Abstract
IntroductionAlthough a skin- and nipple-sparing mastectomy technique offers distinct cosmetic and reconstructive advantages over traditional methods, partial skin flap and nipple necrosis remain a significant source of post-operative morbidity. Prior work has suggested that collateral thermal damage resulting from electrocautery use during skin flap development is a potential source of this complication. This report describes the case of a smoker with recurrent ductal carcinoma in situ (DCIS) who experienced significant unilateral skin necrosis following bilateral skin-sparing mastectomy while participating in a clinical trial examining mastectomy outcomes with two different surgical devices. This unexpected complication has implications for the choice of dissection devices in procedures requiring skin flap preservation.Case presentationThe patient was a 61-year-old Caucasian woman who was a smoker with recurrent DCIS of her right breast. As part of the clinical trial, each breast was randomized to either the standard of care treatment group (a scalpel and a traditional electrosurgical device) or treatment with a novel, low thermal injury dissection device, allowing for a direct, internally controlled comparison of surgical outcomes. Post-operative follow-up at six days was unremarkable for both operative sites. At 16 days post-surgery, the patient presented with a significant wound necrosis in the mastectomy site randomized to the control study group. Following debridement and closure, this site progressively healed over 10 weeks. The contralateral mastectomy, randomized to the alternative device, healed normally.ConclusionWe hypothesize that thermal damage to the subcutaneous microvasculature during flap dissection may have contributed to this complication and that the use of a low thermal injury dissection device may be advantageous in select patients undergoing skin- and nipple-sparing mastectomy.
Highlights
A skin- and nipple-sparing mastectomy technique offers distinct cosmetic and reconstructive advantages over traditional methods, partial skin flap and nipple necrosis remain a significant source of post-operative morbidity
The PlasmaBlade is a US Food and Drug Administration-cleared and CE-marked, low-temperature tissue dissection device that uses pulsed radiofrequency energy discharges in conjunction with a highly insulated electrode design to cut with simultaneous hemostasis and approximately 75% less depth of thermal damage than traditional electrosurgical devices [8,9,10]
While the data concerning these endpoints are still being collected and analyzed, we report the sole incidence of skin flap necrosis as an adverse event in the control (SOC) group and discuss its implications with respect to the use of traditional electrosurgical devices during skin- and nipple-sparing mastectomy
Summary
The use of low thermal injury electrosurgical instruments for subcutaneous dissection may help to reduce the risk of skin flap necrosis following mastectomy in select patient groups. More durable investigations examining this specific hypothesis should be undertaken. Patient’s perspective “I had such a hard time with the left side. My right side is perfect, no pain at all. I had expected and hoped both sides would have been as good as the right side.”. Consent Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal
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