Breast reconstruction with excess reverse abdominoplasty flap

Introduction: Mastectomy is a highly traumatic procedure for many women, and mammary reconstruction is a fundamental part of the treatment. Reconstruction has been shown to improve the psychosocial wellbeing and quality of life of these patients, and several techniques and advancements thereof have been described in order to reach the current diversity of modern procedures, whether associated with breast implants or not. This diversity in techniques enables an appropriate selection for each individual case, thus attaining better results. The objective of this report was to present an alternative breast reconstruction method using an upper abdominal flap along with breast Rev. Bras. Cir. Plást. 2014;29(2):297-302 DOI: 10.5935/2177-1235.2014RBCP0055


INTRODUCTION
Breast reconstruction is a fundamental aspect of mastectomy, and has been demonstrated to improve the psychosocial well-being and quality of life of these patients 1 .
The first attempts at breast reconstruction date back to the late 19 th century [2][3][4][5] , with William Halsted, based on Rudolph Virchow's theory, performing the first radical mastectomy in 1889 2 and considered that plastic surgery interfered with the local control of cancer, and thus recommended avoiding reconstructive surgery in the mastectomized region.
Harold Gilles (1942) used distant skin flaps (tubed flaps of the abdomen and lower chest) to perform the first breast reconstruction 6 .Despite the relatively good results at the time, this technique was abandoned due to the need for multiple surgical events and the high rate of complications and scarring sequelae 3 .
Currently, the trend of less aggressive mastectomy has facilitated breast reconstruction as a result of increased preservation of the dermal cutaneous tissue 2 .
Depending on the experience and preference of the surgeon, some of the most commonly used breast reconstruction techniques include:

Breast implants in breast reconstruction
Developed in 1961 by Cronin, Gerow, and Dow Corning Corp., and first presented in 1963, the silicone gel breast implant changed the field of breast reconstruction, creating the basis of delayed treatment 7 .In 1978, Jarret et al. recommended submuscular placement of the implants 8 .
In France, Arion presented the first tissue expander in 1965, but it was not until in 1982 that Radovan described its use in breast reconstruction 9 , and later, in 1984, Becker first developed a permanent tissue expander 10 .

Latissimus dorsi flap
The use of the latissimus dorsi muscle to restore de-fects caused by the absence of the pectoralis major muscle was first described in 1939 by Hutchins, but it was not until 1974 that this technique was used by Brantigan for radical post-mastectomy reconstruction; subsequently, in 1976, Olivari popularized and perfected the technique 11,12 .
However, due to insufficient volume, this technique usually requires placement of an implant, as described by Schneider in 1977 13 .

Transverse rectus abdominis myocutaneous (TRAM)
and free TRAM flaps The first description of this flap was in 1979 by Robbins, who used a vertically oriented skin-muscle flap of the rectus abdominis muscle 14 .In 1982, Hartrampf described its use with a horizontally oriented cutaneous paddle, providing a more aesthetic donor site closure.Its advantages include the fact that is provides sufficient tissue to cover large defects, while its disadvantages include weakness generated in the abdominal wall and a risk of hernias 15 .Holmström (1979) was the first to describe the free flap of the rectus abdominis 16 , and in 1989, Grotting published a study demonstrating the advantages of this technique such as improved blood supply, reduced risk of necrosis, and improvements in the functional loss of the abdominal wall 17 .
In 2009, Deós 36 revisited and applied new concepts to the reverse abdominoplasty 37,38 , correcting the drawbacks of the original technique, with strategic planning in terms of the markup, flap positioning, and maintenance of a stable scar, referring to this new technique as "tensioned reverse abdominoplasty ".
Although used in many surgical situations, there are no previous reports of reverse abdominoplasty for providing an additional subcutaneous tissue for breast reconstruction to protect the silicone prosthesis.In 1992, Berrino compared different reconstructive techniques for type II breast deformities 39 , one being a flap obtained by reverse abdominoplasty, but did not present any major conclusions or detailed the technique.Nonetheless, reverse abdominoplasty may represent a practical option for breast reconstruction in carefully selected patients.

OBJECTIVE
The aim of the present report was to describe an alternative breast reconstruction method performed using an upper abdominal flap during reverse abdominoplasty.

METHOD
A 59-year-old female patient with a history of radical mastectomy for cancer in the right breast had undergone three previous procedures (in 1997, 2007, and 2009) for breast reconstruction with implants, without success.In the last surgery, a contralateral breast prosthesis was placed with the purpose of symmetrization.

Surgical Technique
The incision of the reverse abdominoplasty was clearly marked, following the mammary fold and midline up to the xiphoid process.The breast area D, which should be detached from the deep layers, is based on the fold and upper pole of the contralateral breast (Figure 1).After incision and reverse detachment of the supraumbilical abdomen, the abdominal flap was fixed with adhesion sutures, followed by five traction sutures to fix it to the muscle fascia in order to prevent it from sliding down (Figure 2 A-B).The excess right dermal-fat flap was decorticated in its distal half, pulled in the cephalic direction and invaginated under the previously detached skin of breast region D, serving as a protective cushion for the breast implant.The skin of the lower portion was maintained for reconstruction of the lower breast pole (Figure 3 A-D).
The excess left flap was discarded and accommodated to the edge of the breast fold on that side.
The de-epithelialized dermal-fat flap was set in the upper pole by five mattress sutures through the skin, impeding the sliding of the flap (Figure 4. A-B).Thereafter, a 255-ml polyurethane breast implant was placed.The formation of the new infra-mammary fold was created using attachment points from the periosteum of the 6 th rib.
A vacuum drain was placed in the detached abdominal area as well as in the breast implant pocket D, with outlets in the medial and lateral scar, respectively, and removed on the 4 th day after surgery, with a net volume of less than 30ml.
Two years later, symmetrization was obtained through mastopexy with a change of the polyurethane prosthesis in the left breast (255ml to 145ml).

RESULTS
In the immediate postoperative period, the patient presented signs of inflammation in the right breast area, especially in the upper pole, which were treated with corticosteroid therapy for two weeks, resulting in complete regression of all signs and symptoms.
Seroma (20 ml) was aspirated with a syringe on the 15 th day after surgery, with no recurrence.
The sternal region (at the height of the drain) presented a small suture dehiscence, resulting in a hypertrophic and unsightly scar; this scar was revised 13 months after surgery.
Figure 5 shows the preoperative findings, and Figure 6 shows the results of the reconstruction and symmetrization after the second surgical procedure (two years later).

DISCUSSION
Mastectomy is highly traumatic for many women, and breast reconstruction is an essential procedure to improve the psychosocial well-being and quality of life of these patients 1 .
Conservative techniques 7,8 involving breast prostheses 9,10 have changed the trends in breast reconstruction, and influenced the advances of several modern techniques.The resulting diversity of breast reconstruction techniques enables an adequate selection for each individual case, thus offering better results.
Most breast reconstruction procedures provide sufficient coverage and volume 2,4,9,14 ; however, breast prostheses are essential to enhance the volume and shape of the breasts and for improving the results [8][9][10] .
In some cases, despite having preserved anatomy, the subcutaneous tissue may be scarce or absent, hence preventing the placement of the prostheses.
In such cases, when placed, they may externalize and require removal.
In addition, many procedures use local flaps of the upper abdominal region for breast reconstruction [27][28][29][30][31] .Reverse abdominoplasty, initially described by Rebello-Franco 37 and recently reviewed and improved by Deós, can provide sufficient tissue from the upper abdomen to cover the breast implant 36 .
Alternatively, the excess flap resulting from reverse abdominoplasty may be another option for breast reconstruction in well-selected patients who have supra-umbilical abdominal flaccidity.

CONCLUSION
Breast reconstruction with an abdominal flap resulting from reverse abdominoplasty displayed satisfactory results in the case described herein, and may represent an alternative option for breast reconstruction in a select patient population.
a) Absence of right breast volume, scar retraction, and thin skin adhering to the deep planes, without subcutaneous tissue and with traces of the nipple areola complex.b) Contralateral breast with volume provided by silicone prosthesis, without changes.c) Upper abdominal flaccidity with sufficient fat volume to use as a dermal-fat flap for covering the breast implant.

Figure 3 .
Figure 3. (B) -Assessment of the area to be decorticated and invaginated.

Figure 4 .
Figure 4. (B) -End suture and placement of a vacuum drain.