An approach to repair of radiation necrosis of chest wall and mammary gland

Abstract

Chest wall reconstruction following radiation no longer need be a protracted sequence of multiple stage tissue transfer with potential necrosis of the flap at each step. Muscle flaps with or without the overlying skin provide very reliable and effective methods of single-stage repair. For the anterior chest the latissimus dorsi, the rectus abdominis, and pectoralis muscles are the choices with omentum as an alternative in salvage cases. For the posterior chest, choices are the latissimus dorsi or trapezius.In selected patients, breast reconstruction can be offered. The use of either the rectus abdominis or latissimus dorsi musculocutaneous flap, singly or in tandem, is the current preferred choice.In the treatment of primary, recurrent, and unresectable chest wall malignancies [1] (e.g., breast [2-17], lung [5], chest wall tumors [8,18], deeply infiltrating skin tumors [10,19]), metastatic disease (e.g., pulmonary seminoma [6]), spinal cord and column metastases (e.g., breast, lung), or primary mediastinal tumors (e.g., lymphoma) [1,20,21], chest wall irradiation is useful and essential. Risks of therapy include not only damage to underlying lung parenchyma, mediastinal viscera, and chest wall and its overlying skin, but also the induction of neoplasia in these sites [3,13,22,23].These hazards of radiation therapy have been observed in virtually every tissue system. Particularly sensitive are those structures with high cellular turnover rates, e.g., breast, bone marrow, and thyroid [3,23]. The first 2 of these are primary constituents of the chest wall. Restoration of the radiation-injured chest wall often requires signifi-Reprint requests:

Plastische Rekonstruktion von Thoraxwanddefekten

“…Als Anwendungsregion fü r das Rectus-abdominis-System gilt die gesamte vordere Sternumregion und ein Lappenrotationsbogen, der die Axilla knapp erreicht [1,8,15,17]. Defekte, die die hintere Axillarlinie miterfassen, werden sicherer durch mikrovasculä re Transplantate oder zusä tzliche lokale Lappen mit unbestrahltem Gewebe vom Rü cken bedeckt.…”

“…Bei posttraumatischen Infekten, postoperativen Wundheilungsstö rungen und radiogenen Knorpel-und Knochenentzü ndungen stellt die Erzielung eines infektfreien Randbezirks den wesentlichen Therapiefaktor dar [5,8,14,15,17]. Dieses Prinzip findet neben den radiogenen Ulcerationen hauptsä chlich bei infizierten Sternotomiewunden Anwendung.…”

Is myocutaneous flap alone sufficient for reconstruction of chest wall osteoradionecrosis?

“…A surface-only mentality in chest wall repair could spell disaster for the patient. In the past decade, reconstruction of the chest wall and the breast has advanced remarkably because of muscle and musculocutaneous transposition flaps [5].…”