Annals of Burns and Fire Disasters - vol. XV - n. 3 - September 2002
RECONSTRUCTION OF THE BURNED BREAST
Hafezi F., Boddouhi N., Nouhi A.H.
Department of Plastic Surgery, Motahary Burn and Reconstructive Centre, Iran University of Medical Sciences, Tehran, Iran
SUMMARY. Thermal injury to the anterior chest wall in adolescent female patients may cause severe disfigurement of the breasts. Direct damage to the breast bud can lead to complete lack of breast development, and even if the breast bud is spared the breast mound will be compressed under the scarred skin of the chest wall. In this article, we report the cases of patients who underwent surgery for burned breast. In 20 patients who had moderate to severe burn scars, we released the breast tissue and used thick split-thickness skin graft for reconstruction. In three patients with milder deformities, the inferior pedicle technique was used. We believe that repeated scar revision and grafting in the growing adolescent is mandatory for normal breast mound growth. In milder forms, the inferior pedicle method gives an acceptable appearance and offers consistent and reliable results in burned breasts.
Thermal injury to the anterior chest wall in young female patients can lead to severe disfigurement of the breasts.1 The end result will be significant asymmetry and displacement of the nipple-areola complex (NAC) due to burn scar contracture, and significant scarring. Heavy pendulous breasts cause physical and psychological trauma. These factors add more psychological discomfort and subsequent behavioural changes.2 Injury to the breast bud can have a variety of effects on later breast growth. Direct damage to the bud itself can result in complete lack of development or partial growth inhibition of the breast (Fig. 1).
If the breast bud is spared but the surrounding chest wall skin is scarred and unyielding, breast development can be extrinsically inhibited.3
Even if the burn injury does not affect the breast bud, the growth and development of the organ may be impaired. However, as shown in Fig. 2, after release of the constricting tissue, the breast mound can be decompressed and normal symmetrical breast tissue will be released. A thick split-skin graft can be used for coverage of big defects since this has better aesthetic results than a thin graft.v
In the female breast and abdomen, excess loose skin is usually present and this can be used to replace scar tissue. In cases of partial inelastic scarring of the breast skin, mastopexy can be performed using scar tissue as the NAC pedicle. This segment can be de-epithelialized and kept hidden by surrounding skin flaps (Fig. 3). With careful excision of the scar over the pedicle, there will be no danger of NAC ischaemia.1 Mammaplasty in these patients is quite safe since the deeper tissues and perforator vessels are usually spared from burn damage. In our experience the inferior pedicle technique is the safest and most reliable way of performing reduction or mastopexy in burn patients, and it brings the mal-located NAC to a more symmetrical position.2 The limitations to this technique are superior chest wall deformities and extensive scarring.
Before starting the operation, breast markings are determined with the patient in the upright position (Fig. 3).
We try to use the burned area as the pedicle of the NAC, so that it can be hidden and covered by lateral flaps.
After general anaesthesia, the operation is started by releasing the burn contracture scar from the anterior chest wall, using the inferior pedicle technique. The preserved mass of breast and NAC attached to it are de-epithelialized in such a way as to use the mass under the scarred tissue as the pedicle. Excision of the scar tissue usually releases the breast mass and underlying breast mound. If there is any excess volume or asymmetry of the breasts, this can be excised at this moment. In cases of mastopexy or reduction mammaplasty, the lateral and medial skin flaps are pulled and sutured together to conceal the burned de-epithelialized breast mass underneath. The wound is closed in two layers of absorbable nylon stitches. Wearing of a bra for at least six months is recommended in order to lessen the chance of scar widening. Two units of autologous blood are prepared for big breasts.
Twenty-three patients with breast burn sequelae are presented in this study (Table I). The cases are divided into three groups, according to the extent of the damage produced by the burn trauma.
All the patients were operated upon by the same surgeon at a university-affiliated hospital in Tehran, Iran. In severe and moderate cases we released the breast tissue under the scar and used a thick split-thickness skin graft. In mild segmental scars, our choice was the inferior pedicle technique.
Not many methods for breast reconstruction are to be found in the literature. Riberio5 suggested the transposition of the nipple onto an inferiorly-based dermoglandular flap. This technique was modified by Courtiss and Goldwyn,6 Robins,7 and Georgiad.8 There has been a natural progression in the state of the art in breast reconstruction. Kornstein and Cinelli9 used the inferior pedicle reduction technique for larger forms of gynaecomastia. Alvi10 and Dicksheet11 reported nipple-bearing inferior mammaplasty with a modification to reduce operating time and blood loss. Pandeya12 described the use of the inferior pedicle technique to reduce breast size. Smith13 and Marks14 discussed the hazard of inferior pedicle breast reduction concurrent with explantation of the subglandular implant.
Thermal injury to the anterior chest in young girls can lead to disfigurement of the breasts. Proper management is important to ensure an optimal aesthetic outcome. Significant burns to the anterior chest may result in mammary entrapment owing to thick, inelastic scar contracture, which impairs the breast’s normal appearance; however, in female patients with full-thickness burns of the skin and breast bud, the breast can also undergo hypoplasia if the damage occurs in the adolescent period.1
We believe that the inferior pedicle technique offers consistent and reliable results and gives an acceptable appearance in mild segmental scars of the burned breast.
In cases of severe burns in the chest wall and damage to the breast bud, complete lack of breast development will be the outcome. In many cases, because of the extent of the burned area and severe contracture, nothing other than release and grafting can be done. In situations where the surrounding tissues are available, conventional methods of breast reconstruction, such as latissimus dorsi and TRAM flap or submuscular placement of the prosthesis, can be used.
In the adolescent age group, the size of the female breast is changing because of the growth of the underlying gland. Multiple skin grafting may be needed as the size of the breast mound grows, and frequent follow-up is recommended in this age group.
In partially scarred breasts, the inferior pedicle technique can cover most of the scarred skin and gives the patients a more pleasing appearance.
RESUME. Les lésions thermiques de la paroi antérieure thoracique dans les patientes adolescentes peuvent causer des défigurations sévères des seins. Le dommage direct subi par le bourgeon du sein peut porter au manque total de son développement et, même si le bourgeon mammaire est intact, l’enflure du sein sera comprimée sous la peau cicatrisée de la paroi thoracique. Les Auteurs présentent des cas de leurs patientes opérées chirurgicalement pour des brûlures au sein. Dans 20 patientes atteintes de cicatrices modérées ou sévères dues aux brûlures, ils ont relâché les tissus mammaires et utilisé une greffe cutanée épaisse à épaisseur variable pour la reconstruction. Dans trois patientes qui présentaient des difformités moins sévères, ils ont employé la technique du pédicule inférieur. Selon les Auteurs, la révision répétée des cicatrices et de la greffe sont impératives dans les jeunes adolescentes encore en phase de croissance pour avoir un développement normal du sein. Dans les formes moins sévères, la méthode du pédicule inférieur donne aux patientes un aspect acceptable et produit des résultats sûrs et positifs dans les seins brûlés.