Latissimus dorsi free flap for reconstruction of extensive full-thickness abdominal wall defect. A case of desmoid tumor

Patient satisfaction after nipple-sparing mastectomy with intraoperative radiotherapy and breast reconstruction for breast cancer

INTRODUCTION

The use of nipple-sparing mastectomy (NSM) combined with breast reconstruction is increasing in breast cancer surgeries despite its controversial safety profile. To reduce the recurrence rate of tumors in the nipple-areola complex (NAC), we used intraoperative radiotherapy (IORT). The purpose of this study was to explore patients' feedback on this novel treatment strategy.

PATIENTS AND METHODS

From January 2014 to May 2018, eligible patients with breast cancer were enrolled in this study and separated into 2 groups. Patients in the NSM group underwent IORT to the NAC flap, and patients in the skin-sparing mastectomy (SSM) group underwent SSM and breast reconstruction. The postoperative satisfaction was collected and assessed using the Breast-Q reconstruction questionnaire and a standardized questionnaire; this was compared between the 2 groups.

RESULTS

There were 46 patients (52 NSMs) in the NSM group and 20 patients (22 SSMs) in the SSM group. The breast-Q scores were higher in the NSM group than the SSM group, with trends for a 'higher satisfaction with breasts' (67.39 ± 20.59 vs. 55.00 ± 19.33; p = 0.026) and 'higher sexual well-being' (61.74 ± 22.24 vs. 49.50 ± 20.12; p = 0.039). All the patients recognized the importance of nipple preservation. Thirty-seven women (80.40%) were satisfied or very satisfied with the appearance and shape of the NAC in the NSM group, while 38/46 women (82.60%) were very unsatisfied or unsatisfied with the sensitivity of the nipples.

CONCLUSIONS

The Breast-Q scores showed great satisfaction with breasts and sexual well-being in the NSM group. However, more effort should be made in improving postoperative NAC sensitivity.

Less-invasive fascia-preserving surgery for abdominal wall desmoid

The mainstay of treatment for desmoid has been shifted to active surveillance (AS). However, surgery is still being performed on abdominal wall desmoid with a wide surgical margin. The purposes of this study are to clarify the treatment results of less-invasive, fascia preserving surgery for patients with abdominal wall desmoid, and to propose a new treatment modality. Since 2009, 34 patients with abdominal desmoid have been treated in our institution. Among them, as a final treatment modality, 15 (44%) were successful with AS, 15 were subjected to less-invasive surgery, and 4 methotrexate and vinblastine treatment. The clinical results of less-invasive surgery were clarified. In the surgical group, although the surgical margin was all microscopic positive (R1), only one patient (6.7%), who has the S45F mutation type of CTNNB1, showed recurrence, at a mean follow-up of 45 months. There were no patients with familial adenomatous polyposis (FAP)-related desmoid in this cohort. Only two patients (13%) required fascia lata patch reconstruction after removal of the tumor. In patients with non FAP-related abdominal wall desmoid, less-invasive, fascia preserving surgery is recommended as a favorable option as active treatment. Based on the results of this study, multi-institutional further research is warranted with an increased number of patients.

The Anatomic Feasibility of a Functional Chimeric Flap in Complex Abdominal Wall Reconstruction

BACKGROUND

Dynamic and functional abdominal wall reconstruction (FAWR) remains a complex challenge. The ideal flap should have a minimal donor-site morbidity and cover a large surface area with motor and sensory capabilities. The goal was to investigate the feasibility of using a free chimeric flap with anterolateral thigh (ALT) and rectus femoris (RF) components pedicled only on the motor nerve branch.

METHODS

Ten fresh cadavers were dissected with a designed chimeric thigh flap including ALT and RF flaps. Anterolateral thigh was designed and raised with the lateral femoral cutaneous nerve integrated, and the descending branch of the lateral circumflex femoral artery was preserved. Rectus femoris was elevated and the common pedicle was dissected up to the femoral origin. Accompanying motor nerve branches were carefully dissected to their femoral origin.

RESULTS

Twenty RF flaps were dissected and 9 were harvested as a true chimeric flap with ALT. The mean number of neurovascular bundles associated with RF flap was 2.11 ± 0.47, and the mean primary motor nerve average length was 9.40 ± 2.42 cm. The common vascular bundle in all 9 chimeric flaps was ligated, and the flap was rotated toward the abdomen pedicled only by primary motor nerve of the RF muscle. Nerve length was adequate for reach up to xiphoid area in all 20 flaps.

CONCLUSIONS

This study demonstrates the feasibility of the chimeric ALT/RF muscle free flap pedicled only by the motor nerve branch, with adequate flap rotation. Even with the limitations in a live patient, this flap would be an excellent option for FAWR in the right patient.

[Case report: Epigastric dermatofibroma reconstruction by reverse abdominoplasty with umbilic transposition]

Dermatofibrosarcoma is the most common cutaneous sarcoma. Its surgical management is a technical challenge due to the high amount of substance loss. We explain a new technique of abdominal wall reconstruction by a reverse abdominoplasty with umbilical transposition. This new surgical technique allowed, in one time, the excision and the abdominal wall reconstruction. Functional and esthetic results are really satisfactory.

Reconstructing abdominal wall defects with a free composite tissue flap: A case report

BACKGROUND

Reconstructive repair of huge full-thickness abdominal wall defects following debridement for abdominal electric burns remains a clinically challenging task. An ideal abdominal wall repair means a re-closure of the defected abdominal wall with pedicled neurovascular myofascial flaps, restoration of the abdominal wall integrity, and maintenance of the abdominal wall muscle tension to prevent the occurrence of abdominal wall hernia. When treating huge full-thickness defects, composite autologous tissue flaps are a good option for the repair.

CASE SUMMARY

This study reported the case of a 43-year-old male patient suffering from full-thickness abdominal wall defects complicated with necrosis of multiple bowel segments and duodenal leak following high-voltage burns involving the left upper limb and abdomen. After debridement for abdominal electric burns and end-to-end anastomosis for the necrotic bowels, reconstruction with acellular dermal matrix grafting and vacuum sealing drainage were performed for temporary abdominal closure. The remaining 18 cm × 15 cm full-thickness abdominal wall defect was repaired using a combined anterolateral thigh and tensor fascia lata free flap. The proposed method achieved the functional reconstruction of the abdominal wall.

CONCLUSION

This approach restored the abdominal wall integrity, maintained certain muscle tension, avoided abdominal hernia, reached satisfactory aesthetic effect, and resulted in no complications in the grafting regions.

Complex abdominal wall reconstruction after oncologic resection in a sequalae of giant omphalocele: A case report

INTRODUCTION

Trauma injuries and oncologic resection are common aetiologies of complex abdominal wall defect. Reconstruction of abdominal wall is an everlasting question for general, paediatric and reconstructive surgeons. The plethora of techniques, bioprosthetic and engineered tissues offer countless possibilities.

PRESENTATION OF CASE

The patient was a 28 years old woman, with past history of untreated giant liver omphalocele, admitted for a suspicious hepatic tumefaction without specific clinical signs. The thoraco abdominopelvic CT scan revealed lung metastasis and a bilobed left hepatic tumour. Pre-operative cytologic findings of mild differentiated hepatocellular carcinoma differed from the post-operative findings of hepatoblastoma. The full-thickness abdominal wall defect after a radical resection was reconstructed with a combined acellular dermal matrix, NPWT and skin graft solution. A total epithelization was obtained after 8 weeks follow-up.

DISCUSSION

Hepatoblastoma in adult is rare, with no consensus. A radical resection in context of giant untreated omphalocele is an unusual challenge for the surgical team. The pre-operative evaluation, the defect classification and the general conditions of the patient are paramount steps for an appropriate reconstruction. Primary or delayed reconstruction with myocutaneous flap as gold standard, depends on the oncologic management and anticipated post-operative complications. Acellular dermal matrix used for a bridged fascial repair directly on viscera and covered by NPWT, favourited a healthy granulation tissue. The full-thickness defect was then reconstructed with an ADM, NPWT and skin graft instead of an association with the myocutaneous flap. The patient follow-up was emphasized in the hepatoblastoma, but the complications of this reconstruction strategy are unknown. A total epithelization was obtained, the abdominal bulge or hernia is the first complication under surveillance.

CONCLUSION

Delayed reconstruction after an oncologic large abdominal wall resection has the advantage to manage post-operative complications and prepare alternative solutions. Acellular dermal matrix was not first designed for skin tissue regeneration, some authors as us experimented the conclusion that this matrix could be used for permanent abdominal wall reconstruction.

Clinical features and long-term outcomes of aggressive fibromatosis of the abdominal wall after surgical resection: A retrospective study and literature review

AIM

Aggressive fibromatosis of the abdominal wall is easily misdiagnosed prior to surgery as abdominal wall endometriosis or other tumors. The authors intend to evaluate the clinical features and outcomes of aggressive fibromatosis of the abdominal wall after surgical resection.

METHODS

We retrospectively analyzed the data from 24 patients treated in the First Hospital of China Medical University from January 2011 to June 2019 and discussed the characteristic of this disease after a review of literature worldwide.

RESULTS

Most patients were female (91.7%) with a mean age of 33 years (range 26-56 years). The most common symptom was progressive abdominal wall discomfort (ie, abdominal pain) in 16 patients (66.7%). Twelve patients (50%) had a history of cesarean section. All 24 patients underwent surgical R0 resection due to progression of disease or pain, including 12 patients treated with simple tumor resection and 12 patients treated with tumor resection followed by abdominal wall tension-free repair using synthetic mesh. Postoperative complications included incisional infection in three patients (12.5%), incisional hernia and postoperative bleeding in one patient each (4.2%). The local recurrence rate was 12.5%.

CONCLUSIONS

Aggressive fibromatosis of the abdominal wall mainly occurs in young women after cesarean section or other surgeries, with a high recurrence rate. Radical resection is an optimal treatment for the patients with progressive cases, and the restoration of extensive defects of the abdominal wall can be achieved with synthetic mesh, which leads to a good restoration of abdominal wall integrity.

Patient satisfaction in one-stage immediate breast reconstruction after mastectomy: A multi-center comparative patient evaluation of prosthesis, LDMF, and TRAM techniques

To analyze patient satisfaction and the predictive factors characterizing three types of one-stage immediate breast reconstruction (IBR) after mastectomy, including prosthesis, latissimus dorsi myocutaneous flap (LDMF), transverse rectus abdominis myocutaneous (TRAM) flap techniques.Data were collected via face-to-face or telephone interviews from eight breast centers in China from January 2012 to December 2016. A standardized questionnaire that evaluated the general satisfaction and aesthetic satisfaction was sent to patients who had undergone IBR. Logistic regression analysis was performed to identify risk factors associated with patient satisfaction among the three types of breast reconstruction.A total of 412 questionnaires were sent out, and 309 copies were collected including 226 prosthesis, 46 LDMF, and 37 pedicle TRAM reconstruction. Logistic regression analysis showed that general satisfaction and aesthetic satisfaction were significantly correlated with radiotherapy (P < .001, P = .018), respectively. Besides, the aesthetic satisfaction was also associated with nipple-areola complex (NAC) preservation (P < .001).Our multi-center study identified factors of higher patient satisfaction, like NAC preservation and absence of radiotherapy, in order to help breast surgeons make better decisions about individualized reconstruction plan.

Nipple-Sparing Mastectomy and Immediate Breast Reconstruction With a Deep Inferior Epigastric Perforator Flap: A Study of Patient Satisfaction

INTRODUCTION

The morphological result of nipple-areola complex (NAC) reconstruction may be disappointing for patients who undergo skin-sparing mastectomies and immediate breast reconstruction, followed by secondary reconstruction of the nipple-areola complex.The aim of this study was to analyze patient satisfaction after nipple-sparing mastectomy and immediate breast reconstruction with a deep inferior epigastric perforator flap.

MATERIALS AND METHODS

Our retrospective study involved all patients who underwent an immediate breast reconstruction after unilateral mastectomy with conservation of the NAC. The following three kinds of surgical approach were used: mastectomy with periareolar incision, mastectomy with hemiperiareolar incision and lateral extension, and mastectomy with inverted-T mammoplasty incision. Our study was based on a survey using a standardized questionnaire and a Likert scale to report patient satisfaction on the basis of criteria defined by the investigators.

RESULTS

We evaluated 17 patients. All reconstruction patients were satisfied or very satisfied with the overall aesthetic appearance, projection, and volume as well as the appearance of scarring on the reconstructed breast. None of our patients reported dissatisfaction in response to the criteria under evaluation. A periareolar incision was used most often to perform the mastectomy (10 patients). Partial NAC necrosis was observed in five patients, without negatively influencing their perception of the morphological outcome of their reconstruction.

CONCLUSIONS

Immediate breast reconstruction using a deep inferior epigastric perforator free flap after nipple-sparing mastectomies met with a high rate of general satisfaction among patients and resulted in a low rate of nipple-areola complex necrosis.

Complex abdominal wall reconstruction, harnessing the power of a specialized multidisciplinary team to improve pain and quality of life

INTRODUCTION

Patients who require highly complex abdominal wall hernia repair with composite soft tissue free flap coverage represent the most challenging population, and the most difficult to definitively treat. For many, this combined procedure represents their last chance to restore any sense of normalcy to their lives. To date, patient reported post-operative outcomes have been limited in the literature, in particular, quality of life has been an under-reported component of successful management.

METHODS

Patient-reported outcomes were analyzed using the 12-question HerQLes survey, a validated hernia-related quality of life survey to assess patient function after complex abdominal wall reconstruction. Using synthetic mesh for structural stability, and microsurgical flaps for soft tissue coverage, ten consecutive heterogeneous patients underwent repair of massive abdominal wall defects. Baseline preoperative HerQLes and numerical pain scores were then compared to those obtained postoperatively (at or greater than 6 months).

RESULTS

All patients experienced improvement in their quality of life and pain scores post operatively with average follow-up at 15.9 months, even in those who experienced complications. All microsurgical flaps survived. There were no hernia recurrences.

CONCLUSION

Despite the extraordinary preoperative morbidity of massive abdominal wall defects, with an experienced General Surgery and Plastic Surgery multidisciplinary team, these highly complex patients are able to achieve a significant improvement in their pain and quality of life following repair and reconstruction with complex mesh hernia repair and microsurgical free tissue transfer.

Complete resection of a rectus abdominis muscle invaded by desmoid tumors and subsequent management with an abdominal binder: a case report

Background

Desmoid-type fibromatosis is characterized by desmoid tumors, which are benign soft tissue tumors that can be locally aggressive but typically do not metastasize. Desmoid tumors can manifest anywhere in the body, and those in the abdominal cavity account for approximately 30 to 50% of all such tumors. Complete resection with free margins has been the standard treatment, but non-surgical therapies have been implemented recently. However, if tumors are strongly invasive and/or persistently recur, radical surgical resection with free margins remains the primary treatment. Unfortunately, radical resection may cause large abdominal defects and hinder reconstruction. Several reports and recommendations have addressed this issue; however, to the best of our knowledge, few reports have described complete resection and the subsequent reconstruction of the rectus abdominis muscle.

Case presentation

A 35-year-old Asian woman presented at our hospital with a chief complaint of abdominal pain. She had abdominal desmoid tumors that required complete resection of her rectus abdominis muscle. Due to necrosis in her own reconstructed tissue, we failed to cover her anterior abdominal wall; thus, we used an abdominal binder as a substitute material to avoid exacerbating the incisional hernia and help her generate intra-abdominal pressure.

Conclusions

This case report may be informative and helpful for the treatment of patients with desmoid tumors, as managing desmoid-type fibromatosis is difficult.

Abdominal wall reconstruction after desmoid type fibromatosis radical resection: Case series from a single institution and review of the literature

BACKGROUND

Abdominal wall desmoid type fibromatosis management has been changing over recent years, from an aggressive approach towards a more conservative one. When radical resection is indicated, the surgical team faces the challenge of abdominal wall reconstruction, for which optimal technique is still debated. The present study reports the experience from a single center with abdominal closures after desmoid type fibromatosis resection.

MATERIAL AND METHODS

Retrospective analysis of patients who underwent abdominal wall closure after sporadic abdominal desmoid type fibromatosis radical resection from 1982 to 2013.

RESULTS

Twenty-seven patients were included, mean tumor diameter was 10 + 5.3 cm, and the main choice of abdominal wall reconstruction was midline closure with anterior rectus sheath relaxing incisions and polypropylene onlay mesh (74% of the cases). Only 7% of the cases required more complex procedures for skin closure. Mean follow-up was 5 years and 89% remained disease-free. No grade 4 or 5 complications were observed.

CONCLUSION

High midline fascial closure rate can be achieved after resection of abdominal wall desmoid tumor using relaxing incisions and mesh, with low complication rate.

Reconstruction of an abdominal wall defect with biologic mesh after resection of a desmoid tumor in a patient with a Gardner's syndrome

INTRODUCTION

Desmoid tumors are rare proliferative and invasive benign lesions. They can be sporadic, but in most instances, desmoid tumors develop in the context of Gardner's syndrome with principal localization in the abdominal cavity and abdominal wall.

CASE-REPORT

We report the case of a 24-year-old female presenting Gardner's syndrome with a symptomatic abdominal wall desmoid tumor. Lack of response to medical treatment led to surgical management consisting in a complete resection and parietal reconstruction with a biologic mesh. Postoperative course was uneventful and there was no evidence of recurrence at 12 months of follow-up.

DISCUSSION

Conventional treatment of abdominal wall desmoid tumors consists in a wide and radical resection. However, complete resection is not always feasible because of difficulty to differentiate the desmoid tumor from adjacent tissues. The surgical approach may require different techniques to repair the parietal defect including prosthetic material such as synthetic or biologic meshes. Biological mesh is an ideal alternative to synthetic graft, mainly in case of infection.

CONCLUSION

We have encountered a case of a symptomatic growing desmoid tumor of the abdominal wall in a young patient with Gardner's syndrome, successfully treated by complete resection and reconstruction with a biologic mesh to correct the parietal defect.

Reconstruction of Desmoid Tumors: Case Series and Systematic Review

BACKGROUND

Desmoid tumors (DT) represent a group of rare, distinct lesions. There are few published studies examining outcomes and safety of complex reconstruction after DT resection.

METHODS

A retrospective review identified 39 patients who underwent surgical treatment of DT at St. Jude Children's Research Hospital over a 12-year period. A systematic review of the literature identified 17 further studies for inclusion. Treatment characteristics were analyzed.

RESULT

Thirty-nine patients were treated during the study period, with a total number of 67 resections. Median age was 12.2 years; 49% of patients were male, and 51% were female. Median tumor size was 9.8 cm. DT most commonly arose in the extremities (40%), thorax (23%), head and neck (21%), and trunk (16%). One- and 5-year recurrence-free survival were 97.1% and 73.1%, respectively. The majority of defects were closed primarily, with the exception of head and neck defects. Long-term outcomes were good for chest, abdomen, and upper extremity defects, but were problematic for head and neck, breast, and lower extremity defects. There were no recurrences at the site of flap harvest in either the study population or in reviewed studies.

CONCLUSION

For patients with DT, surgical extirpation should not come at the expense of functional preservation, as overall survival is excellent. However, specific defects, including those of the lower extremity, breast, and head and neck, will benefit from improved techniques for resection and reconstruction.

Complex abdominal wall defect reconstruction using a latissimus dorsi free flap with mesh after malignant tumor resection

PURPOSE

Extended and full-thickness abdominal wall defects are commonly reconstructed using free flaps. Published surgical outcomes involving the latissimus dorsi (LD) free flap procedure are limited and are less numerous than those with free flaps involving the thigh. The aim of this report was to describe the immediate and long-term evaluation of complex abdominal wall reconstruction using a LD free flap with mesh.

PATIENTS AND METHODS

Between 2005 and 2013, nine patients with extended malignant tumors of the abdominal wall underwent surgeries. After the surgical resection, the mean defect size was 385 cm² (range: 190-650 cm² ). Full-thickness abdominal wall reconstruction was performed with a combination of LD free flaps and meshes. The immediate and long-term outcomes were assessed regarding the complications, sustainable strength of the abdominal wall and cancer recurrence.

RESULTS

The meshes measured 927 cm² in average (range: 500-1036 cm² ). Eight Parietex Composite® and 1 Bard Collamend Implant® were used. No donor site complications occurred, and complete LD flap survival was achieved without partial necrosis or thrombosis. One obese patient who received a porcine dermis mesh developed an eventration four days postoperatively and exhibited a limited amount of abdominal skin necrosis around the flap. Two patients died from cancer evolution. After a mean follow-up of 60.4 months (range: 29-94 months), clinical evaluation of the abdomen revealed 2 patients without anomalies, 4 cases of abdominal bulging without functional discomfort and 1 case of major abdominal distension.

CONCLUSIONS

Complex abdominal reconstruction with LD free flap and mesh allows extended satisfactory coverage with a low incidence of flap and donor site complications. However, patients should be advised of the significant risk of abdominal bulging. © 2014 Wiley Periodicals, Inc. Microsurgery 37:38-43, 2017.

Reconstruction of infected abdominal wall defects using latissimus dorsi free flap

INTRODUCTION

Infected abdominal defects are a challenge to surgeons. In this study, we describe 10 cases in which the latissimus dorsi myocutaneous flap was used for successful reconstruction of abdominal wall defects severely infected with methicillin-resistant Staphylococcus aureus (MRSA).

METHODS

Retrospective review of 10 patients with abdominal wall defects that were reconstructed using the latissimus dorsi myocutaneous flap between 2002 and 2010. All patients had abdominal defects with hernias, combined with MRSA infections. The sizes of the flaps ranged from 120 to 364 cm(2) . The deep inferior epigastric artery was the recipient vessel in nine patients and the internal mammary vessels were used for one patient.

RESULTS

There were no complications relating to the flaps, although there were other minor complications including wound dehiscence, haematoma and fluid correction. After reconstruction, there were no signs of infection during follow-up periods, and the patients were satisfied with the final results.

CONCLUSION

Reconstruction using the latissimus dorsi myocutaneous flap, including muscle fascia structures, is a potential treatment option for severely infected large abdominal wall defects.