a decline in their quality of life. MSFN has been shown to negatively impact on patient satisfaction and quality of life.28 Combined with the challenges of receiving a breast cancer diagnosis, recovering from surgery and adapting to changes in the appearance and feel of one’s own body following mastectomy, the subsequent additional burden of MSFN can be particularly difficult during the very challenging and vulnerable postoperative period.29–31 Support from the patient’s breast care nurse specialist can be particularly valuable, alongside that from her surgeon and general practitioner.
The prolonged wound management with skin flap necrosis, including outpatient appointments, dressings and equipment and possibly repeat admission and surgery if indicated all produce an additional financial burden on health care resources.32 A retrospective study from Baltimore in the US suggests that MSFN results in a 50% increase in the cost of inpatient charges within 30 days of mastectomy and tissue expander reconstruction.33 At a time when health care systems around the world are under pressure for increased efficiency savings, with the UK’s National Health Service no exception to this,34 it is important to consider techniques for anticipating and avoiding MSFN.
Skin flap viability may be influenced by both patient and surgical factors. If mastectomy skin flap perfusion with sufficient oxygenated hemoglobin is compromised, necrosis may ensue.
Patient risk factors for skin flap necrosis
Patient risk factors include smoking,14,35–43 age,14,37,38,44,45 hypertension,14,45 previous scars,40radiotherapy,13,15,21,35,40,42,44,46 diabetes,21 obesity,13,14,21,35,38,40,42–45,47–52 increased breast volume38,48,53 and severe comorbidities.13,54–56
Smoking impairs wound healing and significantly increases the risk of MSFN following reconstruction.55 The purported mechanism of action of smoking on MSFN may be via nicotine (a known vasoconstrictor), reduced oxygenation of hemoglobin (via carbon monoxide binding) and increased platelet aggregation.36,57–59
There is certainly evidence that smoking cessation prior to surgery reduces postoperative complications, as shown in a systematic review and meta-analysis.60 This review examined a range of postoperative complications with different types of surgery and found that the longer the cessation the better, with each week of cessation increasing the magnitude of effect by 19%. However, it is unclear specifically how much smoking cessation is required to reduce MSFN, and this may not always be achievable in the often short time between diagnosis and surgery. Results from an experimental rat model investigating the duration of smoking cessation and its impact on skin survival with random pattern flaps suggest that 4 weeks of preoperative smoking cessation is required for significant decreases in the rates of skin flap necrosis.61