Hyperbaric Oxygen Therapy Does Not Decrease Progression of Skin Flap and Nipple Areolar Ischemia to Necrosis in Nipple-sparing Mastectomy
Michael Sosin, MD1, Alex J. Bartholomew, BA, MS2, Lauren Kerivan, BS2, Eleni A. Tousimis, MD1, Shawna C. Willey, MD1, Troy A. Pittman, MD1.
1Medstar Georgetown University Hospital, Washington, DC, USA, 2Georgetown University School of Medicine, Washington, DC, USA.
PURPOSE: The popularity and number of nipple-sparing mastectomy (NSM) being performed continues to increase. Ischemia or necrosis to the nipple areolar complex (NAC) or breast skin flap (SF) is a known complication after NSM and current management options to salvage the NAC and SF include local wound care and hyperbaric oxygen therapy (HBOT). However, there is a paucity of data in the literature evaluating the efficacy of (HBOT) following NSM. The purpose of this study is to determine whether HBOT prevents transformation of NAC or SF ischemia to necrosis and complete tissue loss. METHODS: After IRB approval, NSM's performed at a single institution from 1989 to 2015 were retrospectively reviewed, individually by breast, for analysis. All NAC and SF ischemia and/or necrosis were identified. Patient demographics, comorbidities, chemo- and radiation therapy, HBOT, and NAC and SF loss (resection or complete tissue loss) were collected. Student's t-test and chi square were used to compare demographics between cohorts, and Fisher's exact test was used to compare rates of progression to necrosis. RESULTS: Data for 693 breasts having undergone NSM was reviewed, 63 (9.1%) breasts incurred NAC ischemia and 51 (7.4%) incurred SF ischemia. A total 53.5% had therapeutic NSM, 10.1% received neoadjuvant chemotherapy, 40.4% received adjuvant chemotherapy, and 13.3% received adjuvant radiation therapy. Due to an overlap between NAC and SF ischemia, final cohort size consisted of 99 breasts. There were 12 NAC's and 15 skin flaps that developed necrosis and were resected (Table 1). The mean age was 46.0 ± 9.2 years, BMI was 23.8 ± 3.8 kg/m2, 8.1% were active smokers until diagnosis, 3% had type 2 diabetes mellitus, and mean breast weight was 414 ± 212g. All patients underwent immediate breast reconstruction, of whom 79.8% had tissue expanders placed with a mean initial fill volume of 247 ± 104ml, 10.1% had tissue expanders, which were not filled during initial placement, and 10.1% received direct implant reconstruction with mean volume of 443.5 ± 207ml. HBOT was implemented for 12.7% (n = 8) of breasts with NAC ischemia and 23.5% (n = 12) with SF ischemia, while the remaining breasts received local wound care. Mean number of HBOT dives completed was 14.8 ± 3.8. Of breasts with NAC ischemia, progression to necrosis was similar whether HBOT was implemented or not (25.0% vs. 18.2%, respectively; p = 0.64). Breasts with SF ischemia and HBOT progressed to SF necrosis at a higher rate compared to those not receiving HBOT (75.0% vs 15.4%, respectively; p < 0.01). CONCLUSION: Hyperbaric oxygen therapy does not appear to prevent the progression of NAC or SF ischemia to necrosis as compared to patients not receiving HBOT following NSM. Although there may be a selection bias of those undergoing HBOT, the use of HBOT needs to be further delineated to support HBOT implementation following ischemia of the NAC or SF after NSM.
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