Use of Thoracodorsal Artery Perforator (Tdap) Flap to Cover a Laparoscopically Harvested Omental Flap After Modified Radical Mastectomy; a Case Report

Abstract

Omental flap was introduced for breast reconstruction after mastectomy either alone or as an adjunct to prosthetic reconstruction. Laparoscopically harvested omental flap was used successfully for this issue. Most of reports had described its use after partial mastectomy, skin or nipple areola sparing mastectomies. In this case, we used the thoracodorsal artery perforator (Tdap) flap as a cover for the omental flap in a patient who underwent modified radical mastectomy. Modified radical mastectomy was done in the usual fashion. The descending branch of the thoracodorsal vessel was traced till its main perforator in an antegrade fashion. Then, the supplied skin island flap was created and rotated to cover the laparoscopically harvested omental flap that was delivered after its mobilization through a small epigastric wound from underneath the inner aspect of the lower mastectomy flap. The overall operative time was around 150 min. No blood transfusion was required. Pain score was around 6–7 in the early postoperative hours. No major complications were encountered, and the patient was discharged at the third postoperative day. The overall esthetic score was expressed as “good.” To our knowledge, this is the first time to report usage of laparoscopically harvested omental flap after modified radical mastectomy with skin coverage by the thoracodorsal artery perforator (Tdap) flap. One criticism that may arise is the dual flap reconstruction; however, this method still as an alternative to the myocutaneous flaps with a reasonable operative time and minimal donor site and overall morbidities with good esthetic outcome. Modified radical mastectomy can be safely and efficiently reconstructed using a laparoscopically harvested omental flap with a cutaneous coverage using the thoracodorsal artery perforator (Tdap) flap.

Background

Omental flap was described a long time ago by Kiricuta for breast reconstruction after mastectomy [1]. Advantages of omentum are numerous [2, 3] especially its vascular reliability, peculiar adaptability that makes it fit for any cavity, peculiar volume increase which is due to its absorptive phenomena, and its immune function [3]. Early trials used the pedicled omental flap in breast reconstruction through a laparotomy incision [2, 4]. Saltz reported a laparoscopically harvested omental flap to cover a large soft tissue defect in 1993 [5]. This opened the gate for a multiple series about the use of laparoscopically harvested omental free flap after either skin sparing mastectomy [6–10] or partial mastectomy [11]. The main drawback of this flap is that its volume is unpredictable; however, an implant can be used in adjunct [4]. Some authors reported a free omental flap transfer also [3, 12]. A systematic review had highlighted results of most trials using this flap [13]. To our knowledge, there is no trial that reported the use of the laparoscopically harvested omental flap after modified radical mastectomy due to absence of skin coverage. We report this case in which we covered the omental flap with thoracodorsal artery perforator (Tdap) flap after a modified radical mastectomy.

Case Presentation

This report is about a 52-year-old lady with a body mass index equals 28 who presented by a left breast lump that was proven to be malignant after a core needle biopsy. This patient gave a history of laparoscopic cholecystectomy 3 years ago, open hysterectomy through a Pannestiel incision for a uterine fibroid 2 years ago, and appendectomy in the past 15 years. Both breasts mammography revealed a large irregular mass 8 × 3.1 × 5.5 cm from 11 to 2 o’clock in the left breast with apparent intraductal extension and foci of calcifications, with another similar lesion at 3 o’clock that measures 1.6 × 1.1 × 0.7 cm and a suspicious ipsilateral axillary lymph node measuring 2.6 × 1.6 cm. Metastatic workup was free, and the patient received a neoadjuvant course of Taxol followed by another reassessment. The new radiology revealed an apparent disappearance of the adjacent masses with reactive axillary nodes and a final mass size of 27 × 16 mm with proximity to the underlying skin. The operative decision was to perform a skin sparing mastectomy with a laparoscopically harvested omental flap reconstruction. Intraoperatively, the mass was so close to the skin and frozen section showed skin involvement, so the decision was changed into a modified radical mastectomy. The laparoscopic team started at the same time and the flap was retrieved; so, we decided the use of thoracodorsal artery perforator (Tdap) flap to be sutured to the mastectomy skin as a cover for the omentum.

Method

Mastectomy was done in the usual manner at the same time of laparoscopic omental flap retrieval (Fig. 1a). For retrieval of the thoracodorsal artery perforator (Tdap) flap, we started by marking of the proposed perforators in the lateral position using the intraoperative Doppler. An incision was made along the anterior axillary fold as a longitudinal ellipse and deepened till the fascia covering the muscles. Dissection started from medial to lateral and from below upwards till the site of expected perforators. The 1st and the largest perforator lies 6–8 cm from the upper axillary crease, 1–3 cm away from the posterior axillary fold. We used an antegrade flap dissection (anterior approach) tracing the descending branch of the throcadorsal artery till we reached the perforators with ligation of the thoracic branch of the thoracodorsal artery to increase the arc of rotation. After releasing the greater omentum from the colonic attachment, ligating the left gastroepiploic vessels and releasing the flap from the greater curvature of the stomach to be based only on the right gastroepiploic vessels, the omental flap was transferred to the mastectomy bed through a small epigastric incision from inside the lower mastectomy flap (Fig. 1b, c). The (Tdap) flap was then transferred to the breast over the omental flap and its skin was sutured to the mastectomy flap edges. A suction drain was inserted in both sites of flap’s harvest and in the axilla. Lastly, the back and mastectomy wounds were closed with a subcuticular proline 3-0 (Fig. 1d).

Fig. 1.

a Ornamental retrieval together with mastectomy done. b Perforator flap was created and the omental flap is shown in the mastectomy bed. c, d The perforator flap was transferred and put over the omental flap as a cover

Results

The overall operative time was approximately 150 min. No blood transfusion was required. Routinely, we used the perioperative antibiotic regimen with giving 1.5 g of ampicillin/sulbactam with induction of anesthesia, 2 h intraoperatively, 2 h and 8 h postoperatively. The postoperative pain score was 7, 6, 7, and 4 at 4, 8, 12, and 16 h postoperatively. No major complications were encountered, and the drain was removed after 7 days postoperatively. The patient started oral feeding once there was an audible intestinal sound and this happened 10 h postoperatively, and the patient was discharged at the third postoperative day. Wound healing was satisfactory (Fig. 2a, b). Postoperative pathology report revealed “high-grade infiltrating duct carcinoma with minor intraduct component about 5% with frequent lympho-vascular emboli, infiltration of the other breast quadrants by intraduct carcinoma, dermal infiltration of overlying skin by invasive component, infiltration of 1/10 of dissected axillary LNs, TNM staging: T2 N1 Mx stage IIB at least, and immune staining showing ER, PR negative, Her-2neu positive score (+ 3), and ki67 low index.” For assessment of the esthetic outcome, we simply used the Harvard scoring system that was expressed as excellent (the treated breast is nearly identical to the untreated one), good (there is slight asymmetry between the two breasts), fair (marked asymmetry), and poor (the treated breast is seriously distorted). When the patient was assessed 2 months later, the patient’s subjective feeling and the physician opinion taken by a different breast surgeon expressed the esthetic outcome as good (Fig. 2c). The patient continued the trastuzumab-based chemotherapy course with adjuvant radiotherapy without hormonal therapy.

Fig. 2.

a Immediate postoperative lateral view showing the scar of perforator flap. b Immediate postoperative front view. c Two months lateral front view

Discussion

Among all methods of postmastectomy reconstruction, the laparoscopically harvested omental flap remains a logic option. It differs from the latissimus dorsi and transverse rectus abdominis myocutaneous flaps that it has a pure fatty tissue that can adapt to any breast envelop, minimal donor site morbidity, relatively shorter time of harvest with no need for a long learning curve [3, 4]. The tradition of its use was after skin sparing and nipple areola sparing mastectomies as this flap has no skin coverage. In this case, we show a new idea that enables the use of laparoscopically harvested omental flap after modified radical mastectomy with a skin coverage using the thoracodorsal artery perforator (Tdap) flap. One criticism that may arise is the multiplicity of techniques and the dual flap use. The answer of this question is the reservation of function of latissimus and rectus abdominis muscles with a relatively shorter time of the surgery. Morbidity is very minimal and the patient/doctor satisfaction was good.

Conclusion

Modified radical mastectomy can be safely and efficiently reconstructed using a laparoscopically harvested omental flap with a cutaneous coverage using the thoracodorsal artery perforator (Tdap) flap.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.