Change of paradigm in thoracic radionecrosis management

Chest wall reconstruction for deep radiation necrosis: case report and overview of surgical options

INTRODUCTION

To report a case of radiation necrosis after reirradiation for breast cancer and the difficulties encountered when treating these complex cases.

PATIENTS AND METHODS

We present an 86-year-old woman with a history of right-sided intraductal breast cancer treated with a right mastectomy followed by local adjuvant radiotherapy (50 Gray). Twelve years later, she was diagnosed with a local recurrence in the mastectomy scar which was treated with local resection (including resection of rib four) and adjuvant radiotherapy up to 32 Gray. In July 2020 she presents at the Department of Plastic and Reconstructive Surgery with a chronic ulcer on the right-sided hemithorax.

RESULTS

A multi-staged, multidisciplinary approach was necessary to secure lasting coverage of the extensive defect.

CONCLUSION

Thoracic radiation necrosis should be subject to a multidisciplinary approach (plastic and thoracic surgeons) pre-, per-, and post-operatively. Each case may require a different surgical approach depending on the size and depth of the defect, patients' age, comorbidities, and previous medical treatment.

Propeller Flaps for the Anterior Trunk

Various types of propeller flaps from multiple donor sites can be used to reconstruct anterior trunk skin defects. The actual selection depends on the condition and location of the recipient site, especially if it is to be the chest or abdomen that requires attention. Before surgery commences, it is always important to use an imaging analyses such as computed tomography angiography to examine and identify perforators that could perfuse a perforator-pedicled propeller flap (PPPF), as it is the most multifaceted imaging technique. Clusters of perforators that can be commonly used for the "workhorse" PPPFs for the thoracic and abdominal regions are the internal mammary artery perforator, the musculophrenic artery perforator, and the deep inferior epigastric perforator. These perforators are reliable and large enough to support long and large propeller flaps that will cover most defects in this region, while still allowing primary donor-site closure.

[Greater omentum flap: Treatment of chronic wounds and seroma: About a case]

INTRODUCTION

Cicatricial complications after abdominal or pelvic surgery are more frequent in obese patients. In this case, infection, seroma and delays in scarring can be extremely difficult to treat. The objective of this technical note is to present an original case of an obese patient operated nine years ago of a hysterectomy by laparotomy and chronically presenting a non-resolving septic seroma despite multiple surgical procedures whose healing could be obtained by a flap of greater omentum.

SURGICAL TECHNIQUE

The ideal is to carry out this intervention in a double team with a digestive surgeon in case of intra-abdominal visceral or vascular wound during dissection. The greater omentum flap was raised in a conventional manner over the gastroepiploic artery. A sufficiently wide orifice should be left at the level of the abdominal aponeurosis in order to avoid any compression of the pedicle. Finally, the flap must be spread over the whole surface of the detachment and fixed to the anterior aponeurosis.

CONCLUSION

Reliability and vascular and lymphatic richness make the greater omentum flap a very effective method in chronic wound cases associated with important seroma. The scarring obtained in the clinical case presented thus highlights the specific qualities of this flap.

Reconstruction of an anterior chest wall radionecrosis defect by a contralateral latissimus dorsi flap: A case report

INTRODUCTION

Soft tissue and bone radionecrosis are rare but serious complications may occur late after radiotherapy.

CASE REPORT

We report the case of an 86-year-old woman with a history an infiltrating ductal carcinoma of the left breast, treated by total mastectomy, left axillary dissection and adjuvant radiotherapy. Eighteen years later, the first radionecrosis lesions appeared and grew progressively in a 6-month period. These lesions are deep, involving the anterior aspect of the 4th to the 6th ribs and infiltrating the chest wall to the left cardio-thoracic space communicating largely with the pericardium. During axillary dissection, the neurovascular pedicle of the left latissimus dorsi muscle had been severed. The first part of the operation consisted of performing a left side parietectomy of the thoracic wall with a large resection of pericardial tissue and a small myocardial patch. The second step consisted of repairing the thoracic wall defect with a contralateral musculocutaneous latissimus dorsi flap.

CONCLUSION

Due to its significant axis of rotation, the latissimus dorsi muscle flap must be considered in the therapeutic algorithm for covering of contralateral anterior chest wall defects.