Skin Necrosis After Methylene Blue Dye Use in Immediate Breast Reconstruction

Summary:

Skin-sparing mastectomy or nipple-sparing mastectomy is usually combined with sentinel lymph node biopsy and often followed by immediate breast reconstruction. Currently, methylene blue dye (MBD) is being used for the localization of the sentinel lymph node during mastectomy in patients with early breast cancer. However, MBD has been associated with skin complications. Two patients underwent a nipple-sparing mastectomy followed by immediate reconstruction with silicone implants. MBD was injected into the subareolar area to identify the sentinel lymph node. The 2 cases were complicated by MBD. The first case developed 2 gangrenous areas on the site of the MBD injection. The second one developed skin necrosis as well. The use of MBD is responsible for skin complications, such as skin necrosis. In detail, discussion before surgery must be done when organizing immediate breast reconstruction using silicone implants.

It is widely known that sentinel lymph node biopsy (SLNB) is a mainstream procedure for patients with operable breast cancer who are about to undergo a skin-sparing or nipple-sparing mastectomy. Nowadays, it is performed in early breast cancer, such as ductal cell carcinoma in situ and clinically node-negative T1-T3 invasive breast cancer. Using methylene blue dye (MBD) injection and/or radioactive isotope, the first lymph node which drains the tumor, can now be identified^1,2 without having to perform an axillary lymph node dissection, an aggressive procedure with significant associated morbidity (20% of lymphedema).³

However, MBD staining has been associated with a few complications, most of them occurring on the remaining skin. In this study, we present 2 different patients who underwent a nipple-sparing mastectomy with simultaneous SLNB using MBD, followed by immediate reconstruction with silicone implant. They both developed early skin complications associated with MBD. We discuss how we used the MBD during the mastectomy and how we handled the complications that occurred.

CASE PRESENTATION

Case 1

A 50-year-old woman with a body mass index of 19% and no medical history was referred to the plastic surgery department because of a diagnosis of invasive ductal carcinoma on the right breast. She had no history of cigarette or alcohol abuse. On the day of the operation a few hours before, intradermal injection of technetium-labeled sulfur colloid was performed over the tumor site. Three milliliters (mL) of 1% MBD was diluted with normal saline to a total volume of 6 mL. After induction of general anesthesia, breast surgeons injected 3 mL of the diluted MBD subdermally at the periareolar area of the upper outer quadrant of the breast. Afterward, a nipple-sparing mastectomy and a sentinel node biopsy were performed. According to our institution’s protocol, assessment of flap thickness was done by palpation and clinical examination right after mastectomy completion to confirm whether indocyanine green dye was necessary. The flap was deemed thick enough, and an immediate reconstruction was performed with a silicone implant placed under the pectoralis muscle. The operation was uneventful (Fig. 1). The weight of mastectomy was 262 g, and the implant inserted was 260 mL anatomical.

Fig. 1.

Photograph of case 1 on day 1 after mastectomy.

Eleven days later, the patient came to the office with signs of skin necrosis of the right breast. More specifically, 2 dry gangrenous areas were developed. The first one was on the upper outer quadrant of the areola, and the second one was on the lower outer quadrant of the areola (Fig. 2). Hence, the patient was taken to the operating theater for surgical debridement of the necrotic areas.

Fig. 2.

Skin necrosis on the sites of MBD injection. Two gangrenous areas developed 11 days postoperative.

Case 2

A 58-year-old woman with no prior medical history was diagnosed with a ductal cell carcinoma in situ G1 of the left breast. Her body mass index was 26%, and she had no history of cigarette or alcohol abuse. Similarly to the previous patient, the preoperative preparation was exactly the same. Afterward, she underwent a left mastectomy (290 g of breast tissue were removed) and SLNB followed by immediate reconstruction with a round silicone implant of 275 mL under the pectoralis muscle (Fig. 3).

Fig. 3.

Photograph of case 2 on postoperative day 1.

Ten days after the operation, skin necrosis had developed on the upper outer quadrant of the areola of the left breast, exactly on the area where the MBD was administered (Fig. 4). The necrotizing tissues were removed in the operating theater, and the skin was sutured and closed by primary intention. She had a good recovery with no further complications. At 6 months of follow-up, the patient was satisfied with the cosmetic result. (See figure, Supplemental Digital Content 1, which displays a 6-month follow-up photograph of case 2. http://links.lww.com/PRSGO/D845.)

Fig. 4.

Skin necrosis 10 days postoperative.

The incision on both patients included almost half of the areolar perimeter and extended to the breast skin by a few centimeters. Concerning the instrument for dissection, the general surgeon used a monopolar diathermy.

We consider that the patients developed the skin and fat necrosis secondary to the MBD injection in the periareolar area because of the fact that the skin necrosis was located exactly where the MBD was injected.

DISCUSSION

Giuliano et al⁴ was the first who described the technique of blue dye mapping for breast cancer in 1994. Initially, isosulfan blue dye was being used for SLNB, but it was later proved that it was associated with severe allergic reactions. As an alternative to isosulfan blue dye, MBD has been used since then because of its effectiveness and fewer complications.

Nevertheless, it has been associated with a number of systemic and local complications. In 2002, Stradling et al⁵ was the first to report skin lesions to the MBD injection site when using combined deep parenchymal and intradermal injections. Additionally, Salhab et al⁶ suggested the avoidance of MBD for SLNB identification in breast cancer patients because of severe skin and fat necrosis that complicated the peri-tumoral injection of MBD. Furthermore, a case of capsular contraction following immediate reconstructive surgery for breast cancer that has been associated with MDB has been reported by Singh-Ranger and Mokbel.⁷ Additionally, according to Lee,⁸ 6 of 34 cases of immediate breast reconstruction using implants were complicated by MBD. One of them had local infection, 2 of them developed partial necrosis and wound dehiscence of the incision areas, and in the last 3 cases, wide skin necrosis was observed.⁸ Finally, yet importantly, although it is rare, severe anaphylactic response to MBD can occur as stated by Bézu et al⁹ and Dewachter et al.¹⁰ Concerning the complication of skin necrosis after MDB use in our institution, the incidence is 5%.

CONCLUSIONS

Even if the use of MBD is widespread, we recommend that its complications should be discussed before the operation by plastic surgeons and breast surgeons. It would be preferable if new and safer guidelines for the use of MBD would be developed regarding the volume of injection, the concentration of MBD, and the location of the injection. Patient’s knowledge of the potential complications is an integral component of the whole procedure. Finally, alternative options of SLNB identification should be considered if possible, such as the use of indocyanine green.¹¹

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.