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29 Tissue Expansion During Abdominal Wall Reconstruction
311
wall fascia. In 1989, Byrd et al. described the fi rst
interfascial expansion by placing the expander
between the internal oblique and transversus
abdominis. However, this technique has been
largely abandoned because the expander is not
placed on a rigid platform and expansion will
occur both outward as well as inward [ 9 ].
Bidirectional expansion will be less effective in
expanding the desired tissue (abdominal wall
fascia/external oblique) and can increase the
intraperitoneal pressure unnecessarily. As a result,
defects in the abdominal wall fascia are treated
with various abdominal hernia repair techniques
such as component separation. Those techniques
are discussed in other chapters.
In addition to increasing the volume of skin,
tissue expanders can incite a fi brous reaction that
interposes an additional connective tissue layer
on the anterior abdominal wall. This vascularized
capsule, combined with any existing anterior
rectus sheath can be used to reconstruct abdominal wall defects [ 3 ]. The use of prosthetic mesh in
conjunction with tissue-expanded skin provides a
durable abdominal closure and is technically
simpler than fl ap closure methods [ 10 ]. Donor
site morbidity is minimized relative to musculofascial techniques. Tissue expansion even allows
excision of unsightly scars and skin grafts while
providing excellent color and texture match. It
also provides well-vascularized skin and softtissue coverage over the prosthetic mesh [ 10 ].
Techniques of TE for Abdominal
Wall Reconstruction
There are wide varieties of expanders differing in
shape, texture, and expansion mechanism.
Selection of expanders and placement of
expander should be tailored to the individual
defect. Preoperatively, the surgeon must take into
consideration previous scars, postoperative scars,
fl ap movement in relation to the defect, and
potential distortion of surrounding structures.
Most abdominal wall expanders are used to
expand abdominal skin and are placed underneath the skin and subcutaneous tissue, but above
the fascia.
Preoperative considerations should include a
physical exam assessing the patient’s general
medical condition, abdominal wall integrity,
extent and location of abdominal wall abnormalities, and the presence of scars. Using these principles, Livingston et al. described their technique
for providing soft-tissue coverage for traumatic
abdominal wall defects. The open abdomen
wounds are fi rst temporized with a split thickness
skin graft which forms a skin bridge. Once the
skin graft demonstrates substantial mobility from
the underlying viscera, the patients are deemed to
be candidates for tissue expander placement,
usually at a minimum of 6 months [ 8 ]. The tissue
expanders are inserted in the subcutaneous plane
above anterior rectus fascia with retention of split
thickness skin graft. Expansion is then carried
out weekly or biweekly over approximately 6
weeks. After adequate expansion, the tissue
expander is removed and the split thickness skin
graft is de-epithelialized to form a “connective
tissue bridge” (deep layer) over which the
expanded subcutaneous tissue and skin is closed
[ 8 ]. The expanded tissue may need to undergo
capsulotomies or capsulectomies of the expander
pocket for greater tissue movement [ 10 ]. It is
important to note that this does not address the
hernia itself, but only provides adequate skin and
subcutaneous tissue coverage for the defect and/
or prosthetic. Potential disadvantages to abdominal wall reconstruction with mesh and tissue
expansion includes a possibility of skin breakdown and resultant mesh exposure and infection
[ 10 ]. However, increased vascularity in the
expanded tissue may decrease the potential skin
fl ap ischemia, necrosis, and subsequent wound
break down and mesh infection [ 10 ].
Another drawback of TE is that the typical
expansion technique involves staged operations
over a period of several weeks or months and
multiple postoperative visits. Tissue expanders
have the potential to become infected or exposed
during expansion. In fact, complications related to
using tissue expanders have been reported to be
about 15% [ 10 ]. Rates of complication vary in
relation to the site of implantation. Expansion over
bony prominences, burn scars, or previous incision
sites tends to have the highest morbidity [ 10 ].
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L. Chmielewski et al.
Unlike internal expanders, external expanders
stretch the skin and subcutaneous tissue by providing constant dermatraction at the wound
edges. This can be achieved by placing an elastic
vessel loop at the wound edges and adjusting the
tension of the vessel loop postoperatively.
Commercially available external tissue expanders, such as the Dermaclose™ (Wound Care
Technologies Inc. Chanhassen, MN), provide
constant and continuous tension at the wound
edges. The wound edges should be adequately
undermined prior to the application of the external dermatraction device to allow for appropriate
movement of the skin fl aps.
Conclusion
Tissue expansion can be a valuable tool in the
reconstructive armamentarium. Its applications in
abdominal wall reconstruction have been thoroughly reviewed in this chapter. Appropriate indications for expansion of the abdominal wall are
when there is a defi ciency in abdominal skin
and subcutaneous tissue and a clean wound.
Advantages of tissue expansion include the ability
to create and recruit tissue having similar
aesthetics of color, texture, thickness, and hair
production. However, these advantages must be
balanced with the downside that expansion
requires staged operations over a period of several
weeks or months and multiple postoperative
visits. Additionally, expansion can be associated
with the risks of infection, fl ap ischemia, extrusion, implant failure, patient intolerance, pain,
and scar widening. Each of these complications
may necessitate prosthesis removal. For these
reasons, judicious use of tissue expanders is
recommended as just one of many tools for
abdominal wall reconstruction.
References
1. Althubaiti G, Butler CE. Abdominal wall and chest
wall reconstruction. Plast Reconstr Surg. 2014;133:
688e–701.
2. Ramirez OM, Ruas E, Dellon AL. “Components separation” method for closure of abdominal-wall
defects: an anatomic and clinical study. Plast Reconstr
Surg. 1990;86:519–26.
3. Byrd HS, Hobar PC. Abdominal wall expansion in
congenital defects. Plast Reconstr Surg. 1989;84:
347–52.
4. Weinzweig J, Weinzweig N. Plastic surgery techniques (Chapter 5). In: Guyuron B, editor. Plastic surgery indications and practice. Saunders/Elsevier:
Edinburgh; 2009. p. 90–108.
5. Leedy JE, Janis JE, Rohrich RJ. Reconstruction of
acquired scalp defects: an algorithmic approach. Plast
Reconstr Surg. 2005;116:54e–72.
6. Arneja JS, Gosain AK. Giant congenital melanocytic
nevi. Plast Reconstr Surg. 2007;120:26e–40.
7. Marks MW, Argenta LC. Principles and applications
of tissue expansion (Chapter 27). In: Neligan PC, editor. Plastic surgery. London: Saunders/Elsevier; 2012.
p. 621–31.
8. Livingston DH, Sharma PK, Glantz AI. Tissue
expanders for abdominal wall reconstruction following severe trauma: technical note and case reports.
J Trauma. 1992;32:82–6.
9. Tran NV, Petty PM, Bite U, et al. Tissue expansion
assisted closure of massive ventral hernias. J Am Coll
Surg. 2003;196:484–8.
10. Paletta CE, Huang DB, Dehghan K, Kelly C. The use
of tissue expanders in staged abdominal wall reconstruction. Ann Plast Surg. 1999;42:259–65.
Flap Reconstruction
of the Abdominal Wall
Donald P. Baumann and Charles E. Butler
Introduction
Soft-tissue fl ap reconstruction of the abdominal
wall implies the inability to recruit local tissue
to resurface the abdominal wall defect. Since the
majority of abdominal wall defects can be reconstructed with the surrounding redundant tissue
from the torso, these defects represent a more
complex subset of abdominal wall reconstructions. Indications for fl ap coverage vary by etiology, defect characteristics, and timeline for closure.
Multiple clinical scenarios can lead to a loss of
abdominal wall soft-tissue requiring fl ap reconstruction, including massive ventral hernia with
loss of domain , traumatic injury, soft tissue infection, oncologic resection, and the open abdomen.
The surface area of soft-tissue loss and the
amount of wound coverage able to be performed
with local skin advancement must be factored
into the reconstructive plan. Abdominal wall
defects requiring soft-tissue fl ap coverage can be
classifi ed as partial thickness defects involving
the skin and subcutaneous tissue only or fullthickness composite defects which involve loss
of the abdominal wall musculofascia in addition
to the overlying skin and subcutaneous tissue.
D. P. Baumann , M.D., F.A.C.S.
C. E. Butler , M.D., F.A.C.S. (
Plastic and Reconstructive Surgery ,
University of Texas MD Anderson Cancer Center ,
Houston , TX , USA
cbutler@mdanderson.org
e-mail:
*)
30
The indications for soft-tissue fl ap coverage in
abdominal wall reconstruction also depend on
the chronicity of the wound defect with some
defects benefi ting from early fl ap coverage, others best treated by delayed fl ap coverage. Certain
other defects are more appropriately managed
with chronic wound care and healing by secondary intention.
Historically, abdominal wounds were treated
with wound care and allowed to heal over time by
secondary intention or were reconstructed with a
skin graft after the local wound environment was
optimized. This resulted in a prolonged course of
care and signifi cant morbidity. In time, the concept of delayed-primary closure gained popularity
allowing certain patients with favorable wound
characteristics to undergo closure after a short
period of wound care instead of being committed
to weeks or months of open wound care. This
enabled patients to achieve defi nitive wound closure without a skin-grafted surgical site and associated donor site morbidity [ 1 ].
Early soft-tissue fl ap reconstruction offers signifi cant advantages over delayed-primary or
secondary healing wound closure. Flap reconstruction is performed as a single stage procedure
obviating the need for chronic wound management. Flap reconstruction can often be performed
at the same time as the musculofascial reconstruction. Flap reconstruction offers immediate
and defi nitive wound closure, effectively ending
the local tissue injury and infl ammatory response
seen in chronic open wounds. These two factors
Y.W. Novitsky (ed.), Hernia Surgery, DOI 10.1007/978-3-319-27470-6_30
313© Springer International Publishing Switzerland 2016
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D.P. Baumann and C.E. Butler
are critical in reconstructions involving abdominal wall reinforcement with bioprosthetic mesh.
When bioprosthetic mesh is interposed between
two well-vascularized tissue planes (posterior
abdominal wall/peritoneal cavity and a soft tissue
fl ap superfi cially), bidirectional vascular
ingrowth can be achieved accelerating the period
of bioprosthetic mesh revascularization and
incorporation. In addition, a closed wound environment diminishes the pro-infl ammatory state
of an open wound, which limits the degree of
enzymatic degradation of the bioprosthetic mesh
during the incorporation phase [ 2 ].
Over the last 20 years, the role of negativepressure wound therapy (NPWT) has revolutionized the approach to wound care, particularly in
the management of abdominal wall defects.
NPWT allows preservation of the wound environment by managing fl uid and protein losses,
decreasing bacterial contamination and accelerating granulation tissue formation. In abdominal
wall reconstruction, this translates in preserving
the option for delayed-primary closure or delayed
fl ap reconstruction [ 3 ].
Composite, full-thickness loss of the
abdominal wall musculofascia and overlying
soft-tissue represent the most complicated abdominal wall reconstructions, sometimes requiring multiple staged reconstructive procedures.
Re-establishment of musculofascial continuity
is paramount to setting the stage for a durable
abdominal wall reconstruction. Reconstituting
the defi cient musculofascia with a mesh inlay
converts the open abdomen to a more manageable
abdominal wall wound. For midline defects, early
abdominal closure with primary rectus musculofascial re-approximation over bioprosthetic mesh
provides superior outcomes to bridging the fascial
defect with bioprosthetic mesh. The risk of developing a hernia increases sevenfold when bridging
fascial repairs are performed instead of reinforced
mesh repairs [ 4 ]. All attempts should be made to
achieve fascial coaptation as bridging repairs are
far more likely to develop hernias. When early
fascial closure is not an option owing to ongoing
debridement of the musculofascia or the need to
perform a second- look laparotomy, a temporizing
abdominal wall closure can be utilized such as the
NPWT system. A static bridging wound dressing protects and insulates the viscera while controlling fl uid loss in the wound bed. NPWT also
provides abdominal stability in the early postoperative period for patients undergoing mechanical ventilation and later when they ambulate and
undergo physical therapy.
When both the soft-tissue and musculofascia
require reconstruction, it is preferred to reconstruct these two components independently, rather
than using the fascia of the fl ap for musculofascial
reconstruction. Historically, before the introduction of mesh material for use in contaminated
cases, fl aps such as the tensor fascia lata fl ap were
used to reconstruct full-thickness abdominal wall
defects, especially in the setting of wound contamination [ 5 ]. Selecting a single fl ap to restore
the musculofascial integrity and resurface the skin
defect can compromise durability of the hernia
repair as well as lead to a perfusion-related complication (wound dehiscence, fl ap necrosis) at the
skin level. The current approach to these defects
includes mesh and often component separation
release to re-establish a physiologic tension bearing musculofascial closure and then a soft-tissue
fl ap is used for the cutaneous defect. The use of
the fascial component of a fl ap for musculofascial
reconstructions can result in increased bulge or
hernia. In addition, insertion of the fascial component can potentially compromise the vascularity
of the soft-tissue component of the fl ap. Thus, for
composite midline defects, myofascial reconstruction is generally performed with either synthetic or bioprosthetic mesh materials. Surgeon
preference and the variables of any given clinical
scenario will determine whether bioprosthetic
mesh or synthetic mesh is used. Regardless of
mesh type, the expectations are that the mesh will
maintain the abdominal musculofascial structure,
integrity, and contour, without development of a
hernia or bulge. Mesh should be placed to avoid
forming extensive adhesions to the intra-abdominal viscera that can lead to bowel obstruction or
fi stulization. Bioprosthetic and synthetic meshes
can meet these expectations, and the decision to
use either is based on patient comorbidities,
degree of wound contamination, prior radiation,
availability of greater omentum to interpose
30 Flap Reconstruction of the Abdominal Wall
315
between mesh and bowel, and the quality of the
overlying soft-tissue.
The reconstructive algorithm for skin coverage of full-thickness abdominal wall defects
begins with local skin advancement fl aps and
expands to local perforator fl aps, regional pedicled fl ap , and ultimately free-fl ap reconstructions. The overlapping angiosomes of the
abdominal wall’s cutaneous blood supply allow
abdominal wall defects can involve signifi cant
loss of innervated myofascia and overlying skin
in a dimension that is greater than the surrounding tissue’s ability to be recruited and mobilized
for closure. In such cases, regional or distant tissue fl aps must be used for closure, and the resultant repair will no longer be dynamic, contractile,
and coordinated with the surrounding abdominal
wall musculature.
for wide undermining and robust skin advancement. In addition, tissue expansion (Chapter 29 )
can be performed in the trunk to increase the surface area and availability of local fasciocutane-
Overview of Reconstruction
by Regio n
ous fl aps as an alternative to a pedicled or
free-fl ap donor site. In cases of prior radiation,
extensive prior scars, or massive skin resection, a
pedicled regional or free fl ap may be required to
provide adequate soft-tissue coverage. Composite
Table 30.1 Abdominal wall fl ap reconstruction algorithm epigastric defects
Local Pedicled Free
Epigastric Transposition IM, IC, SE Rectus Thigh-based (ALT, AMT, VL, TFL, RF, STF)
Keystone Omentum Back-based LD, TAP, Scap/Para
Bipedicled Fasciocutaneous
IM internal mammary artery perforator fl ap, IC intercostal artery perforator fl ap, SE superior epigastric artery perforator fl ap
Thigh-based: ALT anterolateral thigh fl ap, AMT anteromedial thigh fl ap, VL Vastus lateralis fl ap, TFL tensor fascia lata
fl ap, RF rectus femoris fl ap, STF subtotal thigh fl ap
Back-based: LD latissimus dorsi fl ap, TAP thoracodorsal artery perforator fl ap, Scap/Para scapular/parascapular fl ap
The anterior abdominal wall can be divided into
three anatomic regions: the epigastrium, the peri-
umbilical region and the hypogastrium. (Tables
30.1 , 30.2 and 30.3 ) The relationship of defects
Table 30.2 Abdominal wall fl ap reconstruction algorithm periumbilical defects
Local Pedicled Free
Periumbilical Transposition DIEP, SIEP, TLP Rectus Thigh-based ALT, AMT, VL, TFL, RF, STF
Keystone Omentum Back-based LD, TAP, Scap/Para
Bipedicled fasciocutaneous Thigh-based
DIEP deep inferior artery perforator fl ap, SIEP superfi cial inferior epigastric artery perforator fl ap, TLP thoracolumbar
perforator fl ap
Thigh-based: ALT anterolateral thigh fl ap, AMT anteromedial thigh fl ap, VL vastus lateralis fl ap, TFL tensor fascia lata
fl ap, RF rectus femoris fl ap, STF subtotal thigh fl ap
Back-based: LD latissimus dorsi fl ap, TAP thoracodorsal artery perforator fl ap, Scap/Para scapular/parascapular fl ap
Table 30.3 Abdominal wall fl ap reconstruction a lgorithm hypogastric defects
Local Pedicled Free
Hypogastric
DIEP deep inferior artery perforator fl ap, SIEP superfi cial inferior epigastric artery perforator fl ap, TLP thoracolumbar
perforator fl ap
Thigh-based: ALT anterolateral thigh fl ap, AMT anteromedial thigh fl ap, VL vastus lateralis fl ap, TFL tensor fascia lata
fl ap, RF rectus femoris fl ap, STF subtotal thigh fl ap
Back-based: LD latissimus dorsi fl ap, TAP thoracodorsal artery perforator fl ap, Scap/Para scapular/parascapular fl ap
Transposition DIEP, SIEP, TLP
Keystone
Bipedicled Fasciocutaneous
Rectus Thigh-based ALT, AMT, VL, TFL, RF, STF
Omentum Back-based LD, TAP, Scap/Para
Thigh- Based
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D.P. Baumann and C.E. Butler
to these anatomic regions guide decision-making
when regional p edicled fl aps are planned for
reconstruction. Options for pedicled fl aps in the
upper abdomen include latissimus dorsi, and
omental fl aps. Thigh-based fl aps such as anterolateral thigh, vastus lateralis, and tensor fascia
lata fl aps are generally able to reach the hypogastrium and fl ank as pedicled fl aps. If a pedicled
fl ap is not available or feasible, a thoracoepigastric bipedicled fasciocutaneous fl ap may provide
a local tissue alternative in patients who are not
candidates for free tissue transfer.
When the volume of tissue loss or the arc of
rotation needed precludes a pedicled fl ap transfer, a free fl ap is required for soft-tissue coverage.
The thigh can serve as a source of fasciocutaneous fl aps and myocutaneous fl aps that provide
large skin paddles and signifi cant muscle volume.
Recipient vessels in the abdominal wall include
the deep inferior epigastric, superior epigastric,
internal mammary, intercostal artery, and perforating thoracolumbar. When no local recipient
vessels are available, vein grafts to the internal
mammary or femoral vessels may be required
depending on defect location.
Local Flap Options
Local fl aps involve recruiting tissue adjacent to
the wound defect. Well-planned incisions are
critical to preserve blood supply to the local fl ap
and avoid wound-healing complications at the
donor site used to resurface the wound defect.
There are various fl ap transposition designs
available including advancement, rotation/
advancement, interpolation, V-Y advancement,
and bipedicled fl aps. These fl aps can be oriented
in any dimension: vertically, obliquely, or horizontally. Given these fl aps are perfused through
random or axial blood supplies, understanding of
the vascular anatomy in terms of abdominal wall
angiosomes and perforator location is critical to
designing robust local fl aps.
It is also important to consider the impact of
preexisting incisions in the abdominal wall when
planning a fl ap design. A midline laparotomy
may preclude harvesting a local fl ap from the
contralateral abdominal wall. However, a midline
defect bisected by a laparotomy scar can be
divided in half and reconstructed by two local
fl aps, one from each hemi-abdomen. Another key
factor in performing a local fl ap reconstruction is
limiting tension across the wound closure both at
the defect site and the donor site. The fl ap perfusion, especially at the most distal part of the fl ap,
can be compromised if the fl ap is placed on high
tension either by pushing the limits of the fl ap
design or by creating excessive bi-axial tension
across the fl ap when the donor site is closed.
One strategy that can be employed to mitigate
excessive tension across the fl ap is to transpose
the fl ap to cover the defect and then skin graft the
donor site. This concept is the mainstay of the
bipedicled fl ap in trunk reconstruction. For midline defects, a bipedicled fasciocutaneous fl ap is
generally used for midline defects either unilaterally or bilaterally. The fl ap is oriented vertically
with a maximum of a 3:1 length/width ratio and
maintains a blood supply from both the superior
and inferior aspects of the fl ap. The fl ap is then
directly transposed to resurface the defect and by
design the donor site cannot be closed without an
undue degree of tension. To offl oad the tension, a
skin graft can be used to resurface the donor site
preserving blood supply to the distal fl ap to maximize wound healing.
Perforator fl aps are based on a dominant
named vessel which perfuses the entire fl ap
through an organized vascular network.
Perforator fl aps present multiple options for fl ap
design and rotation throughout the entire abdominal wall. Flaps based on internal mammary,
superior epigastric, deep inferior epigastric,
superfi cial inferior epigastric, and superfi cial circumfl ex iliac perforators provide local fl ap
options in all zones of the abdominal wall. The
keystone fl ap is one strategy to reconstruct large
trunk defects with perforator fl aps [ 6 ]. Keystone
fl aps enable one stage resurfacing of both the
defect and donor site. The fl ap is designed as a
large 3:1 ellipse parallel to the long axis of the
defect. The blood supply to the fl ap is based on
cutaneous perforators that shift towards the
defect when the fl ap is advanced. Once the leading edge of the keystone fl ap is inset, the donor
30 Flap Reconstruction of the Abdominal Wall
317
site is then closed on itself from the poles of the
long axis of the fl ap to the side of the fl ap remote
from the defect. The success of this fl ap is due to
the transposition tension from the advancement
and closure being distributed over the lengthy
circumference of the fl ap skin island.
Regional Flap Options
In cases where the defect size exceeds the availability of local soft-tissue for coverage, the next
line option is to consider a regional pedicled
fl ap . Use of regional fl aps is often limited as the
defect is adjacent to the fl ap donor site, particularly if the defect is a full-thickness, or composite defect. Regional pedicled fl aps are harvested
from adjacent anatomic areas such as the chest,
groin, thigh, or back. Pedicled fl aps can be
designed as fasciocutaneous fl aps, myocutaneous fl aps, or muscle fl aps resurfaced with a skin
graft. When selecting a pedicled fl ap it is important to factor the donor morbidity incurred. As
an example, a contralateral vertical rectus
abdominis myocutaneous fl ap can be used to
reconstruct a lower lateral abdominal wall
defect; however, the donor site closure may compromise the fl ap inset, increasing the risk of
postoperative complication s. In addition, not
only must the pedicled fl aps ability to “reach”
the defect be considered, but also how the transferred fl ap will tolerate the rotational, fl exion/
extension forces placed on it in the trunk. As an
example, a vastus lateralis thigh fl ap can be used
to resurface a hypogastric defect however, as the
fl ap’s pedicled vessels remain in their site of origin in the thigh, the fl ap pedicle can pivot and
traverse the groin and have its blood fl ow compromised by compression or rotation during the
postoperative period.
Free Flap Options
Microsurgical free tissue transfer enables the
reconstructive surgeon to provide soft-tissue coverage for abdominal wall defects that are not
amenable to either local or regional fl ap cover-
age. Flaps of essentially any size, volume, dimension, and composition can be transferred from
donor sites remote from the abdominal wall.
While much more technically demanding, the
evolution of microsurgical techniques enables
successful free-fl ap transfer in excess of 98% of
cases [ 7 ].
There is a multitude of free-fl ap donor site
options available for abdominal wall reconstruction. The torso and thigh are the main areas of
fl ap harvest for defects extending from the upper
abdominal wall and epigastrium to the suprapubic region. The posterior c hest wall donor site
yields the latissimus dorsi myocutaneous fl ap,
scapular/parascapular fasciocutaneous fl aps, thoracodorsal artery perforator fl aps, and serratus
anterior muscle fl aps. (Fig. 30.1a–e ) In addition,
these fl aps can be harvested together as a chimeric fl ap to increase the tissue volume for fl ap
transfer. These fl aps can also be transposed to the
upper epigastrium or lateral subcostal region as a
pedicled fl ap. For defects beyond the reach of the
thoracodorsal pedicle, the fl ap can be converted
to a free fl ap and be transposed anywhere in the
abdominal wall.
In cases where a large skin paddle is required
for the abdominal wall defect, a free scapular or
parascapular fl ap can be designed on the circumfl ex scapular branch of the subscapular arterial
system. If a latissimus or serratus fl ap is harvested, the functional donor site impact must be
considered as it relates to the weakened abdominal wall. Patients who have decreased core muscle strength will rely on upper extremity strength
and range of motion to complete activities of
daily living. The impact of impaired shoulder and
upper extremity movement should be considered
in these patients. In addition, in terms of logistical planning, the patient must undergo an intraoperative position change to facilitate fl ap
dissection in the posterior chest wall . This adds
complexity and additional time to the procedure
and extends fl ap ischemia time.
The thigh represents the mainstay for fl ap
donor sites for the abdominal wall. Both pedicled
fl aps for coverage of the infraumbilical abdominal wall and free fl aps can be designed in several
of confi gurations: fasciocutaneous, myocutane-
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D.P. Baumann and C.E. Butler
Fig. 30.1 Free chimeric latissimus myocutaneous fl ap
with serratus muscle fl ap reconstruction of epigastric
defect. ( a ) Preoperative view of planned composite full-
thickness resection of the abdominal wall including anterior refl ection of diaphragm. ( b ) Bioprosthetic mesh inlay
bridging repair of the thoraco-abdominal defect. ( c ) Free
ous, muscle, and chimeric fl aps. The descending
branch of the lateral circumfl ex femoral system
provides blood supply to the vastus lateralis, rectus femoris muscles, and anterolateral thigh skin.
The transverse branch of the lateral circumfl ex
femoral system provides blood supply to the tensor fascia lata fl ap. These fl aps can be harvested
as muscle-only fl aps or as myocutaneous fl aps
with overlying skin paddles. The anterolateral
thigh fl ap is designed by including a skin paddle
overlying vastus lateralis muscle and can be
designed as a myocutaneous or fasciocutaneous
fl ap. The tensor fascia lata fl ap can be designed to
include the distal fascia of the iliotibial tract and
a smaller proximal skin paddle, if needed. The
chimeric latissimus myocutaneous fl ap with serratus muscle fl ap. ( d ) Serratus muscle fl ap inset covering the bio-
prosthetic mesh with the latissimus myocutaneous fl ap
providing skin coverage. Right internal mammary vessels
used as recipient vessels. ( e ) Follow-up 6 months
anteromedial thigh fl ap can be designed on
medial perforators from the descending branch of
the lateral circumfl ex femoral system. The rectus
femoris muscle is more commonly designed as a
muscle fl ap; however, a skin island can be
included over the central muscle when appropriate-sized cutaneous perforators are present.
These thigh-based fl aps can be designed in
any combination as chimeric fl aps, i.e., ALT with
AMT fl aps, ALT with TFL, vastus lateralis with
TFL. For massive abdominal wall defects, the
vastus lateralis, tensor fascia lata, and the rectus
femoris can be harvested with all overlying skin
territory as a subtotal thigh fl ap for increased
volume and skin coverage [
8 ].
30 Flap Reconstruction of the Abdominal Wall
319
Recipient Vessel s
The success of any free tissue transfer relies on
the availability of suitable recipient vessels providing arterial infl ow and venous outfl ow to the
free fl ap. There are several recipient vessels
available for abdominal wall reconstruction with
free fl aps. The main vascular axis in the central
abdominal wall is the internal mammary-superior
epigastric-inferior epigastric system. The internal
mammary and deep inferior epigastric vessels
provide large caliber 2–3 mm diameter recipient
vessels for microanastomosis. However, these
vessels are present at the most cephalad and caudal limits of the abdominal wall. The main challenge for identifying adequate internal mammary
or epigastric recipient vessels in the periumbilical region is that they are much smaller in caliber
and present more technically challenging microanastomoses. In cases where the internal
mammary- epigastric vascular axis is unavailable,
the thoracodorsal pedicle in the axilla can be
reached by using vein grafts.
Recipient vessel options exist beyond the
abdominal wall itself. There are a number of
options in the groin based on the superfi cial femoral system. The superfi cial inferior epigastric
artery, the superfi cial circumfl ex iliac artery, and
the deep circumfl ex iliac artery provide reasonable caliber vessels for free fl ap transfer to the
lower central and lateral abdominal wall. If primary anastomosis is not feasible then vein grafts
or vein loops are required. Vein grafts are often
harvested from the leg (greater or less saphenous
vein) or arm (cephalic vein). In addition, in
abdominal wall reconstructions with concurrent
laparotomy intra-abdominal vessels can be used
as recipients if there are no local options in the
abdominal wall. The omental and gastroepiploic
vessels can be mobilized to reach the undersurface of the abdominal wall. Care must be taken in
insetting and supporting the fl ap pedicle so that
there is no tension on the anastomoses when the
visceral contents shift when the patient transitions from supine to sitting/standing. In addition,
the morbidity of re-entering the abdominal cavity
must be considered if there is a vascular thrombosis requiring fl ap re-exploration. In addition,
when mesh is used for the musculofascial reconstruction as an adjunct to the fascia of the fl ap the
pedicle must traverse an aperture in the abdominal wall mesh that increases the risk of pedicle
kink and vascular compromise. Moreover, defects
in abdominal wall integrity increase the risk of
hernia. For these reasons, local recipient options
should be explored before intra- abdominal vessels are selected.
Vein grafts and arterialized vein loops can be
designed to provide adequate recipient vessels in
the central abdominal wall. Vein grafts can be
harvested from either the upper or lower extremity as a cephalic vein graft or saphenous vein
graft. For central and lower abdominal defects an
arterialized saphenous vein loop can be designed.
(Fig. 30.2a–e ) The saphenous vein is dissected
and transected distally and then anastomosed to
the superfi cial femoral artery or a side branch.
This allows delivery of the loop to the fl aps recipient site where the loop is divided providing an
arterialized afferent limb and a venous drainage
efferent limb. One advantage of this technique is
that it only requires three vascular anastomoses
instead of four as in the case with direct individual
arterial and venous vein grafts. The main recipient vessel sites for vein grafts or arterialized vein
loops are the thoracodorsal vessels in the axilla,
branches of the superfi cial femoral system on the
groin, and the deep inferior epigastric vessels in
the lateral abdominal wall, which can be used to
extend the reach of vein grafts to the central
abdominal wall.
Abdominal Wall Transplantation
Abdominal wall transplantation represents the
zenith of abdominal wall fl ap reconstruction. It is
generally reserved for patients undergoing single
or multi-organ visceral transplants in which
abdominal wall closure by autologous fl aps is not
technically feasible or presents signifi cant donor
morbidity. Abdominal wall closure after visceral
organ transplantation is challenging in the setting
of donor/recipient organ size mismatch and/or
prior recipient abdominal surgery. Transplant
patients can benefi t from vascularized composite
320
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D.P. Baumann and C.E. Butler
Fig. 30.2 Free anterolateral thigh (ALT) fl ap reconstruction
of abdominal wall. ( a ) Preoperative view of open abdomen
treated with NPWT. ( b , c .) A right-sided ALT fl ap with vas-
tus lateralis muscle was harvested on the descending branch
abdominal wall allotransplants as an additional
strategy to expand the domain of the abdominal
cavity to account for either a graft/recipient size
mismatch or inability for closure in the face of
extreme intestinal edema. While the risks of lifelong immunosuppression potentially outweigh
the potential benefi ts of abdominal wall transplantation in healthy non-transplant patients,
transplant patients are already bound to an immunosuppressive regimen and can benefi t from the
addition of allograft abdominal wall musculofas-
of the lateral femoral circumfl ex system. ( d ) A shapeno-fem-
oral A-V loop was delivered into the lower abdominal defect
to serve as recipient vessels. ( e ) Patient at 12 weeks follow-
up. Flap reconstruction algorithm by region
cial tissue to reduce abdominal wall wound complication at the time of transplantation.
In the setting of transplant immunosuppression, the risk of an open abdominal wound,
fascial dehiscence, septic evisceration or fi stula carries signifi cant morbidity and potential
mortality. When conventional abdominal wall
closure techniques are insuffi cient allotransplantation is performed. Extensive study of the vascular supply of the abdominal wall has allowed
design of musculofasciocutaneous fl aps based
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