Gesson-Paute, Amélie M.D.; Ferron, Gwenaël M.D.; Garrido, Ignacio M.D.
Department of Surgical Oncology; Institut Claudius Regaud; Toulouse, France
Correspondence to Dr. Garrido; Department of Surgical Oncology; Institut Claudius Regaud; 20-24 rue du Pont St Pierre; 31052 Toulouse, France
Reconstruction of chest wall defects following extirpation of large locally recurrent breast tumors or radionecrosis after breast cancer treatment remains a challenge for the reconstructive and oncologic surgeon. The defects resulting from such resections are often quite large and could involve not only the skin and soft tissues but also the bone tissues (ribs and sternum), which require a strong chest wall reconstruction. This is essential for improving long-term survival and quality of life after radiation damage.
The majority of these defects can be repaired with the use of local and regional musculocutaneous or omental flaps. The use of the external oblique musculocutaneous flap to reconstruct the chest wall after these surgical treatments was first described in 1950 by Lesnick and Davids1 and for coverage of the chest wall and pelvic defect by other authors.2,3
From August of 2002 to June of 2005, nine patients underwent chest wall reconstruction with the external oblique musculocutaneous flap. They were referred to the Claudius Regaud Cancerology Institute for severe chest wall radionecrosis after breast cancer treatment (n = 4) or for locally recurrent breast cancer (n = 5). The mean chest wall defect covered with an external oblique myocutaneous flap measured 312 cm2 (range, 152 to 595 cm2). There were neither major nor minor flap losses. The upper edge of the flap can reach the infraclavicular area and up to 5 cm beyond the midline, depending on the laxity of skin over the abdominal wall.4 It is a reliable vascular pedicle flap and provides a large area of vascularized fascia and cutaneous coverage. Thus, this flap can be an alternative and can be more easily used when the size of the defect cannot be covered by the latissimus dorsi. The arc of rotation to the specific zone of the chest wall is safe. The skin has the same aspect, the same color, and the same touch and offers a strong, thick coverage (Figs. 1 and 2). This flap is intended mainly for elderly patients because of the better laxity of the skin lacking in collagen fibers caused by aging. This flap provides comfort and a better quality of life compared with the need for daily medical care with radiation-induced damage. There is no major loss of sensibility because the nerve supply of the muscle is preserved during dissection with the separation of the internal oblique muscle. Moreover, during surgery, there are no changes of position for the patient and the surgical team, and it is a relatively short operation (mean operative time, 100 minutes). The donor-site morbidity of the external oblique muscle flap appears to be quite minimal; the internal oblique and transverse muscles compensate for the functional loss of the external oblique muscle.
The main disadvantage of this flap is the rather unsightly, long abdominal scar, but there is no real problem of healing. We described local disunion treated by means of simple medical care (n = 3). Moreover, it does not allow breast reconstruction but only coverage of a plane. There is no sufficient volume and it is not possible to shape this strong flap. We described one case of Spigelian hernia.
We believe that the external oblique musculocutaneous flap is safe and reliable and allows for reconstruction of complex chest wall defects in the context of a local recurrence of breast cancer or a radiation-induced lesion. There is no major morbidity or complications. The good clinical outcome is encouraging.
Amélie Gesson-Paute, M.D.
Gwenaël Ferron, M.D.
Ignacio Garrido, M.D.
Department of Surgical Oncology
Institut Claudius Regaud
1. Lesnick, G. J., and Davids, A. M. Repair of surgical abdominal wall defect with a pedicled musculocutaneous flap. Ann. Surg. 137: 569, 1953.
2. Chang, R. R., Mehrara, B. J., Hu, Q. Y., Disa, J. J., and Cordeiro, P. G. Reconstruction of complex oncologic chest wall defect: A 10 year experience. Ann. Plast. Surg. 52: 471, 2004.
3. Moschella, F., and Cordova, A. A new extended external oblique musculocutaneous flap for reconstruction of large chest wall defect. Plast. Reconstr. Surg. 103: 1378, 1999.
4. Bogossian, N., Chaglassian, T., Rosenberg, P. H., and Moore, M. P. External oblique myocutaneous flap coverage of large chest wall defects following resection of breast tumors. Plast. Reconstr. Surg. 97: 97, 1996.
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