LABC represents 5–20 % of all breast cancer in developed countries. While the incidence is decreasing in mammographically screened populations (less than 5 % of those in the United States), LABC cases represent up to 40–50 % of new cases in underdeveloped countries. The incidence also appears to be higher in younger women and African-American and Hispanic women. In contrast, inflammatory breast cancer (IBC) represents 0.5–2 % of cases in the United States. However, it appears to be increasing in incidence, particularly in white women. It is important to note that the incidence of IBC remains higher in African-Americans. It also tends to be diagnosed at an earlier age (median 59 vs. 66) as compared to LABC [1–3].

Although the specific treatment options are too in-depth for discussion here, some important aspects of treatment for LABC are useful to keep in mind. In general, the treatment of LABC utilizes multimodality therapy that includes systemic chemotherapy, either in the neoadjuvant or adjuvant setting, and locoregional therapy with radiation. As radiation therapy is the standard in the multimodal treatment of LABC and IBC, special attention must be given to its physiologic side effects on the breast. The mechanism of injury may involve vaso-occlusive processes as well as chromosomal alterations in fibroblasts that result in dysfunctional collagen formation [4, 5]. These physiologic aberrations result in markedly increased complication rates after radiation treatment in patients treated primarily with mastectomy. One study cites an institutional complication rate (including wound infections, dehiscence, and necrosis) in up to 50 % of mastectomy patients and 30–87 % of chest wall reconstruction patients previously treated with postoperative radiation [6–9].

The reconstructive surgeon must be prepared to excise much of the irradiated tissue, which can result in a much larger defect than anticipated. Local tissue may often be inadequate because of radiation damage and microsurgical efforts may be complicated by alterations in the wound bed, as well as recipient vessels. As a result, donor tissue must be well outside of the irradiated fields to ensure the greatest potential for flap survival.

Patients with LABC without evidence of distant metastasis can undergo operative treatment with curative intent. The goals of chest wall reconstruction in LABC patients are to alleviate symptoms, to enhance quality of life, and to cover vital structures. Several options are available for chest wall reconstruction, with multiple factors to consider before any particular case. Some of these factors are the patient’s desire, outcome, and willingness to undergo multiple (often lengthy) procedures and extended hospital stays. Physiologic factors that impact operative strategy include size, composition of the defect, quality of donor and recipient tissues, and the effects of radiation as described above.

Although much discussion has been given to the “reconstructive ladder” and after primary closure, the next “simplest” option for chest wall reconstruction is placement of a split-thickness skin graft (STSG). The STSG is only an option, however, when the defect is limited to the skin and subcutaneous tissue. When skin grafts are applied to irradiated tissue, they may not “take” as skin grafts rely on recipient beds for their blood supply. Skin grafting is also the least aesthetically acceptable option of all options for chest wall reconstruction, but it remains a valuable adjunct for coverage of muscle flaps employed in larger defects. The muscle flap that has not been irradiated is an acceptable recipient site for STSG.