Ann Surg Treat Res.  2019 Oct;97(4):168-175. 10.4174/astr.2019.97.4.168.

Single vertical incision thoracoabdominal flap for chest wall reconstruction following mastectomy of locally advanced breast cancer

• Min K
• Choi EJ
• Lee YH
• Eom JS
• Son BH
• Ahn SH
• Kim EK

• KMID: 2459314
• DOI: http://doi.org/10.4174/astr.2019.97.4.168

Abstract

PURPOSE
Skin grafts have been widely used in managing extensive chest wall defects after mastectomy for advanced breast cancer. However, their durability and tolerability to radiotherapy is still controversial. A thoracoabdominal (TA) flap with a few technical refinements can safely transfer a larger flap while minimizing complications.
METHODS
From January 2007 to February 2018, a retrospective review was performed to compare 2 groups after wide breast excision: skin graft group (group 1) and lateral-based, single vertical incision rotation-advancement TA flap (group 2). Patients' demographics, operative details, complications, hospital stay, postoperative outpatient visits, cost, and start of adjuvant therapy were analyzed between the 2 groups.
RESULTS
During the study period, 34 patients received skin graft and 41 patients received TA flap. group 2 had a shorter hospital stay (6.41 ± 2.64 days vs. 12.62 ± 4.60 days, P < 0.001) and shorter time to complete wound healing (29.27 ± 18.68 days vs. 39.24 ± 27.70 days, P = 0.03) than group 1. There was also a difference in the period from surgery to initiation of adjuvant therapy (group 1, 45.04 days ± 17.79 days; group 2, 37.07 ± 15.38 days, P = 0.073). Although limitation in shoulder motion was more frequent in group 2, limitation of motion for >1 year was observed in 4 patients in only group 1 (43.90% vs. 38.24%, P = 0.613).
CONCLUSION
TA flap has a simple design that minimizes concerns involving the donor site. Moreover, it does not require complicated procedures and allows for re-elevation whenever necessary. Finally, it guarantees faster wound recovery than skin graft with fewer complications.

Keyword

Breast neoplasms; Chest wall; Inflammatory breast neoplasms; Reconstructive surgical procedure; Surgical flaps

MeSH Terms

Breast Neoplasms*
Breast*
Demography
Humans
Inflammatory Breast Neoplasms
Length of Stay
Mastectomy*
Outpatients
Radiotherapy
Reconstructive Surgical Procedures
Retrospective Studies
Shoulder
Skin
Surgical Flaps
Thoracic Wall*
Thorax*
Tissue Donors
Transplants
Wound Healing
Wounds and Injuries

Figure

• 

  Fig. 1 Flap design and tissue mobilization. (A) Schematic presenting directions of tissue mobilization. (B) Design of the single vertical incision thoracoabdominal flap; schematic presenting the lateral intercostal, superior epigastric, and deep inferior epigastric perforating vessels. (C) Immediate postoperative image. (D) Intraoperative image after locally advanced breast cancer mastectomy.

• 

  Fig. 2 Measures to prevent tension-related complications. (A) A tension-releasing suture was applied at the middle of the flap between Scarpa's fascia of the flap and anterior rectus sheath (arrow). (B) Lateral redundant tissue (arrow) could be used as a donor site for skin grafting in case of excessive closing tension or compromised flap tip circulation. (C) A small full-thickness skin graft was inserted (arrow) due to excessive closing tension. (D) Two months after completion of adjuvant radiation therapy of patient in panel C.

• 

  Fig. 3 Clinical images of the representative case. (A) A 43-year-old patient diagnosed with invasive ductal carcinoma (cT4dN3M0). (B) At the end of 4 cycles of neoadjuvant chemotherapy with adriamycin and cyclophosphamide. (C) After another 4 cycles of docetaxel, just before surgery. (D) Defect after wide excision of locally advanced breast cancer after neoadjuvant chemotherapy. (E) Adjuvant radiation therapy was started on postoperative day 41.

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  Fig. 4 Rotation-advancement flap transfer and mobilization of the tissue from the upper and lateral parts resulted in a closing line at the center of the initial defect. (A) A 34-year-old patient diagnosed with invasive micropapillary carcinoma (T3N3M0) during adjuvant radiation therapy. (B) A 32-year-old patient with IDC (T4N2M1) after completion of adjuvant radiation therapy. (C) A 43-year-old patient with IDC (T3N0M0) after completion of adjuvant radiation therapy. (D) A 67-year-old patient with myxofibrosarcoma, 1 month postoperatively. IDC, invasive ductal carcinoma.

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