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Principles of burn management: The breast

Principles of burn management: The breast
Literature review current through: Sep 2023.
This topic last updated: Mar 21, 2023.

INTRODUCTION — When managing burns to the chest wall in females, preservation of the breast is fundamental. The female breast is of paramount importance for functional (lactation, female development) and cosmetic (femininity, self-confidence, image, and appearance) reasons. Males may also suffer burns that affect the breast, but management is less complex.

The breast and the nipple-areolar complex are frequently injured in burns involving the anterior chest wall. Most burns to the breast occur in children and in the domestic environment [1-3]. The most common causes of burns to the female breast include scalds (range 66 to 89 percent), flame (range 8 to 34 percent), and cooking oil (range 2 to 5 percent), as well as others (<5 percent) [2,4]. Burns to the breast can potentially impair and/or destroy both function and aesthetics. The later effects of loss of normal tissue and scarring include limitation of movement, pain, disfigurement, and social embarrassment. Absence of a nipple is a noticeable and a striking concern in any burn patient, even when more extensive burns and scarring are present elsewhere [5]. Damage to the breast bud is particularly important to the prepubertal female because it can impair breast development, and more commonly, scarring that encircles the breast and chest may inhibit breast growth.

The specific management of burns to the breast is discussed here. The general principles of management of superficial and deep burns and an overview of burn reconstruction are provided separately. (See "Topical agents and dressings for local burn wound care" and "Treatment of superficial burns requiring hospital admission" and "Treatment of deep burns" and "Overview of surgical procedures used in the management of burn injuries".)

INITIAL CONSIDERATIONS — Superficial (epidermal, superficial partial thickness (figure 1)) and mid-dermal burns can heal with conservative treatment (eg, topical agents), and often without significant cosmetic consequences. Deeper burns (deep partial thickness, full thickness, deeper) will require burn wound excision and coverage. (See "Treatment of minor thermal burns" and "Treatment of superficial burns requiring hospital admission" and "Treatment of deep burns".)

Debridement — Burns to the breast are initially gently washed and debrided of loosened skin and debris and dressed. The mammary gland is located four to eight millimeters deep in the subcutaneous tissue [3]. The breast is anatomically superficial to the pectoral fascia and the chest wall and extends from the second to the seventh rib and from the anterior axillary line to the sternum. The judiciousness of the debridement is the key factor in managing breast burns, as an overly aggressive excision will create misshape, size mismatch, and poor results.

The relative avascular adipose tissue and connective tissue of the nonlactating breast require great care when excising all nonviable tissue [5]. When the nipple-areolar complex is involved, the burn eschar should not be excised but should be allowed to separate spontaneously, as healing will proceed from the deep glandular structures [5,6]. In adult females, the breast mound should not be excised during the debridement of the burned skin, if possible. In prepubertal females, care should be taken not to excise the breast bud from the anterior chest wall [6]. (See 'Prepubertal females' below.)

The depth of the burn (figure 1) helps determine the next phase of the treatment plan. Superficial (ie, superficial, superficial partial thickness) and mid-dermal burns to the breast are treated with conservative management, which may include topical antimicrobial agents until healed. Deep burns (deep partial thickness, full thickness) generally require tissue coverage. Options for deep burns include skin grafting, tangential excision of the eschar and skin grafting with or without the use of skin substitutes after burn demarcation, or spontaneous eschar separation [7]. As with burns to any region, surgical experience, the overall condition of the patient, and the extensiveness of the burn will help determine the best approach. (See "Assessment and classification of burn injury" and "Treatment of superficial burns requiring hospital admission" and "Treatment of deep burns".)

Timing of reconstruction — With respect to management of other burned sites, once areas close to the joints, other key areas (eg, eyelids, neck, axillae), and deeply exposed structures have been addressed, the female breast should be considered the next priority.

The timing of reconstruction relative to the initial burn injury can be classified as:

Immediate reconstruction, which refers to wound closure or grafting procedures to achieve healing of deep partial-thickness and full-thickness burns.

Intermediate or interim reconstruction, which refers to procedures performed to address restriction of the breast envelope (eg, scar not allowing for breast growth).

Delayed or definitive reconstruction, which refers to procedures that are performed to restore breast shape and contour.

Prepubertal females — Chest wall burns in the prepubertal female can be devastating. Burn injury that damages the breast bud may impair breast development [8]. However, if the burn is superficial (eg, scalding), the subcutaneous breast tissue remains viable and the breast bud will be preserved [9]. More commonly, burns encircling the breast or chest trap breast tissue within the breast mound, which can distort normal breast growth.

Attention to detail and avoidance of excision of a viable breast bud are required to preserve future breast development. Knowledge of the location of the breast bud is mandatory prior to beginning a debridement procedure to the anterior chest wall. Embryologic development of the breasts is of a highly ordered series of events that result in a breast bud at the level of the fourth intercostal space on the anterior chest where the mammary gland subsequently develops. (See "Breast development and morphology".)

During puberty, the breast parenchyma can develop beneath the scar but may result in breast contracture and possible disfigurement [10]. The breast mound and the nipple-areolar complex can be displaced, with unclear contours, and with an effaced inframammary fold. Such problems will require reconstruction to achieve a more normal breast appearance [2,11]. As such, prepubertal females with burns to the anterior chest wall must be followed long-term to help ensure proper development and aesthetic appearance of the breasts during and after puberty [2]. Definitive reconstruction is delayed until breast maturity is attained; however, interim procedures (contracture release) may be needed if the burned breast envelope is restricted and will not allow for future breast development [12,13]. (See 'Burns sustained prior to puberty' below.)

BREAST RECONSTRUCTION

General goals — The goals of reconstructive breast surgery include [10]:

Management of postburn scar (See 'Management of postburn scar' below.)

Restoration of shape and volume of the breast mound. (See 'Restoration of shape' below.)

Restoration of contour due to skin damage and loss of definition of the inframammary crease. (See 'Restoration of contour' below.)

Restoration of the nipple-areolar complex. (See 'Restoration of the nipple-areolar complex' below.)

Management of postburn scar — Cutaneous scarring after burn injury contributes to characteristic postburn physical and psychosocial morbidity. Modulation of the burn scar can be accomplished with a variety of physical and surgical techniques. Pressure therapy, massage, intralesional steroids, laser therapy, exercise, and autologous fat transfer have all been used to modulate hypertrophic burn scar [14]. Any of the these may be considered in the management of postburn hypertrophic scarring of the breast. (See "Overview of surgical procedures used in the management of burn injuries", section on 'Burn scar revision and timing' and "Hypertrophic scarring and keloids following burn injuries".)

Useful techniques for managing breast scarring may include:

The use of lasers, including ablative and nonablative fractional carbon dioxide (CO2), and pulse dye lasers have been popularized and are now commonplace in postburn scar management and modulation. Lasers improve appearance and function and reduce the need for more aggressive standard operative techniques [15]. Lasers have been shown to decrease scar erythema, reduce thickness, increase pliability, reduce pain and pruritus, and improve scar color and texture [16]. Laser therapy can be a useful temporizing measure in patients with a developing breast to avoid repeated invasive surgical interventions. (See "Overview of lasers in burns and burn reconstruction".)

In our practice, we use mainly pulsed dye laser to treat hypervascularity postscarring and CO2 laser to resurface any areas of suitable hypertrophy or contracture. The treatment always starts with a test patch to address the potential for unwanted side effects (eg, excessive redness, crusting and blistering of the skin, postinflammatory pigmentation changes). Following the test patch, the full treatment includes characteristically three to five treatments separated at 8-to-12-week intervals according to response. Laser treatment can be combined with the use of scar-modulating substances such as steroids or 5-fluorouracil.

Autologous fat transfer has also been shown to improve burn scar pliability and objective appearance [17,18]. It can also be helpful in the management of breast contour defects and irregularities [19].

Restoration of shape — The shape, volume, and skin of the burned breast can be reconstructed using skin grafts, with or without the use of skin substitutes and/or tissue flaps. Contracture release with autografts and/or autologous tissue reconstruction are the typical techniques used for reconstruction of the burned breast [10,20]. Resurfacing of the postburn skin can be performed using the abdominal skin as a full-thickness skin graft [21].

Reconstruction with a pedicled latissimus dorsi, transverse rectus abdominis myocutaneous (TRAM) flap, or deep inferior epigastric perforator (DIEP) flap provides adequate tissue coverage to reconstruct the shape and volume of a burned breast [22,23]. The decision to use either a free or pedicled flap depends on the availability of unburned skin, the experience of the surgeon, and the reliability of the pedicle vessels (eg, thoracodorsal artery for a latissimus dorsi flap; deep inferior epigastric artery perforators for a TRAM flap; and superior and inferior gluteal artery perforators for a TRAM or DIEP flap; superior and inferior gluteal artery perforators for the gluteal flaps). Free and pedicled flaps can provide a fully autologous option of reconstruction. When more volume is needed than can be provided by a flap alone, or when there is a limited availability of tissue for reconstruction, a flap (eg, latissimus dorsi flap) can be used in combination with a tissue expander or breast implant. Reconstruction follows the principles of standard breast reconstruction. (See "Overview of breast reconstruction" and "Options for autologous flap-based breast reconstruction" and "Implant-based breast reconstruction and augmentation".)

The advantages of flap reconstruction include:

Coverage with well-vascularized skin with superior pliability, elasticity, and durability compared with skin grafts.

Coverage with tissue of similar texture and color.

Reconstruction of breast anatomical landmarks.

An improved cosmetic result since flap reconstruction can be tailored to the patient's defect and provides a more natural appearance of the shape and volume of the breast.

Disadvantages include:

Potentially longer operative times.

Flap donor site morbidity.

Implant infection or extrusion that compromises the result of flap reconstruction.

It is generally believed that scar tissue lacks elasticity and pliability, is more difficult to expand with tissue expanders, and serves as a serious limitation to achieving adequate volume reconstruction of the breast mound [20,23]. However, a retrospective review of 15 females with burns to the breasts reconstructed with contracture release and tissue expanders found no significant differences in major complications, operative time, and amount of time to expansion, compared with the same reconstruction procedures in 20 females with congenital breast anomalies [20]. In another study, burn patients who underwent endoscopically assisted placement of tissue expanders had significantly fewer major complications, required less operative time, and required less time to expand compared with expanders placed by the traditional open method [24].

The use of skin substitutes (figure 2 and table 1) in postburn breast reconstruction reduces the recurrence of scar contracture and provides pliability to the reconstruction [25,26]. Prevention of infection of the template is fundamental, and close monitoring of the burn wounds is necessary. The use of negative pressure therapy helps keep the template in place. (See "Skin substitutes" and "Negative pressure wound therapy", section on 'Clinical applications'.)

Expansion of a skin substitute (eg, Integra) as a staged procedure appears to be reliable and safe [26-28]. Patient satisfaction and short-term evaluation of this technique is promising [28], but no long-term studies or clinical trials are available. The stages of reconstruction using the template, skin grafts, tissue expander, and permanent prosthesis are:

The first stage includes release and excision of contractures and scars, submuscular insertion of tissue expander, and coverage of the anterior chest wall with a skin substitute (eg, Integra).

The second stage is performed one month later and involves removal of the outer silicone layer of the skin substitute, application of a split-thickness skin graft to the burned areas, and partial inflation of an expander.

The third stage involves overinflating the expander. The expander is subsequently removed and replaced with a permanent silicone prosthesis [26].

Unilateral breast burns may develop asymmetry as the growth and development of the burned breast may be restricted as the breast matures and during pregnancy. A combination of augmentation mammoplasty and reconstruction of the burned breast with contracture release offers both functional and aesthetic benefits [29].

Alternatives to flap- or implant-based reconstruction of the burned breast are limited. There are no high-quality data from randomized trials or large reviews for the optimal reconstruction of the burned breast. Some techniques applied to reconstruction of the breast for other conditions (eg, congenital abnormalities, cancer, aesthetics, and trauma) could in theory be applied to the burned breast (eg, fat grafting, which transfers autologous adipose tissue to remodel the breast [30,31]).

Restoration of contour — The distortion of the inframammary fold is functionally disabling and aesthetically disfiguring [32]. The reconstruction and redefinition of the inframammary fold can be performed by simple scar debridement and grafting of the area. Replacement of the burned skin and subdermal tissue with a normal skin advancement flap provides a natural and aesthetic solution. A formal external Ryan procedure can often reconstruct the inframammary fold in a single stage [33,34]. Alternatively, the expanded reverse abdominoplasty recreates the inframammary crease in a multistage process wherein the abdominal skin is advanced and then appropriately sutured in place; this technique cannot be used if burn scars involve the abdomen [32,35].

Restoration of the nipple-areolar complex — Reconstruction of the burned nipple-areolar complex is a challenge due to excessive nipple flattening and the thin dermis secondary to a tight scar. Split-thickness skin grafts and pressure therapy have been described to release the contracture but have not provided satisfactory results [36]. Standard techniques applicable to nipple reconstruction are limited in burn patients. The lack of pliability of burned skin results in loss of projection of the nipple. Most nipple reconstruction techniques use local flaps to reproduce the anatomy of the nipple, nipple sharing, or the insertion of composite grafts subcutaneously as alternative options. A modification of the star flap has produced promising results in terms of maintenance of nipple projection [37]. Nipple-areolar tattooing can be useful in optimizing aesthetic reconstruction of the nipple; however, tattooing of burn scar can be challenging with regards to pigmentation and color match. (See "Overview of breast reconstruction", section on 'Nipple reconstruction'.)

Special circumstances — Reconstruction of a burned breast is particularly challenging in females who sustained burns that result in loss of the breast (amastia), burns prior to puberty, burns in those who are pregnant or lactating, burns to large breasts, or burns associated with prior breast reconstructive or aesthetic procedures.

Amastia — Amastia (absence of a breast) is corrected by performing total breast reconstruction. Reconstruction options include tissue expansion and implant placement, pedicled (latissimus dorsi) with breast implant or free flap options such as the TRAM flap, superior or inferior gluteal artery perforator fasciocutaneous flap, or the DIEP flap. The choice of reconstruction depends on the pliability of the skin envelope affected by the burn. For those who select implant-based reconstruction, the implant is selectively placed in a submuscular plane to avoid problems with skin envelope viability that occur if the chest wall and breast have been skin grafted. (See "Options for autologous flap-based breast reconstruction" and "Implant-based breast reconstruction and augmentation".)

Burns sustained prior to puberty — Chest burns in prepubertal females may require burn scar revision or contracture release or more extensive breast reconstruction if the breast bud is damaged or destroyed (eg, amastia). (See 'Amastia' above.)

Based on observational data, the ideal time to reconstruct the burned prepubertal breast is once breast maturity is attained [2,6,8,38]. The specifics of the burn, breast growth and development, and patient cooperation must be considered when planning reconstructive procedures.

It is also generally best to allow the burn scar to mature prior to reconstruction unless obvious distortion of the nipple-areolar complex or the inframammary folds is observed. If the release of the contracture is ill timed, the postpubertal development and growth of the breast parenchyma acquires a splayed, hypoplastic, and flattened form [10,39]. Total breast reconstruction will be needed if the breast bud and nipple-areolar complex are destroyed by the burn and the breast fails to develop. In severe cases, staged procedures throughout puberty may be required to optimize the aesthetic result.

The following principles are used to reconstruct the prepubertal burned breast [6]:

Expansion of skin surface – Expansion of the breast skin surface can be accomplished by releasing contractures and applying thick split-thickness or full-thickness skin grafts at the inframammary fold, periareolar area, sternal area, and anterior axillary line. Expanded skin flaps allow a near-normal future mammary gland development [40]. Dermal regeneration templates can be used in conjunction with skin grafts. Additional options for augmentation include the use of tissue expansion and/or a breast implant and free flap tissue. An adequate tissue envelope, such as a submuscular insertion, must be used to protect the implant.

Resurfacing – The shape and volume of the breast can be improved by resurfacing a severely scarred chest and breast with full-thickness skin grafts or thick split-thickness, with or without the use of a skin substitute, or by using flap techniques. Full-thickness skin grafts are generally preferred compared with split-thickness skin grafts since full-thickness skin grafts contract less, but availability will be limited if a very large surface area burn coverage is needed. (See "Skin autografting" and "Skin substitutes".)

Asymmetry – Asymmetry is best addressed by performing a breast reduction of the larger breast. In cases of a unilateral burn and impaired breast development, a contralateral mastopexy or breast reduction of the unburned breast may provide for a balanced cosmetic appearance. Burned breasts are less likely to develop a natural ptosis. (See "Overview of breast reduction".)

Absent or disfigured nipple papilla – Volume and shape should be corrected, followed by a second staged procedure to reconstruct the nipple papilla. Local tissue is typically used to form the papilla, but there is a risk of flap failure when using burned skin or skin grafts.

Absent or disfigured nipple-areolar complex – Once the scar is mature, three-dimensional (3D) tattooing provides an excellent option to enhance the appearance of the nipple-areolar complex and can match the color of skin tone or contralateral unburned nipple-areolar complex.

Burns during pregnancy and lactation — For burns that are superficial or only involve a portion of the breast, breastfeeding can continue at the discretion of the patient. Conservative management of superficial burns should be continued until wounds are healed. Silver-containing dressings (eg, silver sulfadiazine), cerium nitrate, and povidone-iodine should not be used due to systemic absorption and presence in breast milk (table 2) [41]. For deep burns, early treatment by tangential excision and split-thickness skin grafts facilitates healing of the wounds and minimizes septic complications [42-45].

Breastfeeding can been successful if residual breast tissue can be preserved [36,46,47]. Absence of a nipple-areolar complex precludes breastfeeding; distortion of the complex does not [36]. Split-thickness skin grafts and customized pressure therapy are used to correct a contracture deformity. (See 'Restoration of the nipple-areolar complex' above.)

For deep burns to the breast, or extensive burns to the body, cessation of lactation may be the optimal approach. Treatment with bromocriptine stops lactation and induces breast involution [48]. Once engorgement has dissipated, treatment of the burn wounds can proceed. (See 'Breast reconstruction' above and "Topical agents and dressings for local burn wound care".)

Burns to the reconstructed breast — Breasts reconstructed with myocutaneous flaps following cancer, aesthetic-related procedures, or previous burns develop cutaneous anesthesia and dysesthesias, which increase the risk for severe burns from thermal exposure [49-56]. Interruption of the afferent and efferent neural pathways resulting in deranged proprioception to thermal injury plays an important role in the pathogenesis of these injuries [53,54,56]. Burns to the reconstructed breast are treated as described above [52]. (See 'Breast reconstruction' above.)

In a review of 59 cases of burns occurring following prior breast reconstruction, most were related to severe sunburns likely related to alterations in sensation [51]. Patients undergoing reconstructive procedures of the breast must be advised of the risk of injury from exposure to the sun and contact hazards. Some recovery of sensation and temperature occurs, although this is variable in both time and degree [55].

BREAST REDUCTION — Breast reduction of the burned breast may reduce or eliminate the deformity. Contralateral breast reduction may also be needed to achieve symmetry [57]. (See "Overview of breast reduction".)

Burns to large breasts — Postburn deformities of the large breast include displacement of the nipple-areolar complex, burn scar contracture, and scarring.

In a retrospective review of 11 females with deep thermal burns to ptotic and hypertrophied breasts with postburn deformities, breast reduction using an inferior pedicle dermal flap [58-61] reduced breast size, eliminated or reduced the appearance of burn scars, and relocated the nipple-areolar complex to a normal position [62].

Postburn mammary hyperplasia — Mammary hyperplasia can occur in patients with previous full-thickness burns of their breasts. In females with postburn mammary hyperplasia, the decision to manage hyperplasia depends on the symptoms (eg, neck pain, back pain, bra strap pain) and the feasibility to perform this surgery.

Reduction mammoplasty has been generally avoided due to concern of devascularization of the skin grafts or the nipple-areolar complex [63,64]. However, reduction mammoplasty in this group of patients may be safe and carry minimal risk. A retrospective review of six patients with full-thickness burns of the breasts and subsequent skin graft coverage observed no nipple loss, hematoma, infection, or major loss of skin flaps.

Burns to the male breast — For burns to the male breast, a decision to remove the contralateral breast to achieve symmetry is individualized. While not a routine procedure, males with great degree of breast tissue on the other side may wish to undergo contralateral breast reduction or simple mastectomy.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Care of the patient with burn injury".)

SUMMARY AND RECOMMENDATIONS

Burns to the breast – Burns to the breast can potentially impair and/or destroy both function and aesthetics. The later effects of burns to the breast, which are related to loss of normal tissue and scarring, include limitation of movement, pain, disfigurement, and social embarrassment. Damage to the breast is particularly important to the prepubertal female, but absence of a nipple is a noticeable and a striking concern to both female and male burn patients. Reconstruction depends on the depth and extensiveness of the burns and the availability of viable, unburned tissue. (See 'Introduction' above.)

Initial management – The initial management of burns to the breast includes gentle debridement of loose burned skin, cleansing, and local topical dressings. The nipple and areolar complex should not be excised. (See 'Initial considerations' above.)

Prepubertal breast – For prepubertal females with burns to the anterior chest wall, the breast bud should be preserved during the debridement procedures. Definitive reconstruction is delayed until after breast development if no obvious misplacement of the nipple-areolar complex or the inframammary fold is observed, in which case there may be a need for early intervention. The release of contractures and more extensive reconstructive procedures, such as free or pedicled tissue transfer, are performed as the breast tissue develops. (See 'Prepubertal females' above.)

Adult breast – For burns to the adult female breast, the breast mound should be preserved if tissue is viable. The reconstruction in the fully developed breast needs to take into consideration the restoration of nipple height; the adequate definition of the inframammary fold; and the symmetry in volume, size, and shape of both breasts. Autologous tissue, either as a free or pedicled flap, provide the optimal cosmetic restoring volume and shape. A tissue expander or implant can be used to enhance the results if the autologous reconstruction is insufficient. (See 'Restoration of shape' above.)

Pregnancy and lactation – For topical treatment of superficial burns to the breast during pregnancy and lactation, we avoid silver sulfadiazine, cerium nitrate, and povidone-iodine due to systemic absorption and presence in breast milk (table 2). For severe burns to the breast during lactation, we use bromocriptine for cessation of lactation. For minor or limited burns to the breast, the option to continue to breastfeed is at the discretion of the patient. (See 'Burns during pregnancy and lactation' above.)

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Topic 15397 Version 20.0

References

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