Keywords medially based abdominal transposition flap - postmastectomy defects - locally advanced
breast cancer
Introduction
Breast cancer is a widely prevalent condition that affects women worldwide. In developing
countries, locally advanced breast cancer (LABC) constitutes a significant proportion
of breast cancer cases. In the aftermath of mastectomy, the presence of sizable soft-tissue
defects often necessitates additional cover. In such instances, the primary objective
of reconstruction is to effectuate prompt and uncomplicated closure with high-quality
skin cover, thereby facilitating early recovery and shortened hospital stay. Breast
reconstruction techniques have undergone significant evolution over time. These techniques
include options such as latissimus dorsi (LD) flap, transverse rectus abdominis myocutaneous
(TRAM) flap, deep inferior epigastric artery perforator (DIEP) flap, as well as locoregional
and microvascular free flaps. Factors such as patient age and comorbidities, institutional
practice, and available surgical expertise[1 ] are critical in selecting the appropriate reconstruction method.
Selecting a suitable technique can enable patients to receive early postoperative
radiotherapy/chemotherapy. Therefore, choosing the most appropriate approach is of
utmost importance.
The transverse fasciocutaneous flap has been an essential technique in reconstructive
surgery since its first description by Tai and Hasegawa[2 ] in 1974. This flap is harvested from the homolateral thoracoabdominal (TA) area
and is based on perforator vessels from the superior epigastric artery and vein. Subsequently,
Davis et al[3 ] modified the technique in 1977. The vascular anatomy of the anterior and lateral
abdominal wall was better understood due to the studies conducted by Brown et al[4 ] in 1975. Their research has helped enhance the effectiveness of the transverse fasciocutaneous
flap and made it a more reliable option for flap reconstruction.
In 1978, Baroudi et al[5 ] proposed a TA fasciocutaneous flap. This flap was subsequently modified by Rivas
et al[6 ] in the 1980s to extend from the middle sternal line to the anterior axillary line
opposite to the defect. During the 1980s, musculocutaneous flaps,[7 ]
[8 ]
[9 ]
[10 ] including the pectoralis major, LD, serratus anterior, rectus abdominis, and omentum
flaps, became the preferred method for chest wall reconstruction, either pedicled
or free,[11 ]
[12 ]
[13 ] providing adequate coverage even from distant sites. In 1980, Hodgkinson et al[14 ] revisited large TA flaps and described new musculocutaneous flaps harvested on the
external oblique abdominal muscle. Similar flaps were later described by Bogossian
et al[15 ] in 1996 and Moschella and Cordova[16 ] in 1999. Despite these surgical variations, few comparative studies have been published,
making it difficult to conclude the superiority of musculocutaneous over fasciocutaneous
flaps.
In 2003, Deo et al[17 ] recommended the fasciocutaneous “TA” flap as the preferred option for patients requiring
mastectomy defect reconstruction. However, the muscle-sparing TRAM flap has emerged
as a promising alternative for elderly and high-risk patients. This article examines
the use of MATF in mastectomy defect reconstruction, including its surgical technique,
benefits, and clinical outcomes.
The MATF procedure involves the transfer of abdominal tissue to the breast area to
reconstruct the defect. Compared with other methods, MATF offers advantages such as
reduced donor site morbidity, shorter hospital stays, and faster recovery time. The
surgical technique involves preserving the rectus abdominis muscle while dissecting
the overlying skin and subcutaneous tissue.
Materials and Methods
The present study entails a retrospective analysis of a prospectively maintained computerized
database pertaining to postmastectomy reconstruction patients in the Department of
Plastic Surgery at MNJ Institute of Oncology & Regional Cancer Centre in India. Specifically,
we have retrieved and analyzed the medical records and clinical details of patients
who underwent MATF flap cover for LABC between 2019 and 2023. Our investigation has
aimed to assess several key factors surrounding patient outcomes, including operative
duration, blood loss, postoperative morbidity, hospital stay, adjuvant therapy, and
recurrence patterns. By conducting a comprehensive analysis of these variables, we
aim to provide critical insights into the efficacy and safety of surgical interventions
for LABC patients, ultimately contributing to the broader body of knowledge in this
field.
The utilization of the MATF flap in reconstructive surgery is a well-established type
C rotation advancement fasciocutaneous flap. This technique employs the skin and subcutaneous
tissue of the anterior abdominal wall while utilizing two distinct sets of perforating
branches. The lateral branches arise from the lumbar and subcostal arteries adjacent
to the anterior border of the LD, while the medial branches arise from the deep epigastric
arcade.[4 ] A subfascial anastomosis between the medial and lateral perforators[1 ]
[18 ] ensures vascular continuity. These features provide the foundation for this technique's
effectiveness in reconstructive surgery.
This article concerns harvesting a flap based on medial direct perforating segmental
arteries originating from the deep epigastric arcades. The flap is fashioned via the
rotation advancement technique, with the surgical plane maintained superficial to
the rectus fascia and aponeurosis of the external oblique muscle. The boundaries of
the flap are limited by the anterior axillary line laterally and a horizontal plane
at the level of the anterosuperior iliac spine inferiorly. The donor site[17 ] can be closed primarily, thanks to the ability to mobilize the loose abdominal skin.
This technique can utilize excess lateral abdominal tissue to restore the breast contour
while preserving muscle function, maintaining a nearly natural appearance, and producing
minimal morbidity ([Figs. 1 ] and [2 ]).
Fig. 1 Patient 1 exhibits a left-sided postmastectomy defect. (A ) Left-sided postmastectomy defect with size 14 × 20 cm. (B ) Elevation of medially based abdominal transposition flap. (C ) Perforators from the epigastric artery. (D ) Postclosure of defect with medial abdominal transposition fasciocutaneous (MATF)
flap.
Fig. 2 Patient 2 exhibits a right-sided postmastectomy defect. (A ) Right-sided locally advanced breast cancer. (B ) Right-sided postmastectomy defect. (C ) Postclosure with medial abdominal transposition fasciocutaneous (MATF) flap. (D ) Postoperative day 3 status of the flap.
Results
A total of 826 cancer breast patient underwent surgery, of which 547 were LABC patients
and 138 (32.5%) of the LABC patients needed flap cover for mastectomy defect. Medially
based abdominal transposition flap was used in 56 of 138 (40.5%) LABC patients for
defect closure, and 42 of these 56 patients in stage IIIB. Upfront surgery was primarily
done in 20 patients and 36 patients underwent surgery after neoadjuvant chemotherapy
(NACT). A total of 56 breast cancer patients underwent surgical intervention, of whom
8 exhibited tip and edge necrosis and 3 were complicated by infection “(Clavien–Dindo
grade 2: 1 case; grade 3a: 7cases; and grade 3b: 3 cases). Three of the eight cases
presented extensive necrosis ([Table 1 ]), requiring debridement and latissimus dorsi flap coverage within 5 days following
surgery. The remaining five cases, marked by marginal necrosis, were treated with
debridement and secondary closure within a week. Of the three instances complicated
by infection, one was successfully treated with intravenous antibiotics, while the
other two were drained and closed through secondary closure. The mean operating time
for these procedures was 58.852 minutes, ranging from 40 to 110 minutes, resulting
in minimal blood loss ([Table 2 ]).
Table 1
Postoperative complications
Sl. no.
Complications
No. of cases
%
1
Tip necrosis
5
8.9
2
Partial necrosis
3
5.3
3
infection
1
1.7
4
seroma
4
7
Table 2
Statistics of patients
Sl. no.
Age (y)
Defect size (cm2 )
Time for reconstruction (min)
Hospital stay (d)
Complications
Adjuvant therapy received after (d)
1
44
18 × 20
55
3
None
26
2
50
21 × 19
90
5
Tip and edge necrosis
23
3
51
23 × 21
55
6
None
22
4
45
25 × 23
50
5
None
27
5
47
22 × 24
65
4
None
24
6
53
20 × 19
40
3
None
21
7
39
24 × 28
55
5
Tip and edge necrosis
25
8
44
27 × 23
45
12
Infection
22
9
38
25 × 16
110
4
None
23
10
41
24 × 15
60
4
None
22
11
60
22 × 18
50
5
None
28
12
40
30 × 15
55
6
None
27
13
56
22 × 12
50
3
None
18
14
49
25 × 30
45
9
Infection
23
15
52
20 × 15
65
5
None
21
16
45
20 × 25
70
3
None
20
17
42
30 × 25
50
14
Tip and edge necrosis
30
18
37
25 × 14
45
4
None
29
19
62
19 × 18
80
5
None
26
20
58
23 × 24
45
8
None
23
21
46
25 × 20
50
6
None
22
22
53
24 × 23
75
3
None
27
23
55
14 × 15
50
10
INFECTION
24
24
39
22 × 21
45
5
None
21
25
33
19 × 19
60
7
None
25
26
41
21 × 20
65
8
Tip and edge necrosis
22
27
46
24 × 22
55
5
None
23
28
44
25 × 23
40
3
None
22
29
52
23 × 20
70
5
None
28
30
49
18 × 17
50
4
None
27
31
65
26 × 20
65
4
None
24
32
47
21 × 19
55
3
None
27
33
53
21 × 20
100
4
None
23
34
34
22 × 17
50
4
None
32
35
40
26 × 26
60
5
None
29
36
45
17 × 15
45
4
None
23
37
54
21 × 15
55
6
None
25
38
68
18 × 14
110
3
None
19
39
62
22 × 21
80
4
None
30
40
58
19 × 24
45
4
None
21
41
43
23 × 12
50
5
None
24
42
39
23 × 16
70
9
Tip and edge necrosis
27
43
53
20 × 15
55
3
None
22
44
37
27 × 21
50
5
None
27
45
46
24 × 17
50
5
None
30
46
54
21 × 22
65
6
None
24
47
70
19 × 16
70
3
None
22
48
63
25 × 18
55
5
None
28
49
42
23 × 20
45
11
Tip and edge necrosis
23
50
59
29 × 23
50
3
None
27
51
45
30 × 21
55
8
Tip and edge necrosis
24
52
36
25 × 19
45
4
None
19
53
64
17 × 17
75
5
None
30
54
57
22 × 18
50
10
Tip and edge necrosis
22
55
38
18 × 21
60
6
None
27
56
46
17 × 20
50
4
None
26
The study revealed that the mean duration of hospitalization for patients was 5.39
days, with the minimum and maximum stays being 3 and 14 days, respectively. The average
time required for patients to show stability and receive adjuvant therapy was 24.57
days. The mean age of the patients in the study was 48.73 years, with the youngest
patient being 33 years old and the oldest being 70 years old. The average defect size
was 441.160 cm2 , with the most minor defect being 210 cm2 and the largest being 750 cm2 . These data provide valuable insights into the clinical outcomes and demographics
of the study population.
Discussion
Breast cancer is the most prevalent type of cancer in women worldwide. It is becoming
more common in India,[19 ]
[20 ] due to lack of awareness, lack of screening, social stigma, delays in referral,
insufficient health care infrastructure, and lengthy waiting lists at tertiary care
cancer centers. The majority of breast cancer patients in developing nations like
India present with locally advanced stage of the disease.
Surgical intervention is a fundamental element of the treatment plan for LABC after
NACT. In some instances, patients who do not respond favorably to NACT may require
a radical excision of the affected skin, which results in extensive soft-tissue defects
that cannot be healed by primary closure. To address these defects, supplementary
surgical procedures may be required. Numerous options are available for treating these
postmastectomy defects, which have been chronicled in the literature dating back to
the Halstead era.[21 ]
In the first half of the 20th century, postradical mastectomy defects of significant
size were typically addressed through a treatment regimen utilizing the principles
of healing by secondary intention, as well as staged split-thickness skin grafting.
However, the results of such an approach were not ideal owing to the suboptimal nature
of the resultant cosmetic and therapeutic outcomes. In addition, the use of skin grafts
is associated with several risks, including secondary infection, morbidity at both
the recipient and donor sites, staged procedures, late contracture, and partial or
complete graft loss following radiotherapy.[22 ]
[23 ]
[24 ]
A range of locoregional tissue transfer techniques have been developed with the aim
of early wound healing and a decreased risk of total flap failure.[1 ]
[11 ]
[17 ]
[24 ]
[25 ]
[26 ]
[27 ]
[28 ]
[29 ] These techniques include the bilateral advancement flap, a relatively uncomplicated
method of wound closure that results in a single horizontal scar on the chest wall.[21 ] However, this technique is unsuitable for more extensive wounds with increased vertical
dimensions, as such wounds may be subject to tension, resulting in wound dehiscence.
The field of reconstructive surgery experienced a significant breakthrough in the
latter part of the 20th century, thanks to the introduction of the dermal muscle flap,
which yielded impressive results. In 1896, Iginio Tansini performed the first broad
dorsal muscle flap (LD) procedure to address a significant defect following a radical
mastectomy.[30 ] However, the utility of the LD flap declined later, as Halstead considered it an
unnecessary and risky procedure.[31 ] Subsequently, it was not until 1975 that the LD flap was reintroduced as a viable
option for reconstructing defects after mastectomy, and it remained popular until
1982.[32 ]
[33 ]
The literature reports the utilization of omentum transposition in conjunction with
skin grafts to conceal defects resulting from mastectomy and chest wall surgeries.
Lopez et al[34 ] reported a 76% success rate and an 8% incidence of abdominal hernia in 50 patients
with advanced breast cancer who underwent omental transposition with Split Skin Grafi
(SSG). Similarly, Cheung et al[35 ] reported a 100% success rate and a median hospital stay of 16 days in breast cancer
patients who underwent omental transposition. Despite its efficacy, omental transplantation
has not garnered much popularity due to associated complications such as hernia, wound
infection, and abdominal rupture, as well as the morbidity of laparoscopic surgery.
Moreover, the feasibility of skin grafts in the omental bed is also limited[35 ] in certain patients.
The TRAM flap technique for breast reconstruction was introduced by Hartrampf et al[33 ] in 1982. This technique is characterized by its superior cosmetic outcomes, reliability,
positional advantage, and added benefit of abdominoplasty, and has been the primary
method for breast reconstruction until the 1990s.[36 ] However, it is essential to note that the TRAM flap technique is technically demanding
and is associated with significant wound and donor site morbidities such as subsequent
muscle weakness and hernias. As such, careful consideration is advised before opting
for this method of breast reconstruction.
The TA flap was first described in 1975 by Brown et al.[4 ] It is a type C fasciocutaneous flap that utilizes the skin and fat from the upper
abdomen based on the medial or lateral perforating vessels. The TA flap has been used
in breast reconstruction with a prosthesis and soft-tissue cover after surgery for
LABC during the late 1970s and early 1980s.[1 ]
[4 ]
[18 ]
[23 ] However, the usage of TA flaps significantly declined with the introduction of myocutaneous
flaps in the 1980s.
Keystone perforator island flap (KPIF) is a local advancement flap based on multiple
perforators, including fasciocutaneous and musculocutaneous perforators, which results
in reliable and versatile vascularization. Introduced in 2003, this flap is relatively
used for small defect throughout the body. In 2011, keystone flap could be used for
larger defect in both the trunk and the extremities. However, there are several modifications
to cover a large defect, such as double keystone flap or deep fascia incision to allow
better mobility. Another modification but commonly overlooked is the omega subtype,
which optimizes a part of the flap with excessive laxity during its insetting.[37 ]
In 2019, we initiated using the medially based abdominal transposition flap as an
alternative to the TA flap for treating lumpectomy breast cancer defects. This technique
has yielded positive outcomes, leading us to primarily employ the MATF flap for patients
who are elderly or in fragile health. But this flap has some drawbacks such as the
following: (1) it mainly covers chest wall wounds for timely healing and adjuvant
rather than true breast reconstruction, (2) it results in visible scars in saree,
and (3) the option of abdomen-based free/pedicle flap is lost forever.
The average operating time for the TA flap, in our study, was 58.852 minutes, with
minimal blood loss. However, compared with the TA flap, the MATF flap provides several
advantages, including a shorter average hospital stay of 5.39 days and reduced morbidity.
Patients who received the MATF flap have also experienced high-quality vascularized
skin coverage and have demonstrated the capacity to tolerate postoperative radiation
without significant wound morbidity.
Overall, our experience with the MATF flap has been favorable, and we believe it is
a safe and effective option for treating lumpectomy breast cancer defects in appropriate
patient populations.
Conclusion
Breast reconstruction is a crucial procedure for patients with LABC. The main goal
is to ensure that the skin cover is simple, efficient, and reliable, allowing for
quick recovery and timely administration of adjuvant therapy. However, for a subset
of LABC patients with aggressive biology that does not respond to NACT, cosmetic breast
reconstruction of the breast mound is not a top priority. The use of myocutaneous
flaps, such as the LD and TRAM flaps, presents technical challenges and is not commonly
practiced by the general surgical community for managing postmastectomy soft-tissue
defects. These flaps are primarily reserved for high-volume centers specializing in
cosmetic breast reconstruction.
Our clinical experience has demonstrated that using the MATF flap technique is a practical,
dependable, and cost-effective solution for managing significant postmastectomy soft-tissue
defects in patients with LABC. This procedure is particularly successful in handling
this type of patient subset, where the patient is at high risk or has other health
conditions. The technique has remarkable potential in developing countries that treat
many LABC patients but may lack the necessary medical expertise or infrastructure.
The procedure is straightforward, has a short learning curve, and promotes efficient
wound healing, making it an excellent option for follow-up treatments. Surgical delay,
either pre- or postmastectomy, can be considered in future modifications to decrease
edge necrosis.
