Keywords
basal cell carcinoma - shoulder defect - functional reconstruction - latissimus dorsi
myocutaneous flap
Advanced giant skin tumors with ulceration are rare in the modern medicine of the
Western world. Therefore, these serious, disfiguring, and life-threatening conditions
are typically found in developing countries. The aim of this publication is to demonstrate
the different options for defect coverage of problematic wounds which are situated
in anatomically complex regions and which demand good functional reconstruction. Hereby
the authors present an exemplary case report.
Patient Case
A 60-year-old Caucasian male patient with an extensive basal cell carcinoma (BCC)
(15 × 15 cm) in the right shoulder region was admitted to our clinic ([Fig. 1]). According to his medical history, the patient had suffered from BCC, which had
first occurred 20 years prior to his current presentation. At that time, it was treated
with radiation with complete resolution of the tumor. Five years later, the patient
unfortunately had recurrence of the tumor but refused further treatment. The patient
kept the tumor recurrence secret from his relatives. From then on, the patient attempted
to manage the constantly growing tumor conservatively himself. At the end of 2012,
the patient suffered heavy bleeding from the tumor, and was at that point referred
to our clinic. A tumor biopsy confirmed an ulcerating BCC. Magnetic resonance imaging
scan showed complete destruction of the lateral end of the clavicle ([Fig. 2]). No metastasis could be detected during further preoperative staging. Following
multiple surgical procedures (totaling more than 10 operations), a subtotal resection
of the clavicle, partial resection of the acromion, cranial, and dorsal parts of the
right scapula, humeral fornix, and the humeral head with deltoid, trapezius, and supraspinatus
muscles together with extensive skin and subcutaneous tissue resections were performed
([Fig. 1]). After confirmed R0 resection status, the authors performed a functional defect
coverage with a latissimus dorsi myocutaneous flap (LDMF) to restore movement of the
shoulder joint ([Fig. 1]). To do this, the authors harvested a right-sided pedicled LDMF with a large myocutanous
island and did a four-point fixation for reliable functional reconstruction. Only
3 weeks after surgery the patient was already able to perform active flexion, extension,
and 90° elevation of the right shoulder. The patient's mobility progressively improved
with continuous daily physical therapy. Postoperative range of motion (1-year postoperative)
is demonstrated in [Table 1].
Table 1
Shoulder movements (active and passive)
|
Range of motion
|
Neutral zero method (shoulder joint)
|
|
Right (plastic soft tissue reconstruction)
|
Left
|
|
Adduction/Abduction
|
20°-0–125° (passive: 30°-0–170°)
|
20°-0°–175° (passive: 20°-0–190°)
|
|
Anteversion/Retroversion
|
140°-0–30°
|
160°-0–40°
|
|
Horizontal extension/Flexion
|
135°-0–40°
|
140°-0–50°
|
|
Internal/External rotation (adduction)
|
80°-0–35°
|
95°-0–50°
|
|
Internal/External rotation in 90° (abduction)
|
60°-0–60°
|
70°-0–70°
|
Note: Demonstration of range of motion after reconstruction of a large shoulder defect
with latissimus dorsi myocutaneous flap, using the neutral zero method.
Fig. 1 Preoperative magnetic resonance imaging (MRI) scan of the right shoulder for tumor
staging. Large destructive basal cell carcinoma in the right shoulder region (TIRM
sequence, T2, vertical axis). Complete destruction of the lateral end of the clavicle
with surrounding soft tissue and trapezius, subclavian, and supraspinatus muscles.
Fig. 2 Ulcerating extensive basal cell carcinoma in the shoulder region before, during,
and after surgery: (A) preoperative view—extensive basal cell carcinoma (15 × 15 cm); (B) intraoperative view with remaining defect after R0 resection status. Resection of
the clavicle, acromion, right scapula, humeral fornix, and the humeral head with deltoid,
trapezius, and supraspinatus muscles together with skin and subcutaneous tissue was
performed; (C) intraoperative view with functional defect coverage using a latissimus dorsi myocutaneous
flap (four-point fixation with nonresorbable suture material at the medial, lateral,
dorsal, and ventral fascia of the remaining deltoid muscle); (D) one-year-follow-up after defect coverage with latissimus dorsi myocutaneous flap
(LDMF).
Discussion
BCC is the most common type of skin cancer and typically develops on sun-exposed areas.[1] While the BCC has a very low metastatic risk, the tumor can cause significant disfigurement
by invading surrounding tissues.[2] BCC has many clinical subtypes—the most malignant one being the ulcus terebrans.
It is characterized by ulceration, invasion, and destruction of the surrounding tissues.[2] Small basal cell tumors are regarded as relatively harmless, but the large and ulcerating
carcinomas can become a surgical challenge with a less favorable prognosis.[2] In our presented case, the patient suffered from an advanced BCC (stage III) due
to a protracted disease course.
The shoulder, together with the scapular complex, is anatomically defined as the junction
between the trunk and the arm.[3] Wide tumor resection in the shoulder region often results in an extensive complex
tissue defect, especially when progressing bone necrosis is involved.[3] Even if the limb is salvaged, wide excision are often associated with wound healing
complications which can result in poor limb function.[3]
To prevent possible complications and to maintain the best possible function of the
shoulder joint, an advance planning of the surgical technique is essential.[4] As a highly mobile joint, the shoulder should be covered by stable and durable soft
tissue to avoid motion limitations and loss of function.[5] To date, multiple authors have described reconstruction of isolated shoulder defects.
In most cases, LDMF is used for defect coverage. Also, pedicled pectoralis major,
trapezius, rectus abdominis, deltoid muscle flaps, and tensor fascia lata (TFL) free
flaps offer interesting treatment options.[5] Ihara et al stated that the LDMF is the best option for reconstruction of large
defects after extensive tumor resection within the shoulder region.[6] LDMF was first described for reconstruction after mastectomy, but today this flap
is used in almost all sites of the body.[7] The advantages of the LDMF are its reliable large vascular pedicle with many cutaneous
perforators, easy flap elevation, and minimal morbidity at the donor site. Furthermore,
this flap does not require a microsurgical vascular anastomosis thereby resulting
in higher success rates.[3]
[8] Alternative options used for shoulder reconstruction are less expendable, smaller
in size, and are associated with greater donor site morbidity compared with the latissimus
dorsi muscle (LDM).[6] Ihara et al believe that in certain situations the TFL flap could be the first choice
for shoulder reconstruction—especially for deltoid replacement.[6] It is stated that the TFL muscle is more compact and is nearly comparable to the
one of the deltoid muscle—whereas the LDM is too large. In our demonstrated case,
TFL flap would not have provided an adequate defect coverage. Furthermore, the authors
believe that the LDMF is a safer choice for such large defect zones.
Nevertheless, there are also some negative aspects concerning usage of the LDMF. Anatomically,
LDM is a part of the shoulder girdle. Although, many publications state that the loss
of LDM does not result in significant functional impairment,[9]
[10] Koh and Morrison revealed that LDM sacrifice may lead to more significant functional
loss than previously documented.[9] A recent systematic review by Lee and Mun showed that limitations in shoulder joint
after harvesting of LDMF could recover over time.[10] However, strength was reduced significantly and could not be recovered to the preoperative
value even in the long run.[10] This needs to be taken into consideration in presurgical planning. In our presented
patient case, the highest priority was the achievement of a negative margin (R0) resection
of the tumor. Possible loss of postoperative range of motion was not taken into consideration
while performing a radical excision. Recovery of range of motion is related to a successful
LDMF transfer following intensive physiotherapy and biofeedback therapy.
Summary
Plastic surgical reconstructive techniques do not only offer complete defect coverage
of large defect zones, but also functional reconstruction with restoration of adequate
range of motion. As demonstrated in our case report, this allows for successful reconstruction
with a LDMF following wide tumor resection in anatomically complex regions such as
the shoulder.
