*7.2.2.4 Plasty technique with expander flap*


With radiation-induced lesions, using the expander flap can still be applied to the narrow soft the areas surrounding lesion.

*Radiation-Induced Skin Reactions and Surgical Management Treating Radiation-Induced Ulcers DOI: http://dx.doi.org/10.5772/intechopen.109753*

#### *7.2.2.5 Plasty technique with seamless pedicled flap*

Pedicled flaps are taken from a non-irradiated area, which is a good plasty material, the first choice recommended by many authors. In particular, the skin and muscle flap contribute to treating ulcer easier. Marayuma's report in 1986 on plasty coverage of thoracic ulcers with rectus abdominis flap on 16 patients gave good results [67].


#### *7.2.2.6 Perforator skin flap*

Besides microsurgical and pedicled flaps, perforator flap is also widely used in covering radiation-induced defects. According to Fujioka's study in 2012 [68], knowledge about perforator anatomy helps select covering flap more diversely, adjacent flaps can cover defects instead of the free flap. The most significant advantage of the perforator flap is not to sacrifice any major blood vessels or muscles and minimize the damage to the flap donor site.

However, because radiation-induced lesion is surrounded by scleroris and vascular lesions, the use of perforator flap is only applicable when perforator branch is found far from the lesion area.

#### *7.2.2.7 Free flap transfer with vascular microsurgery*

Micro-surgical flap transfer has been extensively used in plastic surgery of radiation-induced ulcer management with high success rate. This technique allows the surgeon to choose the most suitable tissue for the area and the shape of the lesion. The most difficult in using free flap is to find vascular supply on a sclerotic base. Therefore, when using the microsurgical flap to treat radiation-induced ulcers, it requires dissection of a long enough flap pedicle and discovery of the vascular receiver located far away from the irradiated area [69].

In the plasty of radiation-induced ulcer, microsurgical skin flap is often applied to treat head-face-neck ulcers, which is abundant, constant and well-supplied blood vessels. The radiation-induced ulcerative lesions in this area are often complicated, the ulcer can be communicated with the oral cavity or accompanied by bone exposure and geode. Therefore, the plasty material by microscopic flap can meet the requirement of covering both sides (external and oral cavity) with perforator flap separated from one/ the same original vessel or ensure to cover the ulcer by skin flap, and geode formation with microsurgical osteomuscular skin flap.Some consequent reconstructive surgery could be performed to cover defects caused by RT. The uses of full-thickness skin grafts, tissue expanders, random-pattern flaps, perforator flaps or axial-pattern flaps, and free flaps were reported for reconstruction after RT-induced ulcer.

#### *7.2.3 Case illustrations*

Deep inferior epigastric perforator (DIEP) free flap and latissimus dorsi muscle flap (LDMF) are commonly used over decades for breast reconstruction. While DIEP is more widely applied because of its advantages, it could be not suitable in some cases because a successful surgery depends on factors consisting of surgeons, equipment, and patients themselves [70–72]. LDMF would be preferable in the case a short duration of sedation is requested. This flap is also more suitable for Asian patients than Caucasian patients because this population requires smaller breast volume. Illustrations of LDMF for breast reconstruction after RT-ulcers are presented in **Figures 1** and **2**. These Asian patients were well-healed after the surgery and no recurrence of ulcer happened.

If deep lesion can affect the blood vessels, pleura, pericardium, it is necessary to carefully examine the lesions on CT or MRI film to see the lesions level related to organizations, thereby taking measures to treat the bottom of the lesions appropriately and safely. Hereby, we presented one female patient born in 1937, who had a left breast ulcer after 30 years of radiotherapy for breast cancer, and ulcer depth reaching the pericardium. Evaluation on CT showed that the boundary between lesions and pericardium is not clear, there is a risk of pericardial lesion during the management of lesions. We have conducted consultation and coordination with the thoracic surgeons during surgery, to ensure the safety for the patient but also need to eliminate all lesions, minimize the risk of cancer or recurrent ulcer after surgery. The patient was treated with maximum width and depth of lesion, using large back muscle skin flap to cover the defect. Skin flap was good after surgery. The incision healed in the cycle 1. No ulcer recurrence occurred after 3 year (**Figure 3**).

Free flaps are also common options due to their good vascularization and rapid healing. **Figure 4** describes a case of a 44-year-old male patient who had an ulcer on his neck after RT. A free flap was used in this patient after the excision of the ulcer. Three months postoperatively, a favorable result was observed.

Superior gluteal artery perforator flaps could be useful in the cases of RT-ulcer on the buttock region. The reconstructive surgery gave a favorable result in a 44-year-old male patient after the excision of RT-induced ulcer on his button (**Figure 5**).

In addition, in the case to avoid intensive surgery and/or to minimize defects on the donor site, a tissue expander or random-pattern flap could be appropriate

#### **Figure 1.**

*A 59-year-old female patient with a ulcer at her axilla after RT (left). The wound was debrided and then covered by LDMF (right).*

*Radiation-Induced Skin Reactions and Surgical Management Treating Radiation-Induced Ulcers DOI: http://dx.doi.org/10.5772/intechopen.109753*

#### **Figure 2.**

*A 55-year-old patient with a ulcer on her chest along with wide infiltrated and fibrotic areas (left). She underwent debridement followed by a reconstruction with LDMF (right).*

#### **Figure 3.**

*Illustration of a RT-induced ulcer case with exposed pericardium. (Above, lef) Before the surgery. (Above, middle) MRI film showed ulcer deep to the pericardium. (Above, right) Lesion removal. (Below, left) After cutting the whole lesion. (Below, middle) 1 week after surgery. (Below, right) 3 years after the surgery.*

choices. The expanded flaps have benefits in terms of good blood supply to tissues of RT-induced wounds, minor complications, and satisfactory esthetic results. Necrotic areas and total infiltrated areas should be entirely removed in the cases of first-degree and second-degree ulcers. In the meanwhile, partial excision would be more appropriate for other ulcers because of a dense vessel system or ribs underneath the wound. Generally, if the base of ulcers could not be completely monitored, drainage should be placed for a long time.

#### **Figure 4.**

*The RT-ulcer appeared on the neck of patient (A). A favorable result was seen after 3 months.*

**Figure 5.** *RT-ulcer on button of a male patient. (Left) Before the surgery. (Right) 3 months after the surgery.*
