Thoracoabdominal Flap: a Simple Flap for Covering Large Post-mastectomy Soft Tissue Defects in Locally Advanced Breast Cancer

Abstract

Locally advanced breast cancer (LABC) constitutes 40-50% of breast cancer in developing countries. Large soft tissue defects after mastectomy often require some additional cover. The primary aim of reconstruction in this group should be an expeditious and simple closure with good-quality skin cover, early recovery, and short hospital stay so that the patients can receive early post-operative radio-chemotherapy. Thoracoabdominal (TA) flap is a type-c fasciocutaneous flap and the skin and fat of the upper abdomen are used, based on medial or lateral perforating vessels. We present our experience of TA flap cover for large post-mastectomy defects. A retrospective analysis of prospectively maintained breast cancer database in the Department of Surgical Oncology from January 1994 to December 2017 at All India Institute of Medical Sciences, New Delhi, was performed. The medical records of patients undergoing TA flap cover were analyzed to assess operative duration, blood loss, post-operative morbidity, hospital stay, adjuvant treatment, recurrence patterns, and survival outcome. A total of 3142 breast cancer patients underwent surgery, of which 1840 were LABC and 88 patients (4.13%) of LABC required flap cover for the closure of mastectomy defect. TA flap was used in majority of these patients 72/83 (86.7%) for cover. Majority was stage IIIB (54 out of 72) and we could achieveR0 resection in all patients. TA flap was done following MRM in 60 patients and RM in 12 patients. Upfront primary surgery was performed in 27 patients and 45 underwent surgery after neoadjuvant chemotherapy. Most commonly laterally based flaps were done, except 4 medially based flaps. The mean operating time was 30 min and blood loss was 45 ml. Mean hospital stay was 4.45 days. Superficial flap necrosis occurred in 6 and wound infection in 4 patients, all managed conservatively. Only 2 patients had major flap loss and required debridement and skin grafting. Planned post-operative radiation could be delivered in most of the patients in time. At a mean follow-up of 24 months, only 9 out of 72 (12.5%) patients had a loco-regional recurrence. Results of our experience show that TA flap is a simple, cost-effective procedure for managing large post-mastectomy soft tissue defects in LABC. It has huge potential in developing countries dealing with a large number of LABC because of simplicity and short learning curve.

Keywords: Locally advanced breast cancer; Post-mastectomy defects; Thoracoabdominal flap (TA flap).

Fig. 1

Showing a laterally based TA flap for large post-mastectomy defect

Fig. 2

Laterally based TA flap to cover post-mastectomy defect and donor site closure

Fig. 3

Showing medially based TA flap for large post-mastectomy defect