Operative Technique in Plastic Surgery – Kevin C.Chung

minimally invasive component separation was
performed, which allowed for complete fascial
coaptation (E). F. Patient at 1 month postoperatively
and by CT scan at 1 year postoperatively (G).

FIG 3 • Pelvic reconstruction and donor-site
management. A. A 47-year-old woman with invasive
cervical cancer required a total pelvic exenteration. B.
Intraoperative defect. C. A pedicled vertical rectus
abdominis muscle (VRAM) flap was elevated from the
right hemiabdomen and passed through the pelvis (D)
and inset for reconstruction of the perineum and
posterior vaginal wall (E). F,G. Patient was thin with
minimal abdominal wall laxity, and therefore a unilateral
component separation was performed to facilitate
closure of the VRAM donor site. H. This allowed for
complete fascial closure. I. One year postoperative
photo and J. CT scan.
■ Comparative data showed laparoscopic component separation to result in a

lower rate of wound morbidity than open component separation. One series
reported a significant reduction in wound morbidity with the periumbilical
perforator-sparing technique compared with the standard open component
separation technique (2% vs 20%; P < 0.05).
■ A controlled study demonstrated that patients had significantly fewer wound
healing complications (32% vs 14%, P = 0.026) and skin dehiscence (28% vs
11%, P = 0.01) with MICS than with traditional open component separation.
COMPLICATIONS
■ Infection
■ In patients with clean-contaminated and contaminated wounds, a prospective
multi-institutional study evaluating the role of a porcine ADM to repair
abdominal wall defects reported a 34% rate of superficial surgical site
infections. In contrast, studies of clean wounds have reported infection rates
of 0% to 12%.
■ Mesh infections are reported to occur in 0% to 3.6% of laparoscopic ventral
hernia repairs and 6% to 10% of open repairs employing mesh.
■ The most common organism infecting abdominal wall repair is
Staphylococcus aureus, seen in up to 81% of cases; this suggests skin flora
contamination.
■ Gram-negative organisms, such as Klebsiella and Proteus spp., have been
implicated in up to 17% of mesh infections.
■ Management of abdominal wall infections is complex and requires patient
individualization as well as a knowledge of bacterial susceptibility for a
particular hospital.
■ Seroma
■ Seroma formation can occur following abdominal wall reconstruction
particularly in cases involving large undermined flaps, which create
significant dead space.
■ If symptomatic, seromas can be aspirated percutaneously or under ultrasound
guidance.
■ In open ventral hernia repair, drains are often placed in an attempt to
obliterate the dead space caused by the hernia and tissue dissection.
■ Seroma formation is common after abdominal component separation and
muscle flaps of the trunk owing to extensive tissue dissection, and drains may
be necessary for up to 4 to 6 weeks.
■ Intraoperative techniques, such as quilting sutures, fibrin sealant, and

postoperative abdominal binders, may help to prevent or reduce seroma
formation.
■ Enterotomy and enterocutaneous fistulas
■ Appropriate management of an enterotomy during a hernia repair is
controversial and depends on the segment of intestine injured (small vs large
bowel) and amount of spillage.11
■ Options include aborting the hernia repair, continuing the hernia repair and
repairing the enterotomy with local tissue or bioprosthetic mesh using a
primary tissue or bioprosthetic mesh repair, or performing a delayed repair
using mesh in 3 to 4 days.
■ When there is gross contamination, the use of synthetic mesh is generally
contraindicated.
■ The treatment of patients with enterocutaneous fistulas (ECFs) is complex
and approximately 1/3 of ECFs will close spontaneously with appropriate
wound care, nutritional support, and medical therapy.
■ Depending on the location of the fistula along the gastrointestinal tract and
the volume of output, significant electrolyte disturbances can occur. In
particular, proximal high-output fistulas can result in substantial losses of
bicarbonate, which must be adequately replaced.
■ Diligent protection of the surrounding skin is one of the most important and
difficult aspects of ECF management. A dedicated enterostomal nurse is
essential to the success of wound management as destruction of local skin can
seriously affect eventual reconstructive options.
■ In cases in which a fistula is already present, negative pressure wound
therapy (NPWT) device can be helpful to isolate a fistula from the
surrounding wound and to allow a skin graft to heal.
■ In cases of uncontrolled intestinal leakage, a proximal diverting stoma can be
lifesaving.
■ Nutritional supplementation is one of the most important aspects of reducing
deaths related to ECFs. During initial management of an ECF, parenteral
nutritional support is preferred. However, once the sepsis is controlled and
the patient is stabilized, enteral feedings are initiated.
■ Hernia
■ The incidence of incisional hernia is approximately 11% following midline
laparotomy.
■ Functional problems in hernia patients include poor respiratory effort, loss of
abdominal domain, and weak abdominal musculature.

REFERENCES
1. 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(3):519-526.
2. Garvey PB, Bailey CM, Baumann DP, et al. Violation of the rectus complex is
not a contraindication to component separation for abdominal wall
reconstruction. J Am Coll Surg. 2012;214(2):131-139.
3. Shestak KC, Edington HJ, Johnson RR. The separation of anatomic
components technique for the reconstruction of massive midline abdominal
wall defects: anatomy, surgical technique, applications, and limitations
revisited. Plast Reconstr Surg. 2000;105(2):731-738.
4. Itani KM, Hur K, Kim LT, et al. Comparison of laparoscopic and open repair
with mesh for the treatment of ventral incisional hernia: a randomized trial.
Arch Surg. 2010;145(4):322-328.
5. Rosen MJ, Jin J, McGee MF, et al. Laparoscopic component separation in the
single-stage treatment of infected abdominal wall prosthetic removal. Hernia.
2007;11(5):435–440.
6. Mommers EH, Wegdam JA, Nienhuijs SW, de Vries Reilingh TS. How to
perform the endoscopically assisted components separation technique (ECS)
for large ventral hernia repair. Hernia. 2016;20(3):
441-447.
7. Butler CE, Baumann DP, Janis JE, Rosen MJ. Abdominal wall reconstruction.
Curr Probl Surg. 2013;50:557–586.
8. Butler CE, Campbell KT. Minimally invasive component separation with
inlay bioprosthetic mesh (MICSNIB) for complex abdominal wall
reconstruction. Plast Reconstr Surg. 2011;128(3):698-709.
9. Ghali S, Turza KC, Baumann DP, Butler CE. Minimally invasive component
separation results in fewer wound-healing complications than open component
separation for large ventral hernia repairs. J Am Coll Surg. 2012;214(6):981-
989.
10. Slater NJ, Knaapen L, Bökkerink WJ, et al. Large contaminated ventral
hernia repair using component separation technique with synthetic mesh. Plast
Reconstr Surg. 2015;136(6):796e-805e.
11. Visschers RG, Olde Damink SW, Winkens B, et al. Treatment strategies in
135 consecutive patients with enterocutaneous fistulas. World J Surg.
2008;32(3):445-453.

9
CHAPTER
Abdominal Hernia
Reconstruction With
Synthetic and Biologic Mesh
Sergey Y. Turin and Gregory A. Dumanian
DEFINITION
■ A hernia is a defect in at least one of the layers of the abdominal wall,
permitting intra-abdominal contents such as bowel and fat to protrude past their
normal confinement layer of transversalis fascia. This is in contradistinction to
a bulge, which is an imbalance between the outward force of the viscera and
the containing force of the intact abdominal wall, as seen in denervation
injuries or rectus diastasis.
■ We will focus on the treatment of incisional hernias in this chapter—hernias
due to a defect in the repaired abdominal wall after a prior laparotomy.
ANATOMY
■ The key in a hernia defect is the disruption of the continuity of the abdominal
wall—depending on the etiology of the hernia and the patient’s surgical history,
this may be one or many layers of the abdominal wall. In incisional hernias,
this often means a midline defect at the site of the previous midline laparotomy
incision (FIG 1).
■ As shown in FIG 2, the abdominal wall lateral to the rectus muscle is intact,
and we can clearly see all three layers—the external and internal oblique and
the transversus abdominis muscles inserting onto the linea semilunaris. The
defect is clearly between the rectus muscles (FIG 2).
PATHOGENESIS
■ Coughing, the Valsalva maneuver, and contraction of the stomach muscles for
postural stability all increase intra-abdominal pressure. This pressure is
normally opposed by the abdominal wall, which is a muscular and elastic organ

and can provide inward force to maintain the viscera in their domain.
■ When one of the portions of the abdominal wall is unable to oppose the intra-
abdominal pressure either due to denervation (as in a bulge) or due to
discontinuity of the musculature (as in a hernia), the viscera are forced through
that portion by the rest of the competent musculature. The abdominal wall
functions uniformly as a pressurized cylinder, whereas sizeable hernias and
bulges serve to lower intra-abdominal pressure.
■ The abdominal wall is muscular but also elastic. This has great bearing on the
choice of reconstructive technique, in that the reconstructed muscular and
fascial components must be able to stretch, so they can absorb and dampen the
sharp rises in intra-abdominal pressure that come with coughing, sudden
exertion, and Valsalva.
■ The most successful repairs occur in the most elastic abdomens, whereas a
fibrotic, scarred abdominal wall that is unyielding will have more of a
tendency for stitches tearing in the postoperative period. A bridging mesh
(synthetic or biologic), besides its inherent inability to provide an inward force,
is also inelastic and has a compliance mismatch with the intact abdominal wall,
leading to a higher rate of dehiscence and suture pull-through, as shown in FIG
3.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ A full history and physical exam is performed, with a focus on prior
abdominal surgeries and the means of closure. Patients are encouraged to
obtain all previous abdominal operative reports. The medical history looking
for bowel dysfunction and comorbid conditions such as diabetes, cardiac
anomalies, and chronic obstructive pulmonary disease is obtained.
■ Gestational history is important in order to ascertain if women have had their
abdominal walls stretched previously.
■ History of weight loss, prior abdominal wall sepsis, or peritoneal dialysis is a
factor that will either increase or decrease the elasticity of the abdominal
muscles.
■ Examine the abdominal wall with the patient both standing and lying down.
Attempt to reduce the hernia to assess the degree of bowel adhesions and the
compliance of the abdomen.
■ Document the scars of previous surgeries. Evaluate rectus diastasis by
watching the patient on the descent phase of a sit-up—a maneuver that clearly
shows muscle separation in all but the most obese patients.

■ Evaluate the skin and subcutaneous tissues for scarring, excess, and wounds
because this will need to be addressed for optimal closure.
■ Social history is necessary, as return to work issues and help at home after
surgery will need to be planned in advance.
IMAGING
■ We routinely obtain a CT scan of the abdomen and pelvis using oral contrast to
assess the layers of the abdominal wall, any implanted meshes, or biologic
materials and measure the size of the defect for all major incisional hernias. If
the patient has no kidney issues, we add IV contrast for an optimal study and to
obviate the need to explore the abdomen at the time of hernia closure to save
dissection time, limit tissue swelling, and avoid possible bowel injury.

Aponeuroses of External oblique m. Internal oblique m. Transversus abdominus m. Linea alba Rectus sheath Anterior layer Posterior layer Transversalis fascia Aponeuroses of External oblique m. Internal oblique m. Transversus abdominus m. Anterior layer of rectus sheath Transversalis fascia External oblique m. Internal oblique m. Transversus abdominus m. Transversalis fascia Latissimus dorsi m. Psoas fascia Psoas major m. Lumbar fascia Anterior layer , Middle layer ,Posterior layer Quadratus lumborum m. Latissimus dorsi m. Sacrospinalis m.

FIG 1 • A,B. Anatomy of the abdominal wall.
NONOPERATIVE MANAGEMENT
■ The indications for repair of an incisional hernia are local hernia pain, a
history of an obstruction, patient discomfort from an inability to raise core
intra-abdominal pressure, unsightliness, and the need for intra-abdominal
visceral surgery.
■ Small asymptomatic defects can be observed (so long as the patient is not
traveling to an area lacking modern medical care), as the risk of surgery
approximates the risk of observation.
■ For every patient, there should be a comparison of the expected benefits with
the magnitude of the procedure required for repair.
FIG 2 • CT Scan demonstrating an incisional hernia.

SURGICAL MANAGEMENT
Preoperative Planning
■ These repairs are invasive procedures usually performed on an elective basis,
so every patient should be optimized for surgery, including an appropriate
perioperative evaluation, nutritional optimization and weight loss, and lifestyle
changes such as smoking cessation.
■ The Caprini risk stratification model is used to assess the individual patient’s
risk for DVT/PE and assign chemoprophylaxis if appropriate.
■ Perioperative antibiotics are routinely given for 24 hours, and topical antibiotic
irrigation is used during the procedure.
■ The history and imaging must be reviewed and an operative plan put in place:
■ What incisions have been previously made? What layers of the abdominal
wall are no longer continuous?
■ Is there mesh? If so, what kind, how large, and how was it affixed?
FIG 3 • Suture pull-through or “cheese wiring” due to
high focal stress placed by the suture on the tissues.
■ Is there a concurrent procedure that needs to be performed (eg, stoma
takedown or relocation or other bowel surgery)?
■ Assume that some level of adhesiolysis will be required, and backup plans
for an enterotomy repair or bowel resection should be in place.

Positioning
■ The patient is in a supine position with the arms out to the sides. The field
should extend from the xiphoid to pubis and down to the midaxillary line on
the sides. Flank defects are repaired in the lateral decubitus position.
Approach
■ We use the prior incision for access into the abdominal cavity. In general, the
incision must be longer than the prior scar, and so extensions into an unscarred
skin are the rule.
■ At the end of the procedure, the prior incision, redundant skin and
subcutaneous tissue, and hernia sac are excised so that healing will occur with
unscarred tissue and so that the soft tissues will lie flat against the abdominal
wall.
■ For improved aesthetics and healing, the umbilicus is removed and a
neoumbilicus created (see umbilicoplasty technique in associated chapter).
T E C H N I Q U E S
■ Laparotomy and Development of Tissue Planes
Video p5-c009_02
■ Make a generous incision.
■ Enter the abdominal cavity immediately rather than trying to preserve the
00:00 / 00:00

hernia sac. In general, start where the hernia sac is most mobile and softest,
as this is where adhesions will be least. After entry into the abdomen, extend
the dissection in either direction until one reaches unscarred tissue, the
xiphoid, and/or the symphysis pubis.
■ Bowel adhesions to the hernia sac and the peritoneal surface of the
abdominal wall should be widely taken down from the anterior abdominal
wall, though a full abdominal exploration is not performed (TECH FIG 1).
■ If there is a mesh, it must be removed completely at this point—it is a
foreign body and will not contribute to the closure. We typically split the
mesh for ease of dissection and take it off as two “halves.” Alternatively,
when there is infected mesh and an enterocutaneous fistula, the mesh is
removed “en bloc.”
■ Using cautery, dissect through the hernia sac to identify the medial borders
of the rectus muscle in their entirety. Clear 4 cm of anterior rectus fascia.
■ To assess the need for a components release, the patient should be under
general anesthesia and the patient fully muscle relaxed.
■ Grasp the dissected rectus muscles in their midportion with two fingers on
either side. If they cannot be brought together to the midline, the patient
will require a components release.
■ This occurs in a patient with normal compliance of the abdominal wall
with a preoperative CT scan that shows a 6- to 10-cm separation.

TECH FIG 1 • Midline laparotomy from the symphysis
pubis to midepigastrium with division of hernia sac.
■ External Abdominal Oblique Release (Anterior
Components Release)
Video p5-c009_01
00:00 / 00:00

■ In cases where a components release is required, palpate the inferior costal
margin and make a 6-cm transverse subcostal incision in order to approach
the linea semilunaris.
■ Using a combination of cautery and spreading with curved Mayo scissors,
the anterior-most external oblique fibers are identified as they blend into their
insertion into the lateral aspect of the rectus sheath.
■ Bluntly dissect a tunnel along the semilunar line going inferiorly and
superiorly.
■ Using electrocautery, make a small, finger-sized incision in the external
oblique muscle just lateral to the rectus sheath. Then, bluntly dissect the
plane between the internal and external obliques and use the cautery against
your finger to release the external oblique just lateral to the rectus sheath. A
narrow Deaver retractor will help visualization.
■ These incisions are continued in the tunnels going inferiorly and superiorly
from the subcostal incision far above the rib cage down to the anterior
superior iliac spine (ASIS). Especially superiorly, a deep fascia of the
external oblique exists and should be divided for maximal movement—it is
completely distinct from the internal oblique muscle.
■ A suprapubic tunnel is brought into continuity with this lateral dissection, all
with blunt dissection and remaining near the ASIS to avoid the periumbilical
perforators.
■ The external oblique release is completed inferiorly with “grabbing” the cut
end of the muscle/fascia from the midline tunnel to allow it to be cut under
direct vision. Once these releases are complete bilaterally, the rectus muscles
should come together in the midline for the majority of hernias (TECH FIG
2) (Videos 1 and 2).

TECH FIG 2 • A. Transverse incisions for perforator
sparing anterior components release located at the
inferior aspect of the costal margins. B. Narrow
Deaver retractor permitting release of external oblique
muscle and fascia over the rib cage. C. From the
suprapubic midline incision, a dissecting finger creates
a tunnel and joins it with the dissections of the lateral
incisions. The cut end of the external oblique muscle
is captured by the index finger. The dissecting index
finger pulls the external oblique fascia into the midline
incision to be visualized and subsequently cut.
■ This approach to releasing the external obliques preserves the periumbilical
perforators that will be supplying the soft tissues overlying the midline
closure and has been shown to decrease surgical site occurrences (SSO).
■ Choice of mesh remains extremely controversial. General guidelines are that
all hernias should be closed with a mesh to distribute forces and to limit
suture pull-through.

■ Achievement of a “direct supported repair” with closure of biologic tissue
over mesh has been shown to decrease hernia rates in comparison with a
mesh that bridges a fascial defect.
■ For prosthetic meshes, coated meshes against adhesions are generally
recommended when placed against bowel, whereas uncoated macroporous
meshes with pore sizes greater than 1 mm to limit bridging scar and
encapsulation are generally used in the retrorectus and onlay positions.
■ Absorbable meshes distribute forces but for only a limited amount of time.
Animal experimentation implies that the foreign body response recedes
when the foreign body is absorbed. Whether absorbable meshes translate to
improved long-term closure remains to be seen. Similarly, biologic meshes
are known to incorporate into surrounding tissues.
■ Whether a net benefit exists or not of added long-term scar or even tissue
regeneration of a fascia is completely unclear at the writing of this chapter.
■ The retrorectus space is developed by incising the linea alba to mobilize the
posterior rectus fascia (above the arcuate line) and the preperitoneal fat
(below the arcuate line) off the rectus muscle for 4 cm. Care is taken to not
injure the inferior epigastric vessels, blood vessels supplying this tissue layer,
or intercostal nerves entering the muscles on their deep and lateral surface.
■ The posterior sheath is then closed with a running 2-0 polydioxanone suture
(TECH FIG 3).
TECH FIG 3 • A,B. Development of retrorectus space.
C. Closure of posterior rectus sheath.
■ Mesh Inset
■ The key of the procedure is a well-fixed narrow mesh that is held flat and

tight against the rectus muscles. Wrinkled mesh will not incorporate well into
the tissues as a load-sharing component of the abdominal wall. Loose mesh is
not load sharing and defeats the purpose of mesh placement.
■ Cut a piece of uncoated midweight macroporous polypropylene mesh to a
width of 7.5 cm and length equal to the length of the abdominal wall defect.
Tension across the narrow width of mesh should maintain macroporosity, as
opposed to allowing the holes of the mesh to close down. Macroporous
meshes have improved tissue incorporation and biocompatibility in
comparison with microporous meshes made of the same material.
■ The mesh is then secured in place using #0 polypropylene sutures in an
interrupted fashion. These stitches start at the lateral edge of the dissection
superficial to the rectus muscle (approximately 4 cm away from medial
edge), traverse the muscle and its anterior fascia, then take a small bite of the
mesh near its edge before coming back out superficially and tying the knot.
■ Large bites of mesh will distort and wrinkle the mesh, hindering
incorporation.
■ Bites should be spaced 2 cm apart or so.
■ The undersurface of the rectus muscle should be well visualized to limit
the injury of segmental nerves and blood vessels during placement of these
transrectus sutures (FIG 4A–C).
■ Most techniques in the hernia literature that look to Rives-Stoppa repairs for
inspiration use few or no sutures to fix the mesh in place. The mesh is held in
place by its size and friction, with medial aspect of the rectus muscles
approximated in the midline to cover the mesh.
■ Placement of even larger meshes requires the release of the transversus
abdominis muscles in what is called the TAR (transversus abdominis release
or posterior components) procedure.
■ Instead, we promote the use of a well-fixed narrow mesh and believe it has
numerous advantages over wide meshes that require additional tissue
dissection including less total foreign material, less opening of wide tissue
planes, and speed of the procedure. SSO and surgical site infection (SSI)
rates for a well-fixed narrow mesh are lower than that for large unfixed
meshes in recently submitted data from our institution.
■ As the mesh is 7.5-cm wide and the bites are taken 4 cm away from the
medial rectus edge on both sides, once the lateral mesh sutures are in place,
the medial borders of the rectus muscles should be able to be approximated

with no tension with #0 polypropylene sutures (FIG 4D–F).
TECH FIG 4 • A. Illustration of retrorectus mesh
position. B. Mesh positioning in the retrorectus space
with placement of upper transfascial sutures. C.
Narrow mesh placed flat and tight in the retrorectus
space. D. Diagram of placement of narrow mesh. E.
Rectus muscles and anterior rectus sheath closed
over the mesh—one can see the lateral suture lines
outlining the borders of the mesh and the midline
closure of the rectus muscles over the mesh. F.
Diagram of the abdominal wall reconstruction

construct.
■ Closure
■ We place at least 1 drain in the subcutaneous tissues, and for patients with
BMI over 30, we place drains in each components release space.
■ At this point, we turn our attention to the soft tissues of the abdomen. With
the fascia closed, redundant skin and soft tissue are excised and yet still
achieving a tension-free closure. This maneuver removes the poorest
vascularized tissue and decreases the potential space where fluid can collect.
■ We routinely excise the umbilical stalk and reconstruct the depression using
“pumpkin-teeth” flaps as described in the umbilicoplasty chapter.
■ Closure is performed with polyglactin dermal sutures and either staples or a
running subcuticular stitch (TECH FIG 5).
Biologic Implant Placement
■ In situations where wounds are contaminated and the clinical situation still
requires abdominal wall closure, there are numerous options, though none of
them are optimal.1,2
TECH FIG 5 • A. Redundant soft tissue after
abdominal wall closure. B. Markings for soft tissue
excision with “pumpkin-teeth” umbilicoplasty flaps. C.
After soft tissue excision, prior to completion of
closure, the umbilicoplasty flaps are approximated at
the edge that will be in the deep aspect of the
umbilicus. D. Preoperative appearance of the patient
illustrated above. E. Postoperative appearance of the
patient illustrated above.
■ A bridging piece of biologic mesh can be placed, with the idea of limiting
further tissue dissection. These bridging biologics have extremely high
failure rates and more likely than not will require a delayed hernia

reconstruction.
■ Primary closure of the abdominal wall augmented by a components
release, biologics, and retrorectus meshes has all been documented to have
recurrence rates in the 20% range.
■ Our current management for contaminated closures is to perform a “mesh
sutured repair.”
• Strips of polypropylene 18 to 20 mm wide are introduced through the
substance of the abdominal wall and tied as simple sutures.
• Conceptually somewhere between a suture repair and a planar mesh, these
mesh sutured repairs in our hands have demonstrated SSI in the 6% range,
SSO to be 18%, and a hernia recurrence rate of 4% with 7.6 months’
follow-up.
■ In the interim, we would recommend that, when a biologic mesh is
indicated, the surgeon use the technique as laid out above—the principles of
flat and tight placement, scar excision, and lateral EAO release all apply in
the same fashion. Secure attachment of the mesh is crucial to allow
vascularization and integration of the material as quickly as possible. All
manufacturer instructions must be followed regarding rehydration of the
mesh and optimal tension of inset.
PEARLS AND PITFALLS
Scar is not
your friend
■ Scar in the subcutaneous tissues, and even more so the scarred
edges of the rectus muscles, may seem like strong tissue that can
hold a stitch, but it is avascular, is inelastic, and has decreased
potential to heal. With time, the suture will simply cheese wire
through the noncompliant tissue leading to failure. We routinely
excise all scar and make it a priority to close healthy tissue to
healthy tissue.
Suture pull-
through is
the enemy
■ Not using enough suture fixation points to spread out the load of
the closure along the suture lines will lead to disproportionately
high force per unit area in the sutures that are placed, leading to a
high risk of cheese wiring through the tissues.
Umbilicus
management
■ Counsel the patient preoperatively that you may need to remove the
umbilicus as part of the closure—if they do want an neoumbilicus,

plan for the extra time needed for an umbilicoplasty.
Lysis of
adhesions
■ As above, make sure that you or a colleague is prepared to deal
with bowel adhesions and any intra-abdominal anatomy challenges,
as well as the possible enterotomy and need for bowel excision.
Mesh
sutured
repairs
■ Are efficacious and efficient means to close abdominal wall, though
long-term follow-up does not yet exist for this novel closure
method. Strips of macroporous mesh 18 to 20 mm wide are passed
through the abdominal wall and used as sutures. The strips of mesh
use the same concepts of force distribution and reduction of pull-
through as tenants of successful abdominal wall surgery. Despite the
permanent material, they have been placed successfully in
contaminated closures.
POSTOPERATIVE CARE
■ Diet management
■ Bowel preps do not decrease SSI or SSO, but a mechanical prep with
Dulcolax that does not alter bowel flora may be helpful to reduce visceral
volume and pressure during and immediately after surgery. An aggressive
antiemetic regimen is necessary to prevent emesis and the associated high
abdominal wall stresses. Patients are allowed to eat after passing flatus,
typically on POD 3 or 4 for major hernias.
■ Activity
■ Patients are up to chair on POD no. 1 and instructed to ambulate on POD no.
2. Patients can ambulate as tolerated thereafter. They can begin nonimpact
exercise (walking, swimming, elliptical training) at 6 weeks. They can do
isometric abdominal exercise at 3 months and gentle impact exercise at 6
months. They have no restrictions at 9 to 12 months after surgery.
■ Foley and UOP monitoring
■ We routinely place and leave a Foley catheter for 24 hours to monitor urine
output. A drop-off in urine output in a patient that otherwise appears
adequately resuscitated raises concern for abdominal compartment syndrome
—a rare but possible complication. Rising intra-abdominal pressure by Foley
catheter monitoring, low urine output, and difficulty with ventilation all point
toward a compartment syndrome.
■ Tidal volume monitoring
■ Returning a large volume of viscera to the abdominal compartment can
significantly impair ventilatory capacity by limiting diaphragm excursion.

Pulmonary therapy is necessary during the immediate postoperative state to
optimize the patient’s respiratory status.
■ Valium
■ We routinely prescribe diazepam to patients postoperatively to reduce muscle
spasms, improve pain control, and off-load the closure.
■ Pain management
■ We avoid the use of ketorolac given the fairly large dissection. Patients who
we anticipate will have pain control difficulties undergo placement of an
epidural catheter by the anesthesia pain team for the immediate postoperative
period. Use of epidurals may help blunt the body’s inflammatory response to
surgical trauma but can lead to greater forces on abdominal sutures from
greater patient activity.
■ DVT prophylaxis
■ DVT prophylaxis must be administered as dictated by patient risk
stratification on the Caprini score.
OUTCOMES
■ In our series of 101 patients who have been treated with a narrow well-fixed
mesh as described above, there was a 0% rate of hernia recurrence, SSO of
7.9%, and SSI of 3%. There were no enterocutaneous fistulae, and no meshes
required removal. Minor complications included 3 infections, 2 hematomas, 2
seromas, 1 reoperation for a subcutaneous collection, and 5 readmissions
within 30 days.3
COMPLICATIONS
■ Hematoma/seroma
■ Soft tissue infection and prosthetic mesh infection
■ Bowel-related complications involving delayed return of bowel function and
compartment syndrome
■ Medical complications including DVT/PE, pneumonia, UTI, and coronary
ischemia
■ Abdominal wall pain
REFERENCES
1. Jason H. Ko, Edward CW, David MS, et al. Abdominal wall reconstruction
lessons learned from 200 “Components separation” procedures. Arch Surg.
2009;144(11):1047-1055.

2. Chow I, Hanwright PJ, Kim John YS. A propensity matched analysis of
58,889 patients comparing ADM to synthetic mesh surgical site outcomes in
ventral hernia repair. Plast Reconstr Surg. 2015;1364S:13-14.
3. Steven TL, Jennifer EF, Kyle RM, Gregory AD. Reliable complex abdominal
wall hernia repairs with a narrow well-fixed retrorectus polypropylene mesh: a
review of over 100 consecutive cases. Plast Reconstr Surg Glob Open.
2016;4(9 suppl):111-112.

10
CHAPTER
Rectus Femoris Flap for
Abdominal Wall
Reconstruction
Alexander F. Mericli and Charles E. Butler
DEFINITION
■ The rectus femoris muscle can be used as pedicled or free flap for
reconstruction of the abdominal wall.
■ The flap can be harvested as a myocutaneous or muscle-only flap, depending
on the requirements of the defect.1–4
■ Several authors have had success employing the flap in an innervated fashion
for abdominal defects.5
■ Depending on the size of the defect, the rectus femoris muscle can be designed
as an isolated flap or can be combined with other components of the lateral
femoral circumflex vascular axis (vastus lateralis, anterolateral thigh skin and
subcutaneous tissue, iliotibial band, and/or tensor fascia lata muscle) for the
creation of a subtotal thigh flap.1 For massive abdominal wall defects, bilateral
flaps can be raised.
■ As a rotational flap, the rectus femoris muscle will easily reach the lower
abdomen, mons, lateral hip, perineum, and groin.
■ Although the rectus femoris is recognized as a useful flap, debate continues
regarding its associated donor-site morbidity.
■ There is disagreement in the literature as to whether the rectus femoris flap is
associated with decreased range of motion or strength with knee extension.6–8
ANATOMY
■ The rectus femoris is part of the quadriceps muscle complex. It is a bipennate
muscle with two distinct muscle bellies (FIG 1A).
■ It has two separate origins: the anteroinferior iliac spine and the anterior rim of

the acetabulum. The muscle inserts onto the patella along with the other
components of the quadriceps complex and both flexes the hip and extends the
knee (FIG 1B).
■ The motor innervation comes from the femoral nerve (L4 nerve root). The
sensory innervation to the skin overlying the muscle is from the intermediate
femoral cutaneous nerve.
■ The vascular supply of the rectus femoris is consistent with that of a type 2
muscle flap, as defined by Mathes and Nahai.
■ The major pedicle is a medial branch from the lateral femoral circumflex
artery (FIG 1C). The branch to the rectus femoris muscle emerges 1 to 2.5 cm
distal to where the lateral femoral circumflex artery splits from the profunda
femoris artery. The pedicle tends to enter the muscle on its deep and lateral
surface. After sending a branch to the rectus femoris muscle, the lateral
femoral circumflex neurovascular bundle continues inferiorly, traveling in the
septum between the vastus lateralis and rectus femoris muscle, to supply the
tissue of the anterolateral thigh flap.
■ The minor pedicles are one to three small branches from the superficial
femoral artery, distally. Generally, the minor pedicles are not independently
sufficient to support flap viability.
■ The muscle is bordered by the vastus medialis medially, the vastus lateralis
laterally, and the vastus intermedius on its deep surface. The sartorius muscle
crosses obliquely over the rectus femoris muscle proximally.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Since the advent of the component separation technique, fascial approximation
of defects up to 20 cm wide at the umbilicus can be achieved. Therefore,
autologous reconstruction of the abdominal wall using thigh-based flaps is
reserved for patients with total or massive subtotal defects of the full thickness
of the abdominal wall.
■ The etiology of these significant defects is variable and includes malignancy
(tumor resection; FIG 2A), trauma (damage control of the abdomen or soft
tissue loss due to ballistic or blunt injury), and infectious processes
(necrotizing fasciitis, full-thickness abdominal wall resection due to extensive
enterocutaneous fistula formation; FIG 2B,C).
IMAGING
■ Imaging studies are not required before performing a rectus abdominis flap for

abdominal wall reconstruction. However, imaging is often present for other
reasons and can be utilized to the reconstructive surgeon’s advantage.
■ Computed tomographic scans of the abdomen and pelvis can be utilized for
visualization of the abdominal defect size and associated anatomy.
■ Computed tomographic angiography of the lower extremity—if present—can
be used to confirm patency of the vascular pedicle (FIG 3).
SURGICAL MANAGEMENT
Preoperative Planning
■ The patient should be seen preoperatively where a full history should be
obtained and physical examination should be performed.
■ Special attention should be paid to a past history of any abdominal, groin, or
thigh surgeries or injuries.

Tensor fasciae latae m. Rectus femoris m.- Vastus lateralis m. Lateral circumflex femoral artery Transverse branch (supplies tensor fascia latae) Descending branch (supplies tissues of the anterolateral thigh flap and vastus lateralis) • Iliopsoas m. Pectineus m. - Adductor longus m. Gracilis m. Sartorius m. • Vastus medialis m. B Deep femoral artery Superficial femoral artery Major pedicle to rectus femoris Minor pedicles to rectus femoris

FIG 1 • A. Muscular anatomy of the thigh. B. The rectus
femoris muscle originates from the anteroinferior iliac
spine and the acetabulum. It spans both the hip and
knee joints, thus serving as both a hip flexor and knee
extensor. C. The rectus femoris muscle is supplied by
the descending branch of the lateral femoral circumflex
artery. The lateral femoral circumflex artery also
supplies the tensor fascia lata, the vastus lateralis, and
the overlying skin, allowing for a subtotal thigh flap to be
designed, if necessary. Color code: rectus femoris
muscle, purple; anterolateral thigh tissues, blue; tensor
fascia lata, green.
FIG 2 • Abdominal wall defects from various etiologies.
Full-thickness defect after oncologic resection (A),
enterocutaneous fistula and associated soft tissue loss
after evisceration (B,C). (© Charles E. Butler, MD.)
■ If vascular disease is suspected, a computed tomographic angiogram should
be considered to verify perfusion of the rectus femoris muscle.
■ Reconstruction of the abdominal wall is typically a multisurgeon case
involving both reconstructive and general surgeons. General surgeons should

be available to assist with adhesiolysis or any enteral repairs, which might be
needed during the exposure.
Positioning
■ The patient is placed in the supine position with the bilateral legs internally
rotated at the hip.
■ The legs are secured in this position at the forefoot with a combination of tape
and foam to relieve pressure.
FIG 3 • Computed tomographic angiography
demonstrating the cross-sectional anatomy of the thigh.
T E C H N I Q U E S
■ Markings
■ With the legs internally rotated, markings are placed on the anterosuperior
iliac spine and the superolateral border of the patella; a line connecting these
two points approximates the lateral border of the rectus femoris muscle.
■ A line is extended superiorly from the midpoint of the patella to the

anterosuperior iliac spine representing the central axis of the rectus femoris
muscle (TECH FIG 1).
■ For a muscle-only rectus flap, either one or two incisions are designed along
the central axis of the muscle.
■ For a more minimally invasive approach, the two-incision technique is
used: a short distal incision is planned for the distal thigh to allow
disinsertion of the muscle from the patella. This incision is directly
overlying the rectus femoris muscle and 6 to 8 cm in length. A separate
incision is designed more proximally, over the region of the major pedicle.
This incision will allow for more proximal dissection and will facilitate
tunneling of the muscle into the abdominal defect, if a pedicled flap is
planned.
■ If a minimally invasive approach is not necessary, an incision is made over
the central anterior axis of the thigh, directly overlying the rectus femoris
muscle, from groin to distal thigh.
TECH FIG 1 • Surgical markings. RF, rectus femoris;
TFL, tensor fascia lata; ITB, iliotibial band. (© Charles
E. Butler, MD.)
■ Pedicled Rectus Femoris Flap
■ If a skin paddle is desired, it is designed as an ellipse centered over the
muscle on the anterior thigh.
■ An 8- to 9-cm skin paddle can generally be harvested without the need for
skin grafting of the donor site.

■ With a large skin paddle, it is useful to suture the edges of the skin to the
muscle fascia once the flap is elevated to prevent any shearing of the skin
during dissection.
■ If no skin paddle is needed, an incision is made distally, along the
midanterior line, directly over the rectus femoris muscle. This first incision
should be made 4 to 6 cm proximal to the patella.
■ Dissection is carried down through the subcutaneous adipose tissue and
through the deep fascia overlying the muscle belly. Blunt dissection is used
to free the muscle along its medial and deep surfaces.
■ Laterally and distally, the transition between the rectus femoris muscle and
vastus lateralis muscle is often indistinct. This part of the dissection must
be performed either sharply or with electrocautery to ensure accuracy;
blunt dissection will likely not be possible.
■ The distal muscle belly is disinserted from the patella, leaving 2 to 3 cm of
tendon with the muscle flap to assist with insetting. The muscle is dissected
proximally, freeing it from its medial, lateral, and deep attachments.
■ Several minor pedicles will be encountered entering the muscle’s deep
surface. These should be clipped and ligated as they are discovered.
■ A lighted retractor may aid the surgeon in dissecting the muscle as
proximally as possible.
■ Either the incision is extended proximally up to the groin or, for a more
minimally invasive approach, a separate incision is made overlying the groin,
and the disinserted muscle is passed from the distal incision to the proximal
incision.
■ The sartorius muscle will be found obliquely crossing over the muscle. The
main pedicle enters the rectus femoris muscle on its deep and lateral
surface at the level of the sartorius (TECH FIG 2A).
■ Passing the flap deep to the sartorius will allow for approximately 5 cm of
additional advancement (TECH FIG 2B).

TECH FIG 2 • A. Main pedicle of the rectus femoris
muscle (branch coming off the descending branch of
the lateral femoral circumflex vessels). B. Passing the
rectus femoris flap deep to the sartorius muscle in
order to allow for greater advancement. (© Charles E.
Butler, MD.)
■ If the defect does not require skin, the rectus femoris flap can be buried as a
muscle-only flap. If skin is required, the flap can either be designed with a
skin paddle or a muscle-only flap can be skin grafted.
■ Reconstructing the quadriceps tendon complex is an extremely important
step of this operation and cannot be underestimated. Doing so will help to
minimize the potential donor-site morbidity and loss of terminal knee
extension.
■ Buried no. 1 polypropylene sutures are typically used to approximate the
vastus lateralis tendon to the tendon of the vastus medialis, thus
centralizing the moment arm of the remaining quadriceps tendon. It is not
uncommon to extend this tenorrhaphy for 10 to 15 cm proximally.
Pedicled Subtotal Thigh Flap

■ The rectus femoris muscle can be combined with other components of the
lateral femoral circumflex vascular tree to create a subtotal thigh flap.
■ The skin paddle possible with this flap is larger than 400 cm2 and can be
used to reconstruct massive abdominal wall defects. Bilateral flaps can be
used to reconstruct the entire anterior abdominal wall1 (TECH FIG 3A-C).
■ The lateral femoral circumflex vessels supply the rectus femoris, vastus
lateralis, and tensor fascia lata muscles and the overlying skin. All these
structures can be incorporated into the flap, if needed.
■ Just as for the rectus femoris flap, the ASIS and patella are marked. A
template is made of the defect and its anatomic requirements (area of missing
fascia; area of missing skin, dimensions, etc.). The template is then
transposed onto the thigh.
■ The iliotibial band can be included in the flap to reconstruct any abdominal
fascial defect.
■ If an abdominal defect is significant enough to require a subtotal thigh flap
for reconstruction, it is unlikely that the iliotibial band will be sufficient in
and of itself to reconstruct the associated fascial defect.
■ Therefore, this flap is often combined with a mesh fascial repair for
reinforcement of the abdominal wall.1
■ The proximal extent of dissection is the branch point between the profunda
femoris and the lateral circumflex femoral artery.
■ Similar to the rectus femoris flap, the subtotal thigh flap should be passed
deep to the sartorius muscle for an additional 5 cm of advancement. Because
of the width of the flap, one or two segmental perforators to the sartorius will
likely need to be divided to provide enough room for the flap to pass.
■ A pedicled subtotal thigh flap will be able to reach to the level of the
umbilicus.
■ If additional length is needed, the flap can be created into a free flap by
way of a saphenous vein graft arteriovenous loop (see TECH FIG 4C).
■ When a partial vastus lateralis muscle flap is included with the distal tendon
intact, a vastus medialis to lateralis tenorrhaphy can be done. When the entire
vastus lateralis is included in this flap, a vastus lateralis to vastus medialis
tenorrhaphy is not possible as it is when only the rectus femoris muscle is
used. Therefore, the patient should be counseled preoperatively that loss of
terminal knee extension and strength is likely.
■ The patient should be maintained in a knee immobilizer for 6 weeks

postoperatively and may complete a formal postoperative physical therapy
program for strength training and range of motion.
TECH FIG 3 • Bilateral pedicled subtotal thigh flaps
can be used to reconstruct the entire surface area of
the abdominal wall. A. Right subtotal thigh flap. B. Left
subtotal thigh flap. C. Right subtotal thigh flap rotated
to the abdomen with left subtotal thigh flap reflected to
display abdominal defect. D. If the flap is less than 9
cm wide, primary closure is generally achieved. E. If
the flap is wider than 9 cm, primary closure is typically
not possible and a skin graft should be used. (©
Charles E. Butler, MD.)

TECH FIG 4 • A. Full-thickness abdominal defect and
preoperative marking. B. Free rectus femoris
myocutaneous flap. C. Inset of flap to the abdomen
via saphenous arteriovenous loop (arrow). Distal
saphenous anastomosed end-to-side to superficial
femoral artery and venous outflow to saphenofemoral
junction. D. Final result demonstrating healed flap and
skin graft donor site. (© Charles E. Butler, MD.)
■ The massive amount of skin taken with a subtotal thigh flap usually
necessitates donor-site closure with split-thickness skin grafts (TECH FIG
3D,E).

Free Rectus Femoris/Subtotal Thigh Flap
■ One significant shortcoming of the rectus femoris and subtotal thigh flaps is
the associated short pedicle.
■ This disadvantage can be obviated by means of a free tissue transfer.
■ If a free flap is required, but there is a short distance between the recipient
vessels and the flap, the branch to the rectus femoris muscle can be transected
as it emerges from the lateral femoral circumflex artery. This preserves the
anterolateral thigh flap and vastus lateralis muscle for future use.
■ Alternatively, for an additional 2 to 3 cm, the distal lateral femoral
circumflex artery can be ligated just distal to the takeoff of the rectus
femoris branch, and the pedicle can be transected where it emerges from
the profunda femoris.
■ The disadvantage of this maneuver is it prevents future use of the
anterolateral thigh and vastus lateralis muscle flap.
■ If a subtotal thigh flap is being used, the pedicle is transected in the typical
location for an anterolateral thigh flap, where the lateral femoral circumflex
artery emerges from the profunda femoris.
■ For abdominal wall reconstruction, potential recipient vessels include either
of the deep inferior epigastric arteries and their associated venae comitantes.
■ Of course, if a patient requires a large flap for reconstruction of their
abdominal wall, it is likely that the deep inferior epigastric system is
unavailable for use. In this situation, a femoral saphenous arteriovenous loop
is a prudent choice (TECH FIG 4).
■ The loop is created by transecting the saphenous vein distally and leaving
it intact proximally.
■ The distal end of the saphenous vein is then anastomosed in an end-to-side
fashion to the superficial femoral artery. The loop is positioned on the
abdominal wall adjacent to the flap’s vascular pedicle. The loop is divided
at its apex to provide both arterial and venous recipient vein grafts.
■ Similar to the pedicled subtotal thigh flap and rectus femoris flaps, unilateral
or bilateral flaps can be employed, depending on need.
PEARLS AND PITFALLS

Marking and
positioning
■ The patient’s legs should be internally rotated at the hip to ensure
accurate markings.
■ The flap can be harvested easily in the supine, lithotomy, or lateral
decubitus positions.
Flap design
and reach
■ The rectus femoris flap can be employed as a muscle-only flap or
myocutaneous flap.
■ A skin paddle wider than 8 to 9 cm will usually require skin
grafting for donor-site closure.
■ The rectus femoris flap can also be utilized as a chimeric flap,
including other elements of the lateral femoral circumflex vascular
axis (vastus lateralis, tensor fascia lata, iliotibial band) for
increased surface area coverage.
■ The flap should be passed deep to the sartorius muscle for an
additional 5 cm of advancement.
■ The flap can reach the lower abdomen as a pedicled flap; if
midabdomen or superior abdomen requires reconstruction, the flap
should be elevated as a free flap.
Donor-site
morbidity
■ Donor-site morbidity is limited to decreased eccentric quadriceps
strength. Range of motion is unaffected.
■ Most donor-site morbidity can be obviated by performing a vastus
medialis-lateralis tenorrhaphy, requiring a knee immobilizer during
the postoperative period, and engaging in a physical therapy
regimen.
Postoperative
management
■ A knee immobilizer should be worn for 6 weeks postoperatively.
Therapy
■ Physical therapy for quadriceps strength training and lower
extremity range of motion can be helpful.
POSTOPERATIVE CARE
■ The patient should be placed into a knee immobilizer postoperatively for 6
weeks, which should be worn at all times except when bathing.
■ Ambulation is encouraged as early as the first postoperative day with weight
bearing as tolerated.
■ The affected lower extremity should be kept elevated at all times when not
ambulating.
OUTCOMES
■ The rectus femoris muscle flap is an effective workhorse flap for abdominal

wall reconstruction (FIG 4).
■ The donor-site morbidity is low.
■ Several authors have reported no loss of knee extension capacity or
strength.1,6–8
■ The only quantitative assessment found knee range of motion to be
unaffected after use of the rectus femoris flap; however, the extension power
had decreased 10.3% (concentric contraction) and 19.3% (eccentric
contraction). This decrease in strength can be obviated by participation in a
postoperative physical therapy regimen.2
COMPLICATIONS
■ The rectus femoris muscle is a robust and reliable muscle flap with a low
complication profile.
■ Published studies cite a 3% to 4% rate of donor-site wound separation and
similar rate of donor-site hematoma.1–8
■ The flap loss rate is negligible as a muscle flap. If the flap is elevated as a
subtotal thigh flap, there is a 2% rate of distal tip skin necrosis.1
■ The donor-site morbidity has been detailed in the outcomes section.
FIG 4 • Preoperative and postoperative photos of two
patients who required rectus femoris flaps for
reconstruction of the abdomen. A,B. This patient had a
wide and superior defect, requiring a free flap with skin
graft for donor-site management. C,D. This patient had
a more inferior and narrower defect, allowing for a
pedicle flap and primary donor-site closure. (© Charles

E. Butler, MD.)
REFERENCES
1. Lin SJ, Butler CE. Subtotal thigh flap and bioprosthetic mesh reconstruction
for large, composite abdominal wall defects. Plast Reconstr Surg.
2010;125:1146-1156.
2. Caulfield WH, Curtsinger L, Powell G, et al. Donor leg morbidity after
pedicled rectus femoris muscle flap transfer for abdominal wall and pelvic
reconstruction. Ann Plast Surg. 1994;32:377-382.
3. Koshima I, Nanba Y, Tutsui T, et al. Dynamic reconstruction of large
abdominal defects using a free rectus femoris musculocutaneous flap with
normal motor function. Ann Plast Surg. 2003;50:420-424.
4. Matthews MS. Abdominal wall reconstruction with an expanded rectus
femoris flap. Plast Reconstr Surg. 1999;104:183-186.
5. Bostwick J III, Hill HL, Nahai F. Repairs in the lower abdomen, groin, or
perineum with myocutaneous or omental flaps. Plast Reconstr Surg.
1979;63:186-194.
6. Sbitany H, Koltz PF, Girotto JA, et al. Assessment of donor-site morbidity
following rectus femoris harvest for infrainguinal reconstruction. Plast
Reconstr Surg. 2010;126:933-940.
7. Dibbell DG Jr, Mixter RC, Dibbell DG Sr. Abdominal wall reconstruction (the
“mutton chop” flap). Plast Reconstr Surg. 1991;87:
60-65.
8. Alkon JD, Smith A, Losee JE, et al. Management of complex groin wounds:
preferred use of the rectus femoris muscle flap. Plast Reconstr Surg.
2005;115:776-783.

11
CHAPTER
Lower Abdominal Wall
Reconstruction With Lateral
Thigh-Based Flaps
Dhivya R. Srinivasa and Jeffrey H. Kozlow
DEFINITION
Abdominal wall reconstruction is required when partial- or full-thickness defects
of the abdominal wall do not allow for primary fascial and/or skin closure. This
situation can arise in a variety of clinical situations, sometimes presenting as an
intraoperative consult requiring immediate closure. Defects should be evaluated
for missing components of the abdominal wall including the skin, subcutaneous
tissue, fascia, and musculature. Reconstruction should aim to close the intra-
abdominal compartment while minimizing the risk of future hernia development.
Techniques to reapproximate the midline fascia for a ventral hernia are reviewed
in a separate chapter. Here, we will focus on restoring soft tissue where it is
deficient in the lower abdomen.
ANATOMY
The anatomy of the abdominal wall is most readily described in layers. Most
superficial is the skin and subcutaneous tissues. Within the subcutaneous tissues
is the Scarpa fascia, a layer of variable thickness that provides some additional
support to a repair. The critical component of the abdominal wall is the
myofascial layer. This layer includes the paired, vertically oriented rectus
abdominis muscles adjacent to the midline along with the internal oblique,
external oblique, and transversalis muscles laterally. The investing fascia
provides significant strength to the abdominal wall and includes both an anterior
sheath and a posterior sheath. The central fascia around the rectus abdominis
muscles extends from the oblique musculature. In the upper abdomen, the
anterior and posterior sheaths are of similar strength; however below the arcuate

line, the posterior sheath is much weaker as only the transversalis fascia
contributes to the fascia deep to the rectus abdominis muscles. FIG 1 depicts the
layers of the abdominal wall.
Blood supply to the abdominal wall derives from multiple vessels
with notable overlap in distribution. Centrally, the superior and
inferior epigastric systems supply the abdominal wall. This is further
enriched by branches from the internal mammary artery, specifically
musculophrenic branches, as well as the superficial epigastric vessels.
Laterally, the circumflex vessels from the iliac artery (deep and
superficial) add to the redundancy in blood supply. Innervation is via
subcostal nerves (from T12) and thoracoabdominal nerves from T7-
T11. These ventral primary rami branches travel between the internal
oblique and transverse abdominal muscles. This is the target for the
TAP (transverse abdominis plane) block that is used to anesthetize the
abdominal wall in select procedures.

FIG 1 • Layers of the abdominal wall. A. Axial view of
abdominal wall above the arcuate line. B. Axial view of
abdominal wall below the arcuate line.
A thorough understanding of the various meshes used in abdominal
wall reconstruction (including the various synthetic and biologic
materials) is critical for surgeons planning to use these materials.
However, details on this topic are beyond the scope of this chapter.

PATHOGENESIS
Abdominal wall defects can arise from a variety of scenarios: trauma, cancer,
and hernia reconstruction being the most common. Acquired hernias present as a
fascial defect and often require abdominal wall myofascial advancement flaps
and/or mesh-related techniques. This chapter will focus on closure of soft tissue
defects that arise from traumatic injury and oncologic resections. However, some
of the principles used for acquired hernia repair, such as component separation,
can also play a role in traumatic and oncologic reconstructions. In trauma, all
devitalized tissue should be debrided prior to closure. With respect to cancer,
margins should be clear and the need for adjuvant radiation should be consider
when choosing a reconstructive technique.
PATIENT HISTORY AND PHYSICAL FINDINGS
In addition to the usual key components of a patient’s history, the following
specifics should also be documented:
■ Prior abdominal surgery
■ Include laparoscopic operations and cesarean sections
■ Need for stoma postresection. If an ostomy is planned, the estimated location
for the stoma should also be noted.
■ History of radiation therapy or planned radiation therapy
■ Medical comorbidities that will affect wound healing including diabetes
mellitus, steroid use, tobacco use, or connective tissue disorders
■ Prothrombotic disease states should be noted and a Caprini score should be
calculated. Appropriate venous thromboembolism prophylaxis should be
tailored accordingly.1
■ Each patient should be examined thoroughly and all prior incisions should be
noted.
■ Evaluation of the thigh for adequate tissue to support transfer of the necessary
tissue from this area to the abdomen.
■ Incisions within the estimated location of the donor flap should be noted. We
also suggest an evaluation of body habitus in this region as thick or thin flaps
may be harvested depending on the reconstructive needs.
IMAGING
No specific imaging is necessary for the reconstructive portion of the case.
However, most patients will have an abdominal computed tomography (CT)
scan, which can be used for planning purposes to understand the anticipated

defect. In oncologic cases, specifically note involvement of the skin, anterior
sheath, musculature, posterior sheath, and intraperitoneal or retroperitoneal
contents. CT angiography of the thigh can be performed in select cases to
evaluate perforator location or regional anatomy in complex situations.
SURGICAL MANAGEMENT
Preoperative Planning
■ Preoperative planning is incumbent on anticipation of the size and depth of the
defect. Whether full-thickness abdominal wall resection is necessary will
dictate if fascial advancement and/or mesh will be necessary. The location of
the defect is also important to note, as it will affect potential flap options. FIG
2 illustrates various abdominal wall defects and how they can be covered with
a thigh-based flap.
■ Inguinal defects can often be addressed with ipsilateral tensor fascia lata
(TFL) based flaps. These flaps provide strong fascial tissue if needed for
reconstruction of the inguinal ligament.
■ Lower abdominal (below the umbilicus) and flank defects can be addressed
with flaps based off the descending branch of the lateral femoral circumflex
system such as the anterolateral thigh (ALT) flap, vastus lateralis, or rectus
femoris flaps.2,3
■ Midabdominal defects can be addressed with component separation
techniques similar to ventral hernia repairs owing to the freedom of the
abdominal wall tissue away from the fixed bony pelvis and rib cage.
■ Upper abdominal defects are the most difficult as thigh-based flaps will
typically not transpose to the upper abdomen without vein grafts.

FIG 2 • Lateral thigh-based flaps are a versatile option
for a variety of lower abdominal wall defects.
■ Preoperative discussion with the patient should include possible donor sites,
skin grafting, and potential use of mesh.
■ Any planned stomas or existing stomas should be discussed so modifications
can be made accordingly. Existing stomas likely pass through the rectus
abdominis muscle. Future stomas should be marked preoperatively.
■ In cases where primary myofascial repair may be possible, preoperative
administration of Botox can be helpful if administered in advance. Typically,

up to 100 units per side can be given at least 1 to 2 weeks prior to surgery to
optimize the timing of neuromuscular blockade. The goal is to allow maximal
relaxation of abdominal wall musculature in anticipation of myofascial
advancement for closure.4
Positioning
■ The patient will likely be positioned supine for the abdominal portion of the
surgery. All of the lateral thigh-based flaps are most easily harvested in the
supine position as well.
■ A safety belt should be used for all cases, but this most often is placed around
the chest area.
■ A warming blanket should be placed to optimize normothermic core
temperatures during the case.
■ SCDs should be placed bilaterally as the critical areas of the thigh need to be
prepped only to the knee and do not require intraoperative rotation of the leg.
■ The thigh should be prepped circumferentially. The contralateral thigh should
also be available in the event skin graft is needed for closure of the defect or
donor site.
Approach
■ Preoperative markings should be made in the preoperative area, prior to patient
positioning in the OR.
■ Anatomic Landmarks: The anterior superior iliac spine (ASIS) and the
superolateral patella are identified. A line connecting these two points is drawn.
For an ALT flap, the midpoint of this line will be near the central axis of the
skin paddle. FIG 3 depicts relevant anatomic landmarks and the axis of the
skin paddle.
■ If a TFL flap is planned, the incision can be adjusted superiorly (cephalad).
■ If a rectus femoris muscle flap is planned, the incision can be adjusted
medially.
■ If an ALT flap is planned, there are two main approaches to identifying
perforators and designing the skin paddle:
■ Some surgeons define the “A, B, and C” perforators. The perforators are
most commonly found approximately 1.5 cm posterior to the line between the
ASIS and superior lateral patella. The center point of this line should be
marked as perforator “B.” Perforators “A” and “C” are 5 cm proximal and

distal to “B.”5
■ Another approach is to draw a 3-cm-radius circle around the midpoint of the
axis line, defining the most common location of skin perforators. A Doppler
can be used to confirm and mark the location of these perforators. The skin
paddle can be centered over these perforators. Most often the perforators are
found in the inferolateral quadrant of the circle (FIG 4).
FIG 3 • External anatomic landmarks for an ALT flap
from the left leg. The hip is on the right side of the
photograph and the knee is on the left side.
■ The initial incision for perforator evaluation is drawn 2 cm anterior/medial to
the line between the ASIS and superolateral patella. This is also 4 cm anterior
to the expected location of the perforators for an 8- to 9-cm-wide flap. The
incision is typically ~15cm in length and centered near the region of the
expected perforators (see FIG 3, dotted line). This initial incision is adjusted
accordingly if a TFL or rectus femoris flap is planned.
■ The final skin paddle is designed after the full nature of the defect is known
and the planned perforators are identified. Delaying the design of the skin
paddle after identification of the selected perforators can optimize flap

perfusion and minimize donor-site morbidity.
FIG 4 • Perforator location based on center of axis line.
The red portion of the circle depicts the most likely
location of perforators.
T E C H N I Q U E S
■ The patient is marked while positioned supine as described earlier. Toes
should be in neutral. Internal rotation of the foot can result in inadvertent
rotation of the leg, which would affect markings.
■ The marked incision anterior to the perforators is made and dissection is
carried down to the fascia. After dissecting through the superficial fascia,
care is taken to identify and preserve any medially directed branches of the
lateral femoral cutaneous nerve to decrease the extent of postoperative thigh
anesthesia.
■ In some situations, a suprafascial dissection can be performed with
identification of the perforators above the fascia. We prefer including the
fascia with the flap for abdominal reconstruction as it provides a robust
layer for closure and anchoring of the flap in to the defect.
■ The muscular fascia is then incised over the rectus femoris muscle. Three
Allis clamps are placed on the fascia, roughly at the A, B, and C perforators,
to gently retract the fascia and visualize the subfascial plane.5