What are the best practices for eschar removal and skin closure on the breast?

Best Practices for Eschar Removal and Skin Closure on the Breast

For breast eschar removal, early surgical debridement with complete excision of necrotic tissue is the standard approach, followed by subcuticular skin closure technique to optimize cosmetic outcomes and minimize complications. 1

Eschar Removal Techniques

Surgical Debridement (Primary Method)

• Surgical debridement is necessary to remove necrotic tissue and mechanically reduce the pathogen burden, particularly in burn injuries where accurate management with early excision of eschar substantially decreases the incidence of invasive wound infection 1
• For burn wounds on the breast, delayed tangential excision after wound demarcation can be performed safely to viable tissue, preserving underlying structures 2
• Early eschar removal within 72 hours improves outcomes by reducing bacterial colonization, infection risk, and hospital length of stay 3

Enzymatic Debridement (Alternative Method)

• Bromelain-based enzymatic debridement (Nexobrid®) offers effective eschar removal in a single application with reduced blood loss and decreased need for surgical excision 3, 4
• When using collagenase ointment, crosshatch thick eschar with a #10 blade to allow better surface contact, and remove loosened debris with forceps and scissors 5
• Apply enzymatic agents once daily after cleansing the wound with normal saline, and terminate use when debridement is complete and granulation tissue is established 5
• Enzymatic debridement reduces the need for autologous skin grafting and the number of wounds requiring surgical excision 3

Critical Technical Points for Debridement

• Remove necrotic tissue completely in one piece rather than multiple fragments to allow proper assessment 1
• When infection is present, apply appropriate topical antibiotic powder prior to enzymatic debridement 5
• Discontinue enzymatic therapy if infection does not respond until remission occurs 5

Skin Closure Principles

Incision Planning and Placement

• Use curvilinear skin incisions following Langer's lines as the standard approach for optimal cosmetic results 6
• For lower breast lesions, radial incisions at three o'clock and nine o'clock positions provide better cosmesis 6
• Periareolar incisions are appropriate only for small subareolar lesions and should be avoided for peripheral breast lesions 1, 6
• Place incisions directly over the lesion, not at distant entry points, avoiding tunneling 1

Closure Technique

• Close all breast skin incisions with subcuticular technique to optimize cosmetic results and minimize visible scarring 1, 6, 7
• Preserve subcutaneous tissue with separate closure to improve cosmetic outcome and structural integrity 6, 7
• Avoid excision of skin segments as this may alter nipple position or inframammary crease 6, 7

Hemostasis Requirements

• Meticulous hemostasis is critically important to prevent hematoma formation, which produces changes difficult to interpret on physical examination and mammography 1, 7, 8
• Hematomas can be long-lasting and lead to unnecessary biopsies due to difficulty in evaluation 1
• Avoid breast drains as they compromise cosmetic results 1

Tissue Management

• Allow the biopsy cavity to fill with serum rather than reapproximating breast tissue, as reapproximation that appears adequate supine often causes distortion when upright 6, 7
• Ensure adequate incision length to permit complete specimen removal in one piece 1
• Avoid excessive tension on closure as this can lead to wound breakdown 7

Management of Mastectomy Skin Necrosis

Treatment Algorithm Based on Necrosis Size

• For necrosis less than 10 cm, perform local debridement in clinic setting with primary closure 9
• For necrosis greater than 10 cm (median 15 cm), operative debridement is required 9
• Median time to treatment should be 15 days postoperatively to expedite wound healing 9
• Timely and appropriate treatment with debridement and primary closure facilitates tissue expander breast reconstruction 9

Common Pitfalls to Avoid

• Do not reapproximate breast tissue in a manner that creates tension on the incision, as this causes distortion when the patient is upright 6, 7
• Avoid removal of lesions in multiple fragments, which precludes margin assessment and size determination 1
• Do not use periareolar incisions for peripheral breast lesions as they provide inadequate exposure 1, 6
• Prevent hematoma formation through meticulous hemostasis, as hematomas complicate healing and may lead to infection 1, 7