Evaluating the effectiveness of plastic surgery in the treatment of chronic wounds caused by radiotherapy at national institute of burns – Hoang Thanh Tuan

Journal of military pharmaco-medicine n o 1-2019 195 EVALUATING THE EFFECTIVENESS OF PLASTIC SURGERY IN THE TREATMENT OF CHRONIC WOUNDS CAUSED BY RADIOTHERAPY AT NATIONAL INSTITUTE OF BURNS Hoang Thanh Tuan1; Vu Quang Vinh1; Trinh Tuan Dung2 SUMMARY Objectives: To evaluate the effectiveness of plastic surgery in the treatment of chronic wounds caused by radiotherapy in 30 patients. Subjects and method: A cross-sectional, prospective study was conducted on 30 patients with chronic wounds caused by radiotherapy, treated at National Institute of Burns from 10 - 2013 to 9 - 2017. Results: In 30 patients, 5 patients were males and 25 patients were females. The mean age was 49.96 ± 18.52. The most common wound was in thoracic region (46.7%), followed by head and neck (33.3%). The size of the soft tissue defects varied from 4 - 300 cm2 (mean 84.7 ± 71.9 cm2). We used 8 local flaps, 17 pedicle flaps, 4 free flaps and 1 Wolf-Krause graft. The latissimus dorsi musculocutaneous flap and gluteal perforator artery fasciocutaneus flap were used in the majority of these cases. The average drainage time was 10.5 ± 6 days. The average length of hospital stay was 52 ± 32 days. The donor site was primarily closed in 18 patients, 12 patients required skin graft. 1 patient had partial flap necrosis, 2 patients had complete necrotized flap. Conclusion: Plastic surgery in the treatment of chronic dermal wounds caused by radiotherapy by maximum debridement and covering with local, pedicle, microsurgical flaps had good results. So far however, the treatment of chronic dermal wounds resulted from radiotherapy remains a big challenge to surgeons because of high risk complication, infection, delayed wound healing, and flap necrosis. * Keywords: Chronic dermal wounds; Surgical reconstruction; Radiation injury. INTRODUCTION Radiation has been used in medicine for more than a century and it plays an increasingly important role in the treatment of cancers. It is estimated that more than 60% of cancer patients receive radiotherapy annually, which is used alone or in combination with other methods [1]. However, up to 95% of patients have acute manifestations of irradiated skin. After irradiation, 5 - 15% of patients [2] present chronic complications such as delayed healing wounds, ulcers, atrophy, cancer. Radiation ulcer is one of the most dangerous and persistent complications, often associated with infection, anemia, malnutrition and fibrosis around the wound, which make it more widespread and deeper. The treatment of skin lesions due to radiation therapy requires an accurate assessment, complete removal of lesions and full restoration of lesions by plastic surgery. Therefore, it is always a big challenge for surgeons, especially plastic surgeons. 1. National Instittue of Burns 2. 108 Military Central Hospital Corresponding author: Hoang Thanh Tuan (tuanht.vb@gmail.com) Date received: 02/10/2018 Date accepted: 18/12/2018 Journal of military pharmaco-medicine n o 1-2019 196 The objective of this study was: To evaluate the effectiveness and complications of plastic surgery in 30 patients with irradiated wounds. SUBJECTS AND METHODS 1. Subjects. 30 patients (5 males and 25 females) with skin ulcers caused by radiotherapy, treated in National institute of Burns from 10 - 2013 to 8 - 2017. All patients were examined the following factors: Age, gender; location, size, component of the wounds. Inclusion citeria: Patients with chronic dermal wound due to radiotherapy, no recurrent cancer, no contraindication of anesthesia. 2. Methods. Corss-sectional, prospective study. * Surgical methods: - Wound assessment, surgical planning. - Making skin incision around the wound so that it is in normal tissue. - Complete removal of necrotized, fibrous tissue; assessment of deep tissues such as muscle and bone. Before treatment After treatment Picture 1: Removing both the central ulcer and infiltration area around it up to the normal tissue. Skin flap design and cover the wound bed, monitor and evaluate the postoperative results. RESULTS 1. Patient’s characteristics. The average age of patients was 49.96 ± 18.52 years, the youngest was 15 years, and the oldest was 80 years, 24 patients aged 40 and over (accounted for 80%). The ratio of male to female was 5/26, women accounted for 83.3% of the studied patients. The site of injury was mainly chest wall, followed by face, extremities and other areas with an average wound size of 84.7 ± 71.9 cm2. * Site of injury: Chest wall: 14 patients (46.7%); head, face: 10 patients (33.3%); extremities: 3 patients (10%); others: 3 patients (10%). Journal of military pharmaco-medicine n o 1-2019 197 2. Treatment of chronic skin lesions. Table 1: Wound covering and flaps. Types of flap Number Percentage Local flap 8 26.6 Pedicle flap 17 56.7 Microsurgical flap 4 13.3 Wolf-Krause graft 1 3.3 Total 30 100 96.7% of the cases were covered the tissue defect with flaps after removing lesions. Among them, the most common pedicle flaps were trapezius and posterior gluteal artery perforator flaps. The average flap size was 119.6 ± 92.2 cm², the smallest was 6 cm² and the largest was 400 cm². Picture 2: (A) The patient underwent radiation treatment. (B) Intraoperative removal of the central ulcer and surrounding infiltration area up to the normal tissue. (C) Intraoperative view of the latissimus dorsimusculocutaneous flap. (D) The radiation ulcer was reconstructed. Journal of military pharmaco-medicine n o 1-2019 198 3. The condition of donor site and flaps. * Status of the donor site (n = 30): Closed sewing: 18 patients (60%); stitching + skin graft: 12 patients (40%). A: Stiching and skin graft of donor site after harvest. B: Closed sewing up donor site after harvest. Picture 3: Condition of donor site. * Condition of flaps: The survival rate of the whole flap was 90% (27 out of 30 patients), partially necrotized flap was 3.3% (1/30) and totally necrotic flap was 6.7% (2/30). The average size of necrotized flap was 13.3 ± 7.6 cm². Picture 4: A: Partially necrotized flap. B: Totally necrotized flap. Journal of military pharmaco-medicine n o 1-2019 199 4. Surgical duration, length of hospital stay and drainage duration. Table 2: Surgical duration, length of hospital stay, drainage keeping duration. Criteria Average n Length of hospital stay 52 ± 32 days 30 Drainage duration 10.5 ± 6 days 30 5. Wound healing and recurrent ulcers. The results revealed that 20 defects (66.7%) were healed primarily, 7 defects (33.3%) healed secondarily and 3 defects (10%) needed a second surgery. * Recurrent ulcer: No patient had recurrent ulcer under 3 months and over 6 months. DISCUSSION 1. Characteristics of radiation ulcers. All patients in our study had radiotherapy- induced chronic wound, in addition to the central necrotizing ulcer, its surrounding infiltration tissue which has various components, mainly fibrosis, embolism, and sepsis. The conventional surgical procedures such as debridement waiting for granulation tissue, or drainage of inflammatory foci is ineffective. Therefore removal of the entire lesion by surgery and covering with flap bring the optimal results. Ulcers in thracic region were the most common with 46.7%, followed by neck and head with 33.3%, the ramaining sites were in the extremities and elsewhere. Our findings were in accordance with a study by Akira Saito et al [3], 36 patients with irradiated wounds, in which thorax was 44.4% and head, neck and face were 33.3%. 2. The effect of surgical treatment. All patients in our study were given simultaneously surgical incision of the lesions and plastic surgery. When removing the lesion, we had to remove the central ulcer and infiltration area around the ulcers up to the normal tissue, which is clinically defined as the bleeding area when cutting to ensure for the blood supply to the wound edge and not affecting the results of wound healing and reducing the risk of recurrent ulcer after surgery. If the base of the lesion did not reach the vital organs and blood vesselse, we would prioritize complete removal of the base. However, we had to keep the organs if they were also damaged. Only 8 patients (26.7%) were completely removed to the base of the lesion, and 22 patients (73.3%) were partially removed a part of lesion. This is because radiation ulcer tends to invade important organs such as the pericardium, pleurae, axillary arteries. For these cases, we used postoperative drainage for a long time. The average duration was 10.5 ± 6 days, in which 4 cases up to 21 days. In our study, all patients were given preoperative and postoperative ultrasound in order to detect pulse, which shortened surgical duration compared with not using ultrasound. In particular, for the patients with the superior gluteal artery perforator flaps, the use of ultrasound to detect the branches prior to surgery is mandatory for the success of surgery. Journal of military pharmaco-medicine n o 1-2019 200 3. The features of flaps. The choice of flap depends on the location of wound and its nature. In our study, various flaps were applied. The most common location of wound was chest wall with 14 out of 30 patients. The best choice for covering the wound was the latissiumus dorsal flap, which is a stable and realiable pedicle. It is possible to take the entire pedicle of the thoracolumbar artery and suitable for free form flap. When taking latissiumus dorsal muscle, the function is not affected much due to the compensation of the pectoralis and teres major muscles. This study was in accordance with Fujioka's, a research on 67 patients with chest lesions, the latissiumus dorsal flap is the most widely used with 34.3% [4]. The musclocutaneous flap is richer in blood supply than the fasciocutaneous flap, so it facilitates antibiotics to reach the incision and reduces the risk of infection. That’s why the musclocutaneous flap is the best choice in covering defects Head and neck surgery is still a challenge for the surgeon. When the radiation-induced wound is in the middle of the face and head, the microscopic flap is the first choice for surgical reconstruction because no pedicle flaps can reach the distal area safely. In our study, microsurgical flaps were mainly used in the reconstruction of defect of head and neck (16.7%) because the wound in these areas are complicated with many blood vessels and nerves. According to Vu Ngoc Lam, a study of 15 patients (2015) using 13 microsurgical flaps and 3 pedicle flaps for ulcer treatment after radiotherapy, which used 8 fibula flaps, 5 ALT free flaps and 2 musculocutaneous pectoralis pedicle flaps [5]. According to Amelie Bourget et al (2011), a study of 137 patients undergoing surgical reconstruction of the posterior area after radiotherapy. All of the patients were given microsurgical flaps, in which ALT is the first choice with 36 out of 137 flaps, followed by the lateral arm and the fibular flaps [6]. Donald P.B et al [7] studied 63 patients with the lower osteonecrosis of jaw after radiotherapy, 65 microsurgical flaps and 13 pedicle flaps were used after wound incision. The posterior gluteal artery perforator flaps is the best choice for covering defect of the sacral area, because of its good blood supply, small donor site, and suit aesthetic demand without affecting the function of donor site. In our study, three patients were applied the posterior gluteal artery perforator flap for covering the scaral lesion with good results. The same successful result was reported by Cheon et al (2008) [8]. 4. Outcomes of short-term and long- term treatment. 20 patients healed primarily (66.7%), 7 patients were slow healing due to leakage, fluid retention. 3 patients with necrotized flaps which were completely removed and covered with the other flaps. The remaining cases, who were given strong antibiotics, dressing change had good results without a second surgery. Monitoring the long-term results of 30 patients, there was no patient with recurrent ulcer (4.3%). Journal of military pharmaco-medicine n o 1-2019 201 Damage caused by radiotherapy is in a volcanic shape, ulcer is merely its crater [9]. Among treatment methods, the most effective one was removal of the lesions and then covered with flaps of many blood vessels. However, the recurrence of ulcers can occur that requires a second surgery. CONCLUSION Radiotherapy-induced skin damage is usually complicated depending on its location and stage. Using flap after removal of lesion is the only treatment for this type of wound. The chosing flaps needs to be large enough and good blood supply but no loss of function of the donor site. Among thirty patients, the most common location of wound is chest wall, then face, neck and sacral area. Survival rate of flaps were up to 90% as using pedicle and microsurgical flaps such as latissimus dorsimyocutaneous flap, posterior gluteal artery perforator flap and ALT flap. Three patients were performed the second surgery and covered with other flap with good result. REFERENCES 1. Bộ môn Y học Hạt nhân - Học viện Quân y. Y học Hạt nhân. Nhà xuất bản Quân đội Nhân dân. 2010, tr.173-179. 2. Mary Wells, MacBride, Sheila. Radiation skin reactions. Supportive Care in Radiotherapy. 2003, pp.137-138. 3. Saito A, Saito N, Funayama E, Minakawa H. The surgical treatment of irradiated wounds: A report on 36 patients. Plast Surg. 2013, p.7. 4. Fujioka M. Surgical reconstruction of radiation injuries. Advances in Wound Care. 2014, 3 (1), pp.25-37 5. Lam Vu Ngoc. Tissue necrosis in cervico facial area after radiation therapy: Assessment of Surgical Management. 2015. 6. Bourget A, Chang J.T, Wu D.B.S, Chang C.J, Wei F.C. 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