Ishii Yuki, Matsuki Hitomi, Uozumi Nozomi, Oura Shoji
Department of Surgery, Kishiwada Tokushukai Hospital, 4-27-1, Kamori-Cho, Kishiwada city, Osaka, 596-8522, Japan.
Surg Case Rep. 2023 Jul 10;9(1):127. doi: 10.1186/s40792-023-01711-x.
Musculocutaneous (MC) flaps are more resistant to infection than implants, but no clinical results have been reported so far about the grafting of MC flap to the overtly infected sites.
A 66-year-old woman had received radiotherapy, a total dose of 50 Gy, to her large mucinous breast cancer to control bleeding from the tumor and was referred to our hospital for further treatment. On her first visit to our hospital, her left breast showed radiation-induced total necrosis with Pseudomonas aeruginosa infection. Removal of the necrotic breast tissue resulted in direct exposure of the left ribs and intercostal muscles with intractable chest pain requiring analgesics. The presence of concomitant life-threatening multiple lung metastases made us change the treatment from letrozole and palbociclib to bevacizumab and paclitaxel, leading to marked regression of the lung metastases. To alleviate her chest pain and get local wound healing, we treated the patient with latissimus dorsi (LD)-MC flap grafting to the exposed chest wall after four months of taxane-containing chemotherapy. The patient has got marked pain relief immediately after the operation. Skin island of the grafted LD-MC flap showed no problems for 4 days just after the operation but gradually turned out to be edematous to ill-colored in the distal part of the skin island. Post-operative clinical outcome suggested that Pseudomonas aeruginosa infection might have had some adverse effect, e.g., microemboli, on MC flap blood flow. Partial necrosis of the LD-MC flap made the patient receive conservative wound management for a very long period of 11 months, finally leading to complete wound healing. After palliative surgery, the patient has been receiving fulvestrant and palbociclib for 14 months and doing well with good control of multiple lung metastases.
Breast surgical oncologists should note that partial flap necrosis can occur when a LD-MC flap is grafted to the infected recipient site and consider the anti-coagulant therapy just after the operation to avoid the adverse effects of the infection.
肌皮瓣比植入物更能抵抗感染，但目前尚无关于将肌皮瓣移植到明显感染部位的临床结果报道。
一名66岁女性因患有大黏液性乳腺癌接受了总量为50 Gy的放射治疗以控制肿瘤出血，随后被转诊至我院接受进一步治疗。她首次来我院就诊时，左乳出现放射性全坏死并伴有铜绿假单胞菌感染。切除坏死的乳腺组织后，左侧肋骨和肋间肌直接暴露，伴有难以忍受的胸痛，需要使用镇痛药。同时存在危及生命的多发肺转移，这使我们将治疗方案从来曲唑和哌柏西利改为贝伐单抗和紫杉醇，导致肺转移明显消退。为缓解她的胸痛并实现局部伤口愈合，在含紫杉烷化疗4个月后，我们采用背阔肌肌皮瓣移植到暴露的胸壁对该患者进行治疗。术后患者的疼痛立即得到明显缓解。移植的背阔肌肌皮瓣的皮岛在术后4天内未出现问题，但逐渐在皮岛远端出现水肿至颜色异常。术后临床结果表明，铜绿假单胞菌感染可能对肌皮瓣血流产生了一些不利影响，例如微栓子。背阔肌肌皮瓣的部分坏死使患者接受了长达11个月的保守伤口处理，最终实现伤口完全愈合。姑息性手术后，患者接受氟维司群和哌柏西利治疗14个月，多发肺转移得到良好控制，情况良好。
乳腺外科肿瘤学家应注意，将背阔肌肌皮瓣移植到感染的受区时可能会发生部分皮瓣坏死，并应考虑术后立即进行抗凝治疗以避免感染的不良反应。
