Tensioned reverse abdominoplasty for reconstruction of large post-mastectomy defects

1 American University of Beirut Medical Center, Beirut, Lebanon. Conflicts of interest: none. As opções reconstrutivas para defeitos da parede anterior do tórax podem ser desafiadoras especialmente quando o defeito é extenso e sujeito a radioterapia pré-operatória. Apresenta-se caso de paciente com carcinoma ductal invasivo de mama não tratado que realizou radioterapia e quimioterapia incompleta no pré-operatória. O exame patológico revelou carcinoma ductal invasivo de 11,5 cm, grau III, com invasão linfovascular e linfonodos axilares positivos (20/20). Após a mastectomia, defeitos estendidos seguido de longa excisão de pele mediram 25 x 20 cm, sendo esses cobertos imediatamente com retalhos em abdominoplastia reversa tensionada. Trata-se do primeiro caso relatado de excisão larga de mastectomia reconstruída exclusivamente com retalhos avançados em abdominoplastia reversa e alta tensão progressiva de pontos de adesão demostrando que nos pacientes selecionados, a pele abdominal pode ser avançada superiormente com segurança e facilidade para atingir a área superior do tórax e cobrir a área com defeito significante. ■ RESUMO


INTRODUCTION
The current advances in screening modalities and improved awareness are enabling the diagnose of most breast cancers at early stages; subsequently, less aggressive ablative surgery such as partial mastectomy, skin preserving and nipple preserving mastectomy became the procedure of choice for most newly diagnosed breast cancer patient.Nevertheless, more radical ablation may be required in certain circumstances making reconstruction of the resultant defect a major reconstructive challenge.Various reconstructive options are available 1 .
Although the majority of such defects could be repaired with the use of skin grafts or local and regional pedicled musculocutaneous flaps, more complicated cases require free flaps or increasingly sophisticated reconstructive techniques 2 .Classification systems have been proposed to help the systematic approach for reconstruction.Careful planning is necessary when considering optimal options, however, the exact choice remains specific for each patient depending on defect size, chest wall location, flap arch of rotation, and availability of recipient vessels for autologous microvascular composite tissue transfer [1][2][3][4] .
We present the case of a neglected large invasive ductal breast carcinoma.Following the mastectomy with wide skin excision, the defect was covered with a tensioned reverse abdominoplasty flap.

METHODS
This was a 64 year-old diabetic woman with BMI of 28 and past surgical history of 4 cesarean sections through a midline infraumbilical incision.She presented a massive left breast invasive ductal carcinoma originally diagnosed 4 years earlier.The patient has previously refused the surgery and was noncompliant with chemotherapy.Three months prior to her current presentation, the patient received 12 Gy of radiotherapy over 6 sessions.Subsequently, she developed painful rapid left breast edema and erythema.After ruling out an infectious process, the patient consented to undergo surgery.
Upon physical examination, she had a massively enlarged left breast mass measuring 10x10 cm in the lateral quadrants associated with peau d'orange and tense irradiated skin (Figures 1A and 1B).Besides a low hematocrit of 29, all of her other blood tests were within normal limits.She underwent a palliative left total mastectomy with ipsilateral axillary lymph nodes dissection.During the ablative surgery, the subcutaneous veins were found to be severely enlarged and engorged, therefore, resulting in heavy bleeding that was controlled by the application of heavy hemostatic sutures along the entire surgical incision (Figure 1C) and intra-operative transfusion with 2 units of whole blood.Gross axillary lymph node involvement was also noted extending to the brachial vessels and plexus.The resultant chest wall defect measured 25 x 20 cm (Figure 1D).
In view of the difficulties experienced by the general surgeon to control heavy bleeding and the palliative nature of the surgery with evidence of grossly residual tumor involvement of the axilla, it was necessary to minimize surgical trauma and limit surgical time.It was hence decided to abort the original preoperative plan to undergo TRAM flap with or without Latissimus dorsii flap and proceed to the reconstruction with a reverse abdominal flap.
An undermining of the left upper abdominal quadrant was performed extending to the level of the umbilicus and advanced superiorly to cover the defect with progressive tension 2-0 vicryl quilting sutures anchoring the flap to the lower costal margin and minimizing the dead space to insure closure of the wound under no tension.Two suction drains were inserted and exteriorized at the axilla (Figure 2A and 2B).

RESULTS
The postoperative was uneventful with ambulation of the patient on the postoperative day one.The patient was discharged 2 days after surgery and drains were removed 6 days after surgery (Figure 2C and 2D).Skin staples were removed 12 days after the procedure.The patient had good wound healing with no evidence of seroma collection on follow up at week 5 (Figure 3).thoracoepigastric fasciocutaneous flap, omental flap, the contralateral breast as a glandular/myoglandular flap or even free flaps 2,[5][6][7] .Occasionally, defects are so large that any single flap would be insufficient for coverage necessitating the simultaneous use of a combination of several flaps or complex chimeric flaps 2,5 .
In selected patients, the reverse abdominoplasty has been described as an alternative to pedicled or free flap reconstruction by recruiting adjacent abdominal tissue for reconstruction of thoracic defects following oncologic resections and for release of burn scar contractures in the upper epigastric region.Expanded reverse abdominoplasty was also described in patients with postburn scars involving the entire epigastric region to reconstruct the inframammary folds and correct breast contour.In these reconstructive cases, the upper abdominal wall tissue has been used either as a random or pedicled fasciocutaneous flap or as part of a musculocutaneous flap 1,8,9 .
Upper abdominal tissues have also been used in various forms for breast reconstruction [10][11][12] .In addition to improving upper abdominal contour, augmentation mammaplasty by reverse abdominoplasty (AMBRA) with autologous deepithelialized excess upper adipofascial abdominal wall tissue shaped as implants and transposed subglandularly has also been described 13,14 .The technique may probably be more advantageous for massive weight loss patients in whom upper abdominal contouring with concomitant breast augmentation can be performed to improve breast shape and projection 8,[15][16][17] .
Despite its potential as a reconstructive procedure, the vast majority of reverse abdominoplasties are performed for aesthetic purposes; however, to date, the number of reported aesthetic reverse abdominoplasties remains very limited in the literature written in English language 8 .The technique implies tissue resection of the upper abdomen and results in submammary scars most often crossing the midline 8,16,18,19 .
Pantelides et al. 1 in 2013 revealed two cases only describing the technique for reconstruction following oncological resection since 1984; the first is about closure of a massive chest wall defect resulting from resection of a chronic ulcer after radiation therapy for advanced breast carcinoma by a combination of multiple flaps including pectoralis major advancement flap, reverse abdominoplasty, omental flap, and latissimus dorsiscapular-parascapular musculofasciocutaneous flap 20 .
The second reports a very large dermatofibrosarcoma protuberans located in the epigastric area.After wide resection, the defect was reconstructed with a bilateral superiorly based mammaplasty combined with reverse abdominoplasty 21 .

DISCUSSION
Reconstruction options for anterior chest wall defects can be complex and very challenging particularly following large tumor resection or when radiation therapy has been given pre-operatively or is being planned postoperatively 5 .Soft tissue flaps are often required to achieve primary wound healing when wide skin excision is mandated by oncologic considerations or even to cover alloplastic materials used to stabilize the chest wall 5 .
Many techniques have been described including pedicled muscle flaps such as pectoralis major, latissimus dorsi, rectus abdominis, and external oblique flaps, Quilting sutures, the concepts of high lateral or superior tension abdominoplasty, and the principle of progressive tension sutures are not new; all these have been previously described with abdominoplasties.Results have been greatly improved and morbidity of simple dermolipectomy reduced.Abdominal flap fixation to the aponeurosis with progressive tension sutures not only minimizes the incidence of seroma formation by decreasing dead space and shear forces, it also greatly reduces the risk of skin necrosis and improves scar quality by distributing tension across the whole abdominal flap.It enables proper flap positioning and results in tension-free suture lines [22][23][24][25][26][27][28][29] .
To our knowledge, this is the first case reported on wide skin excision mastectomy reconstructed solely with a reverse abdominoplasty advancement flap and progressive high-tension quilting sutures demonstrating that in selected patient, abdominal skin can be safely and easily advanced superiorly to reach the upper chest area.

CONCLUSION
Reverse abdominoplasty is not a commonly procedure for aesthetic purposes primarily because of the poor quality of inframammary scars reported mainly whenever crossing the midline over the xyphoid 8,28 .Reconstructive potentials of this procedure, however, should not be underestimated.It is probably an excellent option for some patients.The surgical procedure is easy to perform.The dissection of the abdominal flap can be done safely bilateral and extending to under the umbilicus.

Figure 1 .
Figure 1.A, B -Neglected left breast tumor following 6 sessions of radiotherapy with preoperative planning for TRAM flap reconstruction.Midline infra-umbilical C-section scar indicated by an arrow.C, D -Left mastectomy and axillary node dissection with resultant large defect.

Figure 2 .
Figure 2. A -Undermining of the abdominal flap indicated by arrow limited to the left upper quadrant allowing mobilization of enough soft tissues to achieve primary closure of the defect.Costal margin highlighted by white dashed line.B -Abdominal flap advanced superiorly with tension quilting sutures.C, D -Immediate post-operative result demonstrating abdominal flap fixation to the costal margin indicated by single arrow and double arrow indicating additional quilting sutures to minimize dead space.Note superior skin recruitment allowing wound closure without tension.

Figure 3 .
Figure 3. A, B -Stable wound healing 5 weeks after surgery with redundant superiorly recruited abdominal skin preventing tension due to gravity on the scar.

BA
Analysis and/or interpretation of data; conception and design of the study; final approval of the manuscript; writing the manuscript or critical review of its contents; Completion of surgeries and/ or experiments.SD Analysis and/or interpretation of data; conception and design of the study; final approval of the manuscript; writing the manuscript or critical review of its contents; Completion of surgeries and/ or experiments.JA Analysis and/or interpretation of data; conception and design of the study; final approval of the manuscript; writing the manuscript or critical review of its contents; Completion of surgeries and/ or experiments.NP Analysis and/or interpretation of data; conception and design of the study; final approval of the manuscript; writing the manuscript or critical review of its contents; Completion of surgeries and/ or experiments.