Hyperbaric Oxygen Therapy and Mastectomy Flap Ischemia following Nipple-Sparing Mastectomy and Immediate Breast Reconstruction

Skin flap ischemia following nipple-sparing mastectomy and immediate breast reconstruction is a significant challenge, potentially leading to revision or reconstructive loss. Hyperbaric oxygen therapy is one treatment option to improve nipple-sparing mastectomy blood flow, yet is not widely accepted practice. Although hyperbaric oxygen therapy is well established in the treatment of chronic wounds, recent data suggest a benefit in acute and evolving wounds.1 We have recently initiated a hyperbaric oxygen therapy protocol in nipple-sparing mastectomy immediate reconstruction patients who demonstrate early signs of perfusion-related abnormalities given the current safety profile, oncologic understanding, and potential psychologic benefit. Current evidence suggests this should be an accepted practice in at-risk nipple-sparing mastectomy patients. In our experience, hyperbaric oxygen therapy is most effective if therapy is initiated as soon as possible (<1 week and preferably <48 hours) after mastectomy. As a result, we have a low threshold for identifying and referring patients with potential mastectomy skin flap ischemia for hyperbaric oxygen therapy evaluation. Our early experience with seven consecutive patients treated with hyperbaric oxygen therapy has been positive, with all patients demonstrating subjective improvements in ischemic areas, with no progression to mastectomy skin flap necrosis or implant loss. Only one patient required an early wound revision. The patient shown in Figure 1 was treated with our protocol of hyperbaric oxygen therapy following alloplastic breast reconstruction; however, autologous patients have benefited as well.Fig. 1.: A bilateral nipple-sparing mastectomy patient on postoperative day 7 following bilateral reconstruction with tissue expanders, demonstrating significant ecchymosis concerning for compromise of the right nipple-areola complex (above) and following hyperbaric oxygen therapy treatment and subsequent exchange, with complete preservation of the nipple-areola complex (below).Historically, surgeons have been reluctant to use hyperbaric oxygen therapy in patients with breast cancer, hypothesizing that changes in tissue oxygen tension may lead to tumor metastasis or more aggressive local tumor growth, a concept that has since been refuted. In fact, hyperoxia has recently been shown to induce tumor cell death in animal models, and the molecular mechanisms of this process have been described in human mammary epithelial cells.2 Furthermore, studies examining the effect of hyperoxia with chemotherapy have shown that hyperbaric oxygen therapy may increase the chemotherapeutic effect.3 Such findings suggest that early use of hyperbaric oxygen therapy is oncologically safe even in the setting of adjuvant therapy, although a low risk of ocular and auditory issues exists. Hyperbaric oxygen therapy may have additional benefits outside of wound healing, as demonstrated by recent studies using hyperbaric oxygen therapy for posttraumatic stress disorder. Harch et al. showed significant improvements in mood, posttraumatic stress disorder symptoms, working memory, and anxiety after 4 weeks of hyperbaric oxygen therapy. These benefits reduced the use of psychoactive medications, and symptomatic improvement was persistent at 6 month follow-up.4 The physiology of these benefits continues to be investigated, but recent studies have shown the restoration of neurochemical abnormalities in animal models.5 Such findings have not been translated directly to the breast cancer patient but may demonstrate a psychological benefit given stress related to cancer diagnosis and mastectomy. Given the potential benefit for wound improvement in a high-stakes nipple-sparing mastectomy setting, hyperbaric oxygen therapy may have true potential to impact reconstructive outcomes. This has become a standard practice in nipple-sparing mastectomy patients with early signs of flap ischemia in our center. ACKNOWLEDGMENT The study was supported in part by National Institutes of Health/National Cancer Center Cancer Center support grant P30 CA008748. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. Dr. Dayan is a consultant for Stryker.