How do you manage severe fibrosis/contracture and breast/axilla pain in a patient with a history of breast radiation who cannot tolerate trental?

I have seen some patients with dramatic responses to pentoxifylline (Trental) and vitamin E, but the regimen needs to be continued for at least one year to prevent relapse (Delanian et al., PMID 12829674). However, this patient cannot tolerate Trental, so that is not feasible. Hyperbaric oxygen has been used for radiation injuries like this for many years with apparent benefit. However, a randomized trial for patients with chronic bowel dysfunction after pelvic RT showed no benefit compared to sham controls (Glover et al., PMID 26703894). My recommendation would be to perform mastectomy with immediate reconstruction using a pedicled transverse rectus abdominis muscle (TRAM) flap. That has a more robust blood supply than a free flap, and the...