{"paper_id":"43503ae6-2edd-4242-8d63-38dfca7aff1c","body_text":"134\naaps\nArchives of\nAesthetic Plastic Surgery\nCASE \nREPORT\nTreatment of Abdominal Wall Endometriosis Using a \nMini-Abdominoplasty Design\nINTRODUCTION\nEndometriosis is a common gynecological disease involving the \nectopic growth of endometrial tissue [1]. Endometriosis found on \nabdominal incisions is referred to as abdominal wall endometriosis \n(AWE) [2]. The prevalence of AWE has been estimated to range \nfrom 0.04% to 12.3% [3]. Many cases of AWE are associated with \ncesarean section scars, and laparoscopic port sites, hernia repairs, \nand laparotomies can also induce AWE [4]. Thus, AWE is often \nmisdiagnosed as a hernia, hematoma, or lipoma, resulting in a sur-\ngical consultation. \n The most appropriate treatment of AWE is surgical manage-\nment with a margin of at least 1 cm. In contrast, medical manage-\nment of AWE has shown low levels of success [5]. Preliminary stud-\nies evaluating therapeutic percutaneous cryoablation have shown \npromise, with a decrease in lesion volume [6]. However, some re-\nports of clear cell adenocarcinoma associated with AWE have been \nreported, underscoring the need for wide surgical excision.\n In cases of large abdominal endometriosis, excision of the mass \nand direct closure can result in a conspicuously asymmetric ab-\ndominal contour. Moreover, the large size of the tumor to be re-\nmoved makes it challenging for surgeons to reconstruct the ab-\ndominal wall. Since Kelly [7] first reported the use of a large hori-\nzontal mid-abdominal incision to correct excessive abdominal tis-\nsue, many abdominoplasty techniques have been developed. Some \nsurgeons have performed a mini-abdominoplasty with mesh to \ncover AWE defects, with good cosmetic and surgical outcomes \n[8,9]. In this case study, we present a case of abdominal wall recon-\nstruction using a mini-abdominoplasty design after wide excision \nof a large AWE.\nCASE REPORT\nA 46-year-old woman presented with a palpable mass on the lower \nmid-abdomen without tenderness. She had undergone a cesarean \ndelivery 15 years ago and suffered from an infection. On physical \nKyunghyun Min, Hyun Ho Han\nDepartment of Plastic Surgery, Asan \nMedical Center, University of Ulsan \nCollege of Medicine, Seoul, Korea\nAbdominal wall endometriosis is a condition in which functioning endometrial tissue is \npresent outside the uterine cavity, and the standard treatment is extensive surgical ex-\ncision. A 46-year-old woman presented with an irregular lower abdominal mass mea-\nsuring 8.5×4.5 cm. The patient had a history of a cesarean delivery 15 years previously. \nFor treatment, a mini-abdominoplasty was designed to avoid possible wound compli-\ncations and to optimize the cosmetic outcomes. The lesion was excised with an ade-\nquate margin because of the possibility of recurrence. The resected structures were \nthe lower mid-abdominal skin, subcutaneous fat, anterior and posterior rectus sheath, \nand rectus abdominis muscle. The incisional wound was closed layer by layer, including \nabdominal fascia repair with acellular dermal matrix. At a 3-month postoperative out-\npatient follow-up visit, the patient was highly satisfied with the cosmetic results and re-\nported no complications. Optimal oncological, functional, and cosmetic surgical out-\ncomes can be achieved by complete excision followed by mini-abdominoplasty.\nKeywords Abdominal wall, Abdominoplasty, EndometriosisNo potential conflict of interest relevant to \nthis article was reported.\nReceived: Apr 26, 2018 Revised: May 31, 2018 Accepted: May 31, 2018\nCorrespondence: Hyun Ho Han Department of Plastic Surgery, Asan \nMedical Center, University of Ulsan College of Medicine,  \n88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea.\nE-mail: tripleh1952@gmail.com\nCopyright © 2018 The Korean Society for Aesthetic Plastic Surgery. \nThis is an Open Access article distributed under the terms of the Creative Commons At-\ntribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) \nwhich permits unrestricted non-commercial use, distribution, and reproduction in any \nmedium, provided the original work is properly cited. www.e-aaps.org \nhttps://doi.org/10.14730/aaps.2018.24.3.134\nArch Aesthetic Plast Surg 2018;24(3):134-137\npISSN: 2234-0831 eISSN: 2288-9337\n1 / 1CROSSMARK_logo_3_Test\n2017-03-16https://crossmark-cdn.crossref.org/widget/v2.0/logos/CROSSMARK_Color_square.svg\n\n135\naaps\nArchives of\nAesthetic Plastic SurgeryMin K et al.   Mini-Abdominoplasty on Endometriosis\nexamination, a lower abdominal mass was palpated at the mid-ab-\ndomen (Fig. 1). It was non-tender, irregular, and fixed to the deep \ntissue. On abdominopelvic computed tomography, an irregular \nheterogeneous enhancing lesion measuring roughly 8.5 × 4.5 cm \nwas observed at the lower rectus abdominis muscle (Fig. 2). It ad-\nhered to the subcutaneous tissue and deep fascia, and ultrasonog-\nraphy-guided needle biopsy confirmed that the lesion was endo-\nmetriosis. The gynecologic surgery team at our institution decided \nFig. 1. Preoperative photograph showing lower abdominal bulging with a palpable mass. Mild skin laxity was observed.\nFig. 2. Preoperative abdominopelvic computed tomography. An irregular heterogeneous enhancing lesion measuring 8.5 × 4.5 cm was observed \nat the lower rectus abdominis muscle (red arrow). It adhered to the subcutaneous tissue and deep fascia. Incisional biopsy reported endome-\ntriosis.\n\n\n136\naaps\nArchives of\nAesthetic Plastic Surgery VOLUME 24. NUMBER 3. OCTOBER 2018\nFig. 3. Preoperative design. The lesion did not involve the umbilicus, \nso a mini-abdominoplasty design was planned, including the previ-\nous cesarean section scar .\nFig. 4. Photograph from 3 months postoperatively. The wound had completely recovered without scar widening, recurrence, or complications \nsuch as hematoma, abdominal hernia, or wound dehiscence.\nto remove the mass.\n Under general anesthesia, skin incision and dissection around \nthe mass was followed by a mini-abdominoplasty design, including \nthe cesarean section scar (Fig. 3). Endometrial tissue was found \npenetrating not only the rectus abdominis, but also the posterior \nsheath of the rectus muscle. Moreover, there was a high suspicion \nof bladder involvement. Therefore, the gynecologic team made a \nperitoneal incision at the superior area of the bladder to identify \nthe extent of endometriosis. Fortunately, the urinary bladder was \nintact. The final excised mass measured 10.0 × 9.1 × 3.7 cm, includ-\ning the anterior abdominal. Peritoneal layer repair was performed \nwith Vicryl 1-0 (Ethicon Inc., Somerville, NJ, USA) after meticulous \nhemostasis.\n The plastic surgery team joined the operation afterward. The \nanterior rectus sheath was not closed primarily, so a piece of acellu-\nlar dermal matrix measuring 5 × 4 cm (MegaDerm; L&C Bio Corp., \nSeongnam, Korea) was used for fascia repair with a defect that was \n8 × 5 cm in size. Umbilicus repositioning was not performed, the \nScarpa fascia layer was repaired with Vicryl 1-0, and the dermal \nlayer was repaired with polydioxanone II 3-0 and 4-0 sutures (Ethi-\ncon Inc.). The skin layer was closed using Dermabond Prineo® \n(Ethicon Inc.). All drains were removed 11 days after surgery. The \npatient kept a bandage on the abdomen for a month. At a 3-month \npostoperative outpatient follow-up visit, her scar had healed well, \nand it was hidden when she wore underwear. No postoperative \ncomplications, such as abdominal hernia, seroma formation, surgi-\ncal site infection, or wound dehiscence, were observed. The patient \nwas highly satisfied with the results (Fig. 4).\n\n137\naaps\nArchives of\nAesthetic Plastic SurgeryMin K et al.   Mini-Abdominoplasty on Endometriosis\nDISCUSSION\nAWE tends to recur, so the lesion should be resected with an ade-\nquate ablation margin. Based on the size and depth of the mass, the \nmethod of wound closure varies, so a detailed intraoperative wound \nassessment should be performed. Patel et al. [10] described a com-\nponent separation technique with a medial advancement of 3 to 5 \ncm in the epigastrium, 7 to 10 cm at the umbilical area, and 1 to 3 \ncm in the suprapubic area for a single side, with double these fig-\nures for a bilateral component separation. If the fascia is not closed \nprimarily, or is closed with severe tension, synthetic/biological mesh \ncan also be considered. \n In this case, AWE did not spread widely to the skin. Moreover, \nthe abdominal skin has mild laxity, so wound closure was possible \neven though an extensive amount of tissue was removed. There-\nfore, the mini-abdominoplasty design was possible because skin \nclosure was easy. Additionally, the umbilicus had not been invaded \nand did not need to be repositioned. If a lesion invades the umbili-\ncal area or the abdominal tissue below the umbilicus, a classic ab-\ndominoplasty design is needed [11]. If a neo-umbilicus must be \nmade or umbilical repositioning is needed, a simple method is to \nplace the position of the umbilicus at the highest level of the iliac \ncrest [12]. Furthermore, the ratio between the umbilicus-xiphoid \nprocess and umbilicus-symphysis pubis (1.6:1) can be used to de-\ntermine the umbilicus location [13]. \n For plastic surgeons, abdominoplasty is a basic concept, but it \nmay be an unfamiliar procedure for gynecologists. Sharing of sur-\ngical information between these departments is important, and the \nexcision planning of the gynecologic surgery and the design of the \nplastic surgeon are accordingly important. Collaborative treat-\nments of AWE, which may result in cosmetic issues, can lead to \nmore satisfactory results for the patient. \nPATIENT CONSENT\nThe patient provided written consent for the use of her images.\nREFERENCES\n1. Horton JD, Dezee KJ, Ahnfeldt EP , et al. Abdominal wall endometrio-\nsis: a surgeon’s perspective and review of 445 cases. Am J Surg 2008; \n196:207-12.\n2. Ecker AM, Donnellan NM, Shepherd JP , et al. Abdominal wall endo-\nmetriosis: 12 years of experience at a large academic institution. Am J \nObstet Gynecol 2014;211:363.e1-5.\n3. Zhao X, Lang J, Leng J, et al. Abdominal wall endometriomas. Int J \nGynaecol Obstet 2005;90:218-22.\n4. Blanco RG, Parithivel VS, Shah AK, et al. Abdominal wall endometri-\nomas. Am J Surg 2003;185:596-8.\n5. Chatterjee SK. Scar endometriosis: a clinicopathologic study of 17 cas-\nes. Obstet Gynecol 1980;56:81-4.\n6. Cornelis F , Petitpierre F , Lasserre AS, et al. Percutaneous cryoablation \nof symptomatic abdominal scar endometrioma: initial reports. Car-\ndiovasc Intervent Radiol 2014;37:1575-9.\n7. Kelly HA. Excision of fat of the abdominal wall lipectomy. Surg Gyne-\ncol Obstet 1910;10:229-31.\n8. Lee ET, Park HM, Lee DG, et al. Application of mini-abdominoplasty \nafter conservative excision of extensive cesarean scar endometriosis. \nArch Plast Surg 2012;39:551-5.\n9. Zhao R, Wang XJ, Song KX, et al. Mini-abdominoplasty combined \nwith mesh used for abdominal wall endometriosis. Chin Med J (Engl) \n2012;125:1614-7.\n10. Patel NG, Ratanshi I, Buchel EW . The best of abdominal wall recon-\nstruction. Plast Reconstr Surg 2018;141:113e-36e.\n11. Matarasso A, Matarasso DM, Matarasso EJ. Abdominoplasty: classic \nprinciples and technique. Clin Plast Surg 2014;41:655-72.\n12. Dubou R, Ousterhout DK. Placement of the umbilicus in an abdomi-\nnoplasty. Plast Reconstr Surg 1978;61:291-3.\n13. Duduković M, Kisić H, Baez ML, et al. Anatomical prediction for sur-\ngical positioning of the umbilicus in a Croatian population. Ann Plast \nSurg 2015;75:135-9.","source_license":"CC0","license_restricted":false}