Case 5: Hatchet flap for reconstruction of a defect on the anterior chest wall

Carolina Maria Helena Hilton; Magnus Balslev Avnstorp

Journal of Plastic, Breast & Reconstructive Surgery·Fagfællebedømte kirurgiske case-rapporter med åben adgangFagfællebedømt · Open access

Case 5: Hatchet flap for reconstruction of a defect on the anterior chest wall · JPBRS

Case-rapport

Case 5: Hatchet flap for reconstruction of a defect on the anterior chest wall

Carolina Maria Helena Hilton¹, Magnus Balslev Avnstorp¹

¹Department of Plastic & Breast Surgery, Zealand University Hospital, Denmark

Publiceret 2. april 2025247 visninger5 min læsning

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Resumé

A 73-year-old man was diagnosed with a malignant melanoma on the left anterior chest wall. According to guidelines he was scheduled for re-excision in 20 mm and sentinel node procedure. The defect following re-excision was too large for primary closure. A Hatchet flap was designed, covering the defect, with a cosmetic and functionally acceptable result. Patient medical history A 73-year-old man with a past medical history including hypercholesterolemia, hypertension, coronary stent and multiple earlier skin cancers (non-malignant-melanomas) was referred to the Plastic Surgery Department at Zealand University Hospital, Denmark, with a suspicion of malignant melanoma located on the anterior left chest wall. The tumor was excised with a 5-mm excision margin according to Danish guidelines (from “Dansk Melanom Gruppe” (the Danish Melanoma Group)). Histology showed a 1,9 mm thick malignant melanoma. The initial excision of 5 mm was not radical. The patient was therefore, according to Danish guidelines, planned for re-excision of 20 mm to the muscle fascia and closure with a local flap and sentinel node procedure. Before and After Patient examination The skin examination showed a cicatrice on the left chest wall, close to the neck, measuring around 30 mm, where skin mobility was not sufficient for direct closure if excised with a 20 mm margin. A lymph node scintigraphy showed two sentinel nodes in the left axilla. The patient was taking acetylsalicylic acid which was continued according to Danish guidelines (from “Dansk selskab for Trombose og Haemostase” (the Danish society of Thrombosis and Hemostasis)) . Pre-operative considerations Direct closure would probably result in reduced neck mobility or at least uncomfortable

Vigtigste læringspunkter

Pearls

A Hatchet flap is useful for covering defects in the thoracic area as it allows tissue rotation and advancement. It is a good option for using excess skin on a larger area and to distribute skin traction

Pitfalls

There is a risk of displacing the breast nipple when the hatchet flap is used in the thoracic anterior upper area.

Patient history

A 73-year-old man with a past medical history including hypercholesterolemia, hypertension, coronary stent and multiple earlier skin cancers (non-malignant-melanomas) was referred to the Plastic Surgery Department at Zealand University Hospital, Denmark, with a suspicion of malignant melanoma located on the anterior left chest wall. The tumor was excised with a 5-mm excision margin according to Danish guidelines (from “Dansk Melanom Gruppe” (the Danish Melanoma Group)). Histology showed a 1,9 mm thick malignant melanoma. The initial excision of 5 mm was not radical. The patient was therefore, according to Danish guidelines, planned for re-excision of 20 mm to the muscle fascia and closure with a local flap and sentinel node procedure.

Examination

The skin examination showed a cicatrice on the left chest wall, close to the neck, measuring around 30 mm, where skin mobility was not sufficient for direct closure if excised with a 20 mm margin. A lymph node scintigraphy showed two sentinel nodes in the left axilla. The patient was taking acetylsalicylic acid which was continued according to Danish guidelines (from “Dansk selskab for Trombose og Haemostase” (the Danish society of Thrombosis and Hemostasis)) .

Pre-operative considerations

Direct closure would probably result in reduced neck mobility or at least uncomfortable stricture. Several options were considered. We decided that a Hatchet flap was a good solution for a local flap as the patient had a moderate amount of skin excess caudolaterally to the lesion.

The Hatchet flap is a procedure first described by Emmett in 1977(1). Hatchet flaps allows tissue rotation and advancement, thereby providing sufficient mobilization of tissue with minimal tension on closure as compared to a transposition flap which was also considered(2,3). A skin transplant was not considered as good an option due to post-operative stricture and the thickness of the defect.

Trin 1 — Drawing of the re-excision

The cicatrice was marked, and a surgical margin of 20 mm was drawn.

Trin 2 — Flap drawing

Referencer

The closure of defects by using adjacent triangular flaps with subcutaneous pedicles. Emmett AJ. doi: 10.1097/00006534-197701000-00008.
Random pattern hatchet flap as a reconstructive tool in the treatment of pressure sores: clinical experience with 36 patients. M J Alfeehan 1, Ma-A Aljodah 2, M Z Al-Zajrawee 3, A A Marzook 2 1University of Anbar, Anbar, Iraq 2University of Baghdad, Iraq 3University of Kufa, Najaf, Iraq doi: 10.1308/rcsann.2020.7077.
Long-Term Comparison of Esthetic Outcomes Between Hatchet and Transposition Flaps in Facial-Defect Reconstruction.Taegyu Lee1, Junhyung King1, Woonhyeok Jeong1 , Taehee Jo1 , Jaehoon Choi2 , Sang Woo Park3 Department of Plastic and Reconstructive Surgery, Keimyung University School of Medicine, 56 Dalseong-ro Jung-gu, Daegu, 41931, Republic of Korea1, Department of Plastic and Reconstructive Surgery, Keimyung University School of Medicine, 56 Dalseong-ro Jung-gu, Daegu, 41931, Republic of Korea. psjchoi@dsmc.or.kr2, Department of Plastic and Reconstructive Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea3. doi: 10.1007/s00266-024-04053-7