Case 07 2026: Reconstruction of a Complex Epigastric Abdominal Wall Defect Following Wide Excision of Giant Fibrosarcoma Using Prolene mesh and Modified Keystone Flap in a Resource-Limited Setting: A Case Report”
Abdirahman Abdifatah Mohamed, Numan Omar Ibrahim, Rose Alenyo, Kalanzi Edris
Abstract
Keywords: fibrosarcoma; Soft tissue sarcoma; Abdominal wall tumor; Wide local excision; Keystone flap; Uganda Authors: Abdirahman Abdifatah Mohamed, MD Final Year PRS Trainee 1, Numan Omar Ibrahim, MD PRS Trainee 2, Rose Alenyo, MD Consultant Plastic Surgeon 3, Kalanzi Edris, MD Senior Consultant Plastic Surgeon 4. Abstract Fibrosarcoma is a rare soft tissue sarcoma with aggressive local infiltration and high recurrence risk. We present a 71-year-old Ugandan man with a giant epigastric fibrosarcoma causing a complex abdominal wall defect. Imaging showed invasion of subcutaneous tissue and rectus muscle without metastasis. The patient underwent wide local excision with 5 cm margins, followed by reconstruction using Prolene mesh and a modified keystone flap with skin grafting. Recovery was uneventful, demonstrating effective surgical and reconstructive management in a resource-limited setting. Patient medical history a 71-year-old male who presented with a two-year history of a progressively enlarging anterior abdominal wall mass. The lesion initially appeared as a small, firm nodule and gradually increased in size, eventually becoming a large, fungating tumor associated with ulceration, necrosis, and intermittent bleeding. There was no history of distant symptoms suggestive of metastasis. Imaging confirmed a locally invasive epigastric mass involving the subcutaneous tissue and rectus abdominis muscle, without visceral or distant spread. Before and After Patient examination On physical examination, the patient had a large, exophytic, fungating mass located in the supraumbilical (epigastric) region of the anterior abdominal wall. The lesion was deeply invasive with irregular margins and was associated with ulceration, areas of necrosis, and active bleeding. The overlying skin was stretched, tense, and partially ulcerated. The mass appeared fixed to the underlying abdominal wall musculature, suggesting muscle involvement. There were no clinical signs of peritoneal invo
Hadley GP. Management of soft tissue sarcomas in sub Saharan Africa. S Afr J Surg.Lukande RL Wabinga HR Tumwine LK. Soft tissue sarcomas in Uganda a histopathologic appraisal
BeforeAftera 71-year-old male who presented with a two-year history of a progressively enlarging anterior abdominal wall mass. The lesion initially appeared as a small, firm nodule and gradually increased in size, eventually becoming a large, fungating tumor associated with ulceration, necrosis, and intermittent bleeding. There was no history of distant symptoms suggestive of metastasis. Imaging confirmed a locally invasive epigastric mass involving the subcutaneous tissue and rectus abdominis muscle, without visceral or distant spread.
Fibrosarcoma is recommended 2 to 3cm excision margins due to lack of intraop frozen section we marked 5cm margins to be in safe side
Excised full thickness skin up to parts of rectus abdomens creating defect about 25 to 30cm of lower chest wall exposing lower sternum lower ribs and upper abdominal wall exposing intraabdominal organs.
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such a large defect free flap option will be one of the best options in developed settings due to lack of microsurgery in our settings we planned available loco regional option which is robust reliable can cover the defect and tolerate post op adjuvant radiotherapy
so Modified Keystone flap marked and this is one of the limbs of flap marking
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The other side limb of keystone marking
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Before rising the flap we inserted synthetic Proline mesh patient could not afford Biologic one then raised the flap limbs and advanced a central incision and back cut added(Modified) in order to release and minimize the tension on one side and small areas remained which we grafted STSG
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Immediate Postoperative Care
Close monitoring of vital signs and wound status
Assessment of flap viability (color temperature capillary refill)
Adequate analgesia and prophylactic antibiotics as per protocol
Wound and Flap Care
Regular sterile wound inspections and dressing changes
Early detection of infection seroma hematoma or flap compromise
Gradual mobilization with abdominal support to reduce tension on the repair
Continued care of split thickness skin graft until full epithelialization
Functional Rehabilitation
Encouragement of early ambulation
Avoidance of heavy lifting and activities that increase intra-abdominal pressure
Use of abdominal binder during the early healing phase
Oncologic Surveillance
Postop Adjuvant Radiotherapy
Scheduled outpatient follow up visits for clinical examination
Monitoring for local recurrence at the surgical site
Imaging studies as indicated based on clinical findings
Multidisciplinary review if recurrence is suspected
Long Term Follow Up
Assessment of abdominal wall integrity and functional outcome
Evaluation of quality of life and cosmetic satisfaction
Patient education on signs of recurrence and wound complications
How to cite this article
Abdirahman Abdifatah Mohamed, Numan Omar Ibrahim, Rose Alenyo, Kalanzi Edris. Case 07 2026: Reconstruction of a Complex Epigastric Abdominal Wall Defect Following Wide Excision of Giant Fibrosarcoma Using Prolene mesh and Modified Keystone Flap in a Resource-Limited Setting: A Case Report”. Journal of Plastic, Breast & Reconstructive Surgery. 2026.
Open access. © 2026 The Author(s). Published by the Journal of Plastic, Breast & Reconstructive Surgery. Copyright to this case is shared between the author(s) and the journal; authors may reuse their own case for education, presentations and social media.
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