Breast cancer is a leading cause of morbidity and mortality among women worldwide, and surgical resection remains the cornerstone of its treatment (1). Moreover, postoperative radiation therapy, a vital component of breast cancer management, is not without its complications (2). One such notable complication, the development of chronic ulcers in the chest wall, poses a significant challenge to both the patient and the surgeon (3).

Chronic ulcers resulting from radiation therapy often represent a complex clinical problem as radiation compromises the integrity and regenerative capacity of the skin and underlying tissues, rendering them susceptible to ulceration. The management of these ulcers is not straightforward as they frequently require surgical intervention to achieve both aesthetic and functional recovery.

Several surgical methods, including the free flap, pedicled transverse rectus abdominis myocutaneous (TRAM) flap (4), and conventional latissimus dorsi (LD) flap (5), are available for the reconstruction of chronic ulcers in the chest following breast cancer surgery. Each of which has specific advantages and disadvantages. The free flap, while versatile, may increase surgical time and complexity, particularly in patients with compromised recipient vessels due to prior radiation treatment (3). The pedicled TRAM flap offers a substantial amount of tissue for coverage but necessitates the sacrifice of the rectus abdominis muscle. The conventional LD flap, commonly employed for chest wall reconstruction, often requires repositioning of the patient during surgery from lateral to supine, which complicates the surgical process (6).

In response to these challenges, the vertical muscle-sparing LD flap emerges as a promising alternative (7). This technique boasts several advantages over traditional methods, including reduced operation time, minimal need for intraoperative positional changes, and preservation of muscle integrity (8). These benefits make the vertical muscle-sparing LD flap a valuable option for reconstructing chronic radiation-induced ulcers in the chest wall following breast cancer surgery. In this study, we describe our experience with a vertical muscle-sparing LD flap in the reconstruction of the chest wall in two patients with chronic ulcers after breast cancer therapy, highlighting the practical and clinical advantages of this innovative approach.

Radiotherapy, a crucial adjunct in the management of breast cancer, presents a paradoxical challenge. It significantly reduces local cancer recurrence and improves survival rates, but also poses a risk of severe complications (9), such as radiation-induced ulcers in normal tissues, which initiate the formation of non-healing ulcers and soft tissue necrosis. As highlighted in prior studies, moderate-to-severe skin reactions occur in a substantial proportion of patients (up to 85%) undergoing radiotherapy (10). Chronic radiation-induced ulcers in the chest wall exhibit both progressive and irreversible characteristics. These ulcers represent a formidable challenge owing to their resistance to self-healing, which is attributed to compromised blood supply, tissue fibrosis, and diminished cellular regenerative capacity following radiation exposure. Additionally, chronic radiation-induced ulcers in the chest wall exhibit diverse clinical manifestations, encompassing variations in ulcer size, location, depth, and basal conditions, which influence decisions regarding treatment or reconstruction methods in clinical practice. Nevertheless, the optimization of treatment selection for these ulcers remains an ongoing challenge.

The complexity of these ulcers necessitates a tailored approach that encompasses debridement of an appropriate breadth and depth. This includes not only the removal of the ulcerated tissue but also any radiologically evident changes in the surrounding skin tissue. In patients presenting with radiation-induced osteomyelitis, excision of the affected bone is also crucial (11). Furthermore, preserving the integrity of deeper structures, such as the pleural cavity, is essential unless direct involvement mandates intervention. Therefore, meticulous surgical intervention is paramount for managing these complications.

Following debridement, various reconstructive strategies can be employed, ranging from conservative therapy and primary closure to more complex procedures, such as local or free flaps. However, each technique has limitations. For instance, in a study conducted by Glyn et al., only 22% of radiation-induced ulcers were amenable to primary closure, with the majority requiring a more complex flap or skin graft reconstruction. These findings emphasize the need for versatile and effective reconstructive options (12).

In this context, the vertical muscle-sparing LD flap has emerged as a valuable technique. Its advantages over the traditional methods are corroborated by the cases discussed herein. This approach not only minimizes surgical time and the need for intraoperative positional changes but also facilitates the preservation of muscle function, particularly by conserving the horizontal branch of the thoracodorsal nerve.

Surgeons performing operations in the operating room must meticulously plan and perform patient positioning to minimize the risk of infection. The surgical team, in collaboration with the surgeon, need to adhere to specific protocols and guidelines to guarantee optimal patient placement, ensuring that a sterile environment is maintained throughout the surgery, thereby decreasing the chances of postoperative infections. Additionally, ensuring correct positioning is essential to preserve asepsis and reduce the likelihood of infection at the surgical site. The placement of a patient on the operating table can affect the visibility of the surgical area, efficiency of sterile draping, and prevention of contamination. Therefore, completing the surgery without changing the surgical position during surgery can be considered one of the most important benefits.

The inclusion of muscles in flap construction, as demonstrated in our cases, has shown superior adhesion and functional outcomes compared with the use of skin flaps alone. This aligns with observations from other studies indicating that muscle flaps generally yield better results than skin flaps in similar reconstructive scenarios (3). Furthermore, the capability of elevating flaps up to 10 cm in width, as observed in our cases, provides ample coverage for substantial defects while maintaining aesthetic integrity. Lee et al. also contributed to this discourse by illustrating the efficacy of immediate reconstruction using a vertical muscle-sparing LD flap after mastectomy (7). Their observations regarding the reduced need for additional draping and the feasibility of operating in a single position further validated the practical benefits of this technique.

In conclusion, the vertical muscle-sparing LD flap represents a significant advancement in the reconstruction of radiation-induced ulcers after breast cancer treatment. Its ability to balance effective coverage with functional preservation makes it an invaluable tool in the reconstructive arsenal, especially in cases complicated by extensive radiation damage.