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British Journal of Plastic Surgery (1982) 35,443451 0 1982 The Trustees of British Association of Plastic Surgeons

0007- 1226/82/0406-0443 $02.00

Soft tissue reconstruction of the breast using an external oblique myocutaneous abdominal flap

DONALD R. MARSHALL, E. JOHN ANSTEE and MURRAY J. STAPLETON

Victorian Plastic Surgery Unit, Melbourne, Australia

Summary-A method of breast reconstruction is described in which the soft tissue usually discarded in an abdominal Iipectomy is transferred into the breast as a myocutaneous flap based on the external oblique muscle. The anatomy of the flap is described and two cases are presented. No prosthesis is required.

The latissimus dorsi myocutaneous flap is now used widely to provide skin and muscle cover in post-mastectomy breast reconstruction (Maxwell et al., 1980), but a prosthesis is necessary to provide sufficient breast volume. The opposite breast is occasionally available in breast reconstruction as a donor of soft tissue, providing it is large enough and certain pathological criteria are satisfied (Marshall et al., 1981). The skin and fat of the lower abdomen also provides an occasional source of soft tissue for breast reconstruction and can be transferred in a two-stage flap procedure (Marshall et al., 1981), or as a single-staged micro-vascular repair (Holstrbm, 1979).

While each of these methods of transferring tissue from the lower abdomen is occasionally indicated, the practical difficulties rule them out for routine use. Our experience with the latissimus dorsi flap combined with a prosthesis has been that while the early results are excellent, there are a sufficient number of capsular contractions to make the late results of a soft tissue repair alone superior overall. This conviction has prompted us to continue the search for a simple method of transferring the skin and fat of the lower abdomen normally discarded in an abdominal lipectomy to the breast, as many mastectomy patients have adequate soft tissue for this procedure. Furthermore, the fat of the lower abdominal wall is contained in large discrete compartments and bears an excellent likeness to breast tissue.

While the two-stage flap operation already described produces a satisfactory end result, the large area of temporary skin graft is prone to bacterial colonisation, which, with the present problem of antibiotic-resistant hospital staphylo- cocci, poses major nursing problems.

With the current renewed interest in the anatomy of the skin circulation and the role of the sub- fascial vessels, it seems logical to explore the possibility of carrying this soft tissue to the breast on a muscle flap to achieve the same end result without the raw area: the question is which muscle?

To enable the abdominal skin and fat flap to be transferred to the breast, it is clear that the vascular pedicle has to come from above and the superior epigastric vascular leash appears a possibility. However, the lower portion of the rectus abdominus muscle lies directly beneath the required skin flap and cannot be sacrificed without weakening the lower abdominal wall in a way which seems unacceptable, as in this region there is no posterior rectus sheath.

The only other abdominal muscle which seems a possible carrier for flap transfer is the external oblique, running as it does from the rib cage laterally to the mid-line of the abdomen, anterior to the rectus abdominus and beneath the skin flap (Fig. I).

Anatomical basis of the operation

The segmental intercostal vessels pass forward into the abdomen between the internal oblique and the transversus muscles as far as the rectus sheath (Fig. 2), but their lateral cutaneous branches pass through the internal oblique in the mid-lateral line to pass forward deep to the external oblique to supply the skin and fat of the abdominal wall (Fig. 3).

Cadaver dissections reveal the technical feasi- bility of carrying the skin and subcutaneous tissue of the lower abdomen into the breasts via

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Fig. 1 Line drawing to show: 1. On the left side of the patient the skin flap outlined in a solid black line and the underlying muscle flap outlined in a dotted line. 2. On the right side of the patient the myocutaneous flap with an island of skin and fat transferred superiorly into the region of the breast (skin tunnel not shown). Note the deficiency in the external oblique muscle with the underlying ftbres of internal oblique running as far as the lateral edge of the rectus sheath and the vertical rectus abdominus muscle medial to this.

Fig. 2 Drawing of a transverse section of the left side of the abdominal wall. Note the external oblique, internal oblique, transverse abdominus and the fascial arrangement of the rectus sheath. The segmental nerves and vessels and their mid-lateral branches are shown as a broken line. The plane of the elevation of the myocutaneous flap is shown as a dotted line and passes as far posteriorly as the lateral branches.

I

Fig. 3 Drawing of a transverse section of the abdominal wall with the flap now elevated. Note that the rectus abdominus muscle is undisturbed. The skin and fat overlying the external oblique muscle is raised as an island.

a subcutaneous tunnel lying over the ribs, using such an external oblique myocutaneous flap.

The circulatory competence of the flap can be established during the course of a number of routine abdominal lipectomies, in which the skin and fat is left as an island attached to the muscle flap, which is temporarily developed up to the rib cage. It is later replaced, the skin excised and the lipectomy completed in the usual way. The defect in the external oblique muscle seems unlikely to cause a problem, providing the underlying muscles are in no way damaged.

Method

The patient had a right Patey mastectomy for carcinoma of the breast two years prior to consultation (Fig. 4). She had a moderate abdominal apron and wished to have a breast reconstruction as well as an abdominal lipectomy. It was decided to reconstruct her breast using the tissue which would otherwise be discarded in the abdominal lipectomy. The skin defect in the breast was minimal (Figs. 5 and 6). She had had an abdominal operation via a lower midline incision seven years ago. With the patient lying on her back on the operating table, the skin flap was outlined on the right side from umbilicus to pubis in the midline and extending as a triangle to the anterior superior ilial spine (Fig. 7).

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Fig. 4 Pre-operative photograph showing the transverse scar Fig. 5 Photograph of same patient showing the dependent of a right Patey mastectomy two years before. normal left breast.

Fig. 6 Photograph of same patient showing absence of Fig. 7 Photograph taken on the operating table showing the contour of the right side although there is no shortage of island flap of skin and fat (solid line) and the underlying skin, muscle flap (dotted line). The planned position of the sub-

mammary groove is also shown.

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The incision was deepened through the freed from the iliac crest and the posterior free external oblique aponeurosis and the anterior border of the muscle was transected. The lateral rectus sheath was elevated in continuity. The skin perforating vessels were identified and preserved and fat usually discarded was left attached to the in two spaces as the muscle was elevated from external oblique muscle (Fig. 8). A strip of the lateral surface of the ribs (Fig. 10). The external oblique four inches wide was elevated abdominal skin above the island flap was from the underlying internal oblique muscle back elevated from the abdominal wall to above the as far as the rib cage (Fig. 9). The muscle was umbilicus on each side, as in a normal lipectomy.

Fig. 8 Photograph showing the island of skin and fat which is left attached to the underlying external oblique muscle and the anterior rectus sheath.

Fig. 9 Photograph showing the upper skin flap elevated off the external oblique muscle to above the umbilicus as in an abdominal lipectomy. The strip of external oblique which is left in continuity with the island of skin and fat is also visible.

Fig. 10 Photograph showing the strip of external oblique muscle with the lowest lateral cutaneous branch of the intercostal vessels passing from internal oblique into the overlying muscle.

The mastectomy scar in the breast was opened and the skin flaps raised from the pectoralis major muscle. A subcutaneous tunnel was established from the breast to the abdominal wound and the myocutaneous flap was then passed through this into the breast (Fig. 11). No skin replacement was necessary in this case so most of the skin of the flap was removed to leave an island of skin as a monitor of the circulation of the flap (Fig. 12). The remainder of the flap was then arranged to conform as accurately as possible to the normal breast. No prosthesis was used and the shape and volume of the reconstructed breast was sufficiently close to the normal side that no adjustment to the latter was required (Fig. 13).

The abdominal lipectomy was then completed with a transposition of the umbilicus and excision of the skin and fat on the opposite side. The wounds were closed with drainage and the circulation in the flap appeared adequate at all times. A nipple reconstruction was not performed. The operating time was approximately two hours and the blood loss was 500mls.


Fig. 11 Photograph showing the subcutaneous tunnel from the wound in the breast into the abdominal wound. Note the gloved hand emerging from the tunnel which must be large enough to accommodate the pedicle of the flap without any tightness.

A second operation was performed three months later in which the skin of the flap was removed (Fig. 14) and the pedicle of the flap was divided as low down as possible (Fig. 15) allow- ing the subcutaneous tissue and muscle to be turned superiorly to further augment the breast volume. A nipple reconstruction was performed along standard lines (Fig. 16) (Marshall et al., 1977). The result is a patient with breasts of almost symmetrical contour and consistency in all positions (Figs. 17 and 18) without the need for a prosthesis or adjustment to the normal side (Fig. 19). The breasts feel normal on palpation.

A second patient required a breast reconstruction in which both skin and volume replacement were necessary and here all elements of tKe external oblique myocutaneous flap were used (Figs. 20 and 21). In this patient it was not possible to obtain sufficient soft tissue to produce

Fig. 12 Photograph showing the area of skin of the flap from which the epithelium was removed. This varies depend- ing on the particular patient.

a breast as large as on the normal side and a small reduction was required to achieve symmetry. This was carried out at a second procedure at which the subcutaneous “carry” portion of the flap was transferred into the breast and a nipple was added along with an uplift and reduction on the normal side (Figs. 22 and 23). Again no prosthesis was used.

Results

The method has been used successfully in five patients. There has been one failure due to necrosis of the flap as a result of compression in the subcutaneous tunnel. This occurred in an obese elderly patient and in this situation an incision through the overlying skin of the tunnel may be required to prevent any vascular compression.


Fig. 15 Post-operative photograph showing the normal dependent profile of the mature left breast.

Fig. 13 Photograph showing the skin portion of the flap sutured into the defect created by excision of the old mastectomy scar. The abdominal lipectomy has been completed in the normal manner with transposition of the umbilicus and excision of the excess skin and fat on the left side.

Fig. 16 Photograph of the same patient showing the breast contour on the reconstructed side.

Fig. 14 Post-operative photograph showing the transverse scar after excision of the skin of the flap and nipple reconstruction using local dermal flaps.

Discussion

This method of breast reconstruction using only the skin and fat of the lower abdomen obviates the shortcomings of a prosthesis. It has the added advantage of improving the contour of the abdomen while placing the donor scar in an ac- ceptable position. The operation is done with the patient lying on her back on the operating table and no change in position is required during the


procedure. Blood loss is minimal, the procedure is relatively non-traumatic to the patient and can be carried out in a relatively short time.

The main disadvantage is the loss of a portion of the external oblique muscle but this is unlikely to cause any problem in an otherwise normal

Fig. 19 Photograph of the same patient showing the symmetry of the breast even with the arms extended. Note that no surgery has been carried out on the normal side.

abdominal wall. The deficiency can be made good with a nylon mesh if this is felt to be necessary. There is little reserve circulation in the

Fig. 17 Photograph of the same patient with the arms flap and prevention of haematoma and com- extended to show the change in contour with this soft tissue repair.

pression of the pedicle is essential. In the extremely thin patient there may not be

enough tissue to provide sufficient volume and in these cases a prosthesis may still be necessary with either a latissimus dorsi or an external oblique myocutaneous flap to provide cover. Although the vascularity of the latter is not as good as the former, it has the advantage that the posture of the patient does not need to be changed during the operation and the donor scar is better placed. The main advantage of the method is, however, that it usually provides adequate bulk without the need for a prosthesis and provides an alternative method for post- mastectomy reconstruction for one or both breasts.

The flap is also suitable for the treatment of patients with complications related to the use of a prosthesis, either after total or subcutaneous mastectomy, or after augmentation mammaplasty on one or both sides. If the skin of the myocutaneous flap is removed it can be used to replace breast volume alone and can then be used in-

Fig. 18 Photograph of the same patient showing the alter- stead of a prosthesis when bilateral subcutaneous

ation in contour on extending the arms is almost identical with mastectomy is required as a prophylaxis against the normal left breast. the development of carcinoma of the breast.


Fig. 20 Photograph of a patient who had an external Fig. 21 Photograph of the same patient. Note the bulge over oblique myocutaneous flap reconstruction of the left breast the left rib cage where the pedicle of the flap lies beneath the four weeks previously. The patient had had a left Patey skin. mastectomy two years prior to the reconstruction. Note the post-abdominal-lipectomy appearance of the abdomen and the flap in situ in the left breast.

Fig. 22 Photograph of the same patient after detachment of Fig. 23 Photograph of the same patient showing satisfactory the pedicle of the flap which has been turned into the left symmetry. Note the fullness over the left rib cage is no longer breast to augment the volume further. The right breast has evident. been reduced and the nipple uplifted along with a nipple reconstruction on the left side.


Hohustriim, Hans. (1979). The free abdominoplasty flap and its use in breast reconstruction. An experimental study and a clinical case report. Scandinavian Journal of Plastic Surgery, 13, 423.

Marshall, D. R., An&e, E. J. and Stepleton, M. J. (1981). Post-mastectomy breast reconstruction using a breast- sharing technique. British Journal of Plastic Surgery, 34, 426.

Marshall, D. R., Aasteee, E. J. and Stapleton, M. J. (1981). Post-mastectomy breast reconstruction using a direct flap from an abdominal lipectomy. British Journal of Plastic Surgery, 34, 280.

Marshall, D. R., An&e, E. J. and Stapleton, M. J. (1977). Reconstruction of the breast following radical mastectomy. The Ausrraliun and New Zealand Journal of Surgery, 47, 6.

Maxwell, G. P., Rosato, F. E. and Horton, C. E. (1980). Current problems in surgery-postmastectom~ breast re- consfruction. Vol. XVII No. II.

Acknowledgement This paper was presented at the 55th General Scientific Meeting of the Royal Australasian College of Surgeons in Christchurch, New Zealand in January, 1982.

The Authors

Donald R. Marshall, FRACS, FACS, Senior Plastic Surgeon, Prince Henry’s Hospital, Melbourne, Australia.

E. John Arrstee, FRACS, Senior Plastic Surgeon, Alfred Hospital, Melbourne, Australia.

Murray J. Stapleton, FRACS, Senior Plastic Surgeon, Queen Victoria Medical Centre, Melbourne, Australia.

Requests for reprints to: Mr Donald Marshall, FRACS, FACS, 85, High Street, Kew, 3101, Victoria, Australia.