Prone Positioning following Breast Reconstruction.

Dear Sir,

The COVID-19 epidemic has put strain on healthcare staff and providers. Those patients who require critical care admission and mechanical ventilation may also require prone positioning, as a method of improving oxygenation, decreasing shunting, and a reduction in barotrauma and ventilator induced lung injury. The PROSEVA trial demonstrated a significant reduction in both 28 and 90-day mortality in an acute respiratory distress syndrome (ARDS) population.

Risk factors for development of severe disease include age over 65, pre-existing lung disease and immunosuppression. Our population of breast cancer patients may therefore be of increased risk of critical illness due to the demographic and development of chemotherapy or radiotherapy-induced lung fibrosis predisposing to worsening lung function. Prone positioning is associated with an increased risk of pressure damage; McCormick et al demonstrated 49%, affecting both the face and breasts.

The presence of breast implants may complicate the positioning. A previous case report describes nipple and breast tissue necrosis following a period of 24 hours in the proned position for ARDS caused by pneumonia. She had capsular contracture which prevented normal lateral displacement and held the breast in a more medial position.

A 52-year-old female was admitted to the critical care unit for severe COVID-19 pneumonia, and required proning to improve oxygenation. She had a history of right sided ductal carcinoma in 2014 and underwent wide local excision and adjuvant chemo-radiotherapy. In 2019, recurrence was detected, and she underwent mastectomy. She had immediate reconstruction with a tissue expander and dermal sling followed by chemotherapy which finished 1 month prior to COVID diagnosis. There was a small amount of postoperative haematoma which had been aspirated under radiological guidance.

She required prone positioning for 16 hours on 3 separate occasions. On performing personal care during the critical care admission it was noted that the right breast looked enlarged and inflamed, and on examination was firm. As the patient was mechanically ventilated it was not possible to assess for pain. There was also a blister noted on the mid-sternal area likely to represent grade 2 pressure damage.

Clearly the underlying significant disease process takes priority in this situation, and symptoms should be managed in order of clinical priority, which may or may not include prone positioning if required. The patient has recovered fully, and was safely discharged following a 22 day admission. There were no further complaints regarding the breast.

Rupture of implant due to prolonged pressure would be unlikely, but development of seroma or early capsule formation is possible. The tissue compressed between the expander and mattress is at significant risk of ischaemic damage. Previous recommendations are for medial placement of larger breasts during proned surgery as this can be less painful, however in the presence of implants this should be discouraged.

Therefore, care and attention should be given to this cohort of patients during the proning process to ensure adequate pressure relief and repositioning occurs, and if possible, less pressure placed on the affected side to reduce risk of further complications. Although the first peak in the UK has been reached, cases of COVID-19 will continue and staff will become more familiar with the techniques of managing them.

Conflicts of Interest

All authors declare no conflict of interest.

Funding

None.