Unusual Keloid Formation at the Mammostat Location Following Breast Reduction

Introduction

Breast reduction is a common procedure in plastic surgery. Preserving the underlying dermis at the selected vascular pedicle allows increased vascular viability of the nipple-areolar complex (NAC). Indeed, preserving the dermis enables a dual vascularization of the flap and NAC: by the underlying glandular fatty tissue (perforating branches of the internal mammary, intercostal and lateral thoracic arteries) and by the rich superficial and anastomotic dermal vascularization from these perforating branches. ¹

To preserve the dermis and shorten the operating time (2 operators may simultaneously perform de-epithelialization of a breast), different instruments may be used to stretch the dermis and facilitate de-epithelialization (gloves or wick held by a Kocher clamp at the breast base, tightenable plastic strap, Mammostat) (Figure 1).^1,2

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Figure 1.

Intraoperative use of a Mammostat.

A keloid scar is a pathological scar related to the exaggeration of one of the phases of dermal scarring; it is responsible for a functional and esthetic discomfort. ³ Clinically, it takes the form of a firm, raised, indurated plaque with irregular edges invading healthy edges whose surface is smooth and hyperpigmented. It may lead to pruritus, burning-like pain, contact paresthesia, and sensation of tightness. ⁴

Presentation of the Case

We present the case of a 32-year-old African woman without significant medical and surgical history apart from the presence of hypertrophic abdominal scars secondary to exploratory laparoscopy.

This patient consulted for breast hypertrophy (110 D) that she considered uncomfortable enough to be faced with the risk of new hypertrophic scars secondary to surgery.

Four months after breast reduction (supero-internal pedicle, de-epithelialization using a Mammostat Medtronic, resection of 420 g on the right side and 480 g on the left side), pathological scars appeared not only on the incision lines of reduction mammoplasty, but also, and more significantly, keloids developed on the old imprints of Mammostats used during de-epithelialization (Figure 2).

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Figure 2.

Skin appearance 4 months after reduction mammoplasty.

Our therapeutic approach was based on local treatments: use day and night for 3 months of an occlusive silicone dressing (Mammopatch Gel Medical Z), scar kneading twice daily by the patient with a simple skin emollient, and intralesional corticosteroid injections (Kénacort Retard 80 mg in 2 mL Bristol-Myers Squibb).

There was at least a 2-month interval between corticosteroid injection sessions. The first 4 injections, with a 2-month interval between each injection, involved all the hypertrophic and keloid scars and then, additional injection sessions were performed as needed to meet the patient’s demand and only involved keloid residues.

A total of 15 ampoules of kénacort retard 80 mg were used in 7 years of follow-up.

During the last year of follow-up, the patient was also managed by dermatologists due to a pruritus and scarring paresthesias. She received a treatment with potent dermocorticosteroids (Locoïd, hydrocortisone butyrate), applied topically for 3 weeks (3 daily applications during the first week, twice daily during the second week and then, daily during the third week) (Figure 3).

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Figure 3.

Appearance of patient’s skin at the end of treatment.

After balancing the benefit/risk ratio, our surgical team did not retain the possibility of scar revision (resection and plasty) due to the high risk of recurrence of a pathological scar that could invade the currently healthy skin.

Discussion

Etiologically, several factors are involved in the pathogenesis of keloids: skin trauma, genetic factors, and biochemical and endocrinological factors. ⁵ They can occur at any age but are more common in the peripubertal period. ⁵ In addition, they can occur on all skin phototypes but are much more common in individuals with a melanocyte-rich phototype (Asia, Africa) and affect more commonly skin areas with a high concentration of melanocytes (face, neckline rather than palms and soles). ⁶

The associated skin traumas include dermal wounds, burns, dermatological lesions, punctures and piercing, tattoos, and scarifications. Rare cases of spontaneous keloids are described in the literature but these scars would be related to unnoticed minor traumas. ⁷

A keloid is a skin healing disorder. It results from the fibrous proliferation of the dermis related to an accumulation of collagen fibers secondary to a skin wound. Its pathophysiological mechanism is a dysregulation of collagen synthesis and degradation related to transforming growth factor β (TGFβ) hyperactivity. ⁴

It is important to notice that the difference between a keloid and a hypertrophic scar is not histologic but clinic based on the aspect of the scar and its evolution without treatments. ⁴

Plastic surgeons play an important role in preventing the occurrence of keloid scars by applying simple rules recognized as effective: tension-free skin suture, rapid hydration and photoprotection of scars, and use of silicone dressing or gel. ⁸

Many studies have attempted to assess the real efficacy of silicone dressings in the treatment of pathological scars; however, their sample size was often small and their evaluation criteria were poorly reproducible. The authors agree on the following points: Their role is mainly preventive and they must be applied from the first postoperative day; they have a dual action: they absorb dermal mechanical stresses and thereby prevent scar tensioning; they exert a positive pressure on the scar, thus preventing cell hyperproliferation. Other studies show that the beneficial effect of silicone gels is explained by the fact that the hydration of keratinocytes alters the secretion of growth factors by fibroblasts (Figure 4).^3,9

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Figure 4.

Example of silicone dressing that may be used after reduction mammoplasty (Mammopatch Gel Medical Z).

Regarding the case presented here, the operators performed low tension dermal sutures and used nonabsorbable monofilament nylon sutures (Flexocrin 3 and 4/0) for dermoepidermal stitches (because it is known that absorbable sutures are more inflammatory ¹⁰ ) which were removed at day 7 for the NAC and at day 15 for the horizontal and vertical scars. However, we only used silicone dressings after the occurrence of keloids, and we could assume that the preventive use of such dressings would have decreased the importance of keloids secondary to skin incisions but not of those secondary to the use of Mammostats.

Using Mammostats is common in Europe at the surgical time of de-epithelialization (which rarely exceeds 10 minutes per breast), and it is common to see, at the end of surgery, the cutaneous stigmata of its use. However, we observed in our department that these imprints disappeared during the first 3 postoperative hours and especially that they were never present at the time of patient discharge (ambulatory practice with patient discharge the evening of surgery).

As no similar case has been published in the literature, we hypothesized that the pathogenesis of these keloid scars located at the Mammostat imprints could be due to Mammostat-induced dermal shear stresses.

Surprisingly, the patient only developed scars located at the Mammostat imprint, skin incision scars being slightly hypertrophic but mostly enlarged.

The curative treatment of keloids is necessary when faced with disabling functional signs, mechanical discomfort, and unesthetic appearance. The main risk of treatment is recurrence. The therapeutic arsenal includes nonaggressive treatments, such as pressotherapy, medical treatments (intralesional injection of corticosteroids combined or not with 5-fluorouracil for a growing role), cryotherapy, radiotherapy, brachytherapy, lasers (CO₂, Er:YAG [Erbium-YAG], pushed dye lasers), and surgery.^3,6,11,12

The pressotherapy is the main treatment of keloid scars; its effectiveness is linked to the modification of the tensions in the compression scar. Ischemia induces degradation of collagen and modifies the activity of fibroblasts. The pressotherapy is more effective as the keloid is young/in inflammatory phase and this efficiency is directly related to the duration of the compression. ³

The intralesional injections of corticosteroids have anti-inflammatory and antifibrosing activity, thanks to 2 mechanisms: decreased collagenase levels and changes in fibroblast glucocorticoid receptors. The injections are more effective as the keloid is in an inflammatory phase. ³

The 5 fluorouracil (5FU) is a chemotherapy drug that has an antimetabolic action and induces fibroblastic apoptosis without necrosis. It has proven effective in monotherapy and in combination with corticosteroid therapy.^3,12

The cryotherapy consists of partial destruction of the keloid inducing necrosis by cold (spray or needle). Sessions must be combined with other treatments. ³

Concerning radiotherapy, its effectiveness is all the higher as it is carried out soon after the surgery. Targeted irradiation leads to DNA damage that prevents cellular divisions. ³

The brachytherapy involves introducing a radioactive source into the interior of tubes previously inserted in the exercise site. It is an effective treatment (absence of recurrence in 80% of cases) reserved for cases of resistance to the usual treatments. ³

Concerning lasers, 2 types are used in the treatment of the keloids: Ablative lasers (CO₂, Er:YAG) which realize a central excision of the scar by cell destruction and pulsed dye lasers which are vascular lasers causing a decrease in pruritus and erythema. ³

Surgical excision alone leads to recurrence in 40% to 100% of cases because it stimulates the pathological cicatrization process. Intracicatricial or extracicatricial excisions have not proved superior to one another but they cannot conceive without a combination with other treatments. ³

Their management is most often multidisciplinary and a keloid scar is considered cured when the anatomical area is functional, asymptomatic and esthetically acceptable again, and if there is no recurrence after 2 years. ³

Conclusion

Keloid scars are more common in patients with a melanocyte-rich phototype. Any surgery should be preceded by clear and fair information on the surgical outcomes and possible complications.

It seems important to be aware of the unusual complications to be able to prevent them. In patients at high risk of keloid scars, we therefore recommend to avoid the use of material causing skin shears during de-epithelialization in reduction mammoplasty and to prefer a manual tensioning of the dermis.