A Literature Review of Burns in Reconstructed Breasts After Mastectomy

Objective. The goal of this literature review is to review and combine case studies of accidental burns to the breast, following mastectomy and immediate breast reconstruction with autologous tissue, implants, or tissue expanders. Methods. The authors searched PubMed and Cochrane Library and reviewed cases of burns of reconstructed breasts after mastectomy from July 1985 to May 2015. Only studies in the English language were included in their search. They also report 5 new cases of burns in patients with burns to the breast, which were either reconstructed with implants or tissue expanders at Sheba Medical Center (Ramat Gan, Israel). Results. The authors found 21 publications regarding burns after breast reconstruction dating from 1985 to 2014, which equaled 59 cases of reported burns in the 21 included publications. The most common causes of burns were due to heat conduction (37/59) followed by solar radiation (19/59) and heat convection (3/59). The majority of the cases were treated by a conservative approach. The 5 new cases added were all due to thermal radiation (5/5). Two of these cases were treated conservatively (2/5), and 3 underwent surgery (3/5). Conclusion. The removal of thermoregulatory capabilities of the skin and the thickness of the remaining tissue in the mastectomy procedure are key to understanding the cause of burns to reconstructed breasts.

Over the past decade, the leading breast reconstruction modality has shifted from autologous tissue to implant-based techniques.¹ As of 2010, 83% of breast reconstructions in the United States were performed with devices either in 1 or 2 stages.² In 2014, 102 215 women in the United States underwent breast reconstruction surgery following mastectomy procedures, which is a 30% increase since 2000.³ There has also been a significant expansion in implant use.⁴ In recent years, several cases of partial- and full-thickness accidental burns of the breast after reconstruction have been documented.^5,6 Although thermal injuries subsequent to reconstruction procedures are rare, they are recognized in the medical community. Most importantly, the burns may have been prevented by properly informing the patient regarding the ease of thermal damage to the tissue of the newly reconstructed breast. 

In a literature review by Delfino et al,⁷ 38 cases of burns to reconstructed breasts were included. In their review, the majority of cases followed autologous tissue transfer, while only 4 reported cases followed expander-implant breast reconstruction. In addition, their literature search indicates that second- and third-degree burns of the breast skin seem to occur more often after transverse rectus abdominis musculocutaneous (TRAM) flap reconstructions (76% of the reported cases in the literature). Most importantly, they found no reported cases of burns in the skin of nonreconstructed breasts after mastectomy. This review by Delfino et al⁷ highly suggests a link between the increased susceptibility to thermal injury of the breast tissue following the reconstruction procedure.

Since nearly a decade has passed since the last literature search on the subject was performed, the authors aimed to update the community on the latest reported cases. In addition, they report 5 new cases of patients who have returned to their medical center after an accidental burn on a previously implanted breast. 

Together with this case series, the literature suggests the most common heat sources responsible for the identified burns included: 

1. Heat conduction: using heating pads, hot liquids, and hyperthermia devices.
2. Solar radiation: sunbathing with a dark swimsuit or using a sun lamp.
3. Heat convection: using hair dryers.

In the following sections, the authors review the literature, include their case studies, discuss probable causes, and suggest future studies to better understand the origin of these serious yet preventable thermal injuries.

Search and selection processes
The authors conducted a literature search in PubMed and Cochrane Library for reported cases of burns using the key words “thermal injury breast,” “burn injury breast,” “breast reconstruction burn,” “hot bottle burn,” “sun burn breast,” and “insensate flap.” The authors limited their search to published studies only in the English language; the search produced 1211 articles. After screening the titles of these articles, the researchers discarded 1165 of them, as the titles were considered irrelevant to this review. The abstracts of the 46 remaining articles were screened, and 20 articles were excluded because the abstract was not relevant to the scope of this review. Two of the remaining articles were omitted as the full text was not available, and the other 3 articles did not meet the inclusion criteria once the full text was screened. The complete screening resulted in 21 articles that were included in this review (Figure 1). 

Data extraction and quality assessment
The authors created a data table that includes relevant information extracted from each of the 59 cases in all 21 articles: patient’s age, initial breast reconstruction procedure, any chemotherapy or radiotherapy treatments, the type and cause of burn, the timing of the burn after the reconstruction, and the treatment of the burn (Table Part A, Part B, Part C, Part D). Not all articles provided the information regarding chemotherapy or radiotherapy or the age of the patient. 

From the 21 included publications regarding burns after breast reconstruction dating from 1985 to 2014, 59 cases of reported burns were the combined total. Maxwell and Tornambe⁸ report the largest number of burn cases in a single work (10), while most of the other reports are only single cases. For the total sample of cases, the age of the female patients with burns ranged from 24 to 76 years old, although some of the articles^9-11 did not contain any age information. The majority of the cases occurred in patients who had undergone a TRAM flap reconstruction (31/59 cases), followed by a deep inferior epigastric perforator flap (10/59 cases), tissue expander (TE) (6/59 cases), a latissimus dorsi (LD) flap (5/59), and silicone implants (3/59 cases). Of the 59 cases, the type of flap was unknown in 4. There was only 1 instance of a burn reported following nipple-sparing mastectomy (NSM). The reported timing of the burn after the reconstruction ranged from 10 days to 15 years. The most common causes of the burns were due to thermal radiation (40/59), by applying a heating pad or similar device to the breast for a short time ranging from a few minutes to a few hours. Solar radiation was the second source of burns (19/59), generally caused by sunbathing for a few minutes to a few hours, while wearing dark clothing. The majority of cases were treated with a conservative approach.

In addition to the cases found in the literature, the authors include 5 new cases in this review presenting data they have collected from their own patients with burns after reconstructed mastectomies. 

Case 1
In March 2014, a 61-year-old woman (nonsmoker) underwent right lumpectomy and sentinel lymph node biopsy, followed by only 2 focused radiotherapy treatments and tamoxifen. Due to recurrence of invasive ductal carcinoma (IDC), she underwent bilateral skin sparing mastectomy (SSM) and an immediate breast reconstruction with a submuscular tissue expander to the right breast, and a submuscular silicone implant to the left breast in September 2014. Three months after the submuscular implant surgery, she applied a hot water bottle to her lower back in the evening and fell asleep without removing it. When she woke up (about 6 hours later according to the patient), she found the hot water bottle next to her chest and saw burn marks on her left breast. She self-treated the wound with DermaGran Ointment (Derma Sciences, Plainsboro, NJ) for 3 weeks until admitted to the authors’ hospital with a third-degree burn and full-thickness eschar in the center of the left breast. Due to the burn, the implant was exposed. She was hospitalized for 12 days and was treated with intravenous (IV) amoxicillin/clavulanic acid and local debridement. The patient eventually underwent implant removal and capsulectomy, followed by a breast reconstruction with a TE. 

Case 2
In May 2004, a 64-year-old woman (nonsmoker) underwent bilateral SSM and reconstruction with submuscular silicone implants (400 cc; Mentor, Santa Barbara, CA), followed by chemotherapy and tamoxifen due to cancer in the right breast. Ten years after surgery, she had a burn to the right breast from either a hot water bottle or a home heater (she used both before going to bed).  After 3 weeks of self-treatment at home, she was hospitalized with a full-thickness burn, with redness of the skin in lower pole and a visible eschar. The implant was not exposed to the wound. During 20 days of hospitalization, she was treated with IV antibiotics and local debridement, in addition to 3 courses of maggot therapy.  Two months after discharge, the wound was completely healed. 

Case 3
In 2007, a 46-year-old woman (nonsmoker) underwent left breast SSM and reconstruction, with a submuscular silicone implant, followed by chemotherapy because of IDC of the left breast. In February 2013, the patient underwent a right NSM (due to appearance of IDC) and reconstruction with a TE of the right breast, which was later exchanged to a submuscular implant in October 2013 (345 cc; Mentor). A mastopexy for asymmetry correction was performed on the left breast during the same surgery. Twenty-two weeks after her last surgery, she used a home heater for 1 hour while wearing a t-shirt. The next morning she presented to the emergency room with a burn and was instructed to use one Flaminal Forte (Flen Pharma, Kontich, Belgium) dressing daily. After 3 weeks without improvement under conservative treatment, she was hospitalized with a third-degree burn, a 2 cm x 3 cm eschar, but without erythema or fever. During 6 days of hospitalization, she was treated with IV antibiotics and underwent local debridement and primary closure.

Case 4
In June 2014, a 39-year-old woman (smoker, 3 cigarettes/day) underwent preventive bilateral NSM and reconstruction with TE due to BRCA gene mutation carrier status. Seven months after surgery, she used a heating pad for 1 hour while wearing a t-shirt.  After a week without treatment, she presented to the authors’ outpatient clinic with a full-thickness burn of 2 cm in diameter and started local treatment with a silver
sulfadiazine cream dressing. Complete wound healing was reported after 1 month. No hospitalization was needed for this case.

Case 5
In November 2013, a 48-year-old woman (nonsmoker) underwent right SSM and reconstruction with the acellular dermal matrix AlloDerm and a silicone implant in submuscular position (325 cc; Natrelle, Allergan, Irvine, CA), followed by tamoxifen due to IDC of the right breast. Three weeks after surgery, she had a burn to the right breast after using a heating pad for 1–2 hours, while wearing a sweatshirt. The next morning she noticed the second- to third-degree burn of 10 cm x 6 cm in size, with no exposure of the implant. She started conservative treatment for 1 week and later underwent LD reconstructionwith a silicone implant (365 cc; Natrelle, Allergan). During the surgery, the complete burn was excised and no wound healing issues were reported afterwards.

In the authors’ 5 patients, all implants were located posterior to the pectoralis muscle, which may have allowed for the salvage of 4 out of 5 implants including 1 case of a full-thickness burn. The fact that the location of the implant had an effect on the outcome of the burn should be taken in consideration by the surgeon, even when the mastectomy flap seems to be considerably thick during surgery. Two of the 5 patients with a full-thickness burn and 1 patient with a partial-thickness burn underwent a second operation (local debridement); the implant was exchanged in 1 of the full-thickness burn patients. It is important to examine the injury on a case-by-case basis, because the need for multiple operations might exist in a full- or partial-thickness burn. However, operating does not mean the implant must be removed or exchanged.

In case 3, with a 46-year-old woman, the damaged tissue was exposed to the heat source (home heater, hot water bottle) for at least 1 hour while the patient was wearing a shirt. Extended exposure to a relatively low temperature heat source can cause a slow-cooking injury that seems to be mild initially and does not elicit an immediate pain reflex. Yarmolenko et al¹² showed that a heat treatment at 43°C between 21 and 40 minutes can already induce acute and minor damage to the skin function. Furthermore, due to sensation loss, the burn victims are less aware that the burn has occurred and tend to delay seeking specialized burn care. Nevertheless, early and specialized care is also necessary for low-temperature burns, because these often cause second- or third-degree injuries. Moreover, if the dermal layer is burned at any temperature, the greater the depth of the burn the worse it becomes within the first 48 hours.¹³ 

During total mastectomy, whether skin-sparing or otherwise, the surgeon has to sever sensory branches from the lateral intercostal nerves, supraclavicular branches from the cervical plexus, and anterior intercostal segmental nerves, leading to extensive denervation of the overlying breast skin.¹⁴ Sensory recovery requires that regenerating axons connect to suitable cutaneous receptors. Spontaneous sensory recovery has been reported in free flap breast reconstructions, but this is neither predictable nor reliable.¹⁵ Sensory recovery in non-neurotized breast reconstructions tends to occur in the periphery of the flap from direct ingrowth of peripheral nerve branches from the intercostal nerves. The central area (usually comprising flap tissue and flap skin) in non-neurotized reconstructions impedes sensory recovery due to the lack of neurotropic guidance. When compared to free-flap reconstructions, sensory recovery in implant-based reconstructions is even less likely. This problem is independent of the exact course of the nerve supply of the breast.^16,17 With the exception of those branches that take on a largely superficial course within the native breast skin, the silicone footprint of the prosthesis not only blocks neurotropism, but also acts as a physical barrier against the ingress of regenerating axons from the intercostal nerve branches, thus preventing direct sensitization of the overlying skin.

Another important etiological factor that should be considered as a cause of a burn injury after breast reconstruction is whether or not the area has been treated with radiotherapy. The histological modifications produced in the surgical site by irradiation can delay the neurotization of the flap from the surrounding skin and deeper structures.⁷ Four of the authors’ 5 patients did not receive radiotherapy and yet suffered denervation over a long period of time (until at least the time of injury). This suggests the loss of sensation and the thermal injury are a consequence of the surgical procedure, regardless of radiotherapy treatment.¹⁸ 

The literature herein demonstrates a great variability in flap age at the time of injury, ranging from 6 days to 5 years — the authors’ patients ranged from 3 months to 10 years in length of time— implying no correlation between the time passing from surgery and susceptibility to thermal injury. The underlying cause of the burn is complex and must be explained by another mechanism besides sensitivity loss. 

Regardless of the breast reconstruction procedure, the data reviewed in this study suggest the thermoregulatory function of the skin in the breast is crucially disrupted. When a heat source is applied to healthy tissue, thermal receptors or nociceptors are stimulated depending on the temperature.^19-20 Any temperature > ~45°C is perceived as pain. The human body’s natural response is to keep the skin at a constant temperature to prevent thermal injury, either by a behavioral response or an autonomic efferent response. Although generally the behavioral response is the most effective, the patients in this study did not reach that threshold or had no perception of pain to change their behavior (ie, remove the heat source). 

The autonomic efferent response allows the skin to dissipate heat by evaporation (sweat), convection, and conduction (vasodilatation).^21-26 Burns after breast reconstruction indicate the skin is unable to cool down efficiently as it does in a nonreconstructed breast.²⁷ In addition, when an implant is present, the thermal properties of the silicone implants may enhance the lack of heat dissipation in the breast tissue. Lastly, the breast tissue itself may be much thinner after the reconstruction procedure since TEs may be used. Sergio et al^28-29 have shown thinner skin may reach higher temperatures faster than thicker skin, which could explain the severity of some of the burns presented in this review. 

The authors wish to bring awareness to the plastic surgery community regarding the dangers of postoperative burns in order to inform and warn the patients undergoing this procedure. Since the etiology of this type of burn is still not fully understood, the authors recommend further studies on the sensitivity of breast tissue after reconstruction for different types of reconstruction. In addition, the thermoregulatory function of breast tissue after a reconstruction procedure should be investigated as well as the role played by the presence or absence of an implant in the thermal dissipation in the breast.

Affiliations: The Burn Unit, Department of Plastic and Reconstructive Surgery, Sheba Medical Center (Affiliated to Sackler School of Medicine, Tel-Aviv University); and The Talpiot Medical Leadership Program, Sheba Medical Center, Ramat Gan, Israel

Correspondence:
Marie Jaeger, MD
Resident Physician 
Sheba Medical Center
Emek HaEla St 1 
Ramat Gan, Israel
marie.e.jaeger@gmail.com

^*Marie Jaeger and Yonathan Wagman contributed equally to this article.

Disclosure: The authors disclose no financial or other conflicts of interest.