Nowadays a nice woman’s neckline plays an important role in the life of a modern woman increasingly frequently. Moreover, it is men who become the main reason for such an emphasis that makes women stay focused on their importance through attracting attention and being self-confident. It is not a secret that a woman’s bosom becomes a part of her icon, in particular, when an occupation is related to mass media. Augmentation and reduction mammoplasty should also be mentioned in this respect, but in this article we will focus on the problem of defective scars after breast surgery.
The objective of the research was to show the dependence between chronic untreated fibrocystic mastopathies and post-surgery defective scar appearance, including their repeated appearance, to highlight and explain the author’s own method of defective breast scar treatment aimed to prevent their recurrence.
Materials of the patients treated by the author along with the data taken from the world literature publications were used in this publication.Analysis of the main pathogenic mechanisms of defective scar genesis was performed. The optimal scheme of defective scar treatment using the least invasive non-surgical method, as well as treatment after previous ineffective surgical defective scar removal was selected. The author suggests using his own prophylactic method involving combined usage of glucocorticoid and anesthetic agents administered inside the scar together with silicone patch and compression clothes usage.
So, attention should be primarily paid to the reasons for defective scar appearance. The scar itself is a usual thing in the process of area healing injured through scalpel cut – and it is also a kind of skin lesion.
Here of importance is the fact that sometimes, defective scars caused by the body’s fight against chronic inflammation may develop after surgery related to different forms of mastopathy, mastitis .
The example of a 37-year-old patient G., who underwent surgical treatment for mastitis, demonstrates the nature of scar healing (Fig. 1).
This is also often caused by a cascade of reactions resulting from hormone disorders in the body manifested in irregular menstruations, chronic fatigue, emotional instability, etc. The choice of the right approach of defective scar treatment is of great importance [6, 7].
A scar is the result of replacement of own skin tissue with connective (or scar) tissue as the result of different traumatic injuries. Wound healing consists of the following stages: inflammation and epithelialization; ‘young’ scar appearance; ‘mature’ scar appearance; final transformation.
Differential diagnostics between different types of defective scars should be performed before the treatment. Interview should also be carefully conducted including the hereditary history, with due attention paid to systemic pathology presence (diseases of adrenal glands, thyroid gland, pituitary-hypothalamic and gonadial bridge, chronic inflammatory processes), bad habits, diabetes mellitus .
Some patients have pre-disposition to keloid and hypertrophic scar appearance determined by the process of excessive collagen deposition.
Pathogenesis of defective scar appearance starts with the moment when tissue trauma occurs 5. For example, the scar becomes bigger after surgery due to antigen E appearance in the sensitive area, which results in IgE generation. Calcium concentration is changed. The AgE – IgE complex appears leading to the defective scar appearance. Degranulation of tissue basophiles intensifies and prostaglandins PGF and PGE are released when the endocrine system is in tension. Then genetic code of fibroblasts initiated by functionally active macrophage compounds is generated through PGE and PGF, along with steroid hormones of adrenal glands and pituitary gland. As the result, errors in ribosomal protein synthesis coding appear. Instead of one amino acid the ribosome includes a different one into the protein. Thus, the chain with violated order and number of amino acids is developed.
According to the data of a number of publications, abnormal genes producing new types of protein result from the violations in reactions between intracellular calcium, natrium and potassium and, possibly, other metals. It is also mentioned that collagen of type II and VII and type I and VII with changed amino acidic composition was found in the scars.
The usage of betamethasone dipropionate and dinatrium phosphate together with lidocaine and a compression bandage and a silicone patch provides good results in defective scar appearance prevention in patients with complicated history and with/or inherited disposition to them as well as in treatment of post-surgery defective breast scars. The described method was used in 44 patients. There was no relapse in any case.
It should be mentioned that fibroblast apoptosis and colagenolysis blockade occurs during wound healing and defective scar appearance as the result of surgical trauma. Violation of receptor interaction between cells taking part in wound healing is another important moment in defective scar appearance.
According to Lu F. et al, surface fibroblast receptor plays an important role in the keloid and hypertrophic scar appearance. In case of fibroblast apoptosis induction, it is mediated by the surface Fas receptor. Fibroblasts of keloid scars are not sensitive to apoptosis inductors unlike hypertrophic ones.
The important factors are also the nature of the disease and the condition of mammary gland’s tissue since they influence scar healing after surgery (А. V. Vazhenin, 1998; V. V. Serov et al, 1981; К. Wosikowskietal., 1993). As a rule, dishormonal mastopathies result from abnormal function of numerous endocrine glands. This disease may be suspected when monitoring the pathology in mammary glands (N. I. Rozhkova, 1996; N. N. Kizimenko, 1998).
It should be mentioned that mammary gland is a target organ directly depending on the functional condition of hypothalamus-pituitary and gonadial systems. The structure of mammary gland pre-determines the impact of numerous factors on the mammary gland tissue, which, as the result, is highly sensitive to the risk of defective scar appearance after such surgery as, for example, sector resections or plastic surgery.
Patient Z. underwent surgical removal of fibroadenoma. The check-up examination detected defective scar in the place of the surgery 6 months after the surgery (Fig. 2).
In order to prevent further growing and to destroy the already developed defective scar the author’s own method of minimum invasive treatment of the defective scar was used. The method is further described (Fig. 3, Fig. 4, Fig. 5).
First, the solution for injection is prepared though mixing together corticosteroid and lidocaine. The area around scar is antiseptic-sterilized. The ready-made solution is carefully mixed together and filled into the syringe. An insulin needle is used. In this way the carefully mixed solution is administered directly into the scar by moving in parallel to the line of its location starting with one of its ends to the other one so that it becomes fully white and the lemon skin symptom is observed (Fig. 3). Afterwards the antiseptic treatment procedure is repeated.
The next step – silicone patch is glued so that 3-4 cm margins from the end of the patch to the scar area are available (Fig. 4). Afterwards the compression bandage is placed on the area with the elastic bandage aimed to apply permanent pressure on the scar area. The elastic bandage and patch are removed every 3 days for the purposes of taking a shower, and then placed again – both the patch and the elastic bandage. The patient was monitored by the doctor for 6 months. The procedure was repeated 4 times. Over the next two months of observations no repeated administration of the agent was necessary.
The last examination of the patient was performed 2 months ago. The result was positive (Fig. 5).
Some patients have pre-disposition to keloid and hypertrophic scars. The reason for such a risk lies in abnormally high level of collagen deposition. A very long duration with frequent relapses is characteristic of keloids, and after every new surgical treatment they become bigger as compared to hypertrophic ones. Therefore, after defective breast scar surgery for preventive purposes a silicone patch with compression clothes and elastic bandage were used – in the period after stitch removal – that is on the 12 -14 day after surgery. Further examination of patients was performed every 2-3 weeks. The described method was used in 50 patients. In 80% of cases the result was positive. In 15% of cases complications were observed due to patients’ not following the surgeon’s recommendations – post-surgery wound abscess – resulting from the wrong use of antibiotics and non-compliance with sterility principles in the post-surgery period, early shower and bath taking with stitches, early removal of the compression bandage, sleeping on the breast (pronate), and two cases of trauma of the scar area – kid’s blow and falling down at home.
Concerning the endocrine system, it should be mentioned that thyroid gland pathology and its hyper function in particular, has a negative impact on the adrenal cortex functioning. 56% of patients who treated for defective breast scars had problems with thyroid gland. Among them there were Graves’ disease, hyperthyroidism, thyroid nodule.
This all leads to violated functionality of specific body adaptation. This process is ensured by the two-side connection: limbic system – hypothalamus – pituitary gland – thyroid gland (adrenal glands). However, in case of central nervous system disorders, disorders in this two-side chain can be not accompanied by the thyroid gland disorders.
Adrenal hormones influence connective tissue development to a great extent. Here cortisone should be also included . Patients having pre-disposition to defective scars may show a lower rate of 11-oxicorticosteriods (11-OCS) in the nearest 2-3 months after total healing of the scars or over the convalescence period when blood tests are done in comparison with the healthy human’s blood plasma. Therefore, the intensity of cortisone secretion in the blood depends on the development of connective tissue in the keloid scars. This leads to weakened inhibition influence of this hormone on fibroblasts. Thus, general and specific regulation of the connective tissue characteristics in keloid scars changes as the result of local factors influence. Due to the absence of plasmatic cells and lymphocytes in the growing scar tissue, cellular metabolism processes products are accumulated there. They stimulate the activity of fibroblasts and disrupt antibodies appearance.
In case of scleroderma, tissue fibrosis and liver cirrhosis platelet-derived growth factor (PDGF) can typically be traced. It is a powerful connective tissue mitogen. PGDF also stimulates taxis of fibroblasts, smooth muscle cells, neutrophils and macrophages, increases fibronectine generation and gialyronic acid production .
The result of the research detected that defective breast scars appear as a result of the integrity of multiple pathologies of other organs and systems. Thus, defective scars are one of the first symptoms of other organs pathology. It is also important to carefully interview the patient before breast surgery, focusing on checking for pathologies in the listed body processes in general. Thus, it is important to take the necessary steps to treat them, which, in its turn, will appear to be a good method of preventing defective breast scars.
Improving metabolism and influencing hormonal disorder correction as well as using the suggested methods of preventing recurrence of defective scar after their surgical treatment and using minimum invasive treatment by the described method, chaotic uncontrolled synthesis of collagen may be prevented, and thus it will become impossible to start reactions leading to defective scar appearance.
E Riggio, VV Cividin. Breast Reconstruction Approach to Conservative Surgery. In: M Salgarello, editor. Breast Reconstruction - Current Techniques. InTech. http://cdn.intechopen.com/pdfs-wm/27952.pdf