PMC8192213_01
CT Scan showing fluid collection (red arrow).
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fig1
In order to determine the cause of the swelling, we performed an ultrasonography and a CT Scan that showed a capsulated fluid collection (Figure 1).
A diagnostic thoracoscopy showed no abnormal findings.
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fig2
A diagnostic thoracoscopy showed no abnormal intrathoracic findings (Figure 2), and therefore, an open incision of the collection was performed.
After draining the purulent collection, a hole of the 7th ribs was visualized (green arrow).
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fig3
Intraoperatively, we confirmed the presence of an encapsulated abscess with purulent secretion coming out from a hole in the 7th rib (Figure 3).
Intraoperative picture at time of reconstruction after 4 cycles of VAC Therapy. The defect at the level of the 7th rib measured 10 x 6 x 4 cm. The superior epigastric artery perforator (SEAP) flap was designed with the musculocutaneous perforator reaching the skin at the proximal end of the flap (black dot).
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fig4
After confirming the presence and course of a sizeable perforator originating from the superior epigastric artery in the proximity of the wound by means of a CT angiography and handheld doppler, a perforator-based superior epigastric artery perforator (SEAP) propeller flap was planned (Figure 4).
The superior epigastric artery perforator flap was harvested and the vascular pedicle (superior epigastric artery) skeletonized until the caudal margin of the 8th rib to allow maximum freedom of movement and precise flap insetting.
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After its harvest, most of the flap (about 70% of its surface) was deepithelialized and buried to adequately fill the dead space, while the distal tip of the flap served as a monitor to check its perfusion postoperatively (Figures 5 and 6).
The flap was rotated by 90  and about 70% of the skin surface of the flap was deepithelialized to allow filling of the cavity as a "buried flap." The remaining 30% served as a skin island for postoperative flap monitoring.
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After its harvest, most of the flap (about 70% of its surface) was deepithelialized and buried to adequately fill the dead space, while the distal tip of the flap served as a monitor to check its perfusion postoperatively (Figures 5 and 6).
Postoperative picture at 9 months showing stable conditions. Further surgery to remove the skin island was offered.
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fig7
After a 9-month follow-up, we found no evidence of infection or abnormal wound healing (Figure 7).