Microsurgical breast reconstruction after severe burns

Abstract

Breast deformity, in post-burn patients, is a common problem leading to lower self-esteem and reclusive behavior that impairs quality of life. The authors present the course of treatment of an 18-year-old immigrant girl who suffered second- to third-degree burns over approximately 20% of her total body surface area in her early childhood. The second- to third-degree burns were located on her right trunk and abdomen, as well as her right shoulder, neck, and right groin area. Since it was not offered in her home country, reconstructive surgery, including microsurgical breast reconstruction, was sought abroad. Due to the lack of available skin and soft tissue, a bilateral breast reconstruction with free transverse myocutaneous gracilis flaps was offered. This case illustrates one method of using microsurgery to address post-burn breast deformities in order to alleviate psychological suffering and improve quality of life.

INTRODUCTION

Next to burn injuries of the upper extremities, injuries of the trunk are the most common. In young female adolescents, such injuries can impede breast growth and development through excessive scar contracture, leading to hypoplasia as well as displacement of the nipple-areolar complex . In addition to asymmetry and impaired aesthetics, post-burn breast deformities cause functional problems in patients’ daily life (e.g., trunk movement, breast feeding, and intimacy). Severe burn injuries of the female breasts are challenging to treat, and most surgical approaches offer limited satisfactory aesthetic results. Various operative techniques have been used to address postburn breast deformities, including tissue expansion and silicone implants, as well as using skin grafts, artificial dermal substitutes, or local muscle flaps in combination with symmetrizing techniques such as mastopexy or reduction mammoplasty . Free-tissue reconstruction has been suggested as an alternative technique, but to our knowledge, there are no experiential reports of larger case series where this technique was used. Although routinely performed in many plastic surgery units, microsurgical breast reconstruction remains a sophisticated surgical procedure that requires careful planning, subsequent follow-up, as well as possible corrective surgery to achieve a satisfactory functional and aesthetic result.The case presented here presents the course of treatment of a rarely described bilateral one-stage breast reconstruction with free transverse myocutaneous gracilis (TMG) flaps after a severe burn injury. The authors discuss the advantages and disadvantages of such complex operative approaches and then recommend using microsurgical techniques for post-burn breast reconstruction.

CASE

An 18-year-old girl who suffered second- to third-degree burns over 20% of her total body surface area after an automobile accident 14 years ago presented at our clinic. She had undergone previous multiple scar revisions and contracture releases in order to correct the burn scar contracture and was seeking further reconstructive treatment.

The girl presented with severe scar contractures that mainly affected her posture, but also affected the movement of her head and neck, resulting in abduction of her right arm (Fig. 1). In addition to functional impairment, she complained of social isolation and avoidance behavior caused by the physical disfigurement of her breasts.

Fig. 1. Sensitive image, click to unblur
18-year-old patient during first consultation
Preoperative appearance, with scarring of both breasts. (A) Front view, (B) lateral view.

A very rigid scar was present, spanning both breasts and resulting in symmastia and a downward shift of the right inframammary fold by about 3 cm relative to the left side. There were vestigial remains of the nipple-areolar-complex on the right breast and a complete absence of the nipple-areolar complex on the left breast.Severely contracted burn scars were found on the right side of the neck and on the right trunk down to the abdomen and right groin. Scar contraction impaired the reclination of the head and abduction of the right arm, as well as resulting in an inclined posture.Two separate operations were conducted to recover adequate head, neck, and right arm mobility, and a third operation was conducted for breast reconstruction. During the first operation, the scar contractions of the neck and right axillary region were treated with Z-plasties.

Split skin grafting was performed to release the contracture of the right flank and to improve the patient’s posture, and a tissue expander was implanted in the right parascapular region. After sufficient tissue expansion, we performed the second operation. During this procedure, a free parascapular flap was harvested to improve and reconstruct neck movement and reclination, and plastic surgical reshaping and remodeling of both breasts with local skin flaps was performed to treat the symmastia. In the third operation, one-stage bilateral breast reconstruction with bilateral free TMG flaps, in a modified fashion, was performed. The operation involved 2 teams of surgeons. One team elevated the flaps (Fig. 2) while the second team prepared the recipient vessels (Fig. 3). The operation lasted approximately 7 hours and 48 minutes. In addition to skin-perfusion evaluation and handheld Doppler auscultation, 2 Integra Licox (Integra LifeSciences Co., Saint Priest, France) monitoring devices were used to postoperatively monitor the flaps (Fig. 4).

Fig. 2. Sensitive image, click to unblur
Raised flap, with the pedicle marked
White arrow shows the vascular pedicle of the free transverse myocutaneous gracilis flap.
Fig. 3. Sensitive image, click to unblur
Bilateral breast reconstruction with free TMG flaps
Intraoperative view of the bilateral transverse myocutaneous gracilis (TMG) flap harvest.
Fig. 4. Sensitive image, click to unblur
Final operative result after wound closure

Unfortunately, the healing course was not totally free from complications. Bilateral partial flap necrosis and wound infection had to be addressed with further debridement and negative-pressure wound therapy. Consequently, parts of the left lateral and right medial breast required split skin grafting, which was performed to accelerate wound healing.Approximately 4 weeks after surgery, an asymmetry of both breasts was still visible, which was easily corrected with autologous fat grafting/lipofilling.By the last follow-up, 8 weeks after surgery, the patient was satisfied with the results, including symmetrically reconstructed breasts with a newly formed breast mound and a nipple-areolar complex (Fig. 5).

Fig. 5. Sensitive image, click to unblur
Eight-week postoperative result
(A) Front view, (B) lateral view.

Notes

No potential conflict of interest relevant to this article was reported.

Ethical approval

The study was performed in accordance with the principles of the Declaration of Helsinki. Written informed consents were obtained.

Patient consent

The patients provided written informed consent for the publication and the use of their images.

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