Breast Cancer and Mastectomy-Related Treatment
HBOT is approved for the treatment of compromised delayed radiation injury to chest wall and compromised flaps following mastectomy.

Radiation injuries can occur weeks, months, or even years after radiation has concluded. In addition to attacking cancer cells, radiation therapy can damage healthy cells and blood vessels which compromise normal cellular function and healing.

​A mastectomy is a surgical procedure that involves removing all or part of a breast. Mastectomy skin flap necrosis refers to the death of tissue in the skin flap used during mastectomy and breast reconstruction. ​

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HBOT can help prevent graft/flap compromise by being implemented before and after placement.

Hyperbaric oxygen treatment for mastectomy flap ischaemia: A case series of 50 breasts

Nicole E Spruijt1, Lisette T Hoekstra1,2, Johan Wilmink3, Maarten M Hoogbergen1,4 1 Da Vinci Clinic, Geldrop, the Netherlands

2 Department of Plastic, Reconstructive and Hand Surgery, Maastricht UMC+, the Netherlands 3 Department of Plastic, Reconstructive and Hand Surgery, Maxima Medical Center Eindhoven, the Netherlands 4 Department of Plastic, Reconstructive and Hand Surgery, Catharina Hospital, Eindhoven, the Netherlands

Abstract

Introduction: Hyperbaric oxygen treatment (HBOT) has been suggested as an effective intervention to limit necrosis of ischaemic skin flaps after mastectomy. The purpose of this study was to evaluate outcomes of HBOT in the largest series of patients to date with mastectomy flap ischaemia.

Methods: A retrospective analysis was performed of 50 breasts requiring HBOT for mastectomy flap ischaemia. The severity of the ischaemia or necrosis was evaluated by four independent observers using the skin ischaemia necrosis (SKIN) score. Multivariate logistic regression analyses were used to assess associations between risk factors and re-operation.

Results: HBOT was started a median of 3 days (range 1–23) after surgery and continued for a median of 12 sessions (range 6–22). The breast SKIN surface area scores (n = 175 observations by the independent observers) improved in 34% (of observations) and the depth scores deteriorated in 42% (both P < 0.01). Both the surface area and depth scores were associated with the need for re-operation: higher scores, reflecting more severe necrosis of the mastectomy flap, were associated with increased need for re-operation. Twenty-nine breasts (58%) recovered without additional operation. Pre-

operative radiotherapy (OR 7.2, 95% CI 1.4–37.3) and postoperative infection (OR 15.4, 95% CI 2.6–89.7) were risk factors for re-operation in multivariate analyses.

Conclusions: In this case series, the surface area of the breast affected by ischaemia decreased during HBOT, and most breasts (58%) did not undergo an additional operation. A randomised control trial is needed to confirm or refute the possibility that HBOT improves outcome in patients with mastectomy flap ischaemia.

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Perioperative hyperbaric oxygen treatment and postoperative complications following secondary breast reconstruction after radiotherapy: a case-control study of 45 patients

Eva L Meier1, Stefan Hummelink1, Nina Lansdorp2, Onno Boonstra2, Dietmar JO Ulrich1 Department of Plastic Surgery, Radboud University Medical Center, Nijmegen, The Netherlands 2 Da Vinci Clinic, Arnhem, The Netherlands Corresponding author: Dr Eva Meier, Department of Plastic and Reconstructive Surgery (hp 634), Radboud University Medical Center, P.O. Box 9101, 6500 HB Nijmegen, The Netherland

 

Abstract

Introduction: Radiotherapy reduces the risk of locoregional recurrence of breast cancer. As a side-effect, tissue can become hypocellular, hypovascular, and hypoxic and late radiation tissue injury can develop months or years later. Radiotherapy increases the risk of complications following secondary breast reconstruction. Hyperbaric oxygen treatment (HBOT) improves oxygenation of irradiated tissue and induces neovascularisation. This study evaluated whether the incidence of

complications following secondary breast reconstruction after radiotherapy is decreased with perioperative HBOT.

Methods: In this retrospective case-control chart review study, patients who underwent perioperative HBOT (n = 15) were compared to lifestyle-matched (n = 15) and radiation damage-matched (n = 15) patients who underwent secondary breast reconstruction without HBOT.

Results: The HBOT group had significantly more severe radiation damage of the breast than the lifestyle- and radiation-damage-matched control groups (scoring grade 1−4, mean 3.55 versus 1.75 and 2.89 respectively, P = 0.001). Patients underwent on average 33 sessions of HBOT (18 sessions preoperatively and 15 sessions postoperatively). There was no significant difference in the incidence of postoperative complications between the HBOT group, lifestyle-matched group and radiation damage-matched group. Logistic regression analysis showed a lower risk of postoperative complications in patients who underwent HBOT.

Conclusions: Although the HBOT group had more radiation damage than the control groups, the incidence of postoperative complications was not significantly different. This implied a beneficial effect of HBOT, which was supported by the logistic regression analysis. Definitive conclusions cannot be drawn due to the small sample size. Future research is justified,

preferably a large randomised controlled trial.

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Hyperbaric oxygen therapy in the treatment of radiation-induced wound complications of breast cancer

Rajapakse Y and Hawkins GC

Wound Practice and Research 2020; 28(3):133-136.

DOI https://doi.org/10.33235/wpr.28.3.133-136

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Abstract

Reconstructive surgery is a very common procedure during breast cancer treatment. In the presence of adjunctive radiotherapy, failure rates are very high due to poor wound healing. We present two case studies where expected significant surgery was avoided due to treatment with hyperbaric

oxygen therapy (HBOT), particularly in the presence of a prosthesis.

Introduction

Current breast cancer treatment involves removal of the tumour by either a mastectomy or breast-conserving surgery (lumpectomy). In breast-conserving surgery, radiotherapy is often used as an adjunct treatment following surgery1. 

A 2009 review reported the complication rates following

mastectomy were more than twice as great when surgery was followed by radiotherapy2. Postoperative wound breakdown following radiotherapy is particularly problematic as it occurs in the presence of reconstructive procedures usually with an implant or tissue expander. Subsequent wound breakdown from radiation tissue injury in these situations can result in

prosthetic, and thus reconstructive, failure, resulting in further surgery in a compromised tissue bed. 

Radiation therapy results in progressive loss of small blood vessels in the irradiated field (hypovascularity) leading to hypoxia and cell death (hypocellularity)3. The tissue becomes increasingly fibrotic and, at a critical point, may break down to form a spontaneous ulcer, or may fail to heal following surgical intervention such as reconstruction with or without a prosthesis.

After radiotherapy, wound healing has been shown to be

severely impaired for several reasons4, and has also been shown to increase the surgical complication rate of both autologous and implant-based reconstructions5,6. Hyperbaric oxygen therapy (HBOT) has been well described to treat radiation-induced tissue complications7. However, currently, there are few reports of its efficacy in the treatment of wounds

secondary to radiation therapy of the breast, particularly in the presence of a prosthesis. Enomoto et al.8 describe a human case of a refractory skin ulcer that developed 26 years after an initial mastectomy followed by radiation therapy. This was successfully treated with 101 sessions of HBOT over 1 year. Snyder et al.9 report using 20 HBOT sessions pre-operatively and 10 postoperatively in five patients who had bilateral breast reductions after unilateral lumpectomy and radiotherapy. Complication rates were similar between the irradiated and non-irradiated breasts.

We report two cases of wound complications following radiotherapy, one with an early presentation and one late, both of which were successfully treated with HBOT. Both patients have given full written consent for publication of their clinical course and photographs of their wounds.

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Hyperbaric Oxygen Therapy for the Compromised
Graft or Flap

Ashish Francis and Richard C. Baynosa*

Division of Plastic Surgery, University of Nevada School of Medicine, Las Vegas, Nevada.

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Significance: Tissue grafts and flaps are used to reconstruct wounds from trauma, chronic disease, tumor extirpation, burns, and infection. Despite careful surgical planning and execution, reconstructive failure can occur due to poor wound beds, radiation, random flap necrosis, vascular insufficiency, or ischemia-reperfusion (IR). Traumatic avulsions and amputated composite tissues—compromised tissue—may fail from crush injury and excessively
large sizes. While never intended, these complications result in tissue loss, additional surgery, accrued costs, and negative psychosocial patient effects.
Recent Advances: Hyperbaric oxygen (HBO) has demonstrated utility in the
salvage of compromised grafts/flaps. It can increase the likelihood and effective size of composite graft survival, improve skin graft outcomes, and enhance flap survival. Mechanisms underlying these beneficial effects include increased oxygenation, improved fibroblast function, neovascularization, and amelioration of IR injury.
Critical Issues: Common strategies for the compromised graft or flap include
local wound care, surgical debridement, and repeated reconstruction. These
modalities are associated with added costs, time, need for reoperation, morbidity, and psychosocial effects. Preservation of the amputated/avulsed tissues minimizes morbidity and maximizes the reconstructive outcome by salvaging the compromised tissue and obviating additional surgery. HBO is often overlooked as a potential tool that can limit these issues.
Future Directions: Animal studies demonstrate a benefit of HBO in the
treatment of compromised tissues. Clinical studies support these findings, but are limited to case reports and series. Further research is needed to provide multicenter prospective clinical studies and cost analyses comparing HBO to other adjunctive therapies in the treatment of compromised grafts/flaps.

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Hyperbaric Therapy for Skin Grafts and Flaps

Mark W. Jones1; Jeffrey S. Cooper2.
Affiliations 1 McLaren Greater Lansing, MSUCOM, 2 University of Nebraska Medical Center
Last Update: July 24, 2023.

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Hyperbaric oxygen therapy has shown promise in salvaging flaps in tissue that has been irradiated or in areas where there is decreased tissue perfusion or hypoxia. Hyperbaric oxygen therapy can potentially increase tissue viability and thus decrease the need for repeat procedures. This activity reviews the indications, contraindications, and techniques involved in utilizing hyperbaric oxygen therapy for skin grafts and flaps and highlights the role of the interprofessional team in the management of patients with skin grafts and flaps.

"Hyperbaric oxygen therapy (HBO2T) is neither necessary nor recommended for the support of normal, uncompromised grafts or flaps. However, in tissue compromised by irradiation or in other cases where there is decreased perfusion or hypoxia, HBO2T has been shown to be extremely useful in flap salvage. Hyperbaric oxygen can help maximize the viability of the compromised tissue thereby reducing the need for regrafting or repeat flap procedures".
Hyperbaric oxygen therapy has many uses. It is indicated for certain soft tissue conditions including compromised and ischemic skin grafts. The treating surgeon and wound care specialist must be aware of these indications in order to make the appropriate and timely referral for hyperbaric therapy. This will add to a better outcome and flap salvage for a certain percentage of patients who would otherwise be victims of failed grafts and poor outcomes.