Thoracoacromial Pedicle-Supercharged Conjoined Flap With Cutaneous Advancement Flap and Pectoralis Major Integration for Chest Wall Reconstruction Following Multiple Recurrent Dermatofibrosarcoma Protuberans: A Case Report

Recurrent dermatofibrosarcoma protuberans (DFSP) of the anterior chest wall in elderly patients presents a complex reconstructive challenge, necessitating approaches that balance oncological radicality with minimized morbidity and optimal tissue quality for potential adjuvant radiotherapy. We report the case of an 84-year-old woman with an eighth recurrence of chest wall DFSP. Following wide local excision with clear margins, a significant soft tissue defect remained. To address the patient's advanced age, comorbidities, and need for robust tissue in a planned radiation field, an unconventional reconstructive approach was employed. A laterally based pectoralis major myocutaneous advancement flap was designed, incorporating the lateral remnant of the pectoralis major muscle and overlying skin. Crucially, the pectoral branch of the thoracoacromial artery pedicle was meticulously preserved and utilized to augment the flap's vascularity. This allowed for the strategic transfer of well-perfused muscle tissue into the defect, particularly to the area designated for postoperative radiation. The patient experienced an uneventful postoperative course with excellent flap viability and minimal donor site morbidity. The total operative time was 105 minutes. Adjuvant radiation therapy was well-tolerated by the robust myocutaneous flap. At six-month follow-up, there was no evidence of tumor recurrence, with favorable functional and aesthetic outcomes. The thoracoacromial artery-enhanced pectoralis major myocutaneous advancement flap offers a safe, efficient, and reliable reconstructive solution for complex chest wall defects in high-risk elderly patients with recurrent sarcomas. This technique minimizes operative burden while providing durable, well-vascularized tissue capable of withstanding adjuvant radiotherapy, thereby optimizing both oncological and reconstructive outcomes.