Anterior Abdominal

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Anterior AbdominalWall ReconstructionRoshini Gopinathan, MD, Mark Granick, MD*

& Anatomy of the anterior abdominal wall

& Indications for abdominal wallreconstruction& Preoperative evaluation& Operations

Primary closureVacuum-assisted closure

Skin and fascial grafts

Fascial releaseComponents separationTissue expansionMesh and biomaterialsPedicled muscle and myocutaneous flaps

& References

The anterior abdominal wall serves several func-tions. It contains and protects the abdominal

viscerae. The muscles of the abdominal wall assist

in pulling down on the ribs during forced expira-tion and coughing. When the thoracic cage is fixed,the muscles of the abdominal wall assist with defe-cation, micturition, and child birth. The rectusmuscle helps in flexion of the spine and the rectus,and lateral obliques assist in rotation of the torso.

Anatomy of the anterior abdominal wall

The paired rectus abdominis muscles are enclosed

by the rectus sheaths. The sheath is formed by the

aponeuroses of the internal and external obliquesand the transversus abdominis muscles. The apo-neurosis of the internal oblique splits at the lateralborder of the rectus muscle. The anterior layer fuses

with the aponeurosis of the external oblique toform the anterior wall of the rectus sheath whilethe posterior layer merges with the transverse ab-dominis aponeurosis to form the posterior sheath.

The posterior rectus sheath ends midway betweenthe umbilicus and symphysis pubis, at the arcuateline. Inferior to this line, the aponeuroses of all

three muscles pass anterior to the rectus muscle. The thigh is also a rich source of donor tissue.Surgeons performing abdominal wall repair must

know the neurovascular anatomy and arc of rota-tion of the thigh muscles.

Indications for abdominal wallreconstruction

The clinical problems that require abdominal wall

reconstruction are congenital abdominal wall de-fects, including omphalocele, gastroschisis, and blad-der or cloacal exstrophy; and infection, including

necrotizing fasciitis and clostridial myonecrosis.

Other indications include: tumor resection, includ-ing desmoid tumors, dermatofibrosarcoma protu-berans, sarcomas, metastatic tumors, and radiationulcers; ventral hernia; trauma; and loss of abdomi-nal domain.

Preoperative evaluation

Each abdominal wall defect should be evaluated

individually. The extent of the defect and whetherit includes skin, subcutaneous tissue, or fascia

C L I N I C S I NP L A S T I C

S U R G E R Y

Clin Plastic Surg 33 (2006) 259267

Division of Plastic Surgery, Department of Surgery, New Jersey Medical SchoolUniversity of Medicine andDentistry in New Jersey, 90 Bergen Street, Suite 7200, Newark, NJ 07103, USA* Corresponding author.E-mail address: [email protected] (M. Granick).

0094-1298/06/$ see front matter 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.cps.2005.12.006

plasticsurgery.theclinics.com

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mailto:[email protected]://dx.doi.org/10.1016/j.cps.2005.12.006http://dx.doi.org/10.1016/j.cps.2005.12.006http://plasticsurgery.theclinics.com/http://plasticsurgery.theclinics.com/http://dx.doi.org/10.1016/j.cps.2005.12.006mailto:[email protected]


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should be assessed. Previous abdominal surgeries,history of radiation, and medical comorbiditiesshould be evaluated. The presence or absence of

infection should be noted.Radiation causes progressive obliterative endar-

teritis leading to tissue ischemia. Low tissue oxygentension leads to lack of function of fibroblastsand leucocytes. In the presence of a minimal chal-

lenge leading to increased metabolic demands, the wound breaks down with secondary bacterial in-fection. Such wounds require wide excision and

importing of well-vascularized tissues from non-irradiated areas. Hyperbaric oxygen therapy hasbeen shown to be useful in these patients [1] [Fig. 1].

Soft tissue infections such as necrotizing fasciitisand clostridial myonecrosis are mixed infections

Fig. 1. (A, B) Radiation ulcer extending from anterior abdomen to back. (C) Anterior defect was fixed with rectusabdominis flap and skin graft. (D) Posterior defect was fixed with gluteus maximus myocutaneous flaps.

Fig. 2. (A, B) Necrotizing fasciitis of lower abdomen and thigh. (C, D) Following serial debridement, wound cov-erage was achieved with skin grafts.

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Fig. 3. (A) Osteomyelitis following open reduction internal fixation for pelvic fracture (B) Arteriogram demon-strating patent inferior epigastric vessels. (C) Rectus femoris flap following debridement and removal of hardware.

Fig. 4. (A) Open abdomen with loss of domain; vacuum assisted closure was used to reduce size of defect. ( B) Vicrylmesh placed over viscerae. (C) Widely meshed skin graft. (D) Skin grafts have matured and can be separatedfrom the viscera. (E) Separation of components. (F) Skin closure.

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with aerobic and anaerobic organisms. Aggressivesoft tissue debridement and intravenous antibioticsare essential. Once the infection is controlled, de-

finitive coverage can be achieved. The presence ofosteomyelitis requires removal of all foreign bodiesand sequestra [Figs. 2, 3].

Trauma to the abdominal wall can result in injuryto the abdominal viscerae with subsequent con-tamination. Staged abdominal wall repair is oftennecessary and may be complicated by other se-quelae of major trauma. Loss of domain is treatedsimilarly. In these patients, a visceral insult such

as ischemic bowel prevents ultimate closure of theabdominal wall. Gastrointestinal dysfunction in-

cluding intestinal fistulae may complicate the situa-tion further. Mesh repair of the abdominal wall

with skin grafts placed over mesh or omentum, oreven directly over viscerae may be a good tempo-rizing measure, although a massive ventral herniaresults. Definitive reconstruction is performed 6 to

12 months later, once the skin grafts are matureand can be separated from the viscerae [Fig. 4].

Operations

The techniques used for abdominal wall recon-

struction run the gamut from simple skin graftingto free flap reconstruction. Treatment needs to beoptimized to provide the best functional and cos-metic result with minimal morbidity. Modalitiesare highlighted in Box 1.

Primary closure

Use of local tissues may be feasible, particularly ifthe patient has a pannus. It is important to avoidtension on the fascia and skin [Figs. 5, 6].

Vacuum-assisted closure Vacuum-assisted fascial closure has been helpfulin management of the open abdomen. Suction isapplied to polyurethane foam under an occlu-

sive dressing, pulling the fascia medially. Millerand colleagues described use of this technique in45 patients and showed significantly higher fascial

closure rates, obviating the need for hernia repairlater [2].

Skin and fascial grafts

Skin grafts are very useful for covering extensivewounds resulting from invasive infections such as

necrotizing fasciitis. Once the wound is healthy andgranulating well, meshed skin grafts can be usedto provide coverage. Skin grafts can be applied di-rectly over viscerae or omentum. The disadvantage

Box 1: Various modalities used for abdominalwall reconstruction

Primary closure without tensionVacuum-assisted closureSkin and fascial graftsMeshSkin graft over mesh/omentum/visceraeFascial releaseComponents separationTissue expansionPedicled muscle and myocutaneous flapsFree flaps

Fig. 5. (A) Necrotizing fasciitis of lower abdomen. (B) Following debridement. (C) Closure using pannus.



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Fig. 6. (A) Unstable scar following liver transplant. (B) Osteomyelitis of rib. (C) Following debridement. (D) Lowerabdominal wall used as a flap.

Fig. 7. (A) Ventral hernia. (B) Tensor fascia lata facial graft was harvested. (C) Fascial repair.



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of using skin grafts is poor cosmesis. Autogenousfascia lata grafts have been used to reconstruct theabdominal wall in patients with ventral herniae.

Disa and colleagues reported on a series of32 patients who underwent abdominal wall recon-struction with autologous fascia lata grafts [3]. Indi-

cations included exposed mesh, enteric fistulae,enteric contamination, wound infection, and im-munosuppression alone. Recurrent hernia was seen

in 9% of patients. Good incorporation of fascia wasnoted in three patients who required laparotomyfor unrelated reasons [Fig. 7].

Fascial release

Closure without tension is paramount in achiev-ing stable closure. Relaxing incisions through the

transverse abdominis and external oblique muscles

and subsequent medial advancement can achieveclosure without tension. Thomas used bilateralparasagittal incisions to achieve repair of ventral

herniae [4].

Components separation

Ramirez described the components separation

technique to close large defects [5]. The rectus ab-dominis muscle is dissected from the posteriorsheath, and the external oblique is separated from

the internal oblique. The rectus muscle and anteriorsheath with attached internal oblique and trans-

verse abdominis muscles are advanced mediallytowards the midline. The undermined external

oblique is left in its original position. Up to 20 cmof advancement can be achieved in the umbilicalarea with bilateral advancement. Previous surgicalprocedures can limit use of this technique by de-stroying tissue planes [Fig. 8].

Tissue expansion

Tissue expanders can be placed either above thefascia, between the external and internal obliquemuscles, or between the internal oblique andtransverse abdominis muscles. Use of the intermus-cular plane avoids use of mesh to achieve fascialintegrity. Use of tissue expanders provides good cos-metic results at the expense of prolonged, multi-

stage therapy. Infection may require removal ofexpanders and further delay of treatment. Carlsonand colleagues described tissue expansion in fourpatients with large skin grafted ventral herniae [6].

In the first stage, tissue expanders were placedunder the skin and subcutaneous tissues lateral tothe defect. In the second stage, following adequatetissue expansion, the expanders were removed,Polypropylene mesh was used to reconstruct thefascial defect, and the expanded skin was closedover the mesh.

Mesh and biomaterials

Various synthetic materials have been used to re-construct deficient fascia. Some of them, notablypolypropylene have been associated with high rates

Fig. 8. (A) Sarcoma of anterior chest and abdomen. (B) CT scan showing the lesion. (C) Separation of components.(D) Rearrangement of components with subsequent closure of skin envelope.



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of enteric fistulization and erosion of the mesh.The use of Vicryl (Ethicon, Somerville, New Jersey)and Gore-tex mesh (W.L. Gore, Flagstaff, Arizona)has been associated with fewer fistulae. The inter-position of omentum or absorbable mesh between

viscerae and polypropylene mesh reduces adhe-

sions and fistulization. Danino and colleagues [7]described the use of a Gore-Tex (PTFE) polypro-pylene sandwich, with the Gore-Tex forming a

neoperitoneum, polypropylene used to reconstructthe fascia, and a superficial flap for skin closure.More recently, Danino and colleagues describeduse of the scanning electron microscope to evaluateboth sides of the mesh construct [7]. At the time of2-year delayed reconstruction in 15 patients, frag-ments of the mesh were removed and analyzed.

They showed stability of the PTFE graft at the deepsurface with formation of an intermediate layer be-tween the PTFE and polypropylene layers. The poly-propylene mesh was seen to have dense adhesionsto the surrounding tissue.

Acellular cadaveric dermis (AlloDerm, Lifecell,

Branchburg, New Jersey) recently was used for ven-tral hernia repair and reconstruction of abdominalfascial defects. Buinewicz and Rosen described the

use of Allo-derm for reconstruction of fascialdefects in 44 patients who had ventral herniae or

who were undergoing TRAM flaps [8]. Successful

repair of defects was reported, even in infectedpatients. Animal models have shown good in-corporation of Allo-derm into native tissues. Kolkerand colleagues used Allo-derm in a multi-layer

Fig. 9. (A) Full thickness recurrence of abdominal wall tumor. (B) Abdominal wall defect following radicalresection. (C) AlloDerm was used to reconstruct the abdominal wall. Contralateral rectus abdominis and ipsilat-eral TFL flaps were harvested. (D) Wound closure. (E) Patient developed acute abdomen secondary to volvulus.(F) Flaps remained viable following repair of volvulus.



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fascial repair with components separation in 16 pa-tients who had recurrent herniae; they reported norecurrences [9] [Fig. 9].

Pedicled muscle and myocutaneous flaps

Pedicled muscle flaps are sometimes necessary incontaminated fields or to provide coverage ofmesh. The choice of flap depends on the locationof the defect and available donor tissue. Frequentlyused options for the lower abdomen are tensor

fascia lata and rectus femoris flaps. Latissimusdorsi, external oblique, and rectus abdominis flapsare good options for the upper abdomen.

The tensor fascia lata is a small muscle that origi-nates from the anterior superior iliac spine and thegreater trochanter. It has a large fascial extensionand inserts into the lateral aspect of the knee. Themuscle is supplied by the lateral femoral circumflexartery, and perforators supply the skin. It has a largeskin territory, up to 15 40 cm [Fig. 10].

Fig. 10. (A) Open abdomen treated with skin graft over viscera. (B) Separation of components was not adequatefor closure. (C) TFL flap harvested for successful closure.

Fig. 11. (A) Epigastric hernia at lower end of sternotomy incision. (B) Proximal rectus muscle was freed proximallyand rotated medially to cover the defect. (C) Completed closure.



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The rectus femoris muscle flap can provide mus-cle, fascia, and skin to cover suprapubic and lowerabdominal areas. It originates from the anteriorinferior iliac spine and inserts into the patellar ten-don. The muscle is supplied by the lateral femoralcircumflex vessels.

Once the muscle is harvested, the vastus medialisand lateralis are sutured together to preserve termi-nal knee extension.

The latissimus dorsi muscle flap can provide cov-erage for upper abdominal defects. It is suppliedby the thoracodorsal vessels.

The rectus abdominis muscle is supplied by supe-rior and inferior epigastric vessels. It can be used asa pedicled flap based on either vessel [Fig. 11].

Free tissue transfer may be necessary if pedicledflaps do not reach the defect, as in epigastric de-

fects. They also may be necessary in case of priorsurgery or radiation-destroying muscle pedicles.Sometimes free flaps are necessary when deadspace needs to be filled up [10]. The choice offree flap would depend on the size and loca-

tion of the defect and the condition of the recipi-ent vessels.

Reconstruction of the anterior abdominal wall is

based on six basic principles. First, the anatomy of

the abdominal wall and adjacent donor sites must

be understood clearly. This includes a completeknowledge of the neurovascular anatomy and the

arc of rotation of each subunit. The defect then hasto be exposed completely before the definitive clo-

sure is attempted. Once the defect is established,

abdominal domain is restored with some sort of

support. The next phase of the repair involves reas-

signing local tissue to close the defect. Distanttissue then is imported from donor sites such as

the thigh, if needed. Finally, the skin envelope isreadjusted and closed. These principles help opti-

mize function and restore form, hence achieving

the best possible result.

References

[1] Bennett M, Feldmeier J, Hampson N, et al.Hyperbaric oxygen therapy for late radiation tis-sue injury. Cochrane Database Syst Rev 2005;20(3):CD005005.

[2] Miller PR, Meredith JW, Johnson JC, et al. Pro-spective evaluation of vacuum-assisted fascial clo-sure after open abdomen: planned ventral herniarate is substantially reduced. Ann Surg 2004;239(5):60814 [discussion 6146].

[3] Disa JJ, Goldberg NH, Carlton JM, et al. Restor-ing abdominal wall integrity in contaminatedtissue-deficient wounds using autologous fasciagrafts. Plast Reconstr Surg 1998;101(4):97986.

[4] Thomas WOI, Parry SW, Rodning CB. Ventral /incisional abdominal herniorraphy by fascialpartition/release. Plast Reconstr Surg 1993;91:10806.

[5] Ramirez OM, Ruas E, Dellon AL. Componentsseparation method for closure of abdominal

wall defects: an anatomic and clinical study. PlastReconstr Surg 1990;86:51926.

[6] Carlson GW, Elwood E, Losken A, et al. The roleof tissue expansion in abdominal wall recon-struction. Ann Plast Surg 2000;44(2):14753.

[7] Danino AM, Malka G, Revol M, et al. A scanningelectron microscopical study of the two sides ofpolypropylene mesh (Marlex) and PTFE (Gore

Tex) mesh 2 years after complete abdominalwall reconstruction. A study of 15 cases. Br J PlastSurg 2005;58(3):3848.

[8] Buinewicz B, Rosen B. Acellular cadaveric dermis(Allo-Derm): a new alternative for abdominalhernia repair. Ann Plast Surg 2004;52(2):18894.

[9] Kolker AR, Brown DJ, Redstone JS, et al. Multi-layer reconstruction of abdominal wall defects

with acellular dermal allograft (Allo-Derm) andcomponent separation. Ann Plast Surg 2005;55(1):3641 [discussion 412].

[10] Netscher DT, Valkov PL. Reconstruction of on-cologic torso defects: emphasis on microvascularreconstruction. Semin Surg Oncol 2000;19(3):25563.


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