In breast cancer, radiation therapy is an important treatment for controlling local recurrence . Despite many advances in radiation therapy, complications such as ORN persist. ORN mainly occurs in the mouth after radiation therapy for head and neck cancers. Although rare, it has also been found in patients with breast cancer . ORN occurring in the chest wall is often accompanied by osteomyelitis, with a high possibility of recurrence, and the presence of radiation-induced fibrotic tissue is likely to delay wound healing; hence, extensive surgical resection is important .
This patient was an 81-year-old woman with hypertension, diabetes, and chronic kidney disease as underlying diseases. Due to fibrosis and calcification in the right lung caused by radiation, pulmonary function was reduced. In the pulmonary function test, the forced expiratory volume in one second (FEV1) / forced vital capacity (FVC) was 67%, indicating moderate obstruction. The left ventricular ejection fraction was 40% on preoperative echocardiography, indicating reduced heart function. The overall American Society of Anesthesiologists score was 3, indicating a high risk of postoperative cardiopulmonary complications. Therefore, it was necessary to shorten the operation time and minimize the scope of the operation.
Local flaps of various forms are used for the reconstruction of extensive soft tissue defects in the chest wall. The pectoralis major muscle flap, latissimus dorsi (LD) muscle flap, and vertical or transverse rectus abdominis myocutaneous flaps are the most commonly used, and thoracoabdominal and thoracoepgastric flaps are also sometimes used . The wound in this patient was a deep and exposed to the pleura, and the pectoralis major muscle was damaged during the debridement process, preventing its use. The LD flap is advantageous for covering a large wound, but it requires changing position during surgery and may cause donor site morbidity. The rectus abdominis myocutaneous flap has a wide surgical range and long operative time, with a high risk of postoperative complications. The surgical range of the contralateral breast flap, on the other hand, is relatively small, not beyond the chest area, resulting in quick recovery after surgery. The patient's vital signs were stable immediately after surgery, and she was able to resume daily activities, including ambulation, one day after surgery. No donor site morbidity occurred after surgery, with only some partial dehiscence, which required minor repair.
Reconstruction of the chest wall using a contralateral breast flap should be considered in the following cases: first, patients with severe ptotic or large breast that can cover the contralateral side; second, patients with a high risk of postoperative complications due to old age or poor general condition; and third, patients for whom a LD or rectus abdominis based flap has been used or cannot be used.
This technique has two limitations. First, the anatomy of the contralateral breast may be deformed, making breast cancer screening difficult in the future. Second, covering the entire chest with a single breast is not esthetically pleasing.
Nevertheless, the contralateral breast Y-V flap allows simple and quick reconstruction, and having more options for chest wall reconstruction will allow for a more flexible treatment plan for each patient.