Arch Hand Microsurg.  2018 Jun;23(2):110-115. 10.12790/ahm.2018.23.2.110.

Treatment of Chronic Chest Ulcer Using Two Sequential Perforator Flaps in Latissimus Dorsi Muscle Absence Patient: A Case Report

• Kim S
• Lee S
• Son D

• KMID: 2412480
• DOI: http://doi.org/10.12790/ahm.2018.23.2.110

Abstract

Latissimus dorsi muscle flap is a commonly used reconstructive method on chest wall reconstruction. But meeting patient with absence of latissimus dorsi muscle on intra-operatively is very rare and embarrassing experience. A 73-year-old woman visited our clinic with radiation induced chronic ulceration on the right chest. In the presented case, the patient had received modified radical mastectomy with radiation therapy 36 years ago and lymphatic edema of the upper extremity lasting for 30 years. The ulceration was developed 6 weeks ago and accompanied by profound erythema and abscess pocket. The presence of right thoracodorsal artery in the computed tomography taken before surgery was confirmed and we planned to reconstruct the defect using latissimus dorsi muscle flap. When the authors dissected the skin paddle to elevate the flap, we found that there was no latissimus dorsi muscle. So, we decided to cover the defect by free style perforator flaps. We describe our experience of reconstructing radiation induced chest wall ulceration with intercostal and thoracodorsal artery perforator flaps on latissimus dorsi muscle absence patient. We recommend that the presence of latissimus dorsi muscle be confirmed by imaging before surgery if the patient has a long history of previous breast cancer surgery or lymphatic edema.

Keyword

Latissimus dorsi; Perforator flap; Thorax; Radiation injuries; Perforator flap

MeSH Terms

Abscess
Aged
Arteries
Breast Neoplasms
Edema
Erythema
Female
Humans
Mastectomy, Modified Radical
Methods
Perforator Flap*
Radiation Injuries
Skin
Superficial Back Muscles*
Thoracic Wall
Thorax*
Ulcer*
Upper Extremity

Figure

• 

  Fig.1. Pre-operative view. A 73-year-old woman with radiation induced chronic ulceration on the right upper chest.

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  Fig.2. Histologic findings. (A) Granulation tissues (H&E stain, ×200). (B) Ossification with chronic inflammation (H&E stain, ×200). H&E: hematoxylin and eosin.

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  Fig.3. (A) Pre-operative design of latissimus dorsi flap. (B) Intra-operative view; absence of latissimus dorsi muscle. (C) 1: intercostal artery perforator flap; which was original skin paddle of LD flap. 2: thoracodorsal artery perforator flap; which was used to cover the chest ulcer. (D) Immediate postoperative view; after advancement of intercostal artery perforator flap and transposition of thoracodorsal artery perforator flap. Immediate postoperative view; 1: advanced intercostal artery perforator flap, 2: transposed thoracodorsal artery perforator flap.

• 

  Fig.4. Postoperative view. (A) Ad-vanced intercostal artery perforator flap, 2 months after surgery. (B) Transposed thoracodorsal artery perforator flap, 29 months after surgery.

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  Fig.5. Pre-operative chest CT. Absence of right side latissimus dorsi muscle (red arrow). Presence of left side latissimus dorsi muscle (blue arrow).

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