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Burns of the female breast: a long term study
Burns, 4, 267-270
Printed in Great Britain
267
Burns of the female breast: a long term study J. A. Trott and J. A. E. Hobby Wessex Regional
Plastic Surgery
Unit, Odstock
Summary
Burns to the nipple area in female children were examined a minimum of 14 years after injury. Breast mound development had occurred in all the cases studied, confirming that the conservative management practised in this group of patients was a safe technique. The factors resulting in breast distortion are analysed and the management of this problem is discussed. Mistakes resulting from poorly planned surgery to the anterior axillary fold are reported. SCALDS have been shown to be the commonest cause of childhood burns (Stitz, 1972), and the nature of this injury is such that the upper trunk is most frequently affected (Yiacoumettis and Roberts, 1977). The aim of this study was to assess the breast development of women burnt around the nipple area during childhood, to study the results of treatment and to highlight any problems in management.
PATIENTS AND METHODS The admission records of the Wessex Regional Plastic Surgery Unit at Odstock Hospital from 1955 until 1964 were examined. The names of all female children admitted to the unit with burns to the anterior chest wall were extracted. Letters were sent to the 68 patients who were found to fit these criteria, but only 21 could be contacted. However, all of those contacted agreed to attend an outpatient clinic for review. It was found that the burns in 3 patients did not involve the area of the developed breast, leaving a total of I8 patients for study. In this group of patients the burn injury occurred at an average age of 3 years, with a range of l-7 years. The average age of the group at the time of review was 19 years (range l5-24),
Hospital,
Table 1. Recorded
Salisbury
characteristics Group 1
of burn injury Group
2
Group
3 _
Ratio of scalds: ignition burns 3 :2 Time to heal 13 (2-26) (wk) No. grafts for primary healing 7 (5)* % burn 21 (12-31) *Number
3 :3 8 (6-11) 8 (6) 17 (9-30)
5 :2 5 (2-8) 1 (7) 11 (4-25)
of patients.
while the time from burn to review ranged from 14 to 22 years. Each case was assessed clinically by both authors. Measurements were taken of the distance from the sternal notch to the nipple of each breast with the arms adducted and then abducted 90”. All patients were photographed. The series was then divided into three groups for consideration. Group I : Significant distortion. Distortion of the breast contour with marked inequality of breast volume (comparing sides). Group 2: Mild distortion. Distortion of the breast contour with roughly equal volumes on both sides. Group 3: No distortion. Skin scarred, but no distortion of the breast shape and with roughly equal volumes. Data relevant to the nature of the burn were extracted from the case sheets and are presented in Table 1.
In all patients the original burn had been treated conservatively. The general treatment policy was one of early exposure followed by
Burns Vol. 4/No. 4
268
Fig. 2. Reconstruction transverse scar.
Fig. 1. Z-plasty flap through centre of nipple. Tab/e Il.
Secondary operations
Skin graft to correct breast distortion Z-plasty to correct breast distortion Skin graft to anterior axillary area Z-plasty to anterior axillary area
Table Ill. Findings Group
8 (3)
l(l)
-
-
-
3(l) 8 (3)
4 (2)
-
5 (4)
4 (3)
-
Figures in brackets represent
at review
2 Group 3
Group I
numbers of patients.
dressings if significant infection occurred. The nursing staff performed debridement of loose eschar and slough at each change of dressing. Surgical debridement and skin grafting was carried out in those cases not healed by 2-5 weeks after injury, the average time at which this surgery was performed being 21 days (range 16-34). RESULTS Volume and shape of the breast One of the most important findings of this study was that breast mound development had occurred in every case. Abnormalities of breast shapeand inequalities of volumeenabled eachcase to be allotted into one of the groups previously described. Many patients received secondary surgery to influence breast mound development. These procedures are listed in TableZZ. Nipple and areolar anomalies The nipple and areola were absent or grossly
of nipple resulting in a
Group 1 No. in group (breasts/patients) Absent/distorted nipple-areola Unilateral/bilateral skin scarring *Number tNumber
Group 2
Group 3
715
716
IO/7
3* / 2
113
011
3t I2
412
512
of breasts. of patients.
distorted on 10 breasts in 9 patients. The breakdown of these figures is shown in TableZZZ. Nipple-areolar anomalies were shown on 5 breasts in 4 patients of the 5 in group 1, on 4 breasts in 4 patients out of the 6 in group 2 and on 1 breast in 1 patient out of the 7 in group 3. Therefore, it can be seen that half of the 18 patients with burnt breast skin had either absent or distorted nipple-areolar complexes. The incidence of this finding was considerably higher in groups 1 and 2. Seven of the 9 patients with nipple-areolar anomalies had had split-skin grafts applied to achieve healing of the primary injury. One patient had had the nipple-areolar complex divided by a large Z-plasty which was being used to release an axillary contracture. This operation was subsequently reversed to reunite the complex, leaving an unsightly horizontal scar (Figs. I, 2). Two patients with distorted nipples had been pregnant before the review. Both patients had subsequently lactated through these affected nipples.
Trott and Hobby
: Burns of the Female Breast
269
Tab/e IV. Suggested
Suggested operation Breast release Breast augmentation Reduction of contralateral breast Axillary release Reposition of axillary hair Reconstruction of nipple-areolar complex
F(?. 3. Pattern of axillary
contracture
bands.
Quality of skin The skin was found to have been burnt on 24 breasts in 18 patients. This is broken down further into unilateral and bilateral involvement and is subgrouped in Table III. Skin contour
Pitting and irregularities of the skin surface contour were noted in all patients, but only 2 patients were concerned by this problem. There was no case of lasting hypertrophic or keloid scarring. Two patients found difficulty in wearing a brassiere because of tender submammary scars. Pigmentation
Four patients were concerned by hypopigmentation in areas of previous partial-thickness burn, while 2 patients complained of hyperpigmentation in the areas grafted with skin from the lower limbs. lpsilateral
axillary
anomalies
Contractures
A definite pattern of contracture bands emerged in these patients, passing from the anterior axillary fold on to the chest wall in three major axes (Fig. 3). In each case, the contracture occurred along one of these lines, and this dictated the direction of the force distorting the breast. Axillary hair In 4 cases axillary hair had been transplanted
to the anterior chest wall by Z-plasty.
on
further operations No. of patients Group 1 Group 2 Group 3 5 1
4 -
-
2 1
1
-
1
2
-
5
3
-
DISCUSSION The ratio of scalds to flame burns in this series is 11 : 7 and is similar to that found in a study of all admissions to this burns unit over a lo-year period ( McNeill, 1976). In this respect, therefore, this small series is representative of an unbiased sample of burn injuries from this region. There was a greater incidence of flame burns in groups 1 and 2 compared with group 3, reaffirming the belief that this injury is more likely to produce full-thickness burns than scalds. As the estimated depth of each burn was not recorded on the case sheets, the time taken to heal and the number of grafting sessions required to achieve healing were thought to be the best indications of this parameter. Of course, this does not necessarily indicate that the breast was the most deeply burnt area. However, patients with group 1 and 2 breast deformities did have a longer healing time and more grafting sessions per patient than the patients in group 3, suggesting larger areas of deep dermal or fullthickness burns. The patients with absent nippleareolar complexes are the only ones who can be said to have suffered full-thickness skin loss immediately over the immature breast parenchyma. As there was no case of early surgical excision of burn slough, loss of the nippleareolar complex cannot be attributed to overzealous excision in these patients. Furthermore, examination of the 4 cases with loss of the nipple-areolar complex showed breast development to have occurred in each case. This strongly suggests that conservative management as practised in this series poses no hazard per se to the immature breast parenchyma. The vectors of the forces distorting breast shape in patients in groups 1 and 2 were seen to be parallel to part or all of one or more of the lines shown in Fig. 3. These lines represent
270
Burns Vol. ~/NO. 4
‘shortage of skin’ arising from actual loss, scar contracture or both. The factors responsible for the direction of these lines of skin shortage are thought to include: (a) the location of burnt skin relative to the nipple, (6) growth forces, in particular adolescent breast and whole body growth; (c) movements of the shoulder and respiratory chest movements. Accordingly, careful follow-up of each patient must be maintained, especially during the adolescent growth phase. This will enable early prediction of areas of skin shortage and subsequent distortion of the growing breast. It may then be possible to forestall this distortion by appropriate surgical procedures. It can be seen from Table II that, where necessary, a considerable number of operations were done to improve breast shape in patients in groups 1 and 2. Also, at the time of review, there were still a significant number of patients requiring further surgery (Table IV). As the average age of each patient was 16 years, it then follows that nipple and areolar reconstruction should be deferred until late ‘teens or early twenties, when growth forces have ceased. Of course this does not allow for the fluctuating hormonal influences of pregnancy and menstruation. The hazards of Z-plasty to the axilla are well known and methods of avoiding them have been described (Hirshowitz et al., 1977). Four patients in this series had had axillary hair transplanted to the anterior chest wall by Z-plasty performed before puberty. To avoid this problem, axillary release must be carefully planned, and Z-plasty should never be performed in such a way that the nipple-areolar complex is distorted. Several patients complained of pigmentation irregularities. The degree of loss of pigment in skin which has suffered a partial-thickness burn is claimed to be modified by lyophilized zenograft dressings (Hackett and Bowen, 1974; Hobby and
Requests for reprints should be addressed to: MI Salkbury.
J. A.
E. Hobby,
Levick, 1978). Whether these dressings have a significant long term effect on pigment loss following partial-thickness burns will only be known after further studies are conducted on this technique. If donor sites for skin grafting can be found as close as possible to the area to be grafted, then pigmentation differences between grafted and surrounding skin should be minimized. Finally, it was noted that most patients tolerated the deformities from these injuries very well. Several patients modified their dress during the summer to keep unattractive scars covered, but there were no cases of obesessional behaviour noted. It will be appreciated that firm conclusions cannot be drawn from this work because of the small number of patients examined. However, enough clinical material was seen for consideration of the points mentioned above. It is hoped that basic mistakes in future management will be avoided and overall results improved in these unfortunate injuries.
REFERENCES Hackett M. E. J. and Bowen J. A. (1974) Preliminary
report on the comparative use of lyophilized homograft and xenograft in the closure of raw areas. Br. J. Surg. 61, 427. Hirshowitz B., Karev A. and Yoramlevy B. (1977) A 5-flap procedure for axillary webs leaving the apex intact. Br. J. Plast. Surg. 30,48.
Hobby J. A. E. and Levick P. (1978) Clinical evaluation of porcine xenograft dressings. Burns 4, 188. McNeil1 D. C. (1976) A survey of 1600 admissions to a Regional Burns Unit. In: Calnan J. (ed.) Recent Advances in Plastic Surgery. Edinburgh, Churchill Livingstone, p. 93. Stitz R. W. (1972) Burns in children. A 3-year survey. Med. J. Amt. 1, 357. Yiacoumettis A. and Roberts M. (1977) An analysis of burns in children. Burns 3, 195.
FRCS,
Wessex
Regional
Plastic
Surgery
Unit,
Odstock
Hospital
Printed in Great Britain
267
Burns of the female breast: a long term study J. A. Trott and J. A. E. Hobby Wessex Regional
Plastic Surgery
Unit, Odstock
Summary
Burns to the nipple area in female children were examined a minimum of 14 years after injury. Breast mound development had occurred in all the cases studied, confirming that the conservative management practised in this group of patients was a safe technique. The factors resulting in breast distortion are analysed and the management of this problem is discussed. Mistakes resulting from poorly planned surgery to the anterior axillary fold are reported. SCALDS have been shown to be the commonest cause of childhood burns (Stitz, 1972), and the nature of this injury is such that the upper trunk is most frequently affected (Yiacoumettis and Roberts, 1977). The aim of this study was to assess the breast development of women burnt around the nipple area during childhood, to study the results of treatment and to highlight any problems in management.
PATIENTS AND METHODS The admission records of the Wessex Regional Plastic Surgery Unit at Odstock Hospital from 1955 until 1964 were examined. The names of all female children admitted to the unit with burns to the anterior chest wall were extracted. Letters were sent to the 68 patients who were found to fit these criteria, but only 21 could be contacted. However, all of those contacted agreed to attend an outpatient clinic for review. It was found that the burns in 3 patients did not involve the area of the developed breast, leaving a total of I8 patients for study. In this group of patients the burn injury occurred at an average age of 3 years, with a range of l-7 years. The average age of the group at the time of review was 19 years (range l5-24),
Hospital,
Table 1. Recorded
Salisbury
characteristics Group 1
of burn injury Group
2
Group
3 _
Ratio of scalds: ignition burns 3 :2 Time to heal 13 (2-26) (wk) No. grafts for primary healing 7 (5)* % burn 21 (12-31) *Number
3 :3 8 (6-11) 8 (6) 17 (9-30)
5 :2 5 (2-8) 1 (7) 11 (4-25)
of patients.
while the time from burn to review ranged from 14 to 22 years. Each case was assessed clinically by both authors. Measurements were taken of the distance from the sternal notch to the nipple of each breast with the arms adducted and then abducted 90”. All patients were photographed. The series was then divided into three groups for consideration. Group I : Significant distortion. Distortion of the breast contour with marked inequality of breast volume (comparing sides). Group 2: Mild distortion. Distortion of the breast contour with roughly equal volumes on both sides. Group 3: No distortion. Skin scarred, but no distortion of the breast shape and with roughly equal volumes. Data relevant to the nature of the burn were extracted from the case sheets and are presented in Table 1.
In all patients the original burn had been treated conservatively. The general treatment policy was one of early exposure followed by
Burns Vol. 4/No. 4
268
Fig. 2. Reconstruction transverse scar.
Fig. 1. Z-plasty flap through centre of nipple. Tab/e Il.
Secondary operations
Skin graft to correct breast distortion Z-plasty to correct breast distortion Skin graft to anterior axillary area Z-plasty to anterior axillary area
Table Ill. Findings Group
8 (3)
l(l)
-
-
-
3(l) 8 (3)
4 (2)
-
5 (4)
4 (3)
-
Figures in brackets represent
at review
2 Group 3
Group I
numbers of patients.
dressings if significant infection occurred. The nursing staff performed debridement of loose eschar and slough at each change of dressing. Surgical debridement and skin grafting was carried out in those cases not healed by 2-5 weeks after injury, the average time at which this surgery was performed being 21 days (range 16-34). RESULTS Volume and shape of the breast One of the most important findings of this study was that breast mound development had occurred in every case. Abnormalities of breast shapeand inequalities of volumeenabled eachcase to be allotted into one of the groups previously described. Many patients received secondary surgery to influence breast mound development. These procedures are listed in TableZZ. Nipple and areolar anomalies The nipple and areola were absent or grossly
of nipple resulting in a
Group 1 No. in group (breasts/patients) Absent/distorted nipple-areola Unilateral/bilateral skin scarring *Number tNumber
Group 2
Group 3
715
716
IO/7
3* / 2
113
011
3t I2
412
512
of breasts. of patients.
distorted on 10 breasts in 9 patients. The breakdown of these figures is shown in TableZZZ. Nipple-areolar anomalies were shown on 5 breasts in 4 patients of the 5 in group 1, on 4 breasts in 4 patients out of the 6 in group 2 and on 1 breast in 1 patient out of the 7 in group 3. Therefore, it can be seen that half of the 18 patients with burnt breast skin had either absent or distorted nipple-areolar complexes. The incidence of this finding was considerably higher in groups 1 and 2. Seven of the 9 patients with nipple-areolar anomalies had had split-skin grafts applied to achieve healing of the primary injury. One patient had had the nipple-areolar complex divided by a large Z-plasty which was being used to release an axillary contracture. This operation was subsequently reversed to reunite the complex, leaving an unsightly horizontal scar (Figs. I, 2). Two patients with distorted nipples had been pregnant before the review. Both patients had subsequently lactated through these affected nipples.
Trott and Hobby
: Burns of the Female Breast
269
Tab/e IV. Suggested
Suggested operation Breast release Breast augmentation Reduction of contralateral breast Axillary release Reposition of axillary hair Reconstruction of nipple-areolar complex
F(?. 3. Pattern of axillary
contracture
bands.
Quality of skin The skin was found to have been burnt on 24 breasts in 18 patients. This is broken down further into unilateral and bilateral involvement and is subgrouped in Table III. Skin contour
Pitting and irregularities of the skin surface contour were noted in all patients, but only 2 patients were concerned by this problem. There was no case of lasting hypertrophic or keloid scarring. Two patients found difficulty in wearing a brassiere because of tender submammary scars. Pigmentation
Four patients were concerned by hypopigmentation in areas of previous partial-thickness burn, while 2 patients complained of hyperpigmentation in the areas grafted with skin from the lower limbs. lpsilateral
axillary
anomalies
Contractures
A definite pattern of contracture bands emerged in these patients, passing from the anterior axillary fold on to the chest wall in three major axes (Fig. 3). In each case, the contracture occurred along one of these lines, and this dictated the direction of the force distorting the breast. Axillary hair In 4 cases axillary hair had been transplanted
to the anterior chest wall by Z-plasty.
on
further operations No. of patients Group 1 Group 2 Group 3 5 1
4 -
-
2 1
1
-
1
2
-
5
3
-
DISCUSSION The ratio of scalds to flame burns in this series is 11 : 7 and is similar to that found in a study of all admissions to this burns unit over a lo-year period ( McNeill, 1976). In this respect, therefore, this small series is representative of an unbiased sample of burn injuries from this region. There was a greater incidence of flame burns in groups 1 and 2 compared with group 3, reaffirming the belief that this injury is more likely to produce full-thickness burns than scalds. As the estimated depth of each burn was not recorded on the case sheets, the time taken to heal and the number of grafting sessions required to achieve healing were thought to be the best indications of this parameter. Of course, this does not necessarily indicate that the breast was the most deeply burnt area. However, patients with group 1 and 2 breast deformities did have a longer healing time and more grafting sessions per patient than the patients in group 3, suggesting larger areas of deep dermal or fullthickness burns. The patients with absent nippleareolar complexes are the only ones who can be said to have suffered full-thickness skin loss immediately over the immature breast parenchyma. As there was no case of early surgical excision of burn slough, loss of the nippleareolar complex cannot be attributed to overzealous excision in these patients. Furthermore, examination of the 4 cases with loss of the nipple-areolar complex showed breast development to have occurred in each case. This strongly suggests that conservative management as practised in this series poses no hazard per se to the immature breast parenchyma. The vectors of the forces distorting breast shape in patients in groups 1 and 2 were seen to be parallel to part or all of one or more of the lines shown in Fig. 3. These lines represent
270
Burns Vol. ~/NO. 4
‘shortage of skin’ arising from actual loss, scar contracture or both. The factors responsible for the direction of these lines of skin shortage are thought to include: (a) the location of burnt skin relative to the nipple, (6) growth forces, in particular adolescent breast and whole body growth; (c) movements of the shoulder and respiratory chest movements. Accordingly, careful follow-up of each patient must be maintained, especially during the adolescent growth phase. This will enable early prediction of areas of skin shortage and subsequent distortion of the growing breast. It may then be possible to forestall this distortion by appropriate surgical procedures. It can be seen from Table II that, where necessary, a considerable number of operations were done to improve breast shape in patients in groups 1 and 2. Also, at the time of review, there were still a significant number of patients requiring further surgery (Table IV). As the average age of each patient was 16 years, it then follows that nipple and areolar reconstruction should be deferred until late ‘teens or early twenties, when growth forces have ceased. Of course this does not allow for the fluctuating hormonal influences of pregnancy and menstruation. The hazards of Z-plasty to the axilla are well known and methods of avoiding them have been described (Hirshowitz et al., 1977). Four patients in this series had had axillary hair transplanted to the anterior chest wall by Z-plasty performed before puberty. To avoid this problem, axillary release must be carefully planned, and Z-plasty should never be performed in such a way that the nipple-areolar complex is distorted. Several patients complained of pigmentation irregularities. The degree of loss of pigment in skin which has suffered a partial-thickness burn is claimed to be modified by lyophilized zenograft dressings (Hackett and Bowen, 1974; Hobby and
Requests for reprints should be addressed to: MI Salkbury.
J. A.
E. Hobby,
Levick, 1978). Whether these dressings have a significant long term effect on pigment loss following partial-thickness burns will only be known after further studies are conducted on this technique. If donor sites for skin grafting can be found as close as possible to the area to be grafted, then pigmentation differences between grafted and surrounding skin should be minimized. Finally, it was noted that most patients tolerated the deformities from these injuries very well. Several patients modified their dress during the summer to keep unattractive scars covered, but there were no cases of obesessional behaviour noted. It will be appreciated that firm conclusions cannot be drawn from this work because of the small number of patients examined. However, enough clinical material was seen for consideration of the points mentioned above. It is hoped that basic mistakes in future management will be avoided and overall results improved in these unfortunate injuries.
REFERENCES Hackett M. E. J. and Bowen J. A. (1974) Preliminary
report on the comparative use of lyophilized homograft and xenograft in the closure of raw areas. Br. J. Surg. 61, 427. Hirshowitz B., Karev A. and Yoramlevy B. (1977) A 5-flap procedure for axillary webs leaving the apex intact. Br. J. Plast. Surg. 30,48.
Hobby J. A. E. and Levick P. (1978) Clinical evaluation of porcine xenograft dressings. Burns 4, 188. McNeil1 D. C. (1976) A survey of 1600 admissions to a Regional Burns Unit. In: Calnan J. (ed.) Recent Advances in Plastic Surgery. Edinburgh, Churchill Livingstone, p. 93. Stitz R. W. (1972) Burns in children. A 3-year survey. Med. J. Amt. 1, 357. Yiacoumettis A. and Roberts M. (1977) An analysis of burns in children. Burns 3, 195.
FRCS,
Wessex
Regional
Plastic
Surgery
Unit,
Odstock
Hospital