Journal of Surgical Oncology 2014;110:930–934
The Use of Unilateral or Bilateral External Oblique Myocutaneous Flap in the Reconstruction of Lower Abdominal Wall or Groin Defects After Malignant Tumor Resection RUMING ZHANG, MD,1,2* CHUNMENG WANG, MD,1,2 YONG CHEN, MD,1,2 BIQIANG ZHENG, MD,1,2 AND YINGQIANG SHI, MD1,2 1
Department of Gastric Cancer and Soft Tissue Sarcomas, Fudan University Shanghai Cancer Center, Shanghai, China 2 Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
Background: External oblique myocutaneous flap (EOMF) has been used successfully for many years in reconstructive plastic surgery, its function is mainly concentrated in the restoration of chest wall defects following breast cancer resection. However, for the lower abdominal wall or groin defects after malignant tumor resection, reconstruction with EOMF is little reported. In this study, we report our experience with EOMF downward transposition to repair the defects. Methods: 12 patients with malignant diseases in the lower abdominal wall or groin underwent aggressive tumor resection, the defects were reconstructed immediately with EOMF. Patient characteristics, details of operation and postoperative complications were described. Results: 12 patients received radical resection, the defect size ranged from 140 to 588 cm2. Ipsilateral or bilateral EOMF was utilized to repair the defects. The EOMF had good quality skin and soft tissue to cover the defects, postoperatively, four patients developed seroma, two patients had distal tip necrosis, but no serious complications occurred, the wound of donor site healed well, no abdominal hernia was found. Conclusion: Our study provides a new and alternative approach to reconstruct large defects with EOMF downward transposition after malignant tumor resection in the lower abdominal wall or groin.
J. Surg. Oncol. 2014;110:930–934. ß 2014 Wiley Periodicals, Inc.
KEY WORDS: external oblique myocutaneous flap; lower abdominal wall; groin; reconstruction
INTRODUCTION Lower abdominal wall or groin defects result from multiple etiologies, including tumor resection, trauma, infection, and wound dehiscence [1]. Such defects require flexible and sophisticated closure, especially for management of refractory and large tumors in the regions, aggressively local excision is necessary to attain optimal effects with clean surgical margin and reduced recurrence [2,3]. However, after massive soft tissue resection, immediate reconstruction of the skin and soft tissue defects is indispensable and challenging. Although rectus abdominis flap [4,5], anterolateral thigh flap [6], and tensor fascia lata flap [7] have been used to reconstruct the defects, it is still controversial to design more appropriate flap for the treatment of these malignant diseases. External oblique myocutaneous flap (EOMF) is frequently utilized in the reconstruction of chest wall defects following advanced breast cancer excision, and studies show that it has the capability of extending far beyond the anatomic territory, it represents an effective way for coverage of chest wall defects [8,9]. However, to our knowledge, EOMF has been seldom applied in the restoration of defects after radical tumor resection in the lower abdominal wall or groin. In our study, unilateral or bilateral EOMF was used to reconstruct lower abdominal wall or groin defects following tumor resection, the results shown that the flap could flexibly provide adequate soft tissue coverage for the defects. Our experience and view on this flap are presented.
PATIENTS AND METHODS Patients From 2005 to 2013, 12 patients (seven males and five females) with malignant disease in the lower abdomen wall or groin were treated by tumor resection and immediate EOMF reconstruction at Shanghai
ß 2014 Wiley Periodicals, Inc.
Cancer Center of Fudan University or Shuguang Hospital affiliated Shanghai University of Traditional Chinese Medicine, the follow‐up time was more than 6 months for each patients. With the institutional review board approval, the surgical treatment was performed, patient demographics, treatment histories, flap types, postoperative complications were summarized in Table I.
Tumor History Four patients had dermatofibrosarcoma protuberanses, two had malignant fibrous histiocytomas, the others were diagnosed as liposarcoma, soft tissue osteosarcoma, vascular myopericytoma, fibrosarcoma, metastatic squamous cell carcinoma, and metastatic adenocarcinoma for one patient each. Of these patients, 10 cases were diagnosed as tumor recurrence, 4 cases had received radiotherapy, the data were summarized in Table I.
Disclosures: There are no potential conflicts of interest with regard to this paper. *Correspondence to: Dr. Ruming Zhang, MD, Department of Gastric Cancer and Soft Tissue Sarcomas, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China. Fax: 86‐21‐64430130. E‐mail: [email protected] Received 8 March 2014; Accepted 28 July 2014 DOI 10.1002/jso.23763 Published online 25 August 2014 in Wiley Online Library (wileyonlinelibrary.com).
Reconstruction of Lower Abdominal Wall or Groin
931
TABLE I. Patient Summary
Case 1 2 3 4 5 6 7 8 9 10 11 12
Sex
Age
Location
Pathology
Relapse (times)
Radiation
Defect size (cm2)
Male Male Female Female Female Male Male Male Female Female Male Male
76 62 65 19 36 56 61 30 37 57 54 62
Groin Groin Groin LAW LAW Groin Groin Groin LAW LAW LAW Groin
Malignant fibrous histiocytoma Dermatofibrosarcoma protuberans Vascular myopericytoma Dermatofibrosarcoma protuberans Dermatofibrosarcoma protuberans Malignant fibrous histiocytoma Dermatofibrosarcoma protuberans Soft tissue osteosarcoma Liposarcoma Metastatic SCC from cervix Metastatic adenocarcinoma Fibrosarcoma
3 7 3 0 3 5 1 1 2 0 1 3
No No Yes No No Yes No No Yes Yes No No
20 16 18 15 18 13 20 13 15 10 14 13 20 13 14 10 21 17 42 14 20 18 20 18
Reconstruction (EOMF) Unilateral Unilateralþ scrotum Unilateral Unilateral Unilateral Unilateral Unilateral Unilateral Unilateralþ patch Bilateralþpatch Bilateraþ patch Unilateral
Complication None None seroma None None seroma Distaltip necrosis None seroma seroma Distaltip necrosis None
LAW: Lower abdominal wall, SCC: squamous cell carcinoma.
METHODS Unilateral EOMF Technique After sufficient resection of tumor located in the one side of lower abdominal wall or groin, an incision at the abdominal median line was made from defect area to the point 2 cm above the xiphoid with the depth to anterior rectus sheath, the anterior rectus sheath was included in this flap. Then lateral separation into the gap between external oblique muscle and internal oblique muscle was performed, the dissection of the EOMF was laterally extended around the anterior axillary line (no more than the mid‐axillary line). The upper transverse incision of the flap was close to the nipple (approximately the 5th rib) and axilla, the attachment of external oblique muscle to the ribs was cut off. The EOMF was not separated until it was satisfied to cover the defect, the umbilicus was preserved, drains were placed, the flap was sutured in place with the incision edges in the lower abdominal wall or groin. The hip should be kept in flexion to reduce incisional tension for 4 weeks after surgery (Fig. 1).
Bilateral EOMF Technique After sufficient excision of tumor located over the abdominal midline, the transverse incisions were extended from the upper corners of defect to bilateral sides, even reached beyond the anterior superior iliac spine. There were two ways to free the flap, one was the stealth method: an incision about 10 cm at the thoracoabdominal median line was made from the point 2 cm above the xiphoid to the lower abdomen. Then, from this incision the flap including the right and left sides was subcutaneously separated (Fig. 2), other procedures were similar with Unilateral EOMF Technique. When the defect was very large, the open method was recommended, an additional transverse incision through the lower edge of the areola was required from the point 2 cm above the xiphoid to the bilateral sides of axillary line, so the bilateral flaps could be more fully separated (Fig. 3), other procedures were performed in accordance with Unilateral EOMF Technique.
RESULTS The patients were all diagnosed with malignant diseases, the data were summarized in Table I, the lesions were located in the groin in 7 patients, and in the lower abdominal wall in 5 patients. Among 12 patients, 10 patients were diagnosed as recurrent diseases and 2 patients as primary diseases. Four patients had received irradiation treatment. All 12 patients underwent radical neoplasm resection, the defect areas varied from 14 10 cm to 14 42 cm (from 140 to 588 cm2), the average area was 290 cm2. To cover the defects, unilateral or bilateral EOMF was Journal of Surgical Oncology
exploited. For tumor located in the one side of lower abdominal wall or groin, unilateral EOMF was used to cover the defect (Fig. 1). For tumor located over the abdominal midline, bilateral EOMF should be utilized (Fig. 2), however, when the defect was very large (Fig. 3), the bilateral EOMF could not be fully separated by the stealth method (seen in the methods), the open method (seen in the methods) should be considered, the result shown that the large defect in the lower abdominal wall could be well repaired with EOMF downward transposition by the open method (Fig. 3). One patient had underwent 7 surgeries for the ermatofibrosarcoma protuberans in the left groin, the disease relapsed and invaded the left thigh, after total tumor resection, we took advantage of the ipsilateral EOMF and left scrotum to repair the large defect, meanwhile, the left testicle was removed, after operation, the patient healed well (Fig. 1). In three cases, besides use of EOMF to repair, we utilized artificial materials (artificial blood vessel seen in Fig. 2, Bard patch seen in Fig. 3) to enhance the strength of the defect area. Pathological analysis confirmed that all the tumors were resected with R0 resection. Our results showed that the EOMF was efficient in closing the defects in all 12 patients, no serious complications occurred after surgery, the wound of donor site healed well, no abdominal hernia was found in these patients. Four patients suffered seroma postoperatively, and they all had a radiotherapy history, indicating irradiation increased the risk of seroma. Two patients had distal tip necrosis, the wounds healed spontaneously without infection. No secondary procedure was required for these patients. During follow‐up evaluation for at least 6 months after surgery, one case diagnosed with vascular myopericytoma had underwent radiotherapy and 3 surgeries, one year later after our operation, the patient developed local recurrence and died of lung metastasis. One case was lost to follow up. No local recurrence and ventral hernia were observed in other ten cases.
DISCUSSION Cancer is a leading cause of human death worldwide [10]. For tumors arising from the region of lower abdominal wall or groin, there are few studies to investigate, although surgery, radiotherapy, chemotherapy, and biological target therapy have been employed, surgery is considered as the primary approach in the treatment of these malignant diseases. Especially, for those patients with tumor relapse or undergoing radiotherapy, aggressive resection is still necessary to get negative surgical margins, immediate reconstruction is indispensable and challenging. In this study, we explored a new approach to reconstruct the lower abdominal wall or groin defects with EOMF after tumor resection, our results indicate that this flap can flexibly provide adequate soft tissue coverage for large defects in the areas.
932
Zhang et al.
Fig. 1. The use of unilateral EOMF in the reconstruction of lower abdominal wall defect. Design of an ipsilateral flap extending to the lower abdominal wall defect (above left); EOMF elevation after tumor resection (above right); closure of the defect using EOMF and left scrotum (below left); view of the flap 7 years later (below right).
Fig. 2. The use of bilateral EOMF in the reconstruction of lower abdominal wall defect. The CT scan of the tumor in the lower abdominal wall (above left); design of bilateral EOMF and tumor resection (above right); bilateral EOMF separation with the stealth method and reconstruction with patch (below left), the patch consisted of two longitudinally open artificial blood vessels which were sutured together; view of the flap in a late postoperative time (below right). Journal of Surgical Oncology
Reconstruction of Lower Abdominal Wall or Groin
933
Fig. 3. The use of bilateral EOMF in the reconstruction of large lower abdominal wall defect. The MRI scan of the tumor in the lower abdominal wall (above left); design of bilateral EOMF and tumor resection (above right); large defect after tumor resection (middle left); bilateral EOMF separation with the open method and reconstruction with Bard patch (middle right); immediate postoperative view of the flap (below left); view of the flap 22 months later (below right). The EOMF is a large, strong and flat abdominal muscle, as a flap is successfully applied in closing large defects after advanced breast cancer surgery [8,9,11], however, there are few reports on the use of EOMF in reconstructing the lower abdominal wall or groin defects. In our experience, we found EOMF was useful to cover the defects in these areas, for tumor mainly located in the one side of lower abdominal wall or groin, ipsilateral EOMF was enough to cover the defect following tumor resection. But for tumor located over the abdominal midline, unilateral EOMF was insufficient, bilateral EOMF should be utilized to repair the defect. Of 12 patients, 10 cases were performed with unilateral EOMF reconstruction, other 2 cases with bilateral EOMF reconstruction. EOMF can be classified as an extended flap, we took advantage of the laxity of skin in the up‐lateral chest wall, EOMF could be downward transferred up to 10 cm, in our patients, the maximum distance reached 14 cm. When defect included the inner thigh, we used the scrotal skin for coverage (Fig. 1), the local thigh flap or skin graft can also be considered to reconstruct the thigh defect. The repair of defects was satisfied in our 12 patients, no serious complications happened, the donor site healed well. In the recipient sites, four patients who all had underwent radiotherapy developed postoperative seroma, for 8 cases that had never had a radiotherapy, no seroma occurred, indicating Journal of Surgical Oncology
radiation increases the risk of seroma, as radiation is harmful for tissue healing, cavity is prone to form. For management of the seromas, syringe was used in the drainage of the fluid collections, pressure dressing was utilized for reducing the dead space. From our experience, the treatment with the pressure dressing was very important and necessary for these patients, and the seromas gradually improved. EOMF is a sturdy and good blood supplied myocutaneous flap. After the separation, it is still sensate and largely innervated by the branches of the intercostals nerves from the location of the lateral mid‐axillary line. The blood supply is from the branches of the intercostals and lumbar arteries, in accordance with this, only two patients had a necrosis at the distal tip of the flap. By changing dressings frequently, the necrosis healed conservatively. Taken together, The EOMF is a versatile flap in reconstructive plastic surgery not only for the defects of chest wall, but also for the defects of lower abdominal wall and groin. To reconstruct the defects in the lower abdominal wall or groin after tumor resection, a few methods have been introduced to close the defects, but it is still controversial to design appropriate flap for these patients. The tensor fascia lata (TFL) flap [7,12] has been reported that it is useful to cover the defects, but the donor site may require a skin graft, a hernia can still be a possible complication. The rectus abdominis
934
Zhang et al.
(RA) flap has been used for groin and perineal reconstruction [4,13], postoperatively, this flap can lead to abdominal wall weakness. LoGiudice and colleagues (6) conduct a review on 39 patients that underwent lower abdominal wall or groin reconstruction with anterolateral thigh (ALT) flap or (and) RA flap, the results show that ALT flap is superior to RA flap for covering the defects in the areas. Ramzy [14] reports that the rectus femoris muscle flap is suitable for reconstruction of groin defect resulting from inguinal lymphadenectomy, but a postoperative rehabilitation program may be required for the donor site morbidity. Yang [15] recently reports that lower abdominal wall defects can be reconstructed by the use of the combined technique of intraperitoneal mesh placement, sublay technique, pedicled great omentum flap and rotation skin graft, however, the use of mesh increases the potential risks of relative complications, and the contour is uneven and unsmooth when compared with musculofascicutaneous flap. In our series, 11 of 12 patients had ever underwent operation or (and) radiation therapy, three patients had received the two treatments, even one case had 7 surgeries. After aggressive tumor resection in these oncologic patients, the pathological examination confirmed that the resection margins were negative. Obviously, the reconstruction was difficult, but we found that the EOMF was an alternative and reliable reconstructive choice, the EOMF was not difficult to harvest, could effectively cover the defects in the lower abdominal wall or groin, the donor site needed no skin graft, the flap had good quality skin to cover the defect, and also showed ideal thickness with an even contour, the rectus abdominis remained intact, postoperatively, there was absence of abdominal‐wall weakness, no abdominal hernia occurred in our patients. Like other flaps [16], the EOMF also has the potential to be applied to these diseases such as wound‐healing difficulties, infections, exposed native vessels and radiation‐induced ulcers in these areas. Taken together, we use a new approach to reconstruct the skin and soft tissue defects after tumor resection in the lower abdominal wall or groin. EOMF should be considered as a reliable and effective option to restore the defects in these areas, especially for tumor patients having underwent repeated relapse and (or) radiotherapy. For defect located in the one side of lower abdominal wall or groin, unilateral EOMF is used to cover the defect, for defect located over the abdominal midline, bilateral EOMF should be utilized. However, more cases are required to confirm our observation.
REFERENCES 1. Lowe JB 3rd, Lowe JB, Baty JD, et al.: Risks associated with “components separation” for closure of complex abdominal wall defects. Plast Reconstr Surg 2003;111:1276–1283.
Journal of Surgical Oncology
2. Clark MA, Fisher C, Judson I, et al.: Soft‐tissue sarcomas in adults. N Engl J Med 2005;353:701–711. 3. Randall RL, Bruckner JD, Papenhausen MD, et al.: Errors in diagnosis and margin determination of soft‐tissue sarcomas initially treated at non‐tertiary centers. Orthopedics 2004;27:209–212. 4. Parrett BM, Winograd JM, Garfein ES, et al.: The vertical and extended rectus abdominis myocutaneous flap for irradiated thigh and groin defects. Plast Reconstr Surg 2008;122:171–177. 5. Qi F, Zhang Y, Gu J: Repairs of complex groin wounds with contralateral rectus abdominis myocutaneous flaps. Microsurgery 2009;29:199–204. 6. Logiudice JA, Haberman K, Sanger JR: The anterolateral thigh flap for groin and lower abdominal defects: A better alternative to the rectus abdominis flap. Plast Reconstr Surg 2014;133:162– 168. 7. Saito A, Minakawa H, Saito N, et al.: Clinical experience using a tensor fascia lata flap in oncology patients. Surg Today 2013. 8. Moschella F, Cordova A: A new extended external oblique musculocutaneous flap for reconstruction of large chest‐wall defects. Plast Reconstr Surg 1999;103:1378–1385. 9. Bogossian N, Chaglassian T, Rosenberg PH, et al.: External oblique myocutaneous flap coverage of large chest‐wall defects following resection of breast tumors. Plast Reconstr Surg 1996; 97:97–103. 10. Are C, Rajaram S, Are M, et al.: A review of global cancer burden: Trends, challenges, strategies, and a role for surgeons. J Surg Oncol 2013;107:221–226. 11. Kuge H, Kuzumoto Y, Morita T: Reconstruction of an extensive chest wall defect using an external oblique myocutaneous flap following resection of an advanced breast carcinoma: Report of a case. Breast Cancer 2006;13:364–368. 12. Rifaat MA, Abdel Gawad WS: The use of tensor fascia lata pedicled flap in reconstructing full thickness abdominal wall defects and groin defects following tumor ablation. J Egypt Natl Canc Inst 2005;17:139–148. 13. Sunesen KG, Buntzen S, Tei T, et al.: Perineal healing and survival after anal cancer salvage surgery: 10‐year experience with primary perineal reconstruction using the vertical rectus abdominis myocutaneous (VRAM) flap. Ann Surg Oncol 2009; 16:68–77. 14. Ramzy S: Versatility of rectus femoris muscle flap in groin reconstruction after inguinal lymphadenectomy. Med J Cairo Univ 2011;79:9–15. 15. Yang F: Radical tumor excision and immediate abdominal wall reconstruction in patients with aggressive neoplasm compromised full‐thickness lower abdominal wall. Am J Surg 2013; 205:15–21. 16. Daigeler A, Simidjiiska‐Belyaeva M, Drucke D, et al.: The versatility of the pedicled vertical rectus abdominis myocutaneous flap in oncologic patients. Langenbecks Arch Surg 2011;396:1271– 1279.
The Use of Unilateral or Bilateral External Oblique Myocutaneous Flap in the Reconstruction of Lower Abdominal Wall or Groin Defects After Malignant Tumor Resection RUMING ZHANG, MD,1,2* CHUNMENG WANG, MD,1,2 YONG CHEN, MD,1,2 BIQIANG ZHENG, MD,1,2 AND YINGQIANG SHI, MD1,2 1
Department of Gastric Cancer and Soft Tissue Sarcomas, Fudan University Shanghai Cancer Center, Shanghai, China 2 Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
Background: External oblique myocutaneous flap (EOMF) has been used successfully for many years in reconstructive plastic surgery, its function is mainly concentrated in the restoration of chest wall defects following breast cancer resection. However, for the lower abdominal wall or groin defects after malignant tumor resection, reconstruction with EOMF is little reported. In this study, we report our experience with EOMF downward transposition to repair the defects. Methods: 12 patients with malignant diseases in the lower abdominal wall or groin underwent aggressive tumor resection, the defects were reconstructed immediately with EOMF. Patient characteristics, details of operation and postoperative complications were described. Results: 12 patients received radical resection, the defect size ranged from 140 to 588 cm2. Ipsilateral or bilateral EOMF was utilized to repair the defects. The EOMF had good quality skin and soft tissue to cover the defects, postoperatively, four patients developed seroma, two patients had distal tip necrosis, but no serious complications occurred, the wound of donor site healed well, no abdominal hernia was found. Conclusion: Our study provides a new and alternative approach to reconstruct large defects with EOMF downward transposition after malignant tumor resection in the lower abdominal wall or groin.
J. Surg. Oncol. 2014;110:930–934. ß 2014 Wiley Periodicals, Inc.
KEY WORDS: external oblique myocutaneous flap; lower abdominal wall; groin; reconstruction
INTRODUCTION Lower abdominal wall or groin defects result from multiple etiologies, including tumor resection, trauma, infection, and wound dehiscence [1]. Such defects require flexible and sophisticated closure, especially for management of refractory and large tumors in the regions, aggressively local excision is necessary to attain optimal effects with clean surgical margin and reduced recurrence [2,3]. However, after massive soft tissue resection, immediate reconstruction of the skin and soft tissue defects is indispensable and challenging. Although rectus abdominis flap [4,5], anterolateral thigh flap [6], and tensor fascia lata flap [7] have been used to reconstruct the defects, it is still controversial to design more appropriate flap for the treatment of these malignant diseases. External oblique myocutaneous flap (EOMF) is frequently utilized in the reconstruction of chest wall defects following advanced breast cancer excision, and studies show that it has the capability of extending far beyond the anatomic territory, it represents an effective way for coverage of chest wall defects [8,9]. However, to our knowledge, EOMF has been seldom applied in the restoration of defects after radical tumor resection in the lower abdominal wall or groin. In our study, unilateral or bilateral EOMF was used to reconstruct lower abdominal wall or groin defects following tumor resection, the results shown that the flap could flexibly provide adequate soft tissue coverage for the defects. Our experience and view on this flap are presented.
PATIENTS AND METHODS Patients From 2005 to 2013, 12 patients (seven males and five females) with malignant disease in the lower abdomen wall or groin were treated by tumor resection and immediate EOMF reconstruction at Shanghai
ß 2014 Wiley Periodicals, Inc.
Cancer Center of Fudan University or Shuguang Hospital affiliated Shanghai University of Traditional Chinese Medicine, the follow‐up time was more than 6 months for each patients. With the institutional review board approval, the surgical treatment was performed, patient demographics, treatment histories, flap types, postoperative complications were summarized in Table I.
Tumor History Four patients had dermatofibrosarcoma protuberanses, two had malignant fibrous histiocytomas, the others were diagnosed as liposarcoma, soft tissue osteosarcoma, vascular myopericytoma, fibrosarcoma, metastatic squamous cell carcinoma, and metastatic adenocarcinoma for one patient each. Of these patients, 10 cases were diagnosed as tumor recurrence, 4 cases had received radiotherapy, the data were summarized in Table I.
Disclosures: There are no potential conflicts of interest with regard to this paper. *Correspondence to: Dr. Ruming Zhang, MD, Department of Gastric Cancer and Soft Tissue Sarcomas, Fudan University Shanghai Cancer Center; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China. Fax: 86‐21‐64430130. E‐mail: [email protected] Received 8 March 2014; Accepted 28 July 2014 DOI 10.1002/jso.23763 Published online 25 August 2014 in Wiley Online Library (wileyonlinelibrary.com).
Reconstruction of Lower Abdominal Wall or Groin
931
TABLE I. Patient Summary
Case 1 2 3 4 5 6 7 8 9 10 11 12
Sex
Age
Location
Pathology
Relapse (times)
Radiation
Defect size (cm2)
Male Male Female Female Female Male Male Male Female Female Male Male
76 62 65 19 36 56 61 30 37 57 54 62
Groin Groin Groin LAW LAW Groin Groin Groin LAW LAW LAW Groin
Malignant fibrous histiocytoma Dermatofibrosarcoma protuberans Vascular myopericytoma Dermatofibrosarcoma protuberans Dermatofibrosarcoma protuberans Malignant fibrous histiocytoma Dermatofibrosarcoma protuberans Soft tissue osteosarcoma Liposarcoma Metastatic SCC from cervix Metastatic adenocarcinoma Fibrosarcoma
3 7 3 0 3 5 1 1 2 0 1 3
No No Yes No No Yes No No Yes Yes No No
20 16 18 15 18 13 20 13 15 10 14 13 20 13 14 10 21 17 42 14 20 18 20 18
Reconstruction (EOMF) Unilateral Unilateralþ scrotum Unilateral Unilateral Unilateral Unilateral Unilateral Unilateral Unilateralþ patch Bilateralþpatch Bilateraþ patch Unilateral
Complication None None seroma None None seroma Distaltip necrosis None seroma seroma Distaltip necrosis None
LAW: Lower abdominal wall, SCC: squamous cell carcinoma.
METHODS Unilateral EOMF Technique After sufficient resection of tumor located in the one side of lower abdominal wall or groin, an incision at the abdominal median line was made from defect area to the point 2 cm above the xiphoid with the depth to anterior rectus sheath, the anterior rectus sheath was included in this flap. Then lateral separation into the gap between external oblique muscle and internal oblique muscle was performed, the dissection of the EOMF was laterally extended around the anterior axillary line (no more than the mid‐axillary line). The upper transverse incision of the flap was close to the nipple (approximately the 5th rib) and axilla, the attachment of external oblique muscle to the ribs was cut off. The EOMF was not separated until it was satisfied to cover the defect, the umbilicus was preserved, drains were placed, the flap was sutured in place with the incision edges in the lower abdominal wall or groin. The hip should be kept in flexion to reduce incisional tension for 4 weeks after surgery (Fig. 1).
Bilateral EOMF Technique After sufficient excision of tumor located over the abdominal midline, the transverse incisions were extended from the upper corners of defect to bilateral sides, even reached beyond the anterior superior iliac spine. There were two ways to free the flap, one was the stealth method: an incision about 10 cm at the thoracoabdominal median line was made from the point 2 cm above the xiphoid to the lower abdomen. Then, from this incision the flap including the right and left sides was subcutaneously separated (Fig. 2), other procedures were similar with Unilateral EOMF Technique. When the defect was very large, the open method was recommended, an additional transverse incision through the lower edge of the areola was required from the point 2 cm above the xiphoid to the bilateral sides of axillary line, so the bilateral flaps could be more fully separated (Fig. 3), other procedures were performed in accordance with Unilateral EOMF Technique.
RESULTS The patients were all diagnosed with malignant diseases, the data were summarized in Table I, the lesions were located in the groin in 7 patients, and in the lower abdominal wall in 5 patients. Among 12 patients, 10 patients were diagnosed as recurrent diseases and 2 patients as primary diseases. Four patients had received irradiation treatment. All 12 patients underwent radical neoplasm resection, the defect areas varied from 14 10 cm to 14 42 cm (from 140 to 588 cm2), the average area was 290 cm2. To cover the defects, unilateral or bilateral EOMF was Journal of Surgical Oncology
exploited. For tumor located in the one side of lower abdominal wall or groin, unilateral EOMF was used to cover the defect (Fig. 1). For tumor located over the abdominal midline, bilateral EOMF should be utilized (Fig. 2), however, when the defect was very large (Fig. 3), the bilateral EOMF could not be fully separated by the stealth method (seen in the methods), the open method (seen in the methods) should be considered, the result shown that the large defect in the lower abdominal wall could be well repaired with EOMF downward transposition by the open method (Fig. 3). One patient had underwent 7 surgeries for the ermatofibrosarcoma protuberans in the left groin, the disease relapsed and invaded the left thigh, after total tumor resection, we took advantage of the ipsilateral EOMF and left scrotum to repair the large defect, meanwhile, the left testicle was removed, after operation, the patient healed well (Fig. 1). In three cases, besides use of EOMF to repair, we utilized artificial materials (artificial blood vessel seen in Fig. 2, Bard patch seen in Fig. 3) to enhance the strength of the defect area. Pathological analysis confirmed that all the tumors were resected with R0 resection. Our results showed that the EOMF was efficient in closing the defects in all 12 patients, no serious complications occurred after surgery, the wound of donor site healed well, no abdominal hernia was found in these patients. Four patients suffered seroma postoperatively, and they all had a radiotherapy history, indicating irradiation increased the risk of seroma. Two patients had distal tip necrosis, the wounds healed spontaneously without infection. No secondary procedure was required for these patients. During follow‐up evaluation for at least 6 months after surgery, one case diagnosed with vascular myopericytoma had underwent radiotherapy and 3 surgeries, one year later after our operation, the patient developed local recurrence and died of lung metastasis. One case was lost to follow up. No local recurrence and ventral hernia were observed in other ten cases.
DISCUSSION Cancer is a leading cause of human death worldwide [10]. For tumors arising from the region of lower abdominal wall or groin, there are few studies to investigate, although surgery, radiotherapy, chemotherapy, and biological target therapy have been employed, surgery is considered as the primary approach in the treatment of these malignant diseases. Especially, for those patients with tumor relapse or undergoing radiotherapy, aggressive resection is still necessary to get negative surgical margins, immediate reconstruction is indispensable and challenging. In this study, we explored a new approach to reconstruct the lower abdominal wall or groin defects with EOMF after tumor resection, our results indicate that this flap can flexibly provide adequate soft tissue coverage for large defects in the areas.
932
Zhang et al.
Fig. 1. The use of unilateral EOMF in the reconstruction of lower abdominal wall defect. Design of an ipsilateral flap extending to the lower abdominal wall defect (above left); EOMF elevation after tumor resection (above right); closure of the defect using EOMF and left scrotum (below left); view of the flap 7 years later (below right).
Fig. 2. The use of bilateral EOMF in the reconstruction of lower abdominal wall defect. The CT scan of the tumor in the lower abdominal wall (above left); design of bilateral EOMF and tumor resection (above right); bilateral EOMF separation with the stealth method and reconstruction with patch (below left), the patch consisted of two longitudinally open artificial blood vessels which were sutured together; view of the flap in a late postoperative time (below right). Journal of Surgical Oncology
Reconstruction of Lower Abdominal Wall or Groin
933
Fig. 3. The use of bilateral EOMF in the reconstruction of large lower abdominal wall defect. The MRI scan of the tumor in the lower abdominal wall (above left); design of bilateral EOMF and tumor resection (above right); large defect after tumor resection (middle left); bilateral EOMF separation with the open method and reconstruction with Bard patch (middle right); immediate postoperative view of the flap (below left); view of the flap 22 months later (below right). The EOMF is a large, strong and flat abdominal muscle, as a flap is successfully applied in closing large defects after advanced breast cancer surgery [8,9,11], however, there are few reports on the use of EOMF in reconstructing the lower abdominal wall or groin defects. In our experience, we found EOMF was useful to cover the defects in these areas, for tumor mainly located in the one side of lower abdominal wall or groin, ipsilateral EOMF was enough to cover the defect following tumor resection. But for tumor located over the abdominal midline, unilateral EOMF was insufficient, bilateral EOMF should be utilized to repair the defect. Of 12 patients, 10 cases were performed with unilateral EOMF reconstruction, other 2 cases with bilateral EOMF reconstruction. EOMF can be classified as an extended flap, we took advantage of the laxity of skin in the up‐lateral chest wall, EOMF could be downward transferred up to 10 cm, in our patients, the maximum distance reached 14 cm. When defect included the inner thigh, we used the scrotal skin for coverage (Fig. 1), the local thigh flap or skin graft can also be considered to reconstruct the thigh defect. The repair of defects was satisfied in our 12 patients, no serious complications happened, the donor site healed well. In the recipient sites, four patients who all had underwent radiotherapy developed postoperative seroma, for 8 cases that had never had a radiotherapy, no seroma occurred, indicating Journal of Surgical Oncology
radiation increases the risk of seroma, as radiation is harmful for tissue healing, cavity is prone to form. For management of the seromas, syringe was used in the drainage of the fluid collections, pressure dressing was utilized for reducing the dead space. From our experience, the treatment with the pressure dressing was very important and necessary for these patients, and the seromas gradually improved. EOMF is a sturdy and good blood supplied myocutaneous flap. After the separation, it is still sensate and largely innervated by the branches of the intercostals nerves from the location of the lateral mid‐axillary line. The blood supply is from the branches of the intercostals and lumbar arteries, in accordance with this, only two patients had a necrosis at the distal tip of the flap. By changing dressings frequently, the necrosis healed conservatively. Taken together, The EOMF is a versatile flap in reconstructive plastic surgery not only for the defects of chest wall, but also for the defects of lower abdominal wall and groin. To reconstruct the defects in the lower abdominal wall or groin after tumor resection, a few methods have been introduced to close the defects, but it is still controversial to design appropriate flap for these patients. The tensor fascia lata (TFL) flap [7,12] has been reported that it is useful to cover the defects, but the donor site may require a skin graft, a hernia can still be a possible complication. The rectus abdominis
934
Zhang et al.
(RA) flap has been used for groin and perineal reconstruction [4,13], postoperatively, this flap can lead to abdominal wall weakness. LoGiudice and colleagues (6) conduct a review on 39 patients that underwent lower abdominal wall or groin reconstruction with anterolateral thigh (ALT) flap or (and) RA flap, the results show that ALT flap is superior to RA flap for covering the defects in the areas. Ramzy [14] reports that the rectus femoris muscle flap is suitable for reconstruction of groin defect resulting from inguinal lymphadenectomy, but a postoperative rehabilitation program may be required for the donor site morbidity. Yang [15] recently reports that lower abdominal wall defects can be reconstructed by the use of the combined technique of intraperitoneal mesh placement, sublay technique, pedicled great omentum flap and rotation skin graft, however, the use of mesh increases the potential risks of relative complications, and the contour is uneven and unsmooth when compared with musculofascicutaneous flap. In our series, 11 of 12 patients had ever underwent operation or (and) radiation therapy, three patients had received the two treatments, even one case had 7 surgeries. After aggressive tumor resection in these oncologic patients, the pathological examination confirmed that the resection margins were negative. Obviously, the reconstruction was difficult, but we found that the EOMF was an alternative and reliable reconstructive choice, the EOMF was not difficult to harvest, could effectively cover the defects in the lower abdominal wall or groin, the donor site needed no skin graft, the flap had good quality skin to cover the defect, and also showed ideal thickness with an even contour, the rectus abdominis remained intact, postoperatively, there was absence of abdominal‐wall weakness, no abdominal hernia occurred in our patients. Like other flaps [16], the EOMF also has the potential to be applied to these diseases such as wound‐healing difficulties, infections, exposed native vessels and radiation‐induced ulcers in these areas. Taken together, we use a new approach to reconstruct the skin and soft tissue defects after tumor resection in the lower abdominal wall or groin. EOMF should be considered as a reliable and effective option to restore the defects in these areas, especially for tumor patients having underwent repeated relapse and (or) radiotherapy. For defect located in the one side of lower abdominal wall or groin, unilateral EOMF is used to cover the defect, for defect located over the abdominal midline, bilateral EOMF should be utilized. However, more cases are required to confirm our observation.
REFERENCES 1. Lowe JB 3rd, Lowe JB, Baty JD, et al.: Risks associated with “components separation” for closure of complex abdominal wall defects. Plast Reconstr Surg 2003;111:1276–1283.
Journal of Surgical Oncology
2. Clark MA, Fisher C, Judson I, et al.: Soft‐tissue sarcomas in adults. N Engl J Med 2005;353:701–711. 3. Randall RL, Bruckner JD, Papenhausen MD, et al.: Errors in diagnosis and margin determination of soft‐tissue sarcomas initially treated at non‐tertiary centers. Orthopedics 2004;27:209–212. 4. Parrett BM, Winograd JM, Garfein ES, et al.: The vertical and extended rectus abdominis myocutaneous flap for irradiated thigh and groin defects. Plast Reconstr Surg 2008;122:171–177. 5. Qi F, Zhang Y, Gu J: Repairs of complex groin wounds with contralateral rectus abdominis myocutaneous flaps. Microsurgery 2009;29:199–204. 6. Logiudice JA, Haberman K, Sanger JR: The anterolateral thigh flap for groin and lower abdominal defects: A better alternative to the rectus abdominis flap. Plast Reconstr Surg 2014;133:162– 168. 7. Saito A, Minakawa H, Saito N, et al.: Clinical experience using a tensor fascia lata flap in oncology patients. Surg Today 2013. 8. Moschella F, Cordova A: A new extended external oblique musculocutaneous flap for reconstruction of large chest‐wall defects. Plast Reconstr Surg 1999;103:1378–1385. 9. Bogossian N, Chaglassian T, Rosenberg PH, et al.: External oblique myocutaneous flap coverage of large chest‐wall defects following resection of breast tumors. Plast Reconstr Surg 1996; 97:97–103. 10. Are C, Rajaram S, Are M, et al.: A review of global cancer burden: Trends, challenges, strategies, and a role for surgeons. J Surg Oncol 2013;107:221–226. 11. Kuge H, Kuzumoto Y, Morita T: Reconstruction of an extensive chest wall defect using an external oblique myocutaneous flap following resection of an advanced breast carcinoma: Report of a case. Breast Cancer 2006;13:364–368. 12. Rifaat MA, Abdel Gawad WS: The use of tensor fascia lata pedicled flap in reconstructing full thickness abdominal wall defects and groin defects following tumor ablation. J Egypt Natl Canc Inst 2005;17:139–148. 13. Sunesen KG, Buntzen S, Tei T, et al.: Perineal healing and survival after anal cancer salvage surgery: 10‐year experience with primary perineal reconstruction using the vertical rectus abdominis myocutaneous (VRAM) flap. Ann Surg Oncol 2009; 16:68–77. 14. Ramzy S: Versatility of rectus femoris muscle flap in groin reconstruction after inguinal lymphadenectomy. Med J Cairo Univ 2011;79:9–15. 15. Yang F: Radical tumor excision and immediate abdominal wall reconstruction in patients with aggressive neoplasm compromised full‐thickness lower abdominal wall. Am J Surg 2013; 205:15–21. 16. Daigeler A, Simidjiiska‐Belyaeva M, Drucke D, et al.: The versatility of the pedicled vertical rectus abdominis myocutaneous flap in oncologic patients. Langenbecks Arch Surg 2011;396:1271– 1279.
