Adjuvant radiation therapy (RT) is a standard treatment for soft tissue sarcoma, yet it can lead to severe radiation-induced necrosis, clinically equivalent to a fourth-degree burn.We report a rare case of severe deep tissue injury in a 71-year-old female at the pretibial area.Following wide excision and latissimus dorsi free flap reconstruction for a lower extremity pleomorphic liposarcoma, the patient received adjuvant RT (60 Gy).Despite initial mild erythema, the injury progressed rapidly to full-thickness skin loss with extensive necrosis of the reconstructed tissue, involving 2% of the total body surface area.The clinical presentation was characterized by a significant discrepancy between the superficial appearance and the underlying deep tissue destruction.Management involved aggressive serial debridement followed by negative pressure wound therapy (NPWT).While multiple debridements brought the wound to the brink of bone exposure, NPWT successfully promoted robust centripetal granulation tissue, which completely encapsulated the endangered cortical bone.Definitive coverage was achieved with a split-thickness skin graft (STSG).This case emphasizes that radiation-induced injuries in reconstructed tissues can be highly deceptive, initially presenting as minor superficial wounds while masking extensive necrosis reaching the deep fascia and bone.Recognizing this discrepancy is crucial for timely surgical intervention and a staged reconstructive approach in managing these complex fourth-degree burn-like injuries.(
Kim et al. (Mon,) studied this question.