Hyperbaric Oxygen and Breast Reconstruction

Hyperbaric oxygen (HBO₂) is an emerging and promising modality for breast reconstruction after skin-sparing and nipple-sparing mastectomy. By providing increased oxygenation to tissues, it may play a critical role in salvaging threatened breast skin, which can preserve the final aesthetic outcome and prevent delays in adjuvant therapy.

A skin-sparing mastectomy removes all breast tissue, along with the nerves and blood vessels that run through the breast parenchyma, and preserves the overlying breast skin. Because of this, the remaining breast skin experiences a significant reduction in blood flow. Sometimes the blood flow is reduced too much for skin survival, leading to skin loss or mastectomy flap necrosis – cell death in the injured tissue. Mastectomy flap necrosis has been associated with a number of risk factors, such as smoking, diabetes, obesity, age over 50, prior radiation or chemotherapy, prior breast surgery and scars, large breasts (high mastectomy weight), ptotic breasts (long sternal notch or mid-clavicle-to-nipple distance), tumescent mastectomy technique, certain mastectomy access incisions, thickness of mastectomy skin flaps, and high intraoperative tissue expander fill.

A nipple-sparing mastectomy preserves all breast skin, including the nipple and surrounding pigmented circle or oval called the areola. Nipple-sparing mastectomies are performed on patients who meet oncologic and aesthetic criteria, which is based on tumor size, tumor distance from nipple, and nipple-areola position. After a nipple-sparing mastectomy, mastectomy flap necrosis can also involve the nipple and areola, which may lead to nipple-areola loss.

Immediate breast reconstruction involves performing the first stage of reconstruction at the time of mastectomy. A tissue expander (most commonly), permanent implant, or autologous flap can be used to create a breast mound immediately after the mastectomy is performed. If mastectomy flap necrosis occurs, additional surgery is often required to excise non-viable skin or the nipple-areola complex and may also require removal of the tissue expander or implant. This may delay tissue expander fills, require slower expansion or a greater number of fills, require additional surgery, and delay adjuvant therapy. Losing the nipple-areola complex compromises the final aesthetic outcome and patient satisfaction.

Several studies have proven benefit to using hyperbaric oxygen treatment to prevent mastectomy flap necrosis once compromised perfusion, or blood flow, has been identified. Compromised perfusion can be detected based on intraoperative exam findings (color, capillary refill, bleeding), indocyanine green angiography assessment, and postoperative exam findings (color, capillary refill, ecchymosis). Current literature stresses the importance of early HBO₂, with recommendations to start within 48 hours, preferably within 24 hours if possible. The largest published series (n=50) found decreased surface area affected by ischemia after HBO₂ (34% of breasts) and that found many patients did not require an additional operation (58% of breasts).¹ Other studies have found HBO₂ leads to subjective improvement in mastectomy flaps,² increased relative perfusion values,³ reduction in at-risk skin area,³ prevention of necrosis progression,² and successful implant salvage.² A series focusing nipple areola complex (NAC) ischemia found fewer average days to healing after HBO₂ compared to the control group but was not statistically significant.⁴ There is less of a role for HBO₂ after a total or simple mastectomy because most of the breast skin is removed and therefore at lower risk for compromised perfusion. Most studies are limited to small case series, case reports, and viewpoints, highlighting a need for larger studies.^1-8 A randomized controlled trial would strengthen the current literature but would require withholding HBO₂ from some women with impending mastectomy skin necrosis.

HBO₂ has been less utilized for autologous or free flap breast reconstruction. To date, scientific articles have not collected evidence to support a clear benefit. Early postoperative changes in perfusion, whether arterial or venous in nature, require timely surgical intervention for flap salvage. Most frequently, a vascular thrombus or pedicle kink/twist is found to be responsible. These issues would not be solved with HBO₂ treatment. However, focal fat necrosis can result from localized areas of decreased blood supply. To date, HBO₂ indications do not include prevention of fat necrosis. Future hyperbaric oxygen research could focus on evaluating the role of routine HBO₂ to minimize the rates and size of fat necrosis after autologous breast reconstruction.

Melissa Mueller, MD
Assistant Professor
Division of Plastic Surgery
Indiana University School of Medicine

References

1. Spruijt NE, Hoekstra LT, Wilmink J, Hoogbergen MM. Hyperbaric oxygen treatment for mastectomy flap ischaemia: A case series of 50 breasts. Diving Hyperb Med. 2021 Mar 31;51(1):2-9.
2. Lotfi P, Dayan J, Chiu ES, Mehrara B, Nelson JA. Hyperbaric Oxygen Therapy and Mastectomy Flap Ischemia following Nipple-Sparing Mastectomy and Immediate Breast Reconstruction. Plast Reconstr Surg. 2020 Jun;145(6):1114e-1115e.
3. Rajpal N, Walters ET, Elmarsafi T, Pittman TA, Johnson-Arbor KK. Use of hyperbaric oxygen therapy for tissue ischemia after breast reconstruction. Undersea Hyperb Med. 2019 Jun-Jul-Aug – Third Quarter;46(4):461-465.
4. Shuck J, O’Kelly N, Endara M, Nahabedian MY. A critical look at the effect of hyperbaric oxygen on the ischemic nipple following nipple sparing mastectomy and implant based reconstruction: a case series. Gland Surg. 2017 Dec;6(6):659-665.
5. Alperovich M, Harmaty M, Chiu ES. Treatment of nipple-sparing mastectomy necrosis using hyperbaric oxygen therapy. Plast Reconstr Surg. 2015 Jun;135(6):1071e-1072e.
6. Copeland-Halperin LR, Bruce SB, Mesbahi AN. Hyperbaric oxygen following bilateral skin-sparing mastectomies: a case report. Plast Reconstr Surg Glob Open. 2016 Apr 20;4(4):e680. eCollection 2016 Apr.
7. Fredman R, Wise I, Friedman T, Heller L, Karni T. Skin-sparing mastectomy flap ischemia salvage using urgent hyperbaric chamber oxygen therapy: a case report. Undersea Hyperb Med. Mar-Apr 2014;41(2):145-147.
8. Mermans JF, Tuinder S, von Meyenfeldt MF, van der Hulst RR. Hyperbaric oxygen treatment for skin flap necrosis after a mastectomy: a case study. Undersea Hyperb Med. May-Jun 2012;39(3):719-723.