Introduction

The breast is important in both function and appearance in females and males. The prominent anatomic location of the breast and the nipple-areolar complex makes these structures prone to damage in all types of burn injury to the anterior chest wall. Burns to the breast can potentially impair and destroy both function and aesthetics. Due to its anatomical location, the breast is commonly injured in both small and large burn injuries, commonly scald injuries in children and as part of an injury to the whole trunk in major full-thickness flame injuries.

The management of the burned breast is undertaken concurrently with the management of the patient and their injury as a whole. Initially, stabilization airway control and resuscitation are a priority followed by wound management and optimization of healing potential depending on the depth and extent of injury. After healing, scar management and surveillance become important particularly in the female child to monitor development and growth of the breast during puberty.

The later effects of burns injury, which are related to loss of normal tissue and scarring, include limitation of movement, pain, disfigurement, and social embarrassment. Damage to the breast is particularly important in the prepubescent young girl. Absence of a nipple is a noticeable and striking concern to both male and female burn patients, even when more extensive burns and scarring are present elsewhere. Reconstruction of the burned breast is dependent on optimal early wound healing to prevent deformity. Once disfigurement and deformity are established accurate assessment, characterization and planning are crucial to timely and successful reconstruction.¹

Breast anatomy

The breast is made up of both fatty tissue and glandular milk-producing tissues. The ratio of fatty tissue to glandular tissue varies among individuals. The relative amount of fatty tissue changes over time as the glandular tissue initially grows then diminishes. The glandular tissue is arranged in a series of lobules and ducts which are connected to the nipple areolar complex (NAC). The gland in children lies 4–8 mm beneath the skin and is attached to the nipple by the pars infundibularis of the milk ducts. The ducts themselves are lined by epithelial cells which can act as a source of proliferating cells to resurface the nipple and areolar area. In addition, there is an intimate approximation of the NAC and breast gland bud in children which is important as excisional surgery may result in unnecessary removal of the breast bud with subsequent damage to the growth potential of the breast.²

The breast overlies the pectoralis major muscle as well as the uppermost portion of the rectus abdominis muscle inferomedially. The nipple should lie above the inframammary crease and is usually level with the fourth rib and just lateral to the mid-clavicular line. The average nipple-to-sternal notch measurement in a youthful, well-developed breast is 21–22 cm; an equilateral triangle formed between the nipples and sternal notch measures an average of 21 cm per side.²

Epidemiology

Burn injury to the trunk is common and can lead to significant problems.³ It has been reported as the second most commonly injured area following the upper extremity, with the breast being the most frequently injured area on the trunk.⁴

Burn injury to the breast can occur at any age and to either sex but causes most problems in the female. Aetiology is varied but in one study 66% of injuries to the female breast were due to scald injury with a significant number having isolated breast burns.⁵

In particular two patterns of injury emerge. Scald injury usually affecting the upper torso and breast in children and trunk burns involving the breasts in patients who have extensive flame burn injury.

In prepubescent females, most of the burns to the anterior chest wall are scalds, and depending on burn depth, the subcutaneous tissue may remain viable, thus preserving the breast bud. During puberty, if healing has led to abnormal scarring, the breast parenchyma develops under the scar and can result in breast contracture and disfigurement. The breast mound and the nipple-areolar complex are displaced, the contours are ill-defined, and the inframammary fold is effaced.⁶

Chest wall burns in the prepubescent female can be devastating to both the child and the parents, as normal breast growth and development may be compromised. Attention to detail and avoidance of excision of the breast bud is required to preserve the development of the breast in prepubescent girls. Young girls with burns to the anterior chest wall must have long-term care to help ensure proper development and aesthetic appearance of the breasts during and after puberty.⁶

There are no prospective trials available on the longitudinal results of burns to the anterior chest wall in prepubescent females, nor are there any retrospective reviews with large numbers of young girls.

In a retrospective review of anterior chest wall burns in prepubescent girls treated with surgical debridement and split-thickness skin grafts, long-term problems with scarring and impaired breast development requiring reconstructive surgery many years after the initial burn were identified. In this single-institution study, 193 prepubescent girls were treated for anterior chest wall burns over 20 years; 52 (27%) were treated with surgical debridement and split-thickness skin grafts, and 11 with documented burns to the breast and nipple-areolar complex were available for long-term follow-up. In this small sample, the mean timeframe from burn to follow-up was 26.5 years (range 19–32 years). All 11 women required reconstructive procedures after the onset of breast development to improve breast appearance. Complications of the burns included breast asymmetry, distortion, banding, and unpleasant skin texture.³

In a longitudinal assessment of 28 prepubescent girls with severe burns to the anterior chest wall, 17 (61%) lost the nipple-areolar complex, but all developed breast tissue at puberty. However, 20 (71%) of these young patients experienced entrapment of the breast and required surgical intervention and incisional releases of the anterior chest wall to allow for proper breast development.⁷

Acute care

Burns to the breast are initially gently washed and debrided and dressed with topical antimicrobials and dressings prior to surgical excision if the burns are too deep to warrant spontaneous healing. The burn eschar should not be excised from the nipple-areolar complex, as healing occurs from the deep glandular structures. The eschar should be allowed to separate spontaneously.¹

Minor and superficial partial-thickness burns to the anterior chest wall are treated with local antimicrobial agents and dressings, while deeper burns are treated with excision and soft tissue coverage. Spontaneous eschar separation and grafting versus tangential excision of the eschar and grafting after burn demarcation are two options for the management of the burned breast. Surgical experience, the overall condition of the patient, and the extensiveness of the burn will help determine the best approach.⁸

It is well recognized that even with nipple loss, breast development can occur⁶ and that conservative management of the NAC is beneficial as the breast bud underneath is viable and retains the potential for growth and development.

If surgery is required, care should be taken not to excise the breast bud from the anterior chest wall of pre-pubertal girls during the debridement of the burned skin.⁹ The mammary gland in children is located 4–8 mm deep in the subcutaneous tissue.⁴ Nor should the breast mound be excised, if at all possible, in adult females. The relative avascular adipose tissue and connective tissue of the non-lactating breast requires a very careful excision of all non-viable tissue.

Debridement and grafting of the breast, especially the large pendulous breast, is a technically challenging undertaking. Debridement of a complex convex surface while trying to avoid injury to the nipple areolar complex needs a judicious approach. In the pendulous breast, tissue traction may be applied by tissue forceps or towel clips to allow an even tangential excision plane. Resurfacing of the breast must be undertaken with prevention of future deformity in mind. Cosmetic units of the breast must be preserved and grafts placed to avoid future disfiguring contractures. Sheet grafts often do not contour well and a narrowly meshed unexpended autograft (1 : 1.5, 1 : 2) is preferred.

Post-skin grafting positioning of the patient and the breast is important to avoid shearing of grafts on the lateral border and the inframammary area where friction can be significant. Abduction of the upper limb is important for this reason as well as preventing axillary contracture. In addition tie-over bolsters can be used on the breast to reduce graft shear. Despite all these measures, the take of grafts on the large pendulous breast is often unsatisfactory in the inframammary and lateral borders leading to graft loss, re-grafting and suboptimal outcome, which can give rise to post-burn contracture and deformity.

Classification of post-burn sequelae

In order to plan reconstruction, the post-breast-burn deformity must be evaluated and analysed so that a systematic approach may be undertaken. However, in major burn injury, donor sites may be sparse and the tissue available for reconstruction may be less than optimal.¹⁶ With limited donor sites, a systematic approach may not be possible and the patient’s requests and desires, coupled with judicious use of tissue and realistic expectations, may be the optimal solution. Post-burn breast sequelae can be classified according to the description in Table 55.1.

Table 55.1 Classification of post-burn breast deformity

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Pathophysiology of burn shock and burn edema Enzymatic debridement of burn wounds Functional sequelae and disability assessment Mitigation of burn-induced hypermetabolic and catabolic response during convalescence Musculoskeletal changes secondary to thermal burns The burn problem: A pathologist’s perspective

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