Breast cancer, a widely prevalent and devastating disease impacting millions of women globally, frequently necessitates mastectomy as a pivotal treatment approach. Mastectomy serves as a crucial surgical intervention that is essential in eliminating the disease and mitigating the risk of recurrence, ultimately enhancing patient survival outcomes.
Hyperbaric oxygen therapy has been increasingly used before and after mastectomy to address complications from the surgery and subsequent radiation treatment. This paper summarises medical research on using hyperbaric oxygen therapy to prevent and treat complications from mastectomy.
Mastectomy procedures can be broadly categorised into three principal types:
- Total or simple mastectomy, which involves the removal of the entire breast.
- Modified radical mastectomy, which includes the excision of the breast and adjacent lymph nodes while still preserving the pectoral muscles; and skin-sparing mastectomy (SSM), which retains the skin of the breast to facilitate reconstruction. Skin-sparing mastectomy (SSM) encompasses a range of surgical subtypes.
- Nipple-sparing mastectomy (NSM) is similar to SSM with the additional preservation of the areolar complex, representing an advancement toward more aesthetically pleasing outcomes for the patients. While nipple-sparing mastectomy is generally viewed as a more aesthetically pleasing surgical option for patients, this procedure is subject to strict eligibility criteria that preclude certain individuals from undergoing this approach. For patients ineligible for nipple-sparing mastectomy, alternative surgical approaches may be considered. One potential option is the wide-based inframammary fold flap technique, which preserves the nipple complex. This procedure, when performed with appropriate surgical methods and adequate tissue perfusion, demonstrates promising outcomes, though care must be taken to mitigate the risk of nipple necrosis.
Skin-sparing mastectomy (SSM) and its related techniques, including nipple-sparing mastectomy (NSM), present significant surgical challenges owing to the imperative to conserve as much of the patient’s native breast skin as feasible. This highlights the importance of meticulous surgical planning and execution to ensure adequate tissue perfusion and minimise the risk of subsequent complications, such as skin necrosis.
Timing of HBOT Intervention on Managing Threatened Skin Flap Necrosis Post-NSM
Idris et al.’s (2024) systematic review of seven studies involving a total of 63 female patients revealed varying initiation timeframes for hyperbaric oxygen therapy (HBOT), with specific post-operative HBOT timelines reported for 27 individuals.
10 patients underwent HBOT within the recommended 48-hour period after nipple-sparing mastectomy. In the group that received HBOT within 48 hours after the surgery, 90% of patients had successful treatment of skin flap necrosis, with only one patient experiencing unresolved complications.
The prompt application of HBOT highlights its potential to improve surgical outcomes and expedite recovery. In contrast, for patients who received HBOT seven days or more after the surgery, the rate of successful salvage of threatened skin flap necrosis was 88%. (Idris et al., 2024)
Treating Flap Ischemia and Threatened Skin Flap Necrosis After Nipple-Sparing Mastectomy
Nasr et al. (2023) conducted a retrospective study examining the use of hyperbaric oxygen therapy to treat ischemia and necrosis in patients who underwent nipple-sparing mastectomy. A total of 17 breast patients and 25 breasts met the inclusion criteria. HBOT was used to treat ischemia/venous congestion in 15 breasts and partial thickness necrosis in 10 breasts. Flap salvage was achieved in 22 of 25 breasts (88%), though 3 required reoperation (12%). HBOT-related complications, including mild ear pain ( 3 patients) and severe sinus pressure (1 patient). The study concluded that HBOT is a useful intervention for managing threatened flaps after NSM, resulting in excellent flap salvage rates.
Alperovich et al. (2015) reported the case of a 31-year-old female patient who underwent bilateral prophylactic nipple-sparing mastectomy with tissue expander and acellular dermal matrix reconstruction. She developed postoperative necrosis of the right nipple-areola complex and mastectomy flap, which was subsequently treated with 30 sessions of hyperbaric oxygen therapy, resulting in nearly complete healing of her breast envelope and nipple-areola complex.
A study by Lotfi et al. (2020) and colleagues reported on seven consecutive patients who received hyperbaric oxygen therapy, and the outcomes were highly encouraging. All patients exhibited subjective improvements in areas of ischemia, and crucially, there was no progression to mastectomy skin flap necrosis or implant loss. Remarkably, only one patient required an early wound revision, suggesting the efficacy of this treatment approach. Based on their experience, early initiation of HBOT, within 48 hours of surgery, has shown an approximately 90% success rate in treating skin flap necrosis. Additionally, HBOT has been effective in salvaging ischemic or necrotic flaps in NSM patients, with flap salvage rates around 88%.
The study by Shuck et al. (2017) examined the outcomes of threatened skin flap necrosis (TSFN) and ischemia in 13 patients treated with hyperbaric oxygen therapy (HBOT) following nipple-sparing mastectomy (NSM). The researchers found that the use of HBOT enhanced flap survival and healing, suggesting its utility in preventing ischemia-related complications and promoting accelerated tissue recovery.
Copeland-Halperin et al. (2016) investigated the efficacy of HBOT in preserving tissue following bilateral nipple-sparing mastectomy (NSM). Their research demonstrated that HBOT sessions substantially enhanced the appearance of ischemic skin flaps. This case study underscores the benefits of administering HBOT in the early postoperative period, as it can prevent the progression of ischemia into skin flap necrosis and reduce the necessity for additional surgical interventions.
Research by Rajpal et al. (2019) has demonstrated the efficacy of hyperbaric oxygen therapy (HBOT) in managing threatened skin flap necrosis (TSFN) and ischemia following breast reconstruction procedures. The findings indicate that HBOT facilitated the healing of compromised mastectomy skin flaps, enhanced neovascularization, and improved the overall viability of the reconstructed tissue. Additionally, the study suggests that incorporating indocyanine green angiography monitoring in conjunction with HBOT interventions provides a useful strategy for controlling TSFN and ischemic complications in reconstructive breast surgery.
Hyperbaric oxygen therapy (HBOT) has been shown to significantly reduce the incidence of ischemia and the progression to necrosis in the breast tissue, which are common postoperative complications in nipple-sparing mastectomy (NSM). This effectiveness was demonstrated in a retrospective analysis of 50 breasts after mastectomy, where HBOT led to a notable decrease in the surface area affected by ischemia. Remarkably, 58% of the analyzed cases did not require further surgical intervention after receiving HBOT, highlighting its potential to limit the need for additional surgeries by effectively managing threatened skin flap necrosis (TSFN) in the postoperative period (Sprujit et al., 2021). A separate study reported on four patients with recurrent breast cancer who underwent NSM and received HBOT. Two patients underwent both pre- and post-operative HBOT, one received only pre-operative HBOT, and one received only post-operative HBOT. After the surgical procedure, only one of the four patients experienced superficial TSFN, which was successfully managed with topical nitroglycerin application. The authors concluded that HBOT, administered either before or after surgery, may be a beneficial intervention for addressing complications associated with mastectomy (Lotfi et al., 2020).
Research summary
- The existing literature indicates that Hyperbaric oxygen therapy has the potential to mitigate various postoperative complications associated with nipple-sparing mastectomy, including ischemia and necrosis/ flap loss, infections, seroma, and hematoma. By improving tissue oxygenation and vascularization, HBOT can effectively reduce inflammation, stimulate angiogenesis, and promote cellular repair, ultimately leading to better outcomes for patients.
- Notably, a substantial proportion of patients did not require additional surgical interventions, indicating HBOT’s potential to limit the need for further surgeries by effectively managing threatened skin flap necrosis in the postoperative period.
- Although early initiation of hyperbaric oxygen therapy (HBOT) within the optimal 2-day post-operative period is ideal, patients can benefit from HBOT even if treatment is delayed beyond this timeframe.
- The evidence indicates that HBOT does not appear to stimulate tumour metastasis or more aggressive growth, suggesting its oncological safety.
- While the existing evidence suggests that hyperbaric oxygen therapy holds promise in managing postoperative complications associated with nipple-sparing mastectomy, further rigorous clinical research with well-designed control groups is necessary to establish standardised HBOT protocols that optimise its effectiveness in this context.
- HBOT is generally safe and well-tolerated when administered correctly, but there are rare side effects, and it may not be suitable for every oncology patient. Therefore, patients need careful assessment by a physician with expertise in hyperbaric oxygen medicine before considering this therapy as an adjunctive treatment option.