Summary 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.

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

Perforator flap use in breast cancer reconstruction has evolved significantly in the last decade. The authors reviewed their experience and evaluated thoracodorsal artery perforator (TDAP) flap outcomes in breast reconstruction.A retrospective chart review was conducted of all women undergoing breast reconstruction between 2012 and 2018. Included were patients who underwent a mastectomy (unilateral or bilateral) with immediate reconstruction or requiring a revision reconstruction with a TDAP flap. Reconstruction for nonmalignant causes were excluded. Patient demographics, risk factors, indications, operative details, and complications were reviewed. Major (partial or total flap necrosis, hematoma, and wound breakdown requiring operative management) and minor (cellulitis, seroma, and minor wound breakdown managed with local wound care) complications were recorded.A total of 138 charts were reviewed for the years 2012 and 2018, and 126 patients met inclusion criteria. Mean patient age was 52.1 years. Mean patient body mass index was 29.1 kg/m 2 . A total of 174 TDAP flaps were performed. The success rate was 98.3 percent. There were three flap losses (all partial). Operable fat necrosis rate was 3 percent. Donor-site morbidity was low at a rate of 1.2 percent. There was no difference in complications between patients who had a history of radiation therapy and those who did not (16.7 and 18.6 percent, respectively; p = 0.829).This study is the largest series in the literature that highlights the utility of the TDAP flap in breast reconstruction. This flap is a powerful tool that should be considered in patients for whom other reconstructive options have been exhausted or unavailable.Therapeutic, IV. 

The Thoracodorsal Artery Perforator Flap: A Powerful Tool in Breast Reconstruction

Rib-sternal osteoradionecrosis is a rare but serious complication of chest radiotherapy. No consensus-based method of managing deep sternal wounds that develop after radiotherapy is available. Usually patients require long-term antibiotics. The surgical placement of a muscle, an omental flap, or a prosthesis is described. We report, in pictures, four successful omental flap placements. Between March 2015 and July 2018, four women with deep sternal wound injuries that developed after radiation therapy to treat breast cancer underwent rib-sternal reconstruction with omental flap placement. The first signs of infected radionecrosis developed 28.5 years after radiotherapy. Despite prolonged antibiotic treatment, surgery was necessary. The mean age at surgery was 76 years (range: 62–86 years). All necrotic tissue was excised and debridement was performed before the placement of a pedicled omental flap dissected along the transverse colon and raised through a subcutaneous tunnel. No skin graft or osteosynthesis was required. After surgery, lubricated bandages were applied daily, and antibiotics were prescribed for a few weeks. Complete healing was obtained after surgery without clinical complication. Our experience suggests that a pedicled omental flap is an affordable, simple, and very useful option for reconstructing deep rib-sternal wounds caused by radiation.

Management of Osteoradionecrosis of the Anterior Thoracic Wall Using Omental Flaps: a Prospective Case Series and Literature Review

Resume Introduction Les complications cicatricielles post-chirurgie abdominale ou pelvienne sont plus frequentes chez les patientes obeses. L’infection, les seromes et les retards de cicatrisation occasionnes peuvent dans ce cas etre extremement difficiles a traiter. L’objectif de cette note technique est de vous presenter un cas original d’une patiente de 48 ans obese, operee neuf ans auparavant d’une hysterectomie par laparotomie et presentant de maniere chronique une fistule chronique associee a une lymphorree septique non resolutive malgre de multiples interventions chirurgicales, dont la guerison a pu etre obtenue par un lambeau de grand epiploon. Technique chirurgicale L’ideal est de realiser cette intervention en double equipe avec un chirurgien digestif en cas de survenue de plaie viscerale ou vasculaire intra-abdominale durant la dissection. Le lambeau de grand epiploon etait leve de maniere classique sur l’artere gastro-epiploique droite. Un orifice suffisamment large doit etre laisse au niveau de l’aponevrose abdominale afin d’eviter toute compression du pedicule. Enfin, le lambeau doit etre etale sur toute la surface du decollement et fixe a l’aponevrose anterieure. Conclusion La fiabilite et la richesse a la fois vasculaire et lymphatique font du lambeau de grand epiploon une methode tres efficace dans les cas de plaies chroniques associees a une lymphorrhee majeure. La cicatrisation obtenue dans le cas clinique presente met ainsi en valeur les qualites specifiques de ce lambeau.

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

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.

Propeller Flaps for the Anterior Trunk.

Classically, muscular or omental flaps are the gold standard in the management of thoracic defects following radionecrosis debridement. Their vascular supply and antibacterial property was supposed to enhance healing compared with cutaneous flaps. The evolution of reconstructive surgery allowed us to challenge this dogma. Therefore, we present five consecutive cases of thoracic radionecrosis reconstructed with cutaneous perforator flaps. In four patients, we performed a free deep inferior epigastric perforator (DIEP) flap and one patient had a thoracodorsal perforator (TDAP) flap. Median time healing was 22.6 days with satisfactory cutaneous covering and good aesthetic results. There were no flap necrosis, no donor site complications. We believe that perforator flaps are a new alternative, reliable and elegant option that questions the dogma of muscular flaps in the management of thoracic radionecrosis.

Change of paradigm in thoracic radionecrosis management

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Change of paradigm in thoracic radionecrosis management