Correction of postburn breast asymmetry using the LeJour-type mammaplasty technique

Postburn breast reconstruction: a scoping review

Introduction

Postburn breast deformities pose functional and aesthetic concerns for burn patients, particularly when injury occurs before puberty, as normal breast development may be hindered. Postburn breast reconstruction aims at restoration of native anatomic features, as well as re-establishment of symmetry. The objectives of this scoping review are to map the literature on scar management and breast reconstruction, highlighting strategies that are particular to postburn deformities, as well as to establish optimal timing principles.

Methods

A comprehensive search of the English literature across MEDLINE and EMBASE databases, including the grey literature, was conducted. Literature of all study designs were eligible, provided it discussed the treatment of postburn breast deformities.

Results

A total of 64 studies were included. The most common study design was case series (58%) followed by retrospective cohorts (28%). Scar contracture release with split thickness skin grafts (26%) and various techniques for nipple-areola reconstruction (22%) were the most common reconstructive procedures.

Discussion

Scar contracture releases predominate when there is normal breast development under a contracted skin envelope, and should be performed as soon as breast mound development is restricted. Surgical techniques widely used for postmastectomy reconstruction are required for patients with amastia or hypoplastic breasts.

Conclusion

Given the heterogeneity of defects, availability of donor sites, and patient preference, no standardized guideline is available. Surgeons should combine basic scar management principles with postmastectomy techniques, adapting the surgical approach to features that are particular to thermally injured patients, as well as taking into account ideal timing considerations.

Lay Summary

Breast deformities secondary to burn scars pose functional and aesthetic concerns for burn patients, particularly when injury occurs before puberty, as normal breast development may be hindered. Postburn breast reconstruction aims at restoration of native anatomic features, as well as re-establishment of symmetry. This literature review aimed at summarizing the available techniques to treat postburn breast deformities, as well as establishing optimal timing guidelines, given these issues may occur at any phase of breast development. When there is breast development under a scarred skin envelope, treatment entails scar contracture release and should be recommended as soon as the diagnosis is established, in order to allow the breast to further develop in an unrestricted manner. When there is absence of breast tissue, surgical techniques widely utilized for breast cancer reconstruction are warranted, and should be delayed until no further breast development is expected. Given the heterogeneity of deformities, availability of donor sites, and patience preference, no standardized guideline is available. Treatment options include several surgical techniques, in addition to non-surgical scar management, and timing considerations must take into account the patient's developmental phase and psychosocial wellness.

Breast Reduction in the Burned Breast

Mammary hypertrophy can occur in the postburn breast. Patients with burned breasts exhibit the same symptoms of symptomatic macromastia as patients with unburned breasts. The extent of the deformity, the location of the deformity, and the status of the surrounding soft tissue are all assessed before embarking on any surgical plan, which then proceeds in a conservative stepwise fashion. Although many plastic surgeons are reluctant to operate on burned breasts for fear of devascularizing the skin graft or nipple areolar complex, reduction mammaplasty in this group of patients is safe and carries minimal risk if key concepts are followed.

Principles of surgical treatment of congenital, developmental and acquired female breast asymmetries

Background/Aim. There is a natural asymmetry in normal female brests. When the difference in the shape, size or position of the breast and nipple-areola complex is visible, surgical correction is the only treatment option and presents one of the greatest challenges for a plastic surgeon. Based on the Nahai classification presented in details, the aim of the study was to present the possibilities of plastic surgery to correct primary (congenital), secondary (developmental) and tertiary (acquired) brest asymmetries. Methods. We conducted a retrospective analysis of female breast asymmetry surgeries performed in the Clinic for Plastic Surgery and Burns, Military Medical Academy (MMA), Belgrade over the last seven years (January 2002 - January 2009). Results. During the above mentioned period, 82 female patients, 18 - 65 years of age, underwent surgery for breast asymmetry. The most frequent asymmetries were developmental, 'pubertal' (n = 43); acquired asymmetries as a consequence of tumor surgery were found in the other 22 patients, while 7 patients were diagnosed with primary asymmetries such as congenital chest-wall asymmetry (Sy. Poland), accessory and tuberous breasts. All patients underwent preoperative ultrasound examination, while hormone status was determined in those with developmental, 'pubertal' asymmetries. The selection of surgical procedure for correction of breast asymmetry depended upon clinical examination findings and patient's wish relating to the shape and size of the breasts. The most of breast asymmetries were corrected by a combination of surgical procedures including primary and secondary reconstruction, reduction, suspension or augmentation mammoplasty. Having combined different surgical procedures, we managed to achieve satisfactory results. The hypertrophic scar formation after reduction mamoplasty was seen in some cases, however, they caused no significant patient's discomfort. Conclusion. Application of plastic, reconstructive and aesthetic surgical principles can considerably contribute to achieving excellent results in corrective surgery for breast asymmetries. In addition to most suitable breast asymmetry surgical procedures choice, motivation of a patient is also very important for achieving satisfactory results.

Restoration of the shape, location and skin of the severe burn-damaged breast

Thermal injuries to the anterior chest in pre-pubescent girls result in breast contracture. During puberty, the breast parenchyma develops and grows underneath the scars, resulting in being flattened and disfigured. The breast mound, as well as the nipple-areolar complex, is partially or completely levelled out and displaced. The contours are unclear and the inframammary fold is effaced. This feature of the most severe breast contracture still poses a challenge for most surgeons. This type of breast contracture can be successfully eliminated with the author-suggested, improved free-skin grafting technique. The scars are excised and the shifted area of parenchyma is mobilised symmetrically to the border of the undamaged breast. Then, the shape and positioning of the breast as well as the nipple-areolar complex are reconstructed with the help of circular suturing through the fat layer on two to three breast levels. The suture ends are led beyond the wound area and are affixed with certain tension contralateral to the breast displacement. The suture ends, being in state of tension, are tied into untied knots around bolsters and are retained in place for about 3 months. During this time, the form and the positioning of the breast can be corrected using the traction of the untied sutures; the skin transplants are stabilised, under which the scar tissue is formed. Skin transplant and the scar tissue hold the shape and positioning of the breast and the sutures can be removed at this stage. In this series, 11 patients were operated upon and 13 breasts were reconstructed. Good results were achieved in all cases: the breast's shape and skin was restored and the positioning was corrected.