Alternative technique for the treatment of osteonecrosis in breasts: description and results
Alternativa técnica para tratamento de esteatonecrose em mama: descrição e resultados

INTRODUCTION

Steatonecrosis is a common benign condition that may be asymptomatic or may manifest as a palpable mass, pain, or associated findings, such as skin thickening or nipple retraction. Steatonecrosis can have several mammographic aspects. Common and characteristic findings are circumscribed radiolucent masses or mixed density masses with fat and soft tissues, with or without a calcified border; these masses are known as lipid or oily cysts^1,2 (Figure 1).

Figura 1 - Magnetic resonance image of the right breast with areas of steatonecrosis.

Figura 1 - Magnetic resonance image of the right breast with areas of steatonecrosis.

These are observed after any breast trauma, including surgery. Steatonecrosis is commonly observed after nodule resection and radiotherapy for breast carcinoma and after extensive surgery³. It is a complication that occurs frequently during breast surgeries, especially in breast reconstructions and in the conservative surgeries or TRAM. Steatonecrosis is initially characterized by hardening of the tissue that may develop into a nodule of different sizes in any mammary region with oily cysts and fibrosis. This condition is a constant concern for the patients, oncologists, mastologists, and plastic surgeon, due to the possibility of tumor recurrence.

Pathology

The initial change is the disruption of fat cells, where vacuoles with the remains of necrotic fat cells are formed, as observed under a microscope. The cells then become surrounded by lipid-laden macrophages, multinucleated giant cells, and acute inflammatory cells. Fibrosis develops during the repair phase, peripherally enclosing a possibly palpable area of necrotic fat and cellular debris at the surgical site. Fibrosis may eventually replace the degenerated fat area by a scar or the degenerated fat may persist for years within a fibrotic scar^4,5 (Figure 2).

Figure 2 - Magnetic resonance image of the left breast with an area of steatonecrosis and an area of fibrosis (measured).

Figure 2 - Magnetic resonance image of the left breast with an area of steatonecrosis and an area of fibrosis (measured).

Radiological Findings

The density and spicules, common in recent extensive surgeries associated with radiotherapy, disappear or become radiolucent and circumscribed nodules (oily cysts; Figure 3) over a variable period of time, lasting up to 4 years. In addition, amorphous and nonspecific calcifications become more peripheral and coarse. Coarse calcifications associated with steatonecrosis should be described as dystrophic^6-9.

Figura 3 - Magnetic resonance image of the right breast with areas of steatonecrosis and fatty cysts.

Figura 3 - Magnetic resonance image of the right breast with areas of steatonecrosis and fatty cysts.

In subcicritrial recurrence, the mammographic findings become more suspicious compared to previous examinations. The density of the tissue and the number of spicules and/or amorphous calcifications increase^10,11.

The markings of the surgical scar by appropriate radiopaque marker may be useful for the spatial correlation between the mammographic findings and the scar. The linear radiopaque marker is usually standardized for surgical scarring in the breast¹².

OBJECTIVE

To describe an alternative technique for the treatment of steatonecrosis after aesthetic and reconstructive mammoplasty.

METHODS

The medical records of the patients admitted for breast surgery, either for the treatment of breast neoplasia and adjuvant therapies or cosmetic surgery, during the period of 2012-2016 were retrospectively reviewed. Patients who developed steatonecrosis and were treated by liposuction, similar to the technique performed by orthopedists for the treatment of bone necrosis, were included.^1,2

All patients signed an informed consent form authorizing the use of their records and information about their treatment, as well as their photographs and examination findings for scientific purposes.

The data analyzed included the characteristics of the skin (deformities), previous surgeries performed, and the aesthetic results associated with the surgical technique for the alternative treatment of steatonecrosis.

The treatment of steatonecrosis was defined by the plastic surgeon, preceptor author, inspired by the technique of bone perforation for the treatment of bone necrosis, performed by orthopedics (forage)^1,2. A lipped aspiration cannula was developed for the treatment of hydroadenitis and hyperhidrosis. It was decided to experiment with the perforation and aspiration of steatonecroses which are develop frequently in mammary reconstructions and mammoplasties.

We delimited the area of necrosis (Figure 4), and after routine infiltration of the region, we introduced the cannula inside the necrotic nodule and made several perforations with it; the cannula was connected to the liposuction device, which sucked part of the necrotic tissue and the surrounding oily contents that eventually develop into cysts in these nodules.

Figura 4 - Preoperative markings for liposuction.

Figura 4 - Preoperative markings for liposuction.

We believe that there is neovascularization in these areas; the areas are softened, thus, preventing the development of deformities due to surgical resection in these areas.

All procedures were performed by the same surgeon. The method chosen was based on the careful analysis of the case by the assistant plastic surgeon, and the procedure was explained to the patient.

All patients underwent postoperative follow-up for at least 10 months.

RESULTS

Eight patients were selected from the study period reviewed.

The mean age of the patients was 56 years.

All patients showed some deformity in the affected breast that was detected by nuclear magnetic resonance; the average size of the nodule was 1.8 cm, with oily cysts, reported in 5 patients (62.5%), being the most common.

Of the total number of patients, 75% had a history of breast neoplasia.

DISCUSSION

The classic treatment consists of removing the nodules and fibrosis, which often lead to deformity of the breast, with loss of volume and the shape of the reconstructed breast. The technique proposed in this work proposes to minimize these effects of the classical resection technique by liposuction and stimulation of neovascularization.

This study is one of the pioneering works in the national literature on the evaluation of an alternative method for the treatment of steatonecrosis.

When searching for articles from other countries on this subject, we noticed a few specific works.

CONCLUSIONS

We conclude that the individualization of the patient is the key to the successful treatment of steatonecrosis and an essential tool to satisfy the expectations and wishes of the patient after this complication. Each technique has its indications, advantages and limitations, which must be widely discussed with the patient to obtain the best possible result. The advantages of the proposed technique include absence of deformities and patient satisfaction.