British Journal of Plastic Surgery (2005) 58, 556 560 CASE REPORT Aesthetic surgery techniques after excision of dermatofibrosarcoma protuberans: a case report G. Dagregorio a, *, V. Darsonval b a Department of Plastic Surgery, Centre Hospitalo-Universitaire de Poitiers, Rue de la Milétrie, BP 577, 86021 Poitiers Cedex, Poitiers, France b Department of Plastic Surgery, Centre Hospitalo-Universitaire d Angers, Angers, France Received 28 December 2003; accepted 15 October 2004 KEYWORDS Dermatofibrosarcoma protuberans; Taylor flap; Wide margins; Mammaplasty; Reverse abdominoplasty Summary Dermatofibrosarcomata protuberans are rare locally aggressive tumours that have a very high recurrence rate in the absence of wide resection. Normally, when the area to be covered is exceptionally large or when skin grafting is not possible because of the location, pedicle or free flaps are used. We report one case of wide excision where the opportunity arose to apply aesthetic surgery techniques combining bilateral superiorly based mammaplasty and reverse abdominoplasty. Q 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. Dermatofibrosarcomata protuberans are rare, locally aggressive tumours that have a very high recurrence rate unless widely excised. In France, as in many other European countries where Mohs micrographic surgery 1 5 is not routinely used, surgeons usually perform a standard surgical excision with a wide margin of 4 5 cm. 6,7 The significant defects created by such wide excision are difficult to repair cosmetically. We report our first case of wide excision on the trunk where the opportunity arose to substitute 20-year-old aesthetic surgery techniques for the usual reconstructive techniques. Case report In 1986, a 66-year-old female was referred for * Corresponding author. Tel.: C33 5 49 44 43 03; fax: C33 5 49 44 39 71. E-mail addresses: g.dagregorio@chu-poitiers.fr (G. Dagregorio), verone4@wanadoo.fr (V. Darsonval). Figure 1 Very large dermatofibrosarcoma protuberans of the thoracoabdominal region. S0007-1226/$ - see front matter Q 2005 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2004.10.008
Aesthetic surgery techniques after excision of dermatofibrosarcoma protuberans: a case report 557 Figure 2 Immediate preoperative view showing the excision area (17!21 cm 2 ). excision of a very large dermatofibrosarcoma protuberans located on the thorax and the abdomen (Fig. 1). Preoperative markings (Fig. 2) show the area to be excised (17!21 cm 2 ). Part of the proximal portion of the rectus abdominis muscles and had to be removed, leaving a major thoracoabdominal wall defect. The exposed omentum was covered with a rotation flap of the anterior layer of the rectus sheath. And a bilateral superiorly based mammaplasty was combined with reverse abdominoplasty (Figs. 3 and 4). As a preliminary step to mammaplasty, the cephalad portion of the defect was closed with a bilateral advancement flap of the lower outer quadrants of the breast combined with a bilateral Z-plasty procedure to recreate normal inframammary folds. The bilateral mammaplasty based on a superolateral pedicle allowed correction of the position of the nipple areola complexes displaced by the advancement flaps. The caudad portion of the defect was closed by reverse abdominoplasty with repositioning of the umbilicus. Photographs taken 2 months postoperatively show good cosmetic results with satisfactory reconstruction of the breasts (Figs. 5 and 6). Two years later, the patient s abdominal wall was reinforced with a sheet of synthetic mesh. Postoperative recovery was unremarkable. The patient Figure 3 Intra-operative view showing the omentum. Figure 4 Immediate postoperative view after bilateral mammaplasty and reverse abdominoplasty.
558 G. Dagregorio, V. Darsonval Figure 5 Results at 2 months. Left side view. Figure 6 Results at 2 months. Right side view. had regular follow-up visits over the following 11 years. By which time, she was almost 80 years old and still in good health. Discussion Of the nearly 200 cases of dermatofibrosarcoma protuberans reported in the world literature to have been treated with Mohs surgery, slightly more than 2% have recurred locally. The results are remarkable, but Mohs surgery requires special structures and standard wide excision still has its place. 6 The recurrence rate drops from 40% with 2 cm margins, to less than 1.75% with margins superior or equal to 4 cm, 8 which compares favourably to Mohs technique. For this reason, we usually excise 5 cm around dermatofibrosarcoma protuberans. Few other lesions necessitate such margins. Those defects are often repaired with skin grafts. When a graft is not feasible because of the location, pedicle or free flaps, for example latissimus dorsi or parascapular flaps, may be used (Figs. 8 10). When the trunk is involved, large tumours may be easier to reconstruct with a good cosmetic outcome using aesthetic surgery procedures. In the reported case, we combined reduction mammaplasty with reverse abdominoplasty, 9 a combination already detailed in a series of aesthetic cases in 1979. This combination, when applied to our 66-year-old patient, allowed us to cosmetically repair the defect with the excess tissue obtained, even though imperfections were noticeable (Fig. 7). More precisely the depression left at the original location of the umbilicus was not corrected, as we did not want to reduce abdominal flap vascularisation. In addition, the neoumbilicus was distorted due to the excessive tension applied by stitches between the deep dermis and fascia to help anchor the abdominal flap. At the two-month follow-up visit, the patient was offered revisional surgery under local anaesthesia to correct these minor imperfections, but refused as she was satisfied with the cosmetic results.
Aesthetic surgery techniques after excision of dermatofibrosarcoma protuberans: a case report 559 Figure 8 Dermatofibrosarcoma protuberans of the left groin area. Preoperative markings (excision of a 17 cm disk and Taylor flap reconstruction). Figure 7 Results at 2 months. Front view. When reviewing the literature on dermatofibrosarcomas of the trunk, we found only one comparable publication about aesthetic surgery techniques, reporting reconstruction following dermatofibrosarcoma of the breast with mammaplasty using a keyhole shaped incision. 10 Since this first case, we have had other opportunities to use aesthetic surgery techniques such as lipectomy or buttock plasty procedures, even though they were applied to the repair of smaller defects. Chiang et al. 11 reported a total thoracoabdominal wall defect measuring 28!25 cm 2 and extending from the left nipple to 3 cm below the umbilicus, reconstructed with a flow-through forearm flap and an inferiorly based latissimus dorsi-groin flap. It seems logical to favour aesthetic surgery techniques whenever they are applicable, given the post operative morbidity, the scar sequelae, the risks involved with microsurgery as well as the global aesthetic outcome of reconstructive techniques. Figure 9 Taylor flap. Postoperative results at 3 days.
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