Dear Editors,
1.
The herpes zoster virus has a latent period of 2 weeks. During this period, the latent varicella zoster virus (VZV) in the dorsal root ganglion can be reactivated in the nerve continuity. Because the nerve continuity is destroyed during flap surgery, cases of VZV infection are extremely rare. VZV infection following flap surgery could indicate reinnervation. However, the exact mechanism underlying reinnervation has not yet been fully elucidated.1
Our patient was a 58‐year‐old woman who underwent surgery for cancer of her left breast (stage IIIA, T2N2M0) 8 years ago. The patient had previously received treatment with modified radical mastectomy, chemotherapy, radiation therapy, and hormonal therapy. The cancer recurred on her T‐spine and caused cord compression. A neurosurgery team performed a laminectomy (total laminectomy on T10‐T11 and partial laminectomy on T12) and removed an epidural tumour. Following surgery, she received palliative radiation therapy (3250 cGy) and boosting radiation therapy (1500 cGy). However, the wound‐healing process was compromised because of radiation therapy. Therefore, one stage of debridement and coverage with a double keystone flap was performed, and bilateral flaps were fully elevated to maximise mobility (Figure 1). Schematic illustration was shown in Figure 2. Four days following reconstruction, an erythematous skin rash with a linear vesicle appeared on her right back, which invaded the keystone flap territory. She was given gabapentin (300 mg), tramadol (75 mg), and acetaminophen (650 mg) daily, which masked her symptoms. VZV infection was diagnosed using a polymerase chain reaction test and Tzank test. However, the flap survived uneventfully without any compromise (Figure 3).
Figure 1.
Preoperative, intraoperative, and postoperative appearances [Colour figure can be viewed at wileyonlinelibrary.com]
Figure 2.
Schematic illustration of our double‐opposing keystone flaps [Colour figure can be viewed at wileyonlinelibrary.com]
Figure 3.
Healing process of varicella zoster virus‐infected flap [Colour figure can be viewed at wileyonlinelibrary.com]
Few studies have described the use of a keystone flap in the back.2, 3, 4, 5 The most common indication for keystone flap coverage of back wounds is to cover the meningomyelocele in infants4 (Table 1). Double‐opposing keystone flaps that successfully covered large open wounds have been described in previous case series, suggesting that this approach could be applied to a back wound.3
Table 1.
Literature review on double opposing keystone flap reconstruction in meningomyelocele
| Patient demographics | Follow up | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Number of patients | Age at operation (days) | Gender | Birth weight | Apgar score | Mode of delivery | Level of lesion | Associated Chiari abnormality | Hydrocephalus | ||
| 1 | 5 | 1‐3(mean: 1.4) | M: 4 (80%) | 1190‐3285 g (mean: 2495.2 g) | Not mentioned | Not mentioned |
S1‐S5 S2‐S3 L5‐S1 S1‐S5 L5‐S1 |
3 | 3 | 10‐66 months |
| F: 1 (20%) | ||||||||||
| 2 | 1 | 2 | M: 0 (0%) | 3020 g |
1 min: 7 5 min: 9 |
Caesarean section: 1 | T1‐T2 | 1 | 1 | 3 months |
| F: 1 (100%) | ||||||||||
| 3 | 3 | 1‐3(mean: 1.7) | M: 2 (67%) | 1920‐3230 g (mean: 2667 g) |
1 min:(mean: 7) 5 min: 9 (mean: 9) |
Caesarean section: 2 Home birth: 1 |
S1‐S5 S2‐S3 L5‐S1 |
2 | 1 | Ongoing (not mentioned exactly) |
| F: 1 (33%) | ||||||||||
| 4 | 6 | 1‐3(mean: 1.7) | M: 5 (83%) | Not mentioned |
1 min: 5‐9 (mean: 7.4) 5 min: 7‐9 (mean: 8.4) |
Caesarean section: 3 Home birth: 1 Vaginal delivery: 2 |
S1‐S5 S2‐S3 L5‐S1 L1‐S1 L4‐L5 L5‐S2 |
4 | 3 | 4‐94 months (mean: 49.7 months) |
| F: 1 (17%) | ||||||||||
Abbreviations: F, female; M, male.
We reconstructed a radiation ulcer of the back with double‐opposing keystone flaps harvested from the adjacent soft tissue. In our case, as subfascial elevation was performed in a previous spine surgery, we preserved the fascia of the outer arc of the keystone flaps to prevent flap congestion. On postoperative day 4, vesicular lesions on the right flank and back appeared, suggesting possible VZV infection. However, as the patient did not complain of zoster pain, the infection was not detected sooner; in addition, the patient's pain medications may have masked the symptoms of infection.
VZV infection following flap surgery is considered powerful evidence of reinnervation of flaps6 (Table 2). Spiegel et al observed nerve regeneration from 23 to 302 weeks (mean: 111 weeks) following breast reconstruction.7 In this study, sensory recovery from deep inferior epigastric perforator flaps was significant, with lower thresholds found with a nerve conduit compared with direct nerve coaptation.7 Kuriakose et al confirmed sensory recovery from 8 to 38 months following tongue reconstruction; recovery occurred within 8 months in all 17 patients.8 Beugels et al found that sensory recovery took 6 months for innervated flaps and 12 months for non‐innervated flaps.1 In studies that used herpes zoster lesions as objective proof of reinnervation, lesions occurred after 2 and 6 years after surgery.6, 9 Taken together, these studies have shown that the minimum time to confirm the recovery of sensory nerve is approximately 6 months.
Table 2.
Literature review on VZV infection in a reconstructed flap
| Patient demographics | Heerpes zoster skin lesion | Sensory test | ||||||
|---|---|---|---|---|---|---|---|---|
| Number of patients | Age and gender | Cause of defect and location of defect | Chemotherapy and radiation therapy | Date of appearance | Site of appearance | Antiviral therapy | ||
| 1 | 1 | 50 (female) | Modified radical mastectomy for stage II breast cancer (left breast) | 6 cycle | 6 years after breast reconstruction | From T5 dermatome of the left hemithorax to reach the edge of reconstructed areola | Not exactly mentioned (completely recovered) | Reduced general sensitivity (left breast) |
| 2 | 1 | 58 (female) | Not mentioned (right breast) | Not mentioned | 2 years after breast reconstruction | Th5 and Th6 dermatome of the right hemithorax | Brivudin(completely recovered) | Reduced general sensitivity (right breast) |
| 3 | 1 | 30 (male) | Machinery injury and crushing injury (right forearm) | Not mentioned | 21 days after the operation | Not mentioned | Acyclovir(completely recovered) | Not mentioned |
Our herpes zoster case was identified within a very short postoperative period. However, we do not believe that reinnervation occurred in this patient because of the patient's immunocompromised condition. The patient had previously been treated with radiotherapy for bone metastasis of breast cancer and was therefore vulnerable to virus infection. Improved perfusion following flap surgery could have facilitated viral reactivation.
Prior to this case, we believed that the nerve must be connected for VZV infection to occur above the keystone flaps. VZV infection occurs when latent VZV in the dorsal root ganglia along the nerve is reactivated. The virus from the dorsal root ganglion spreads to the skin through sensory nerves and skin, and lesions then appear within a week. Although the exact mechanism is unknown, VZV infection can spread even if innervation continuity is completely destroyed.
As vesicular lesions from VZV infection can appear for longer than a week, VZV likely undergoes reactivation. In this case, VZV spread through the nerve. The patient's skin lesions appeared along the same level of sensory nerves, indicating that the keystone flap is an effective way to treat lesions by maintaining normal anatomical structure. Lee et al proposed that the virus could hide in the ganglion and spread through the anastomosed blood vessel.10 This report raises the possibility that the virus can spread through the environment when perfusion is performed in immunocompromised patients.
ACKNOWLEDGEMENTS
This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korea government (MSIP; Ministry of Science, IC T & Future Planning) (No. 2017R1C1B5017180 and 2017R1B5A2085456, TH Park) Jeong Hyun Kim contributed to this article during his clerkship at our department in 2017.
REFERENCES
- 1. Beugels J, Cornelissen AJM, Spiegel AJ, et al. Sensory recovery of the breast after innervated and non‐innervated autologous breast reconstructions: A systematic review. J Plast Reconstr Aesthet Surg. 2017;70(9):1229‐1241. [DOI] [PubMed] [Google Scholar]
- 2. Park HS, Morrison E, Lo C, Leong J. An application of keystone perforator island flap for closure of lumbosacral myelomeningocele defects. Ann Plast Surg. 2016;77(3):332‐336. [DOI] [PubMed] [Google Scholar]
- 3. Jamjoom H, Alnoman H, Almadani Y. Closure of a large thoracolumbar myelomeningocele using a modified bilateral keystone flap. Plast Reconstr Surg Glob Open. 2016;4(12):e1114. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4. Gutman MJ, Goldschlager T, Fahardieh RD, Ying D, Xenos C, Danks RA. Keystone design perforator island flap for closure of myelomeningocele. Childs Nerv Syst. 2011;27(9):1459‐1463. [DOI] [PubMed] [Google Scholar]
- 5. Donaldson C, Murday HKM, Gutman MJ, et al. Long‐term follow‐up for keystone design perforator island flap for closure of myelomeningocele. Childs Nerv Syst. 2018;34(4):733‐736. [DOI] [PubMed] [Google Scholar]
- 6. Weitgasser L, Valina SW, Schoeller T, Ehebruster G. Herpes zoster lesions on reconstructed breast skin: rare objective proof of reinervation. Arch Plast Surg. 2017;44(1):72‐75. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7. Spiegel AJ, Menn ZK, Eldor L, Kaufman Y, Dellon AL. Breast reinnervation: DIEP neurotization using the third anterior intercostal nerve. Plast Reconstr Surg Glob Open. 2013;1(8):e72. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8. Kuriakose M, Loree TR, Spies A, Meyers S, Hicks WL Jr. Sensate radial forearm free flaps in tongue reconstruction. Arch Otolaryngol Head Neck Surg. 2001;127(12):1463‐1466. [DOI] [PubMed] [Google Scholar]
- 9. Lee JH, Ahn HC, Chung MS. Herpes zoster in a free transverse rectus abdominis myocutaneous flap after delayed breast reconstruction: evidence of spontaneous reinnervation. Ann Plast Surg. 2015;74(6):693‐694. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10. Lee JH, Choi HJ. Rare Varicella zoster virus infection in an ALT free flap. Int Wound J. 2016;13(5):1052‐1053. [DOI] [PMC free article] [PubMed] [Google Scholar]