Hyperbaric Oxygen and Reduction Mammaplasty in the Previously Irradiated Breast

Sir: With expanding use of radiation therapy in treating malignancy, managing complications of radiation therapy becomes more important. A principal clinical manifestation of delayed radiation injury is impaired wound healing. With the known risk of poor wound healing, elective surgery is relatively contraindicated in areas of previous irradiation. With lumpectomy/adjuvant radiation therapy becoming the treatment of choice for early-stage breast cancer, there is an increasing population of post–radiation therapy women who have difficulty obtaining breast reduction. There are few case reports describing reduction mammaplasty after radiation therapy. Handel et al.1 reported one case, with delayed healing and an inferior cosmetic result. Spear et al.2 reported three cases using modified surgical technique, with acceptable but again cosmetically inferior results. Hyperbaric oxygen therapy induces angiogenesis and increases tissue oxygen content in irradiated tissue.3 Previous studies have shown benefits of hyperbaric oxygen therapy in patients with delayed radiation injury, including as a surgical adjuvant in multiple irradiated areas.4 We conducted a retrospective chart review of five patients undergoing reduction mammaplasty in previously irradiated breasts along with adjuvant hyperbaric oxygen therapy at Virginia Mason Medical Center in Seattle. All were scheduled to receive 20 preoperative hyperbaric oxygen therapy treatments, each consisting of 90 minutes of 100% oxygen at 2.36 atm, followed by 10 similar postoperative treatments. Study approval and waiver of informed consent was obtained from the Institutional Review Board of the Virginia Mason Medical Center/Benaroya Research Institute. Initial Late Effects on Normal Tissue/Subjective, Objective, Management and Analytic breast symptom scores5 measuring late effects of radiation were calculated based on clinical notes before initiation of preoperative hyperbaric oxygen therapy, and final Late Effects on Normal Tissue/Subjective, Objective, Management and Analytic scores were based on the last recorded plastic surgery follow-up. Case data are outlined in Table 1. To summarize, five women underwent bilateral reduction mammaplasty 2 to 6 years after unilateral lumpectomy and postoperative radiation therapy. Wound healing in all irradiated breasts was complete, with delayed healing in two patients of 4 and 11 weeks. In the nonirradiated breasts, delayed healing of 5 and 6 weeks also occurred in two patients. In all cases, surgeon evaluation of the final cosmetic result was good. All patients expressed satisfaction with the final cosmetic results. Representative preoperative and postoperative images for case 5 are included as Figures 1 and 2. No significant complications of hyperbaric oxygen therapy occurred. One patient terminated postoperative hyperbaric oxygen therapy treatment after 8 of 10 planned treatments, because healing was already complete.Table 1: Summary of Case DataFig. 1.: Preoperative view of the patient in case 5.Fig. 2.: Postoperative view of the patient in case 5.These cases illustrate that with adjuvant hyperbaric oxygen therapy, elective reduction mammaplasty is a safe option for some patients who have previously undergone breast irradiation. Our patients ranged in age from 38 to 57 years. All but one patient we treated showed improvement in their Late Effects on Normal Tissue/Subjective, Objective, Management and Analytic symptom scales for late effects of radiation. This series benefits from internal controls, as all patients underwent surgery on one previously irradiated and one nonirradiated breast. Complication rates were equal, with two each of the irradiated and nonirradiated breasts demonstrating delayed wound healing. In conclusion, it is our hope that awareness of these positive results will make the combination of hyperbaric oxygen and reduction mammaplasty more widely available to an appropriate population. DISCLOSURE This was an author-initiated chart review study. Neither the study nor its authors received any financial support. No author has any conflict of interest to disclose. Sean M. Snyder, M.D. General Internal Medicine Kevin M. Beshlian, M.D. Section of Plastic and Reconstructive Surgery Neil B. Hampson, M.D. Center for Hyperbaric Medicine Virginia Mason Medical Center Seattle, Wash.