Reverse Abdominoplasty: A Novel Practical Approach Using Oncoplastic Reconstruction in Managing Major Chest Wall Defects for Patients With Loco-Regional Recurrence Following Breast Cancer Surgery

Abstract

Background Loco-regional recurrence of breast cancer in patients with large chest wall defects following mastectomy poses significant oncoplastic challenges. Reverse abdominoplasty is most commonly used to treat patients with excess upper abdominal soft tissue and laxity following massive weight loss. Widely employed as a technique for aesthetic contouring of the upper anterior trunk, as well as in augmentation mammoplasty, its use to date for reconstructive purposes is mainly limited to burns and large site surgical tumour ablation. Method Here we review our experience of using reverse abdominoplasty as a novel approach to filling major anterior chest wall defects in patients with cutaneous manifestations of loco-regional or distant recurrence of breast cancer. Results Seven patients with metastatic breast cancer underwent reverse abdominoplasty for disease recurrence following mastectomy, with good patient-reported outcomes, and minimal surgical complications. Moreover, follow-up data in the patients surveyed also showed minimal to no limitations on their activities of daily living following the procedure. Conclusion Here we demonstrate the successful employment of reverse abdominoplasty - a technique not usually reserved in breast oncoplastic surgery - to treat fungating breast lesions and/or other manifestations of loco-regional recurrence in metastatic breast cancer. This may herald a paradigm shift in the way surgeons approach breast cancer recurrence in patients with pre-existing major chest wall defects.

Keywords: aesthetic abdominoplasty; chest wall repair & reconstruction; locally advanced breast-cancer; modified radical mastectomy (mrm); oncological reconstruction.

Figure 1. Case 1, IH

Figure 1A: Preoperative appearance, ulcerating right breast mass. Figure 1B: Close up of ulcerated lesion, defect measuring 14.0x10.0cm. Figure 1C: Immediate post-operative appearance following right-sided mastectomy and reverse abdominoplasty.

Figure 2. Case 2, LT

Figure 2A: Left primary breast cancer (grade three invasive ductal carcinoma) with cutaneous metastases. Figure 2B: Intra-operative mobilisation of superior and inferior flaps. Figure 2C: Reverse abdominoplasty and z-plasty used to close wound.

Figure 3. Case 3, RP

Figure 3A: Anterior view of left breast lesion – grade two invasive lobular carcinoma. Defect measured 31.7cm (width), 9.6-14.7cm (superior to inferior) Figure 3B: Intra-operative view at time of removal of right breast and axillary contents. Figure 3C: Chest wall defect following bilateral mastectomy. Figure 3D: Post-operative appearance of closed abdominal and chest wall defect.

Figure 4. Case 4, AF

Figure 4A, 4B: Anterior and close-up views of fungating lesion through the left breast with skin breakdown. Figure 4C: Anterior view of thoracic defect following left mastectomy. Figure 4D: Anterior view of closure of defect using reverse abdominoplasty.

Figure 5. Case 5, MB

Figure 5A: Regional recurrence - fungating right breast IDC on a background of ipsilateral DCIS; (IDC: invasive ductal carcinoma; DCIS: ductal carcinoma in-situ). Figure 5B: Postoperative appearance following mastectomy and reverse abdominoplasty.

Figure 6. Case 6, GM

Figure 6A: Preoperative appearance; recurrence at right mastectomy scar with metastatic spread to left sided axillary lymph nodes. Figure 6B: Postoperative appearance. Closure with 2'0 Vicryl interrupted deep dermal sutures & 3'0 Monocryl subcutaneous sutures.

Figure 7. Case 7, DV

Figure 7A: Preoperative appearance; left breast tumour with overlying cutaneous metastases. Figure 7B: Intra-operative appearance; chest wall defect following left mastectomy tissue removal, with superior flap raised to clavicle. Figure 7C: Intra-operative appearance; left chest wall defect following removal of breast tissue and dissection of inferior flap to level of umbilicus Figure 7D: Post-operative appearance following closure of left chest wall defect using reverse abdominoplasty technique. Two drains in situ in left axilla and anterior rectus sheath in inferior flap.