Back Muscle Flap Rebuilds Armpit a Decade After Mastectomy

When breast cancer returns a decade after a mastectomy, it can arrive in one of the most surgically awkward places in the human body: the armpit. A team of surgeons at An-Najah National University Hospital in Nablus, Palestine, has now reported in detail how they tackled exactly that scenario, using a living slab of back muscle to rebuild a deep, infected, ulcerated axillary wound in a 63-year-old woman whose cancer had resurfaced ten years after her original operation. The case, published in BMC Plastic and Reconstructive Surgery, offers a rare, fully documented look at how reconstructive surgeons weigh anatomy, infection, prior radiation and function when the stakes include the nerves and vessels that keep an arm alive.

The patient’s story began in 2011, when she noticed a small mass in the lower quadrant of her left breast. Like many patients facing a frightening symptom, she initially avoided medical care and tried to treat herself. Over three years the mass grew, became tender and pulled her nipple inward, finally prompting her to seek help. A biopsy confirmed breast cancer, and in 2015 she underwent a modified radical mastectomy with left axillary lymph node dissection at another hospital, followed by adjuvant chemotherapy and radiotherapy to the chest wall and axillary region. Detailed records of that treatment were unavailable to her new care team, a gap that would complicate later decisions.

For nearly a decade she did well. Then, roughly four months before admission, a mass appeared in her left armpit. Two weeks before she reached the hospital, a foul-smelling discharge began leaking from the old surgical incision site, and she had been attempting to sterilize the wound at home with alcohol. On examination she had no diabetes, hypertension or smoking history, but her body mass index was 35, a factor that raises the technical difficulty of any flap operation. The wound itself was ulcerated and infected, a clinical picture the team judged consistent with recurrent disease, so no preoperative biopsy was taken.

Imaging told a more sobering story than the visible wound. A contrast-enhanced chest CT scan revealed multiple enlarged, matted left axillary lymph nodes, the largest measuring 6.6 by 3.7 centimeters, along with soft tissue thickening at the mastectomy bed and in the axilla. It also showed several tiny bilateral lung nodules and, unexpectedly, a destructive bone lesion with soft tissue involvement in the sternum, although the patient felt no symptoms from it. Crucially, the scan showed no narrowing or encasement of the major axillary vessels, which meant the surgeons could proceed without a dedicated angiogram. Orthopedic and cardiothoracic consultants concluded that even if the sternal lesion represented oligometastatic disease, there was no indication for sternal resection or additional surgery.

The operation itself was a study in positioning and technique. Under general anesthesia, the patient was first placed supine while surgeons completely excised the recurrent mass and all infected, ulcerated tissue. The team chose the latissimus dorsi flap, the broad, fan-shaped muscle of the back, for three reasons: its robust and predictable blood supply, its ample tissue volume, and its anatomical proximity to the axilla. The patient was then turned onto her side for flap harvest, returned supine for insertion, and the flap was rotated 180 degrees to cover the defect without twisting its pedicle, the leash of vessels, chiefly the thoracodorsal artery and vein, that keeps the transferred tissue alive. The thoracodorsal pedicle is typically preserved even after axillary lymph node dissection, which is precisely what makes this flap viable in patients who have already had armpit surgery.

The early postoperative course was promising, then tested. The flap initially looked healthy, but within days signs of infection appeared at the drain site, and a small wound dehiscence produced serous discharge. Swabs from the drain fluid and wound edges grew Pseudomonas aeruginosa, a hardy hospital-associated bacterium. The team responded with five days of gentamicin and ciprofloxacin, local wound care and daily dressing changes. The fever resolved, inflammatory markers fell, the infection signs disappeared and the small dehiscence closed completely, with ciprofloxacin continued to finish the course. The flap itself survived fully, which is the single most important benchmark of success in this kind of reconstruction.

Pathology added an unexpected twist. The resected mass proved to be a focal squamous cell carcinoma, positive for p63 immunostaining, that had infiltrated the dermis, subcutaneous fat and skeletal muscle fibers, with areas of epidermal ulceration and necrosis. Hormone receptor testing showed the tumor was negative for estrogen and progesterone receptors and negative for HER2 overexpression, a triple-negative profile that limits options for endocrine or targeted therapy. Because the surgery was explicitly palliative rather than curative, the team decided that re-irradiation and additional adjunctive treatments were not indicated, a decision shaped by the patient’s overall condition and the goals of care.

One month after surgery, a new problem surfaced: tingling and numbness in the ulnar distribution of the left hand, particularly the medial half of the fourth and fifth fingers. The ulnar nerve had not been injured during the operation; the neuropathy was attributed to compression and traction caused by the tension of the flap sitting in a space crowded with the brachial plexus, axillary artery and axillary vein. This is a recognized hazard of axillary reconstruction, where the reconstructive material must coexist with the neurovascular bundle that supplies the entire arm. The condition was managed medically, and the authors note that pressure on any of these structures is an inherent risk whenever tissue is placed into the axilla.

At seven months of follow-up the results were largely encouraging. The wound had healed completely, there was no recurrence or reinfection, and functional and cosmetic outcomes were judged satisfactory. The trade-offs were real but modest: a hypertrophic scar at the donor site on the back, left shoulder abduction roughly 30 degrees short of the right side, and a slight limitation in internal rotation. For a patient whose alternative was an open, infected, recurrent tumor in a previously irradiated field, preserving near-normal shoulder function is a meaningful outcome, since the primary goals of axillary reconstruction are protecting vital neurovascular structures and restoring shoulder mobility.

The case also sits within a broader surgical landscape. Local and regional flaps, including the latissimus dorsi and the thoracodorsal artery perforator flap, are usually the first choice for axillary defects because they bring reliable blood supply and good contour into a difficult region. When local tissues are unavailable, free tissue transfer such as the anterolateral thigh flap becomes an alternative for large defects, using recipient vessels like the thoracoacromial or transverse cervical arteries. The latissimus dorsi flap carries its own known complication profile: seroma formation occurs in roughly 70 percent of cases, surgical site hematoma in about 5 percent, and late hypertrophic scarring in 28 percent of patients, while some women experience mild back muscle weakness affecting overhead lifting. Some authors argue that an asymptomatic seroma should be considered an inevitable side effect rather than a true complication. What this report ultimately demonstrates is that a well-vascularized muscle flap can succeed even in a contaminated, previously radiated axilla, and that careful flap selection combined with multidisciplinary teamwork, spanning plastic surgery, oncology, orthopedics and cardiothoracic consultation, remains the decisive factor in reconstructing recurrent breast cancer.

Subject of Research: Latissimus dorsi flap reconstruction of an axillary defect following excision of recurrent breast cancer ten years after mastectomy

Article Title: Latissimus dorsi flap reconstruction of axillary defect caused by excision of ulcerated and infected mass ten years after mastectomy: a case report

Article References: Alashqar, M., Alashqar, A., Giacaman, Y., Hadya, F., Draidi, R., & Hasan, M. (2025). Latissimus dorsi flap reconstruction of axillary defect caused by excision of ulcerated and infected mass ten years after mastectomy: a case report. BMC Plastic and Reconstructive Surgery, 1(1), Article 11. https://doi.org/10.1186/s44452-025-00011-7

Image Credits: AI Generated

DOI: 10.1186/s44452-025-00011-7

Keywords: breast cancer recurrence, latissimus dorsi flap, axillary reconstruction, mastectomy, reconstructive surgery, flap surgery, ulnar nerve compression, Pseudomonas aeruginosa, radiotherapy, case report, plastic surgery, shoulder mobility