Review of Procedures for Reconstruction of Soft Tissue Chest Wall Defects Following Advanced Breast Malignancies

Abstract

The purpose of this article is to review closure options for complex chest wounds in patients with locally advanced breast cancer. Experiences of the plastic and oncologic surgery teams at Moffitt Cancer Center were reviewed, and the literature researched for various surgical options of complex chest wound closure. Multiple treatment modalities exist for reconstruction of complex chest wall wounds with the external oblique and V-Y latissimus dorsi musculocutaneous advancement flaps serving as workhorses in reconstruction. Treatment of cancer has moved from simply a surgical solution to include other modalities such as hormonal therapy, chemotherapy, and radiation—the latter 2 having serious consequences for wound healing. A team approach and knowledge of available flap options are vital for closure of complex wounds in a timely manner. Appropriate planning can optimize the primary goal of the oncologic surgeon to remove the cancer and the plastic surgeon’s objective to reconstruct the defect and achieve a closed, durable wound prior to chemotherapy and radiation. We present the experience at the Moffitt Cancer Center in reconstructing challenging chest defects and review the reconstructive ladder.

Chimeric ALT Plus TFL Perforator Flap for Breast Reconstruction Post Radical Mastectomy with Large Skin Defect

“…A laterally placed defect might overlap with donor site. 2 Pedicle TRAM or freeDIEP/Transverse rectus abdominis myocutaneous (TRAM) flap can be used for the same, donor site permitting.…”

“…7 The TFL perforator flap can be the harvested by same surgical access used for the ALT flap. 2 TFL perforator flaps or lateral thigh flaps for breast reconstruction are well described as opportunistic alternative to traditional donor sites. 8,9 The use of combined/split TFL and ALT flap together for cover of large chest wall defects following advanced breast malignancies has been described by Pelzer.…”

Skin grafting utilizing a skin of lateral thoracic area for chest wall reconstruction in patient who underwent mastectomy for locally advanced breast cancer

“…Locally advanced breast cancer sometimes requires tissue coverage of an extensive chest wall defect at mastectomy. One of the simple ways to close the wound is a bilateral local skin advancement flap in which the skin and subcutaneous fat is undermined superiorly toward the clavicle and inferiorly toward the abdomen [1,2]. Several procedures have been reported including skin grafts, fasciocutaneous flaps, myocutaneous flaps and perforator flaps when the skin defect is difficult to close by primary or undermining [1][2][3][4][5][6][7].…”

“…One of the simple ways to close the wound is a bilateral local skin advancement flap in which the skin and subcutaneous fat is undermined superiorly toward the clavicle and inferiorly toward the abdomen [1,2]. Several procedures have been reported including skin grafts, fasciocutaneous flaps, myocutaneous flaps and perforator flaps when the skin defect is difficult to close by primary or undermining [1][2][3][4][5][6][7]. Among these procedures, skin graft is a simple, less invasive and less time-consuming procedure compared to the other procedures; however, an additional scar at the donor site is unavoidable [1,2,8].…”

“…Several procedures have been reported including skin grafts, fasciocutaneous flaps, myocutaneous flaps and perforator flaps when the skin defect is difficult to close by primary or undermining [1][2][3][4][5][6][7]. Among these procedures, skin graft is a simple, less invasive and less time-consuming procedure compared to the other procedures; however, an additional scar at the donor site is unavoidable [1,2,8].…”