Interestingly, Gdalevitch et al100 from the University of British Columbia have recently reported the results of an RCT into the effects of applying nitroglycerin ointment (a potent topical vasodilator of both arteries and veins) to mastectomy skin flaps following immediate reconstruction. A single application of 45 mg of nitroglycerin ointment (2%) was applied to the mastectomy skin flaps at the end of the operation at the time of dressing application, and the dressings were left in place for 48 hours. They terminated the study after 165 patients had been recruited (85 to treatment, 80 to placebo), as the interim analysis showed a significant reduction in MSFN in the group receiving the nitroglycerin ointment (15.3% flap necrosis rate) versus placebo (33.8% flap necrosis rate, p=0.006). They concluded that the application of this vasodilator “is a simple, safe and effective way to help prevent mastectomy skin flap necrosis”. However, the evidence base in support of its widespread use is still somewhat limited as this was only a single study of 165 patients.
MSFN can be managed operatively or nonoperatively. Operative management first necessitates debridement of necrosed tissue and then several options to deal with the skin loss, including resuturing, replacing skin (with grafting or flaps), conversion to another breast reconstruction (where indicated) and allowing healing by secondary intention. Nonoperative options involve allowing the necrosed tissue to shed and subsequent healing by secondary intention, but this requires regular and active wound management entailing numerous dressing changes, often over a prolonged period, while this process occurs. Wound management devices, such as vacuum dressings, may aid wound healing, particularly for larger areas of necrosis.
No clearly defined course of action exists, with management often decided on a case-by-case basis, in line with the surgeon’s preference. The risk of further operation in order to expedite wound healing must be weighed up against a protracted course of wound healing, requiring long-term dressing care. Some feel that patients at a higher risk of MSFN, or with full-thickness defects, should be treated more aggressively.9 Patients awaiting the timely administration of adjuvant therapy may benefit from operative management to try and expedite wound healing.101
Nonoperative management remains the favored course of action for MSFN following simple mastectomy, or with autologous reconstruction, with skin grafts reserved for massive skin necrosis.21Allowing the wound to heal by natural wound contraction and re-epithelialization may lead to less significant contour defect and avoid the patch appearance of a skin graft.4 The use of hyperbaric oxygen has had successful results within case reports, but has no robust evidence to support its use.102,103
Nonoperative management involves the use of dressings, such as alginates and silver preparations (to reduce bacterial burden) in a dynamic manner, adapting to wound appearance, improvement and patient preference. Antimicrobials may be required in case of infection, while small areas of eschar may be debrided in the outpatient setting.4,101 Wound management devices, such as vacuum dressings, may facilitate wound healing, particularly where larger areas of necrosis are encountered.
Consideration of early operative intervention for MSFN is particularly important where there is an underlying implant reconstruction. Partial-thickness MSFN with an underlying vascularized dermal sling may be suitable for nonoperative management (Figure 1). However, where an ADM has been used, consideration should be given to early excision of any skin necrosis and resuturing, to try and save the implant from extrusion.83
Where the risk of MSFN is considered to be very high during mastectomy, other operative management strategies may involve the use of skin banking104 or skin grafts, which may be split or full thickness, using redundant abdominal dog ear tissue, for example.9
Skin banking is a method of delayed inset of the flap – the autologous tissue is not de-epithelialized at the time of primary reconstruction and is placed into the subcutaneous pocket, providing options where there is questionable viability of skin flaps, should native mastectomy skin necrose.4,104However, this does commit the patient to a second operation and therefore should perhaps be reserved sparingly for patients with multiple risk factors, where it is considered very likely that they will experience skin necrosis.
There has been a report of excising a questionably viable skin flap, thinning it and then replacing it as a full-thickness skin graft following radical mastectomy.105 While this was reported in relation to radical mastectomies in the 1970s, it could be theoretically applicable to any graftable bed, but is not widely used.
Rates of NSM are on the increase, but this procedure carries with it the attendant risk of nipple necrosis. This has been extensively reviewed by O’Connell and Rusby and may be avoided through a combination of careful surgical technique and a good working knowledge of the skin and nipple vasculature.73 However, when it does occur, it may be treated by excision of the nipple.
The technique of “surgical delay” has been reported to improve NAC survival rates.106 This is where the NAC is disconnected from the tissue beneath a few weeks prior to NSM, allowing not only the blood supply from the adjacent breast skin to augment but also confirmation of clear retroareolar margins. If the biopsy proves to be involved, the NAC can then be removed at the subsequent mastectomy. Jensen et al reported very good NAC survival rates with this technique.
This article has reviewed the challenges of MSFN, along with possible solutions. In summary, MSFN occurs more frequently than perceived, reported somewhere in the range of 5%–30% of cases in the literature. MSFN may be partial or full thickness. A SKIN score based on depth and extent correlates with the need for reoperation. Patient risk factors for MSFN include a history of smoking, obesity, diabetes, previous radiotherapy, previous scars and severe medical comorbidities. Careful preoperative planning may reduce the chances of MSFN, such as modification of patient risk factors (where feasible), consideration of neoadjuvant therapies and considering the most appropriate type of and timing of reconstruction for that individual’s risk profile, for example, perhaps avoiding immediate SSM in very high-risk cases.
Surgical technique plays an important role in avoiding MSFN, including optimizing mastectomy skin flap thickness and using the oncoplastic plane. A number of intraoperative techniques have been developed to detect areas of skin at risk of MSFN, including clinical evaluation, handheld Doppler devices, laser Doppler, fluorescein angiography and indocyanine green techniques. MSFN leads to a number of challenges, including immediate and long-term wound management problems, delays to adjuvant therapy, esthetic penalty, risk of infection and extrusion of breast implants, psychological morbidity and an increased financial burden. A recently published RCT has reported that nitroglycerin ointment applied to mastectomy skin flaps following immediate reconstruction may reduce the incidence of MSFN, but the evidence base is still limited. MSFN may be managed operatively or nonoperatively, depending on the individual case. Early intervention in selected cases may avoid or reduce some of the possible adverse consequences, such as implant loss.
Research by RIC is supported by Cancer Research UK and Breast Cancer Now.
Stuart A. Robertson,1 Johann A. Jeevaratnam,2 Avi Agrawal,2 Ramsey I. Cutress,3,4
1Department of Surgery, University Hospital Coventry and Warwickshire NHS Trust, Coventry,2Department of Breast Surgery, Portsmouth Hospitals NHS Trust, Cosham, Portsmouth, 3Department of Breast Surgery, University Hospital Southampton NHS Foundation Trust, Princess Anne Hospital,4Somers Cancer Research UK Centre, Southampton General Hospital Southampton, UK
The authors report no conflicts of interest in this work.
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