Coverage of exposed pericardium with a lateral thoracic artery perforator flap

Vijay Yashpal Bhatia; Pradnya Desai Sarwade; Pranav Chandrashekhar Thusay; Sukumar H Mehta; Nirav M Visavadia

doi:10.4103/ijb.ijb_16_20

CASE REPORT

Year : 2020 | Volume : 28 | Issue : 1 | Page : 104-107

Coverage of exposed pericardium with a lateral thoracic artery perforator flap

Vijay Yashpal Bhatia¹, Pradnya Desai Sarwade¹, Pranav Chandrashekhar Thusay¹, Sukumar H Mehta², Nirav M Visavadia³
¹ Department of Plastic Surgery, Sterling Hospital, Ahmedabad, Gujarat, India
² Department of Cardiothoracic Surgery, Sterling Hospital, Ahmedabad, Gujarat, India
³ Department of Critical Care, Sterling Hospital, Ahmedabad, Gujarat, India

Date of Submission	27-Jun-2020
Date of Decision	08-Oct-2020
Date of Acceptance	24-Nov-2020
Date of Web Publication	21-May-2021

Correspondence Address:
Dr. Vijay Yashpal Bhatia
23, Armaan Bunglows, Near Sindhu Bhavan, Behind Mann Party Plot, Thaltej, Ahmedabad - 380 059, Gujarat
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/ijb.ijb_16_20

Abstract

Electricity is an indispensable part of the society that we live in, depending on it from household appliances to farms and industries. Electrical burn injuries, although form a small proportion of the total burn cases, pose significant challenges in their management due to their varied manifestations and the high associated morbidity and mortality. Most high voltage electrical injuries are work related. The entry wounds are most commonly seen over the upper extremities, whereas the exit wounds are seen over the lower extremities. The thorax presents an uncommon site for an entry wound. In this case report, the authors present one such case of electrical injury with an entry wound over the thorax presenting as a left parasternal defect that was debrided and covered successfully with a lateral thoracic artery perforator-based flap from the lateral chest wall.

Keywords: Chest defect, debridement, electrical injury, exposed pericardium, perforator flap

How to cite this article:
Bhatia VY, Sarwade PD, Thusay PC, Mehta SH, Visavadia NM. Coverage of exposed pericardium with a lateral thoracic artery perforator flap. Indian J Burns 2020;28:104-7

How to cite this URL:
Bhatia VY, Sarwade PD, Thusay PC, Mehta SH, Visavadia NM. Coverage of exposed pericardium with a lateral thoracic artery perforator flap. Indian J Burns [serial online] 2020 [cited 2023 Jun 9];28:104-7. Available from: https://www.ijburns.com/text.asp?2020/28/1/104/316568

Introduction

Clinical features in a patient with electrical injury vary depending on the electrical voltage and current the patient has come in contact with, the points of contact over the body, the tissues that pass through the course between entry and exit points, and so on. Timely intensive care and surgical interventions such as fasciotomy for compartment syndromes can prove limb and lifesaving. Sometimes, they can present with abdominal visceral damage in abdominal wall contact injuries, defects over the scalp, chest, and perineum that may need urgent surgical interventions to prevent the associated morbidity and mortality.

Case Report

A 15-year-old male presented to our hospital with electrical injury due to contact with a high voltage live wire while working in the fields. He was referred after initial resuscitation and was hemodynamically stable at presentation. He sustained 19% total body surface area electric contact and flash burns involving the scalp, bilateral upper limbs, anterior and posterior chest, anterior abdomen, and left lower limb. The contact points appeared to be on both hands and over the anterior chest wall (left lower parasternal area) which was a defect measuring 6 cm × 8 cm with exposed ribs and costal cartilages. The edges of the chest defect appeared nonviable and the crater of the necrotic area showed denuded anterior ends of the fourth, fifth, and sixth ribs. The skin surrounding the defect, the anterior abdominal wall, and the posterior thoracic wall showed second-degree superficial to deep burns [Figure 1]. He was investigated as per protocols with a computed tomogram of the brain, an electrocardiogram, cardiac enzymes, urinalysis, a complete blood count, and a computed tomogram of the chest to gauge injury to the internal organs of the chest;^[1] the investigations showed an elevated creatinine phosphokinase (total) with a value of 4270 (normal range 55–170), and a positive Troponin I 4.3 (normal range up to 0.03). His electrocardiogram, however, was normal. He was monitored closely and Troponin I levels were repeated at regular intervals. Troponin I levels decreased rapidly with normalization on the 3^rd day of presentation. A tissue culture was sent from the chest defect on admission showed the presence of a heavy growth of Acinetobacter baumannii sensitive to various antibiotics. Antibiotics were started accordingly. The wound was debrided on day 4 postinjury, and the anterior ends of the fourth, fifth, and sixth ribs were excised subperiosteally to prevent damage to the underlying pericardium and pleura. The final defect measured 19 cm × 6 cm with an exposed pericardium and pleura. The left lateral thoracic artery perforators were marked in the left fourth intercostal space along the lateral border of pectoralis major muscle using a handheld Doppler and a fasciocutaneous flap of 19 cm × 8 cm was raised based on these perforators [Figure 2] and [Figure 3]. A back cut was placed at its base to facilitate tension-free coverage. The final flap dimensions were 19 cm × 6 cm. The flap was inset over the defect with a negative drain in place. The donor area and raw areas over the anterior chest were covered with a split-thickness skin graft. We observed necrosis of a 1 cm margin of the flap along its inferior border in the first 48 h [Figure 4]. The drain, however, maintained its negative pressure, the defect remained well covered, and there was no significant retraction of the flap. The split skin graft on the anterior chest wall showed graft loss. A second surgery was done on the 14^th postoperative day, where the necrosed rim of the flap was excised and the flap tacked to surrounding tissues to prevent any retraction. The drain was removed at this time. Other involved areas were grafted with split-thickness graft on day 21 postinjury after separation of eschar. The right hand thumb, index, and middle fingers required amputation with grafting of the resulting raw areas.

Figure 1: Preoperative image showing the chest defect and deep second degree burns over the upper abdomen and posterior thoracic wall

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Figure 2: Intra-operative image showing postdebridement defect, image of the flap raised and inset over the defect

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Figure 3: Diagram showing the location of lateral thoracic artery perforators emerging along the lateral border of pectoralis major muscle (on the left); A pictorial illustration of the flap design based on the perforators (on the right)

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Figure 4: Immediate postoperative result (on the left) and result at follow-up (on the right)

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Discussion

Infected anterior chest wall wounds often can cause a plethora of deep tissue infections such as mediastinis, pericarditis, pleuritis or osteomyelitis of the ribs, costal chondritis, and costal cartilage necrosis.^[2],[3] The presence of necrotic bone or cartilage at the base of the defect or exposure of pericardium or pleura, as in our case, can further increase the chances of such complications, and thus higher morbidity and mortality. Early debridement and vascularized soft-tissue coverage thus become vital to reduce the incidence of these complications and can prove to be life-saving.^[2]

The flaps most commonly used for reconstruction of anterior chest wall defects include the pectoralis major muscle, latissimus dorsi, and rectus abdominis muscle flaps.^[4] In our patient, however, the use of these flaps was precluded given the involvement of the overlying skin with deep second degree burns over the flap donor sites, i.e., the left posterior thoracic wall, and the upper anterior abdominal wall. In addition, there was a possibility of damage to the superior epigastric vessels due to its vicinity to the high voltage contact injury over the lower parasternal region and questionable viability of the intrathoracic part of the rectus abdominis. The use of free flaps was ruled out considering the possible damage to vessels in the vicinity of the defect and their unsuitability for anastomosis in electrical injuries.^[5] Hence, a perforator-based flap from the lateral chest wall based on the lateral thoracic artery perforator was planned for coverage of this defect.

The lateral thoracic artery is a branch of the axillary artery. It supplies the muscles of the anterior chest wall, the breast as well as the anterolateral thoracic wall. The cutaneous perforators emerge along the lateral border of the pectoralis major muscle no further than the fifth interspace.^[6],[7] These perforators are quite inconsistent and a preoperative Doppler is necessary to confirm their presence.^[8]

Flaps based on these perforators have been used for coverage of the axilla following release of postburn contracture of the axilla or following excision of hidradenitis suppurativa,^[9] or in partial breast reconstruction^[10] as pedicled flaps, or as a free flap for reconstruction of various defects ranging from head and neck malignancies to leg defects.^[11]

Kim et al. raised a propeller flap based on lateral thoracic artery perforators for coverage of a radiation ulcer on the anterior chest.^[12] The dimensions of the flap, in this case, were 16 cm × 7 cm.

In this case, we have explored the utility of a similar flap for coverage of a left parasternal defect with exposed pericardium and pleura following electrical injury.

We could safely say that this can be considered as a choice for coverage of similar defects given its ease to harvest and the reduced operative time.

Conclusion

Many options are available for coverage of chest wall defects with exposed pericardium, but when other options are not available, this flap based on lateral thoracic artery perforators is a reliable choice for coverage.

Consent for publication

Informed written consent has been obtained from the patient for publication. It can be presented on request.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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4.	Bakri K, Mardini S, Evans KK, Carlsen BT, Arnold PG. Workhorse flaps in chest wall reconstruction: The pectoralis major, latissimus dorsi, and rectus abdominis flaps. Semin Plast Surg 2011;25:43-54.
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10.	McCulley SJ, Schaverien MV, Tan VK, Macmillan RD. Lateral thoracic artery perforator (LTAP) flap in partial breast reconstruction. J Plast Reconstr Aesthetic Surg Churchill Livingstone 2015;68:686-91.
11.	Kim JT, Ng SW, Naidu S, Kim JD, Kim YH. Lateral thoracic perforator flap: Additional perforator flap option from the lateral thoracic region. J Plast Reconstr Aesthet Surg 2011;64:1596-602.
12.	Kim DY, Kim HY, Han YS, Park JH. Chest wall reconstruction with a lateral thoracic artery perforator propeller flap for a radiation ulcer on the anterior chest. J Plast Reconstr Aesthet Surg 2013;66:134-6.