Arch Hand Microsurg 2018; 23(2): 110-115  
Treatment of Chronic Chest Ulcer Using Two Sequential Perforator Flaps in Latissimus Dorsi Muscle Absence Patient: A Case Report
Seoyoung Kim, Seongwon Lee, Daegu Son
Department of Plastic and Reconstructive Surgery, Keimyung University School of Medicine, Daegu, Korea
Correspondence to: Daegu Son
Department of Plastic and Reconstructive Surgery, Keimyung University School of Medicine, 56 Dalseong-ro, Jung-gu, Daegu 41931, Korea
TEL: +82-53-250-7636, FAX: +82-53-255-0632, E-mail: handson@dsmc.or.kr
Received: May 3, 2018; Revised: May 13, 2018; Accepted: May 14, 2018; Published online: June 1, 2018.
© Korean Society for Surgery of the Hand, Korean Society for Microsurgery, and Korean Society for Surgery of the Peripheral Nerve. All rights reserved.

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Latissimus dorsi muscle flap is a commonly used reconstructive method on chest wall reconstruction. But meeting patient with absence of latissimus dorsi muscle on intra-operatively is very rare and embarrassing experience. A 73-year-old woman visited our clinic with radiation induced chronic ulceration on the right chest. In the presented case, the patient had received modified radical mastectomy with radiation therapy 36 years ago and lymphatic edema of the upper extremity lasting for 30 years. The ulceration was developed 6 weeks ago and accompanied by profound erythema and abscess pocket. The presence of right thoracodorsal artery in the computed tomography taken before surgery was confirmed and we planned to reconstruct the defect using latissimus dorsi muscle flap. When the authors dissected the skin paddle to elevate the flap, we found that there was no latissimus dorsi muscle. So, we decided to cover the defect by free style perforator flaps. We describe our experience of reconstructing radiation induced chest wall ulceration with intercostal and thoracodorsal artery perforator flaps on latissimus dorsi muscle absence patient. We recommend that the presence of latissimus dorsi muscle be confirmed by imaging before surgery if the patient has a long history of previous breast cancer surgery or lymphatic edema.
Keywords: Latissimus dorsi, Perforator flap, Thorax, Radiation injuries, Perforator flap


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