Hyperbaric chamber therapy
Preventing necrosis after mastectomy: A real-life hyperbaric therapy success
Intro
Mutations of the BRCA-1 and BRCA-2 gene have been proven to elevate the risk of ovarian and breast cancer within women (1). To manage the risk associated with this mutation, a recommendation is to complete a prophylactic mastectomy and salpingo-oophorectomy (2). Nipple-sparing mastectomy has common complications of nipple-areolar complex (NAC) ischemia which involves a lack of blood supply to a tissue and results in hypoxia (low oxygen levels) in this area (3). Without effective treatment, hypoxia in this area could lead to necrosis of the tissue (4). However, these complications can be managed with hyperbaric oxygen therapy (HBOT). HBOT is a therapeutic approach which involves the use of pure oxygen at increased pressure levels (5). According to the Undersea and Hyperbaric Medical Society (UHMS), standard hyperbaric oxygen therapy requires individuals to be on 100% oxygen at a minimum pressure of 2 atmospheres (5). Undertaking HBOT allows for higher levels of oxygen to reach an individual’s blood stream and tissues, which thus is expected to reduce hypoxic conditions (5). Therefore, hyperbaric oxygen therapy could be effective in reversing tissue hypoxia associated with nipple-sparing procedures. in treating hypoxia in ischemic tissues caused by mastectomy surgery.
Case details
A 48-year-old female presented to our clinic following a prophylactic nipple-sparing mastectomy and breast reconstruction as she had tested positive for a BRCA-1 mutation. Upon evaluation after both procedures, it was discovered that her right nipple and inferior breast wedge appeared ischaemic (low oxygen supply with discolouration). It was determined that she would complete at least five HBOT treatments for 120 minutes at 2.4 atmospheres.
Due to post operative patient-controlled analgesia (PCA)for pain control with associated nausea and vomiting, there was a higher risk of central nervous system oxygen toxicity (CNSOT). This was accommodated by reducing the dose of oxygen of her HBOT by treating at 2.0 atm reduced from 2.4 atm 10 metres below sea as opposed to 14 m). At the fourth treatment, pressure was increased to 14 metres below sea level (2.4 atm) and some nausea with vomiting was present. Prior to the fifth treatment, glyceryl trinitrate (GTN) was administered to assist in vasodilation. Upon evaluation, it was evident that there was overall improvement in appearance, no skin breakdown and there were two remaining areas of superficial ischemia- however, evidence of perfusion was present between these two areas.
The patient was consistently monitored and completed a total of 15 treatments. After each treatment, the dusky appearance of the right breast improved. This provided evidence of a reduction of ischemia within the tissues. When no further changes were present treatment ceased.
Discussion
This case has provided evidence of the effects of HBOT, particularly within ischemic tissue in the setting of surgery with high risk of complications involving the NAC. After completing HBOT, the ischemic appearance of the patient’s right breast had improved.
Further studies have also provided support for the use of HBOT in healing ischemic tissues (6). Specifically, a case series by Spruit et al7 demonstrated that HBOT serves as an effective post-operative therapy to reduce the incidence of necrosis following a nipple sparing mastectomy.
Through increasing the amount of oxygen inspired by patients at higher pressures, it has been shown there is increased vascular endothelial growth factors (VEGF) (8). An increase in VEGF causes an upregulation in the migration of capillary endothelial cells adjacent to hypoxic tissues, allowing for angiogenesis- the formation of new blood capillaries- in damaged areas (8). With this, there is a greater blood supply to ischemic areas, allowing more oxygen to reach the tissue and minimise hypoxia.
Additionally, a higher pressure in the hyperbaric chamber, creates a higher arterial oxygen tension and a pressure gradient which induces an osmotic effect, causing fluid to exit tissues and reduce oedema (9,10). With a reduction of oedema in the affected tissues, it reduces the distance at which the high dose oxygen in the blood stream will have to travel, which allows oxygen to reach the hypoxic tissues (10). This increases the ability for damaged tissues to heal. Furthermore, the increased oxygen arterial tension from HBOT enhances the immune response which further improves healing within affected tissues and reduces the risk of post operative infection.
The high pressure and dose of oxygen that is associated with HBOT has multiple mechanisms which improves healing within ischemic tissues and prevents the progression to necrosis. Therefore, HBOT has been seen as a viable option for patients, when available, who suffer ischemic injuries, particularly as a result of a nipple sparing mastectomy procedure.
References
- Kuchenbaecker KB, Hopper JL, Barnes DR, Phillips KA, Mooij TM, Roos-Blom MJ, et al. Risks of Breast, Ovarian, and Contralateral Breast Cancer for BRCA1 and BRCA2 Mutation Carriers. JAMA : the journal of the American Medical Association. 2017;317(23):2402–16.
- Bertozzi S, Londero AP, Xholli A, Azioni G, Di Vora R, Paudice M, et al. Risk-Reducing Breast and Gynecological Surgery for BRCA Mutation Carriers: A Narrative Review. Journal of clinical medicine. 2023;12(4):1422.
- Ahn SJ, Woo TY, Lee DW, Lew DH, Song SY. Nipple-areolar complex ischemia and necrosis in nipple-sparing mastectomy. European journal of surgical oncology. 2018;44(8):1170–6.
- Park JK hyung, Myung Y. Treatment of delayed venous congestion of the nipple-areolar complex after reduction mammoplasty. Archives of Aesthetic Plastic Surgery. 2021;27(1):39–42.
- Ortega MA, Fraile-Martinez O, García-Montero C, Callejón-Peláez E, Sáez MA, Álvarez-Mon MA, et al. A General Overview on the Hyperbaric Oxygen Therapy: Applications, Mechanisms and Translational Opportunities. Medicina. 2021;57(9):864.
- André-Lévigne D, Modarressi A, Pignel R, Bochaton-Piallat ML, Pittet-Cuénod B. Hyperbaric oxygen therapy promotes wound repair in ischemic and hyperglycemic conditions, increasing tissue perfusion and collagen deposition. Wound repair and regeneration. 2016;24(6):954–65.
- Spruijt NE, Hoekstra LT, Wilmink J, Hoogbergen MM. Hyperbaric oxygen treatment for mastectomy flap ischaemia: A case series of 50 breasts. Diving and hyperbaric medicine. 2021;51(1):2–9.
- Buckley CJ, Cooper JS. Hyperbaric Oxygen Effects On Angiogenesis. [Updated 2023 Sep 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482485/
- Woo J, Min JH, Lee YH, Roh HT. Effects of Hyperbaric Oxygen Therapy on Inflammation, Oxidative/Antioxidant Balance, and Muscle Damage after Acute Exercise in Normobaric, Normoxic and Hypobaric, Hypoxic Environments: A Pilot Study. International journal of environmental research and public health. 2020;17(20):7377.
- Kahle AC, Cooper JS. Hyperbaric Physiological And Pharmacological Effects of Gases. [Updated 2023 Jul 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482485/