Use of Lumbar Perforator Recipient Vessels for Salvage Chest Wall Reconstruction: A Case Report

Summary:

Abdominal-based free flaps are commonly used for breast reconstruction, and the internal mammary or thoracodorsal vessels are typically used as recipient sites. Conversely, free tissue transfer is less commonly used for chest wall reconstruction in the setting of chest wall recurrence, in part, because of a paucity of recipient vessels. Here, we describe a case of a 68-year-old female smoker with metastatic breast cancer, who presented with a chest wall recurrence. There was a large area of chronic ulceration with foul smelling drainage, in addition to radiation-induced tissue injury, and palliative resection was performed. The area was reconstructed with a free transverse rectus abdominis myocutaneous flap using lumbar perforators as recipient vessels, because conventional recipient sites were unavailable because of scarring from radiation and residual tumor. This case demonstrates that uncommon recipient vessels such as lumbar perforators may allow for successful palliative chest wall reconstruction. We hypothesize that the tumor burden, previous surgeries, and radiation may have rendered the recipient field relatively ischemic, thereby inducing hypertrophy of the lumbar perforators, similar to a delay phenomenon.

A 68-year-old woman with recurrent, metastatic breast cancer to the right chest wall presented for extirpation and reconstruction in July, 2014. On presentation, she had a large area of ulceration with foul smelling drainage over a previous drain site overlying a large mass, which had been present for 3 to 4 years (Fig. 1). She previously had been diagnosed with breast cancer in 2005 and underwent mastectomy. She developed a right axillary recurrence in 2010. She underwent radiotherapy to the right axilla and chest wall, which was completed in April, 2014. She also received multiple rounds of chemotherapy. Over the past few months, she had an approximate 70-pound weight loss and was a current smoker who smoked 2 packs per day.

Fig. 1.

Preoperative lateral view of the patient with exophytic chronic open wound containing metastatic tumor.

The patient was brought to the operating room on July 31, 2014, and the mass was resected by thoracic surgery. There was extension of the mass into the axilla, and it was indeterminate whether this represented radiation or postsurgical changes or tumor after resection by the ablative surgical team. The decision was made to leave this area undissected as to not cause additional morbidity (Fig. 2). Although the resection was taking place, a contralateral left free transverse rectus abdominis myocutaneous (TRAM) flap was raised concurrently. After the completion of the extirpation, the defect was explored for recipient vessels. There were vessels visualized on the subscapular pedicle that appeared heavily radiated, scarred, and adjacent to the tissue potentially representing scar or residual tumor. Because of the findings, alternate recipient vessels were sought. There was a suitable lumbar perforator that was visualized (Fig. 3) lower on the truncal area. Anastomosis was performed, and once flow was established through the artery and vein, the flap was inset without complication.

Fig. 2.

Chest wall defect after tumor extirpation for palliation.

Fig. 3.

Lumbar perforator recipient vessels (A) and flap inset after anastomosis (B).

The patient did well during her hospitalization and was able to be discharged on postoperative day 4. She returned to clinic the following week, the flap was warm and well perfused, and the drains were removed (Fig. 4). She continued to do well perioperatively at last follow-up. Institutional review board exemption was granted by our institutional review board.

Fig. 4.

Postoperative views of the patient 3 weeks postoperatively.

DISCUSSION

The TRAM flap was first described in 1982 by Hartrampf.¹ The pedicled TRAM flap as described by Hartrampf evolved into the free TRAM flap, described by Holmstrom, and eventually led to the deep inferior epigastric perforator flap, popularized for breast reconstruction.¹ Microvascular free flap reconstruction has become a staple in breast reconstruction because of improved blood supply at the recipient site and reduced anatomical defects and scarring at the donor site.^2,3 In addition, patients actively smoking undergoing reconstruction using a free TRAM flap had lower complications than those undergoing one using a pedicled TRAM flap⁴ secondary to the adverse affects nicotine has on vascular health, resulting in decreased number of perforators and reduced blood supply.

The choice of the recipient vessel during reconstruction is dependent on the surgeon and timing of the reconstruction such as delayed versus intermediate, but commonly the internal mammary and thoracodorsal vessels are used as recipients.⁵ In rare cases, subscapular vessels, transverse cervical, and lateral thoracic vessels are utilized.⁵ In this case, because of scarring from the previous chest wall irradiation, previous surgical intervention, and concern about unresectable tumor encasing some of the vasculature, neither the internal mammary nor the thoracodorsal vessels were suitable recipients. Anastomosis with the axillary artery was avoided because of feared upper limb complications from shunting and/or postoperative occlusion.

Cadaveric and clinical anatomical studies have demonstrated that lumbar perforators can be often used as both donor and recipient vessels for free flap surgeries. Despite the variability in their sizes, 1 study identified lower lumbar perforators as having adequate lumen size and being easily verifiable by computed tomographic angiography.⁶ There have been reports describing the use of a lumbar artery free perforator flap for autologous breast reconstruction; however, to our knowledge, there have been no reports describing the use of a lumbar artery perforator as a recipient vessel for free flap palliative chest wall reconstruction in the setting of previous mastectomy and radiation for breast cancer.⁷

In the presented case, the success of the reconstruction was potentially aided by a tumor “delay phenomenon.” Although the exact mechanism of the delay phenomenon has not been elucidated, it is hypothesized that ischemia induces hypertrophy of remaining vasculature and increases ischemia tolerance through locally mediated factors.^8,9 In many cases, the donor tissue is delayed by partially incising the tissue, which creates an ischemic environment, and hypertrophy of existing vessels, which improves graft survival during transposition of tissue in a delayed fashion. In this case, however, the longstanding tumor burden, previous surgeries, and irradiation of the recipient field created an ischemic environment similar to a delay phenomenon. In this patient, vessels in the area, specifically lumbar perforators, may have hypertrophied because of the prolonged ischemic conditions to become suitable recipients for free tissue transfer.

Chest wall reconstruction in the setting of recurrent metastatic breast cancer after previous radiation therapy can pose a difficult reconstructive challenge. The ischemic environment induced by various factors including tumor burden and radiation may have a beneficial effect on lumbar perforators, which may become suitable recipients for free flap reconstruction when traditional vessel recipients are unusable in certain cases.