Abstract
Ulcer in radiation‐damaged tissue is a dilemma with limited treatment strategies. The study aimed to evaluate the safety and efficacy of regional flaps for patients with post‐radiation ulcers through a 10‐year experience. A retrospective study of consecutive patients with post‐radiation ulcers at a single institute from 2012 to 2022 was conducted. Reconstruction included complete excision of irradiated tissue and coverage with well‐vascularised tissue, including local flaps, regional flaps and free flaps. Study outcomes included complications, reoperation rates, overall flap success and recurrence rates. Thirteen patients (six males and seven females; mean age, 56.85 ± 13.87 years) with a mean 10‐month history of post‐radiation ulcers were enrolled. Ulcers are predominantly located in the chest (n = 3, 23.1%), head (n = 2, 15.4%) and neck (n = 2, 15.4%), with a mean size of 33.1 cm2 (range from 1 cm2 to 120 cm2). Eleven patients underwent reconstruction with 15 regional flaps and three local flaps, one patient received a free anterolateral thigh fasciocutaneous flap and one patient underwent amputation. Among these 15 regional flaps, one (6.7%) had wound dehiscence and four (26.7%) had localised necrosis requiring reoperation. In addition, one patient with a non‐healing sinus tract underwent reoperation. The overall success rate of the regional flap was 100% and no recurrence was observed with a mean follow‐up of 23.3 months. Regional flaps seem a safe and effective reconstructive method for post‐radiation ulcers.
Keywords: myocutaneous flap, plastic surgery, postoperative complications, radiotherapy, reconstructive surgical procedures, ulcer
1. INTRODUCTION
Radiotherapy (RT) is an indispensable part of treatment regimen for a range of malignancies, but along with tumour cells, the surrounding healthy tissue is often destroyed, including skin atrophy, soft tissue fibrosis, desquamation and epithelial ulcers. 1 , 2 Post‐radiation ulcers, as one of the serious complications, affect not only the physical but also the psychological health of patients and constitute a major surgical difficulty and therapeutic challenge, despite all efforts.
As a result of the poor quality and vascularity of radiation‐damaged tissue, the treatment of post‐radiation ulcers relies on complete excision followed by covering with well‐vascularised tissue. Skin grafts have limited success with reduced vascularity and dermal atrophy, and local flaps may also be unreliable as in the irradiation regions. 3 Although free flaps have been successfully used for large complex radiation ulcers, the difficulty and high complication rate of this microsurgical technique limit its widespread clinical application. 4 Regional flaps could restore healthy tissue to the irradiated field which may provide an alternative treatment for chronic post‐radiation ulcers. 5 , 6 , 7 , 8
Although there have been previous reports on the treatment of post‐radiation ulcers, these studies were mainly case reports or had a relatively small sample size. Besides, studies on regional flaps for post‐radiation ulcers are rare. Therefore, this study aimed to evaluate the safety and efficacy of regional flaps for the treatment of patients with post‐radiation ulcers over a 10‐year experience, which may facilitate clinical decision‐making.
2. MATERIALS AND METHODS
2.1. Study design
This study was approved by the Institutional Review Board (No. IRB00006761‐M2020576) with a waiver of informed consent. We retrospectively reviewed consecutive patients with post‐radiation ulcers who underwent reconstructive surgery between September 1, 2012 and August 31, 2022. The inclusion criteria were all as follows: (1) ulcer in the region of RT lasting more than 1 month; (2) previous history of cancer and RT. The exclusion criteria were any of the following: (1) ulcers from other causes, such as foreign body reaction, infection, denervation and other potential causes; (2) RT for keloids, not for cancer; (3) patients with severe systemic disease, such as severe cardio‐cerebrovascular accidents, cachexia and so on; (4) patients without complete medical records; (5) at least 3‐month follow‐up that could not be completed.
Clinical data were reviewed for demographic information, surgical parameters and postoperative complications. Surgical parameters included histopathological diagnosis, ulcer size, flap size, reconstructive strategy, operative duration and intraoperative bleeding. Surgical complications included infection, haematoma, dehiscence and necrosis within 2 weeks postoperatively. Wound infection and breakdown became clinically evident approximately 11 days after the operation.
2.2. Lesion excision and surgical debridement
When conservative treatment was unsuccessful, a definitive surgical repair with transposition of well‐vascularised, non‐irradiated tissue was performed to repair the defect and preserve deep structures. Complete excision of the lesion and surgical debridement of the ulcer was first planned and carried out.
Under general anaesthesia, the location of the radiation ulcer was marked, with margins approximately 2 cm beyond normal skin, and the lesion was completely incised along the markings. A tissue biopsy was sent for histopathological examination to rule out local recurrence or radiation‐induced cancer. Reconstructive surgery can be performed only after the complete excision of the tumour, including the margins and base of the lesion. The remaining necrotic tissues and deep surfaces were then debrided until bleeding tissue was exposed, paying particular attention not to destroy arteries, veins and nerves. Complete haemostasis was conducted through electrocoagulation. The operative field was sterilised alternately with 3% hydrogen peroxide, 1% diluted povidone‐iodine and normal saline.
2.3. Negative pressure wound therapy
Based on the fact that chronic post‐radiation ulcers were usually associated with bacterial infection, the negative pressure wound therapy (NPWT) technique was provided. The NPWT auxiliary material was cut into an appropriate size and placed on the wound surface. The continuous negative pressure was set at −125 to −450 mm Hg (1 mmHg = 0.133 KPa). The colour and amount of drainage fluid were observed, and the abnormalities were handled in time. When the NPWT auxiliary material was removed 5–7 days later, the wound surface would become fresh and covered with new granulation tissue. If there was remaining necrotic tissue, surgical debridement with NPWT was repeated. The patients usually underwent multiple surgical debridements with NPWT before reconstructive surgery.
2.4. Reconstructive surgery
The reconstructive method was designed according to the extent and location of the defect. The location of the regional flap was carefully selected in an area of the skin unaffected by irradiation and designed a little bit larger than the defect size with a sufficient rotational arc. Then soft tissue of the skin was incised along the markings and the potential perforators were carefully explored during dissection. The regional flap was detached by electrocautery and raised from the distal to the proximal side until the region of the perforator, preserving the tissue around the perforator. A considerable pedicle length was obtained by dissecting the nourishing vessel through the muscle, which gave the flap superior mobility. The flap was then inserted into the defect, and the donor defect was closed primarily with minimal subcutaneous undermining or skin grafting if necessary.
2.5. Statistical analysis
Categorical variables were summarised as the number and proportion, and continuous variables were summarised as the mean and standard deviation. All statistical analyses were performed with SPSS statistical software (version 26.0, SPSS, IL, USA).
3. RESULTS
A total of 13 patients (six males and seven females; mean age, 56.85 ± 13.87 years; mean BMI, 23.73 ± 2.55 Kg/m2) were included in this study, all of whom were treated for post‐radiation ulcers. Most patients were healthy without alcohol/smoking addiction or a history of severe chronic diseases. In our series, the mean latency period from RT to ulcer development was 66 months (range 3–156 months). The mean hospital stay was 58.46 ± 29.64 days and the mean follow‐up time was 23.3 ± 19.4 months. The demographic parameters of the patients were summarised in Table 1.
TABLE 1.
Demographic characteristics.
| Patient | Sex | Age (years) | BMI (Kg/m2) | Alcohol/Smoking (yes/no) | Comorbidities | Chemotherapy (yes/no) | Time of RT (months ago) | Times of operations | Length of stay (days) | Follow‐up (months) |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | M | 53 | 24.2 | No/ Yes | None | Yes | 48 | 10 | 137 | 3 |
| 2 | M | 82 | 24.9 | No/ No | None | Yes | 48 | 5 | 54 | 7 |
| 3 | M | 33 | 26.0 | No/No | None | No | 132 | 4 | 70 | 6 |
| 4 | F | 32 | 23.1 | No/No | None | Yes | 48 | 4 | 98 | 9 |
| 5 | F | 53 | 21.3 | No/ No | None | Yes | 144 | 2 | 29 | 10 |
| 6 | M | 70 | 25.7 | No/ No | None | Yes | 18 | 3 | 43 | 19 |
| 7 | M | 56 | 19.2 | No/ No | None | Yes | 3 | 3 | 38 | 19 |
| 8 | F | 57 | 28.2 | No/ Yes | Hypertension | Yes | 36 | 2 | 34 | 21 |
| 9 | F | 69 | 20.5 | No/ No | Hypertension | No | 24 | 5 | 66 | 22 |
| 10 | F | 54 | 22.5 | No/ No | Diabetes/Hypertension | Yes | 156 | 4 | 64 | 26 |
| 11 | F | 77 | 20.6 | No/ No | Diabetes/Hypertension | Yes | 144 | 2 | 61 | 65 |
| 12 | M | 59 | 27.0 | No/ No | Diabetes | Yes | 60 | 3 | 66 | 64 |
| 13 | F | 51 | 21.7 | No/ No | None | No | 3 | 2 | 36 | 32 |
Abbreviations: BMI, body mass index; F, female; M, male.
All patients developed ulcers after tumour resection and various regimens of RT with/without chemotherapy, with a mean duration of 10.15 ± 10.52 months (ranging from 1 to 36 months). Ulcers were mainly located on the chest (n = 3, 23.1%), head (n = 2, 15.4%), neck (n = 2, 15.4%), groin (n = 2, 15.4%) and perineum (n = 2, 15.4%), followed by the back (n = 1, 7.7%), and shoulder (n = 1, 7.7%), with a mean size of 33.1 cm2 (range from 1 cm2 to 120 cm2). The depth of ulcers reached muscle (n = 7, 53.8%), and even bone (n = 6, 46.2%). In all patients, the ulcers were completely resected and sent for histopathological examination, which revealed chronic inflammation and ulceration in 11 patients and squamous cell carcinoma in two patients. One of the patients with cervical squamous cell carcinoma previously received cervical neurofibroma resection and RT, and the other was considered to have a recurrence of localised squamous cell carcinoma of the groin. Before the reconstruction, most patients underwent debridement with NPWT at least one time. The mean operative duration was 319.5 ± 184.1 min. The mean intraoperative bleeding was 277.6 ± 269.2 mL and blood transfusion was 1.6 ± 2.0 U erythrocyte suspension and 315.8 ± 385.6 mL fresh frozen plasma. The surgical parameters of the patients were summarised in Table 2.
TABLE 2.
Characteristics of post‐radiation ulcers.
| Patient | Pathological types of the tumour | Duration of ulcer (months) | Ulcer location | Ulcer size (cm2) | Ulcer composition | Pathological types of the Ulcer |
|---|---|---|---|---|---|---|
| 1 | Lung adenocarcinoma | 3 | Back | 50 | Osseomyocutaneous | Chronic inflammation and ulceration |
| 2 | Neuroendocrine carcinoma | 2 | Groin | 2 | Myocutaneous | Chronic inflammation and ulceration |
| 3 | Neurofibroma | 36 | Neck | 24 | Myocutaneous | Squamous cell carcinoma |
| 4 | Glioblastoma multiforme | 3 | Head | 120 | Osseomyocutaneous | Chronic inflammation and fibrosis |
| 5 | Breast invasive lobular carcinoma | 24 | Chest | 3 | Osseomyocutaneous | Chronic inflammation and ulceration |
| 6 | Squamous cell carcinoma | 5 | Groin | 15 | Myocutaneous | Squamous cell carcinoma |
| 7 | None small cell carcinoma | 1 | Head | 2 | Osseomyocutaneous | Chronic inflammation and ulceration |
| 8 | Cervical cancer | 7 | Perineum | 1 | Myocutaneous | Chronic inflammation and ulceration |
| 9 | Fibrosarcoma | 6 | Shoulder | 64 | Myocutaneous | Chronic inflammation and ulceration |
| 10 | Breast cancer | 7 | Chest | 30 | Osseomyocutaneous | Chronic inflammation and ulceration |
| 11 | Breast cancer | 24 | Chest | 10 × 10 | Osseomyocutaneous | Chronic inflammation and ulceration |
| 12 | Rectal carcinoma | 12 | Perineum | 1 | Myocutaneous | Chronic inflammation and ulceration |
| 13 | Tongue cancer | 2 | Neck | 25 | Muscle | Chronic inflammation and ulceration |
Eleven patients underwent reconstructive surgeries with 15 regional flaps and 3 local flaps, one patient received a free anterolateral thigh fasciocutaneous flap, and one patient underwent amputation. The regional flaps mainly included trapezius myocutaneous flap (TMC, n = 4), rectus abdominis myocutaneous flap (RAM, n = 4), latissimus dorsi myocutaneous flap (LDM, n = 2), lateral maxillo‐cervical fasciocutaneous flap (LMC, n = 2), pudendal thigh fasciocutaneous flap (PTF, n = 2) and supraclavicular artery perforator flap (SAP, n = 1). Among these regional flaps, four flaps (26.7%) had local necrosis and one (6.7%) had wound dehiscence. Four patients with local necrosis and one patient with a non‐healing sinus tract underwent reoperation and achieved ulcers covered with healthy vascularised tissue. No cases of haematoma or infection were observed. The donor sites were closed primarily in 14 cases, and five sites were covered by skin grafts. There was one case of graft loss at the donor site. All post‐radiation ulcers healed at the last follow‐up (overall flap success rate of 100%), with no recurrence of ulceration. Postoperative complications were summarised in Table 3.
TABLE 3.
Surgical parameters and complications.
| Patient | Regional flap (cm2) | Operative duration (min) | Intraoperative bleeding (mL) | Blood transfusion (RBC, U/FFP, mL) | Complications |
|---|---|---|---|---|---|
| 1 | LDM (35 × 15) + skin graft (23 × 6 + 25 × 6) to donor site | 620 | 1000 | 6/1200 | Local necrosis of flap and skin graft |
| Scalp graft (13 × 12) to donor site | 200 | 150 | 1.5/400 | ||
| TMC (25 × 8), local pedicled perforator flap (15 × 6) at shoulder and neck | 220 | 500 | 4/400 | ||
| 2 | VRAM (26 × 6) | 240 | 200 | No | Dehiscence |
| 3 | TMC (27 × 9) | 640 | 50 | No | Local necrosis |
| Chest local flap (6 × 8) + scalp graft (4 × 8) to donor site | 200 | 50 | No | ||
| 4 | Free ALT (15 × 12) + skin graft (26 × 8) to donor site | 720 | 400 | 4/600 | Local necrosis |
| 5 | TRAM (27 × 10) | 400 | 500 | 4/− | No |
| 6 | Amputation | 120 | 800 | 4/800 | Local necrosis |
| 7 | LMC (15 × 3) | 200 | 20 | No | No |
| 8 | PTF (4 × 10) | 240 | 15 | No | No |
| 9 | TMC (31 × 17) | 320 | 500 | 2/− | Local necrosis |
| Scalp graft (15 × 8) | 300 | 500 | 4/− | ||
| Scalp graft (10 × 10) | 240 | 50 | No | ||
| 10 | TRAM (40 × 11) | 570 | 300 | 2/800 | Local necrosis |
| LDM (21 × 12) + skin graft (14 × 14) to donor site | 410 | 300 | 4/− | ||
| 11 | Chest local flap (14 × 12) + skin graft (13 × 15) to donor site | 150 | 200 | −/200 | Local necrosis |
| VRAM (15 × 10) | 180 | 400 | −/800 | ||
| 12 | PTF (16 × 6) | 120 | 20 | No | Non‐healing sinus tract |
| GMF (10 × 4) | 220 | 20 | No | ||
| 13 | SAP (10 × 16) + TMC (23 × 15) | 380 | 300 | −/800 | No |
Abbreviations: ALT, anterolateral thigh fasciocutaneous flap; FFP, fresh frozen plasma; GMF, gluteus maximus fasciocutaneous flap; LDM, latissimus dorsi myocutaneous flap; LMC, lateral maxillo‐cervical fasciocutaneous flap; PTF, pudendal thigh fasciocutaneous flap; RBC, erythrocyte suspension; SAP, supraclavicular artery perforator flap; TMC, trapezius myocutaneous flap; TRAM, transverse rectus abdominis myocutaneous flap; VRAM, vertical rectus abdominis myocutaneous flap.
3.1. Case 1
A 53‐year‐old man (patient No. 1 in Tables 1, 2, 3) presented with a post‐radiation ulcer in the interscapular region with a duration of 3 months (Figure 1). Four years ago, he underwent lung adenocarcinoma resection followed by chemoradiotherapy, and 14 months ago metastatic tumours in the cervical and thoracic vertebrae (C7 and T1) were resected through a posterior transpedicular technique. Three months ago, the patient underwent revision surgery for an internal fixation fracture. Subsequently, a progressive post‐radiation ulcer (10 × 5 cm2) developed in the interscapular region, with polyaxial pedicle screw instrumentations exposed. The patient underwent a complete ulcer excision and fast frozen pathology revealed chronic inflammation and ulceration. Then a right latissimus dorsi myocutaneous (LDM, 35 × 15 cm2) flap was grafted to close the interscapular wound, and bilateral hit full‐thickness skin grafts (left, 23 × 6 cm2; right, 25 × 6 cm2) were transplanted to the donor site. Although postoperative local necrosis happened at both recipient and donor sites, the ulcer was successfully closed using a trapezius myocutaneous flap (TMC, 25 × 8 cm2) and a local pedicled perforator flap (15 × 6 cm2) in shoulder and neck, and the donor site was closed using a 13 × 12 cm2 scalp graft.
FIGURE 1.
A 53‐year‐old man with post‐radiation ulcer and exposure to polyaxial pedicle screw instrumentations in the interscapular region. (A) Post‐radiation ulcer (10 × 5 cm2) in the interscapular region and a latissimus dorsi myocutaneous flap (LDM, 35 × 15 cm2). (B) Good coverage of the defect with LDM after complete excision of the ulcer and skin grafts (buttock, left, 23 × 6 cm2; right 25 × 6 cm2) to the donor site. (C) Complete coverage with trapezius myocutaneous flap (TMC, 25 × 8 cm2) and local pedicled perforator flap (15 × 6 cm2) at shoulder and neck. (D) Resolution of the post‐radiation ulcer at 3‐month follow‐up.
3.2. Case 2
An 82‐year‐old man (patient No. 2 in Tables 1, 2, 3) presented with a post‐radiation ulcer (1 × 1 × 2 cm3) in the right groin with a duration of 2 months (Figure 2). He received neuroendocrine carcinoma resection followed by RT 4 years ago. The patient underwent a complete excision of the ulcer with a 7 × 8 cm2 defect and histopathological examination showed chronic inflammation and ulceration. Then, he underwent reconstructive surgery with a vertical rectus abdominis myocutaneous (VRAM, 26 × 6 cm2) flap. Although postoperative wound dehiscence was observed in the regional flap, the ulcer healed without reoperation and no ulcer recurrence occurred during a 7‐month follow‐up.
FIGURE 2.
An 82‐year‐old man with a post‐radiation ulcer in the right groin region. (A) A vertical rectus abdominis myocutaneous flap (VRAM, 26 × 6 cm2) was designed after the complete excision of the ulcer. (B) The VRAM flap covered the defect area (7 × 8) cm2. (C) Immediate post‐operative view showed the insertion of the VRAM flap without tension and the donor site was closed directly. (D) A 7‐month post‐operative result showed resolution of the post‐radiation ulcer and good coverage of the defect.
4. DISCUSSION
The patients in the present study all presented with post‐radiation ulcers and underwent complete resection followed by reconstructive surgeries. Although 4 of 15 (26.7%) regional flaps developed local necrosis and required reoperation, all ulcers healed at a mean follow‐up of 23.3 months, and the overall success rate of the flaps was 100%.
RT, as a primary adjuvant treatment for tumours, has minimal or no side effects at low doses, while higher doses produce varying side effects during or after treatment, even decades of cumulative radiation damage. Locally irradiated tissue shows decreased vascularity, dermal atrophy and tissue necrosis. In the present study, histopathological examination showed chronic inflammation and ulceration in 11 (84.6%) patients. Post‐radiation ulcers may occur at any time, even decades afterward. 9 In our series, the mean latency period from RT to ulcer development was 66 months (range 3–156 months).
Conservative treatments, such as wound dressings, antibiotics, and hyperbaric oxygen, are first in line for infection control and wound healing. 10 , 11 However, inadequate blood supply and damaged adnexal structures usually make these treatments ineffective for post‐radiation ulcers. Recently, many clinical studies reported the efficacy and safety of NPWT for the treatment of chronic non‐healing wounds, including those caused by RT, infection, prostheses and denervation. 12 , 13 And long‐term NPWT helped to promote debridement and wound healing. In the present study, most patients underwent NPWT at least one time before reconstructive surgery and the negative bacterial examination results proved its efficacy for infection control.
Reconstructive surgeries are often required when conservative treatments fail. 14 The basic prerequisite is to remove irradiated tissue to the level of active bleeding after debridement. The excision of the ulcer should be large enough that the margins extend approximately 2 cm beyond normal skin. In addition, the atrophied, thinned and pigmented lesioned skin surrounding the ulcer and degenerated cartilage or bone should be excised along with the ulcer. 15 Inadequate excision may quickly lead to progressive pathological changes. Besides, surgeons should always keep in mind that the causes of post‐radiation ulcers may be the result of residual, recurrent, or new malignancy. Radiation‐induced cancers, as one of the dreaded long‐term complications, tend to occur within the RT region, and the typical pathological type is squamous cell carcinoma or sarcoma. 16 , 17 , 18 Frozen sections should be routinely employed for soft tissue margins to determine adequate excision. In the present study, all excised ulcers were sent for histopathological examination during surgery to verify the presence of malignancy, and ulcers from two patients, which were diagnosed as squamous cell carcinoma, were completely resected with negative surgical margins.
It is critical to reconstruct irradiated defects with healthy tissue rather than directly closing both irradiated wound edges. The methods of reconstruction are determined by the nature of the wound, the extent and depth of excision, and the location and condition of the base. Depending on the severity, the “reconstructive ladder” is from simple skin grafts to local and regional flaps and microvascular‐free flaps. It is insufficient to adopt skin grafts or local flaps as the primary reconstructive method, because of decreased vascularity, dermal atrophy, and wide radiation damage. 3 , 19 Although free flaps remain the standard reconstructive method for larger or more complex defects requiring composite flaps or functional reconstruction of the innervation, a complication rate of 40% has been reported, mainly because of pedicle thrombosis when recipient's vessels were in irradiated tissue. 8 , 20 In a rabbit model, free flaps anastomosed to irradiated vessels have a much higher failure rate than those anastomosed to non‐irradiated vessels. 21 In a porcine model, skin expansion potential and skin flap viability are reduced after radiation. 22 Therefore, free flaps should be carefully selected under adverse anatomic conditions with a compromised blood supply (previous history of RT). 1 , 5 In the present study, a free anterolateral thigh fasciocutaneous (ALT) flap was used for a defect area of 12 × 10 cm2 and only local necrosis was observed postoperatively with no other complications. However, the operative duration was 720 minutes and the hospital length was 98 days, which were longer than the mean time of 292.4 minutes and 55.17 days for other patients with regional flaps. Owing to the technical complexity and long operative duration of free flaps, regional flaps may be more appropriate for patients with severe comorbidities or oncologic prognosis.
Recently, the utilisation of regional flaps to reconstruct post‐radiation ulcers has increased partly because of decreased operative time, cost, and hospital stay compared with free flaps. 23 It is a faster procedure and allows the reconstruction of ulcers with regional healthy tissue in many regions of the body, achieving low donor site morbidity, faster recovery, and better aesthetic results. 8 , 24 , 25 Cheon et al. achieved favourable clinical results in 10 patients with post‐radiation sacral ulcers using a gluteal artery perforator flap, with only one patient requiring reoperation because of partial flap loss at 25.7 months of follow‐up. 8 Le et al. reported the use of a thoracodorsal artery perforator flap for the treatment of axillary radiation‐induced ulcers in 5 patients, with no complications during a 2‐year follow‐up. 25
When designing a regional flap, the best pedicle site is one located close to the edge of the defect (within 2–3 cm is preferred). This allows the shortest flap with the maximum effect in reconstruction. To identify appropriate perforators, common local perforators used for free flaps, subfascial exploring suitable skin perforators during surgery, and preoperative hand‐held Doppler or computed tomogram angiography (CTA) have been proven useful. 24 It is preferred to close the donor site directly. As marginal skin tension can induce dehiscence with infection and necrosis, we would choose skin grafting if direct closure of the donor site is not possible. The suturing technique should ensure as little trauma to the skin as possible, with everted wound edges and infection prophylaxis.
Regional flaps seem to cover post‐radiation ulcers well, while for larger or more complex defects, free flaps remain the standard reconstructive method to achieve functional reconstructive goals. 5 Besides, not all superficial defects have appropriate perforators nearby, and the relative redundancy and availability of the donor skin is often limited. 24 Although BMI is not a selection criterion for regional flaps, patients with lower BMI are more likely to achieve direct closure of the donor site without skin grafting.
The study has several limitations. First, the present study was a retrospective study without a control group, and the lack of comparison with other reconstructive methods limited the evaluation of the benefits of regional flaps. However, it would be difficult to design a prospective study with a control group because of the complex pathology and different locations of the primary tumour. Second, with only 13 patients in the present study, in‐depth statistical analysis cannot be performed, although the sample size was larger than most reported studies, especially as most of them were case reports.
5. CONCLUSION
Post‐radiation ulcers should be invested with histopathological examination for malignant changes. Adequate excision of irradiation tissue was the foundation of successful extensive reconstruction. Although reoperation might be required for partial necrosis, regional flaps with healthy vascularised tissue seem a safe and effective reconstructive method for post‐radiation ulcers with good aesthetic and functional outcomes.
CONFLICT OF INTEREST STATEMENT
The authors declare that they have no conflict of interest.
ETHICS STATEMENT
All procedures performed in studies involving the human participants were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This study has been approved by the Institutional Review Board of Peking University Third Hospital (No. IRB00006761‐ M2020576).
ACKNOWLEDGEMENTS
None.
Dong W, Zhang X, Luo X, et al. Regional flap: A reliable coverage for post‐radiation ulcer. Int Wound J. 2023;20(6):2224‐2232. doi: 10.1111/iwj.14103
Contributor Information
Xin Yang, Email: yangxin6@126.com.
Zhenmin Zhao, Email: zhaozhenmin0098@vip.sina.com.
DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the corresponding author upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.