Treatment of Abdominal Wall Endometriosis Using a Mini-Abdominoplasty Design

Endometriosis is a common gynecological disease involving the ectopic growth of endometrial tissue [1]. Endometriosis found on abdominal incisions is referred to as abdominal wall endometriosis (AWE) [2]. The prevalence of AWE has been estimated to range from 0.04% to 12.3% [3]. Many cases of AWE are associated with cesarean section scars, and laparoscopic port sites, hernia repairs, and laparotomies can also induce AWE [4]. Thus, AWE is often misdiagnosed as a hernia, hematoma, or lipoma, resulting in a sur- gical consultation. The most appropriate treatment of AWE is surgical manage- ment with a margin of at least 1 cm. In contrast, medical manage- ment of AWE has shown low levels of success [5]. Preliminary stud- ies evaluating therapeutic percutaneous cryoablation have shown promise, with a decrease in lesion volume [6]. However, some re- ports of clear cell adenocarcinoma associated with AWE have been reported, underscoring the need for wide surgical excision. In cases of large abdominal endometriosis, excision of the mass and direct closure can result in a conspicuously asymmetric ab- dominal contour. Moreover, the large size of the tumor to be re- moved makes it challenging for surgeons to reconstruct the ab- dominal wall. Since Kelly [7] first reported the use of a large hori- zontal mid-abdominal incision to correct excessive abdominal tis- sue, many abdominoplasty techniques have been developed. Some surgeons have performed a mini-abdominoplasty with mesh to cover AWE defects, with good cosmetic and surgical outcomes [8,9]. In this case study, we present a case of abdominal wall recon- struction using a mini-abdominoplasty design after wide excision of a large AWE. CASE REPORT A 46-year-old woman presented with a palpable mass on the lower mid-abdomen without tenderness. She had undergone a cesarean delivery 15 years ago and suffered from an infection. On physical Kyunghyun Min, Hyun Ho Han Department of Plastic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea Abdominal wall endometriosis is a condition in which functioning endometrial tissue is present outside the uterine cavity, and the standard treatment is extensive surgical ex- cision. A 46-year-old woman presented with an irregular lower abdominal mass mea- suring 8.5×4.5 cm. The patient had a history of a cesarean delivery 15 years previously. For treatment, a mini-abdominoplasty was designed to avoid possible wound compli- cations and to optimize the cosmetic outcomes. The lesion was excised with an ade- quate margin because of the possibility of recurrence. The resected structures were the lower mid-abdominal skin, subcutaneous fat, anterior and posterior rectus sheath, and rectus abdominis muscle. The incisional wound was closed layer by layer, including abdominal fascia repair with acellular dermal matrix. At a 3-month postoperative out- patient follow-up visit, the patient was highly satisfied with the cosmetic results and re- ported no complications. Optimal oncological, functional, and cosmetic surgical out- comes can be achieved by complete excision followed by mini-abdominoplasty.

Abdominal wall, Abdominoplasty, EndometriosisNo potential conflict of interest relevant to this article was reported. Received: Apr 26, 2018 Revised: May 31, 2018 Accepted: May 31, 2018 Correspondence: Hyun Ho Han Department of Plastic Surgery, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea. E-mail: [email protected] Copyright © 2018 The Korean Society for Aesthetic Plastic Surgery. This is an Open Access article distributed under the terms of the Creative Commons At- tribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. www.e-aaps.org https://doi.org/10.14730/aaps.2018.24.3.134 Arch Aesthetic Plast Surg 2018;24(3):134-137 pISSN: 2234-0831 eISSN: 2288-9337 1 / 1CROSSMARK_logo_3_Test 2017-03-16https://crossmark-cdn.crossref.org/widget/v2.0/logos/CROSSMARK_Color_square.svg 135 aaps Archives of Aesthetic Plastic SurgeryMin K et al. Mini-Abdominoplasty on Endometriosis examination, a lower abdominal mass was palpated at the mid-ab- domen (Fig. 1). It was non-tender, irregular, and fixed to the deep tissue. On abdominopelvic computed tomography, an irregular heterogeneous enhancing lesion measuring roughly 8.5 × 4.5 cm was observed at the lower rectus abdominis muscle (Fig. 2). It ad- hered to the subcutaneous tissue and deep fascia, and ultrasonog- raphy-guided needle biopsy confirmed that the lesion was endo- metriosis. The gynecologic surgery team at our institution decided Fig. 1. Preoperative photograph showing lower abdominal bulging with a palpable mass. Mild skin laxity was observed. Fig. 2. Preoperative abdominopelvic computed tomography. An irregular heterogeneous enhancing lesion measuring 8.5 × 4.5 cm was observed at the lower rectus abdominis muscle (red arrow). It adhered to the subcutaneous tissue and deep fascia. Incisional biopsy reported endome- triosis. 136 aaps Archives of Aesthetic Plastic Surgery VOLUME 24. NUMBER 3. OCTOBER 2018 Fig. 3. Preoperative design. The lesion did not involve the umbilicus, so a mini-abdominoplasty design was planned, including the previ- ous cesarean section scar . Fig. 4. Photograph from 3 months postoperatively. The wound had completely recovered without scar widening, recurrence, or complications such as hematoma, abdominal hernia, or wound dehiscence. to remove the mass. Under general anesthesia, skin incision and dissection around the mass was followed by a mini-abdominoplasty design, including the cesarean section scar (Fig. 3). Endometrial tissue was found penetrating not only the rectus abdominis, but also the posterior sheath of the rectus muscle. Moreover, there was a high suspicion of bladder involvement. Therefore, the gynecologic team made a peritoneal incision at the superior area of the bladder to identify the extent of endometriosis. Fortunately, the urinary bladder was intact. The final excised mass measured 10.0 × 9.1 × 3.7 cm, includ- ing the anterior abdominal. Peritoneal layer repair was performed with Vicryl 1-0 (Ethicon Inc., Somerville, NJ, USA) after meticulous hemostasis. The plastic surgery team joined the operation afterward. The anterior rectus sheath was not closed primarily, so a piece of acellu- lar dermal matrix measuring 5 × 4 cm (MegaDerm; L&C Bio Corp., Seongnam, Korea) was used for fascia repair with a defect that was 8 × 5 cm in size. Umbilicus repositioning was not performed, the Scarpa fascia layer was repaired with Vicryl 1-0, and the dermal layer was repaired with polydioxanone II 3-0 and 4-0 sutures (Ethi- con Inc.). The skin layer was closed using Dermabond Prineo® (Ethicon Inc.). All drains were removed 11 days after surgery. The patient kept a bandage on the abdomen for a month. At a 3-month postoperative outpatient follow-up visit, her scar had healed well, and it was hidden when she wore underwear. No postoperative complications, such as abdominal hernia, seroma formation, surgi- cal site infection, or wound dehiscence, were observed. The patient was highly satisfied with the results (Fig. 4). 137 aaps Archives of Aesthetic Plastic SurgeryMin K et al. Mini-Abdominoplasty on Endometriosis

AWE tends to recur, so the lesion should be resected with an ade- quate ablation margin. Based on the size and depth of the mass, the

of wound closure varies, so a detailed intraoperative wound assessment should be performed. Patel et al. [10] described a com- ponent separation technique with a medial advancement of 3 to 5 cm in the epigastrium, 7 to 10 cm at the umbilical area, and 1 to 3 cm in the suprapubic area for a single side, with double these fig- ures for a bilateral component separation. If the fascia is not closed primarily, or is closed with severe tension, synthetic/biological mesh can also be considered. In this case, AWE did not spread widely to the skin. Moreover, the abdominal skin has mild laxity, so wound closure was possible even though an extensive amount of tissue was removed. There- fore, the mini-abdominoplasty design was possible because skin closure was easy. Additionally, the umbilicus had not been invaded and did not need to be repositioned. If a lesion invades the umbili- cal area or the abdominal tissue below the umbilicus, a classic ab- dominoplasty design is needed [11]. If a neo-umbilicus must be made or umbilical repositioning is needed, a simple method is to place the position of the umbilicus at the highest level of the iliac crest [12]. Furthermore, the ratio between the umbilicus-xiphoid process and umbilicus-symphysis pubis (1.6:1) can be used to de- termine the umbilicus location [13]. For plastic surgeons, abdominoplasty is a basic concept, but it may be an unfamiliar procedure for gynecologists. Sharing of sur- gical information between these departments is important, and the excision planning of the gynecologic surgery and the design of the plastic surgeon are accordingly important. Collaborative treat- ments of AWE, which may result in cosmetic issues, can lead to more satisfactory results for the patient. PATIENT CONSENT The patient provided written consent for the use of her images.

1. Horton JD, Dezee KJ, Ahnfeldt EP , et al. Abdominal wall endometrio- sis: a surgeon’s perspective and review of 445 cases. Am J Surg 2008; 196:207-12. 2. Ecker AM, Donnellan NM, Shepherd JP , et al. Abdominal wall endo- metriosis: 12 years of experience at a large academic institution. Am J Obstet Gynecol 2014;211:363.e1-5. 3. Zhao X, Lang J, Leng J, et al. Abdominal wall endometriomas. Int J Gynaecol Obstet 2005;90:218-22. 4. Blanco RG, Parithivel VS, Shah AK, et al. Abdominal wall endometri- omas. Am J Surg 2003;185:596-8. 5. Chatterjee SK. Scar endometriosis: a clinicopathologic study of 17 cas- es. Obstet Gynecol 1980;56:81-4. 6. Cornelis F , Petitpierre F , Lasserre AS, et al. Percutaneous cryoablation of symptomatic abdominal scar endometrioma: initial reports. Car- diovasc Intervent Radiol 2014;37:1575-9. 7. Kelly HA. Excision of fat of the abdominal wall lipectomy. Surg Gyne- col Obstet 1910;10:229-31. 8. Lee ET, Park HM, Lee DG, et al. Application of mini-abdominoplasty after conservative excision of extensive cesarean scar endometriosis. Arch Plast Surg 2012;39:551-5. 9. Zhao R, Wang XJ, Song KX, et al. Mini-abdominoplasty combined with mesh used for abdominal wall endometriosis. Chin Med J (Engl) 2012;125:1614-7. 10. Patel NG, Ratanshi I, Buchel EW . The best of abdominal wall recon- struction. Plast Reconstr Surg 2018;141:113e-36e. 11. Matarasso A, Matarasso DM, Matarasso EJ. Abdominoplasty: classic principles and technique. Clin Plast Surg 2014;41:655-72. 12. Dubou R, Ousterhout DK. Placement of the umbilicus in an abdomi- noplasty. Plast Reconstr Surg 1978;61:291-3. 13. Duduković M, Kisić H, Baez ML, et al. Anatomical prediction for sur- gical positioning of the umbilicus in a Croatian population. Ann Plast Surg 2015;75:135-9.