Phẫu Thuật Tạo Hình (Tập 4): Chi Dưới, Thân Mình Và Bỏng – Neligan (2018)

273
Special clinical situations
presenting with small areas of drainage where on palpation a
piece of hardware can be reached. Similarly, patients with
fluid collections or “fluid cysts” in association with hardware
have chronic infections. These infections can be present for
months or years without suppurating or making the patient
overly ill, which is undoubtedly due to the low virulence of
the organism, such as Staphylococcus epidermidis.
Debridement, irrigation, and soft-tissue coverage of these
chronic exposures may be initially successful, but eventually
fail. Perhaps these procedures can buy enough time for the
spine to achieve clinical and radiographic evidence of fusion.
However, for most patients the involved hardware should be
removed. The question is: should all of the hardware be
removed, or just a local portion (such as a large bolt) and the
soft tissues closed (Fig. 11.29A–D)? These are decisions made
in the operating room. All hardware in association with exu-
dative fluid should be removed, and well-incorporated
hardware encased in bone should be allowed to remain. No
flaps are typically required for closure when all of the hard-
ware is removed as outcomes depend more on the structural
stability of the spine than on any soft-tissue work. The soft
tissues are simply approximated over drains, and complete
healing is the rule rather than the exception. Antibiotics are
not needed for prolonged periods in these situations.
Esophageal fistula after spine procedures
A brief mention of this spine related soft-tissue complication
is made, despite the wound being on the anterior surface
of the torso rather than the posterior surface. A small number
of patients undergoing cervical spine fusion will suffer a
traumatic injury to the esophagus, causing drainage and
Chronic hardware exposures
Chronic hardware exposures act differently from acute expo-
sures and are arbitrarily defined as an exposure occurring
more than 6 months after placement. From experience, long-
term coverage of chronically exposed hardware is not success-
ful. A hardware infection is likely to be present in patients
Fig. 11.26  This patient, with previous back surgery, radiation, a long planned
fusion length, and a wide woody feel to the soft tissues, should have a planned
prophylactic flap closure. She underwent closure with a pedicled omental flap.
Fig. 11.27  This man has a wide radiated defect and a prior laminectomy. A long
fusion is planned.
Fig. 11.28  The midline tissue was completely replaced with a free myocutaneous
latissimus flap. A long cephalic vein graft loop was fashioned with inflow taken off
the external carotid artery. Prophylactic flaps require a high level of coordination
between spine and plastic surgery teams.

274
SECTION II
CHAPTER 11 • Reconstruction of the soft tissues of the back
contamination of the fusion site.22 Another group of patients
will develop a pressure sore of the cervical spine hardware
into the esophagus, and so the hardware can be seen during
an esophagoscopy. Everything depends on the timing of the
esophageal leak with the placement of the hardware. If the
esophageal injury occurred at the time of hardware place-
ment, then the spinal fusion is not solid, and the hardware is
still needed. Simple repair of the esophageal defect is prob-
lematic even without the spine issues, as the standard treat-
ment by otolaryngology is to drain fluid collections and let
the wounds heal by secondary intention. Improvement of the
soft tissues between the spinal hardware and the cervical
esophageal repair is important. Local flaps from the neck, the
pectoralis flap, and omental free flaps are all thin flaps that
A
B
Fig. 11.29  (A) Patient over 1 year after thoracosacral fusion with bilateral lower back wounds. Large pelvic rim bolts are palpable from within the wound. The patient has
not achieved clinical and radiographic evidence of fusion. (B) Radiograph of construct. (C) Large bolts from the hardware to the posterior iliac crest are visible with minimal
soft-tissue cover. No purulence is noted around more superior hardware. (D) The bolts were excised and the superior hardware was allowed to remain in place with a good
long-term result.
C
D
can be interposed into this space. The omentum is perhaps
best able to deal with the contaminated drainage, and it easily
conforms to the space crevices. Incisions on both sides of the
neck facilitate bringing of the flap completely across the
anterior body of the cervical spine. However, this would
simultaneously put both recurrent laryngeal nerves at risk.
Pectoralis flaps are perhaps best avoided in spinal cord
patients that use their accessory chest muscles to breathe.
Gastrostomy tubes obviate the need to eat in the postopera-
tive period and are extremely helpful. Even more rarely, the
esophageal leak requires removal of the previously placed
construct used to fuse the anterior vertebral bodies. A short
fibular free flap “press-fit” into the defect can be used in this
situation to achieve fusion, but to stay completely autogenous

275
Special clinical situations
in the reconstruction. A longer fusion of the posterior spine is
required for these cases so that neck movement will not cause
the free fibula flap to extrude anteriorly. The microvascular
surgeon used to head and neck reconstructions for cancer will
be frustrated in these cases by the lack of neck movement for
positioning and the soft tissues of the neck (that did not have
a lymphadenectomy) that limit exposure.
Patients that develop pressure sores of the hardware into
the cervical esophagus are often found months after the cervi-
cal fusion, and the hardware can often be removed. Repair of
the esophagus if possible and interposition of the soft-tissue
flap is much easier in the absence of hardware and when the
bone is fused.
1. Dumanian GA, Ondra SL, Liu J, et al. Muscle flap salvage of spine
wounds with soft tissue defects or infection. Spine. 2003;28:1203–
1211. Long-term results of successful salvage of posterior hardware with
soft-tissue reconstruction of the back is presented.
2. Wilhelmi BJ, Snyder N, Colquhoun T, et al. Bipedicle paraspinous
muscle flaps for spinal wound closure: an anatomic and clinical
study. Plast Reconstr Surg. 2000;106:1305–1311. This is an early
description of paraspinous muscle flaps for repair of soft-tissue defects
after spine surgery.
6. Nojima K, Brown SA, Acikel C, et al. Defining vascular supply and
territory of thinned perforator flaps: part II. Superior gluteal artery
perforator flap. Plast Reconstr Surg. 2006;118:1338–1348. This paper
illustrates the performance of superior gluteal artery flaps that can then be
used for spine reconstruction.
7. O’Shaughnessy BA, Dumanian GA, Liu JC, et al. Pedicled omental
flaps as an adjunct in complex spine surgery. Spine. 2007;32:3074–
3080. Small series illustrating the use of pedicled omental flaps in spine
reconstruction surgery.
14. Lee MJ, Ondra SL, Mindea SA, et al. Indications and rationale for
use of vascularized fibula bone flaps in cervical spine arthrodeses.
Plast Reconstr Surg. 2005;116:1–7.
15. Erdmann D, Meade RA, Lins RE, et al. Use of the microvascular
free fibula transfer as a salvage reconstruction for failed anterior
spine surgery due to chronic osteomyelitis. Plast Reconstr Surg.
2006;117:2438.
16. Said HK, O’Shaughnessy BA, Ondra SL, et al. Integrated titanium
and vascular bone: a new approach for high risk thoracic spine
reconstruction: P34. Plast Reconstr Surg. 2005;116:160–162.
17. Mathes DW, Thornton JF, Rohrich RJ. Management of posterior
trunk defects. Plast Reconstr Surg. 2006;118:73e–83e.
18. Mitra A, Mitra A, Harlin S. Treatment of massive thoracolumbar
wounds and vertebral osteomyelitis following scoliosis surgery.
Plast Reconstr Surg. 2004;113:206–213.
20. Glass BS, Disa JJ, Mehrara BJ, et al. Reconstruction of extensive
partial or total sacrectomy defects with a transabdominal vertical
rectus abdominis myocutaneous flap. Ann Plast Surg. 2006;56:
526–530.
21. Garvey PB, Rhines LD, Dong W, Chang DW. Immediate soft-tissue
reconstruction for complex defects of the spine following surgery
for spinal neoplasms. Plast Reconstr Surg. 2010;125:1460–1466. Large
series of prophylactic flaps from the MD Anderson group demonstrates
improved outcomes.
23. Duffy FJ, Weprin BE, Swift DM. A new approach to closure of large
lumbosacral myelomeningoceles: the superior gluteal artery
perforator flap. Plast Reconstr Surg. 2004;114:1864–1868.
Access the complete reference list online at

Bonus content for this chapter can be found online at

Special Clinical Considerations
“Tethered cord surgery” or “lipomas of the spine”.
Pseudomeningocele repair and cerebrospinal fluid leaks.
Fig. 11.30 (A) This 45-year-old female had a lipoma resected from her spinal
cord in infancy. Now, she has a recurrent “lipoma” and symptoms of a tethered
spinal cord. (B) The dura is entered and the spinal cord dissected from scar
tissue, holding it inferiorly. A dural patch is constructed. A temporary lumbar
drain is visible and is used to keep cerebrospinal fluid pressure low in the
immediate postoperative period. (C) A superior gluteal artery perforator flap is
placed over the dural repair. The tissue of the flap is taken from the right buttock
in this case, and near the trochanter.

275.e1
Special clinical situations
“Tethered cord surgery” or “lipomas of
the spine”
Infants will receive procedures for closure of their spinal canal
in their infancy. The spinal cord can become adhered to the
spinal canal and, with growth and aging, the spinal cord can
be unusually stretched. Opening of the dura and freeing the
spinal cord from these attachments typically allows the cord
to slide cephalad. This is an analogous procedure to what has
been reported in infants.23 The problem occurs in the postop-
erative healing. These patients tend to have a large “lipoma
of the spine” overlying the area of the lumbosacral spine, and
this tissue is difficult to work with due its relatively avascular
nature (Fig. 11.30A–C). Other patients have thick transverse
scars from prior procedures performed in infancy. Preopera-
tive debulking of the tissue can be difficult if there is an associ-
ated pseudomeningocele.
Close work between spine and plastic surgery teams is nec-
essary for optimal outcomes in these patients. Some patients
with just thick fat over the lumbosacral recess have done
well with preoperative liposuction. Patients with thick scars
can be resurfaced with tissue expanders prior to the spine
exploration. Others with pseudomeningoceles and need for
cord re-exploration do best with superior gluteal artery based
soft-tissue reconstructions as described below.
Fig. 11.30  (A) This 45-year-old female had a lipoma resected from her spinal cord in infancy. Now, she
has a recurrent “lipoma” and symptoms of a tethered spinal cord. (B) The dura is entered and the spinal
cord dissected from scar tissue, holding it inferiorly. A dural patch is constructed. A temporary lumbar drain
is visible and is used to keep cerebrospinal fluid pressure low in the immediate postoperative period. (C) A
superior gluteal artery perforator flap is placed over the dural repair. The tissue of the flap is taken from the
right buttock in this case, and near the trochanter.
A
B
C
Pseudomeningocele repair and cerebrospinal
fluid leaks
Pseudomeningoceles are contained leaks of CSF through dura
into the soft tissues of the back, while CSF leaks of the spinal
cord exit through drains or through the skin. The former situ-
ation typically requires treatment due to pressure of the fluid
on the spinal cord with worsening motor and sensory func-
tion. The latter situation must be addressed to prevent ascend-
ing meningitis.
Analysis of the cause of the complication is made by the
spine team. Typically, the hole in the dura must be repaired
or patched, and it is up to the plastic surgery team to improve
the soft-tissue envelope for the dural reconstruction to heal.
The concepts of this chapter suffice for the management of
these problems. When the patient is fused, erector spinae flaps
are useful to bring new non-scarred tissue to the area. The
lumbosacral recess is often the site of these leaks, as the dura

275.e2
SECTION II
CHAPTER 11 • Reconstruction of the soft tissues of the back
neurosurgery team to keep the pressure low on the recon-
struction. Drains are left in place after surgery, and the patient
is carefully allowed to resume a vertical position. Postopera-
tive CT scans and examination for chronic headaches are both
means of monitoring for recurrent CSF leaks. The CSF
pressure is probably more important than the quality of the
soft-tissue reconstruction long-term for pseudomeningocele
recurrences.
can be opened to untether spinal cords. The superior gluteal
artery based flaps are effective for improving the soft tissues
in this area with a minimum of morbidity. Important adjuncts
to these procedures are a temporary or permanent decom-
pression of the CSF pressure on the flap. This should involve
the patient being positioned flat on a pressure relief air fluid-
ized sand bed for a week after the procedure. This often also
involves a lumbar or head drain of CSF monitored by the

275.e3
References
References
1. Dumanian GA, Ondra SL, Liu J, et al. Muscle flap salvage of spine
wounds with soft tissue defects or infection. Spine. 2003;28:1203–
1211. Long-term results of successful salvage of posterior hardware with
soft-tissue reconstruction of the back is presented.
2. Wilhelmi BJ, Snyder N, Colquhoun T, et al. Bipedicle paraspinous
muscle flaps for spinal wound closure: an anatomic and clinical
study. Plast Reconstr Surg. 2000;106:1305–1311. This is an early
description of paraspinous muscle flaps for repair of soft-tissue defects
after spine surgery.
3. McCraw JB, Penix JO, Baker JW. Repair of major defects of the chest
wall and spine with the latissimus dorsi myocutaneous flap. Plast
Reconstr Surg. 1978;62:249–252.
4. Angrigiani C, Grilli D, Karanas YL, et al. The dorsal scapular island
flap: an alternative for head, neck, and chest reconstruction. Plast
Reconstr Surg. 2003;111:67–78.
5. Wendt JR, Gardner VO, White JI. Treatment of complex lumbosacral
wounds in nonparalyzed patients. Plast Reconstr Surg.
1998;101:1248–1253.
6. Nojima K, Brown SA, Acikel C, et al. Defining vascular supply and
territory of thinned perforator flaps: part II. Superior gluteal artery
perforator flap. Plast Reconstr Surg. 2006;118:1338–1348. This paper
illustrates the performance of superior gluteal artery flaps that can then be
used for spine reconstruction.
7. O’Shaughnessy BA, Dumanian GA, Liu JC, et al. Pedicled omental
flaps as an adjunct in complex spine surgery. Spine. 2007;32:3074–
3080. Small series illustrating the use of pedicled omental flaps in spine
reconstruction surgery.
8. Netscher DT, Baumholt MA, Bullocks J. Chest reconstruction: II.
Regional reconstruction of chest wall wounds that do not affect
respiratory function (axilla, posteriolateral chest, and posterior
trunk). Plast Reconstr Surg. 2009;124:427e.
9. Feinendegen DL, Klos D. A subcostal artery perforator flap for a
lumbar defect. Plast Reconstr Surg. 2002;109:2446–2449.
10. Kiil BJ, Rozen WM, Pan WR, et al. The lumbar artery perforators: a
cadaveric and clinical anatomical study. Plast Reconstr Surg.
2009;123:1229–1238.
11. Dumanian GA, Heckler FR, Bernard SL. The external oblique
turnover muscle flap. Plast Reconstr Surg. 2003;111:22203–22208.
12. Few JW, Marcus MJ, Ondra S, Dumanian GA. Treatment of hostile
midline back wounds—an extreme approach. Plast Reconstr Surg.
2000;105:2448–2451.
13. Di Benedetto G, Bertani A, Pallua N. The free latissimus dorsi flap
revisited: a primary option for coverage of wide recurrent
lumbosacral defects. Plast Reconstr Surg. 2002;109:1960–1965.
14. Lee MJ, Ondra SL, Mindea SA, et al. Indications and rationale for
use of vascularized fibula bone flaps in cervical spine arthrodeses.
Plast Reconstr Surg. 2005;116:1–7.
15. Erdmann D, Meade RA, Lins RE, et al. Use of the microvascular
free fibula transfer as a salvage reconstruction for failed anterior
spine surgery due to chronic osteomyelitis. Plast Reconstr Surg.
2006;117:2438.
16. Said HK, O’Shaughnessy BA, Ondra SL, et al. Integrated titanium
and vascular bone: a new approach for high risk thoracic spine
reconstruction: P34. Plast Reconstr Surg. 2005;116:160–162.
17. Mathes DW, Thornton JF, Rohrich RJ. Management of posterior
trunk defects. Plast Reconstr Surg. 2006;118:73e–83e.
18. Mitra A, Mitra A, Harlin S. Treatment of massive thoracolumbar
wounds and vertebral osteomyelitis following scoliosis surgery.
Plast Reconstr Surg. 2004;113:206–213.
19. Dumanian GA. Abdominal wall tumors and their reconstruction.
In: Butler CE, Fine NA, eds. Principles of Cancer Reconstructive
Surgery. Germany: Springer Publishing; 2008.
20. Glass BS, Disa JJ, Mehrara BJ, et al. Reconstruction of extensive
partial or total sacrectomy defects with a transabdominal vertical
rectus abdominis myocutaneous flap. Ann Plast Surg.
2006;56:526–530.
21. Garvey PB, Rhines LD, Dong W, Chang DW. Immediate soft-tissue
reconstruction for complex defects of the spine following surgery
for spinal neoplasms. Plast Reconstr Surg. 2010;125:1460–1466. Large
series of prophylactic flaps from the MD Anderson group demonstrates
improved outcomes.
22. Hanwright PJ, Purnell CA, Dumanian GA. Flap reconstruction for
esophageal perforation complicating anterior cervical spinal fusion:
an 18-year experience. Plast Reconstr Surg Glob Open. 2015;3(5):e400.
doi: 10.1097/GOX.0000000000000350. eCollection 2015 May.
23. Duffy FJ, Weprin BE, Swift DM. A new approach to closure of large
lumbosacral myelomeningoceles: the superior gluteal artery
perforator flap. Plast Reconstr Surg. 2004;114:1864–1868.

SECTION II • Trunk Surgery
12 
Abdominal wall reconstruction
Mark W. Clemens II and Charles E. Butler
SYNOPSIS
■ Defects due to failed laparotomy closures, tumor ablation, congenital
anomalies, and trauma are the most common indications for
abdominal wall reconstruction (AWR).
■ Ventral hernias can be the result of a genetic predisposition in impaired
collagen formation or due to acquired structural collagen abnormalities
from mechanical strain and predisposing risk factors, such as tobacco
use, diabetes, and obesity.
■ Direct suture repair of ventral hernia defects results in an extremely
high rate of recurrence compared with mesh reinforcement of similar
hernia defects.
■ Tissue-based bioprosthetic mesh has gained popularity for its use in
complex AWRs due to the lower rates of mesh infection, fistula
formation, and mesh explantation than the rates reported with
synthetic mesh.
■ Successful surgical techniques require complete fascial coaptation,
inset of mesh under physiologic tension, judicious use of drainage
catheters, and reduction of subcutaneous dead space with quilting
sutures.
■ Adjunctive reconstructive techniques such as components separation
with musculofascial advancement flaps, pedicled muscle flaps, and
free flaps are important for assisting in fascial closure and soft-tissue
coverage of large abdominal wall defects.
Access the Historical Perspective section online at

Introduction
The principle goal of reconstructive surgery is to restore form
and function, and ideally to restore “like with like”. For the
abdominal wall, this maxim dictates that reconstructive sur-
geons must anatomically repair abdominal defects by
re-establishing the integrity of the myofascial layer, protecting
abdominal viscera, providing durable cutaneous coverage,
and minimizing the risk of hernia recurrence (i.e., restoring
form and function). In the United States, there are an estimated
four million laparotomies performed annually carrying a
2–30% incidence of incisional hernia, which produces roughly
150 000–250 000 ventral hernias.1 This equates to a cost of
approximately $2 billion dollars, which is at a time when
healthcare is transitioning toward value-based reimburse-
ment and pay for performance concepts, and where efficiency
and cost containment are prioritized with little tolerance for
complications.2 There have been three quantum advances in
abdominal wall reconstruction over the past year 25 years that
define the field. The first development was the surgical tech-
nique of components separation as described by Ramirez et al.
in 1990.3 Creation of musculofascial flaps with medialization
of the rectus complexes allowed for complete midline fascial
coaptation by releasing the external oblique aponeuroses and
posterior rectus sheath bilaterally. The second major advance-
ment was the observation in prospective randomized con-
trolled trials that direct suture repair of ventral hernia defects
results in an unacceptably high rate of recurrence compared
with mesh reinforcement of repairs.4 This important concept
indicates that restoration of integrity to the abdominal wall is
a slow process that requires recuperation and fascial support
through a critical remodeling period, and that this is affected
by mechanical strain, genetic predisposition in collagen for-
mation, and predisposing risk factors, such as tobacco use,
diabetes, nutritional status, and obesity. The third develop-
ment was the introduction of bioprosthetic mesh to act as a
tissue scaffold for collagen deposition as an alternative to
synthetic meshes in selected indications. Each of these surgi-
cal advances work synergistically to improve durability and
resilience, while mitigating complications. This chapter will
focus on patient diagnosis, pertinent anatomy, basic aspects
of these techniques, postoperative care, and outcomes, as well
as adjunctive procedures, such as workhorse flaps, that are
essential for reconstructive surgeons.
  Access video content for this chapter online at expertconsult.com

276.e1
Historical perspective
Historical perspective
Since the first historical recordings of surgical procedures,
there are accounts of attempts at repair and restoration of the
abdominal wall. As early as 3000 BC, hernias (kele/hernios
(Greek): bud or offshoot) of the abdomen were treated with
external reduction and binding of the torso.5 The Egyptian
Papyrus Ebers contains a description of a hernia as a swelling
that protrudes from the abdomen or groin and is exacerbated
by coughing. Hernia and prolapse were well described around
400 BC by Hippocrates in ancient Greece and Celsus in ancient
Rome. Restraining methods would remain the exclusive treat-
ment for several millennia with limited inconsequential
advancements made in improved trusses. The term eventra-
tion, in essence the loss of abdominal domain, was used to
describe serious abdominal wall damage as sequelae to trau-
matic war injuries, pregnancy, and failed surgical endeavors.6
The advance of general anesthesia at the turn of the 19th
century for the first time allowed surgical innovation within
the abdominal cavity by such luminaries as Billroth, von
Winiwarter, Mikulicz-Radecki, Murphy, and Halsted. With
surgical advancement came the inevitable need for manage-
ment of complications associated with violation of the
abdominal wall and postoperative eventration as well as the
need for repair of these defects. Surgical treatment of eventra-
tion first developed with direct suture repair, either in one or
more anatomic layers and then progressed to aponeurotic
plasties that allowed for relaxing incisions to reduce closure
tension. Quenu7 in 1896 described the importance of incorpo-
rating the anterior and posterior laminae musculi recti
abdominis in a multilayered closure. Suture techniques devel-
oped to include U-shaped full-thickness muscle-aponeurosis
stitches and figure-of-8 shaped stitches in this seminal descrip-
tion. William Mayo8 described a “duplication repair” proce-
dure in 1901 to treat incisional hernias, essentially advancing
one side of the abdominal wall over the top of the contra-
lateral fascia and thereby doubling the thickness of the
abdominal wall at the repair site. In 1920, Gibson9 described
lateral fascial relaxing incisions to reduce midline tension,
which was subsequently modified by Cames and Acebal10
who included a third suture line between the released rectus
sheaths and the underlying muscle. In 1941, Welti and Eudel11
incorporated a segment of the anterior rectus sheath as a
hinge to reinforce the midline closure. These early surgical
forays based upon dissecting the anatomic planes of the
abdomen undoubtedly led to Ramirez description of “compo-
nents separation” and our modern understanding of the
pathogenesis of ventral hernias.

277
Abdominal wall anatomy
Abdominal wall anatomy
The lateral abdominal wall musculature is composed of three
layers, with the fascicles of each muscle directed obliquely at
different angles to create a strong envelope for the abdominal
contents. Each of the muscles forms an aponeurosis that
inserts into the linea alba, a midline structure joining the two
sides of the abdominal wall. The external oblique muscle is
the most superficial muscle of the lateral abdominal wall.
Deep to the external oblique muscle lies the internal oblique
muscle. The fibers of the external oblique muscle course from
superolateral to inferomedial (as hands in pockets), and those
of the internal oblique muscle run perpendicular to the exter-
nal oblique muscle’s fibers. The deepest muscular layer of the
abdominal wall is the transversus abdominis muscle; its fibers
course horizontally. These three lateral muscles give rise to
aponeurotic layers lateral to the rectus abdominis muscle,
which contribute to the anterior and posterior layers of the
rectus sheath. It is noteworthy that in contradistinction to
what is stated in most anatomy books, the transversus
abdominis muscle does not insert into the linea semilunaris
medially, but instead the transversus abdominis aponeurosis
actually forms the posterior rectus sheath and continues as a
muscular component laterally in the upper abdomen. This
feature is important when considering the technical aspects
of a posterior components separation.
The medial extension of the external oblique aponeurosis
forms the anterior layer of the rectus sheath. At the midline,
the two anterior rectus sheaths form the tendinous linea alba.
On either side of the linea alba is a rectus abdominis muscle,
the fibers of which course vertically and run the length of the
anterior abdominal wall. The width of these muscles averages
5–7 cm in men. Below each rectus muscle lies the posterior
layer of the rectus sheath, which also contributes to the linea
alba.
Another import anatomic structure of the anterior abdomi-
nal wall is the arcuate line, located 3–6 cm below the umbilicus
and delineates the point below which the posterior rectus
sheath is absent. The arcuate line is composed of the transver-
salis fascia and peritoneum. Above the arcuate line, the apo-
neurosis of the internal oblique muscle contributes to both the
anterior and posterior rectus sheaths, and the aponeurosis of
the transversus abdominis muscle passes posterior to the
rectus abdominis muscle to form the posterior rectus sheath
as described previously. Below the arcuate line, the internal
oblique and transversus abdominis aponeuroses pass com-
pletely anterior to the rectus muscle.
The abdominal wall receives the majority of its innervation
from the 7th to 12th intercostal nerves and the 1st and 3rd
lumbar nerves. These rami provide innervation to the lateral
abdominal muscles, the rectus abdominis muscles, and the
overlying skin. The nerves traverse the lateral abdominal wall
between the transversus abdominis and internal oblique
muscles and penetrate the posterior rectus sheath just medial
to the linea semilunaris.
The lateral abdominal muscles receive their blood supply
from the lower three to four intercostal arteries, the deep
circumflex iliac artery, and the lumbar arteries. The rectus
abdominis muscles have a more complex blood supply
derived from the superior epigastric artery (a terminal branch
of the internal mammary artery), the inferior epigastric artery
Basic science/disease process
Indications for abdominal wall reconstruction are multi-
factorial and include tumor ablation, congenital anomalies,
trauma, and iatrogenic complications second to laparotomies.
Each indication has an underlying distinct pathophysiology,
which must be specifically addressed for successful surgi-
cal correction. Hernias of the abdominal wall can result
from genetically impaired collagen formation, deposition,
organization, or degradation; from wound-healing deficien-
cies; and from injury, failed laparotomy closures, or failed
hernia repairs.12–14 Decades ago, it was suggested that both
primary and recurrent hernias resulted from abnormal
collagen metabolism.15,16 Original proposed risk factors for
the development of hernias included tobacco use and a
strong family history of hernia, which suggests a genetic
predisposition. Subsequently, ratios of type I and type III
collagen and tissue metalloprotease expression in patients
with inguinal and incisional hernias were studied in an
attempt to isolate an etiology.17 Further studies suggested
that mechanical strain on load-bearing tissues can induce
secondary changes in tissue fibroblast function that in turn
can result in failure of abdominal wall repairs.18 Although
more studies are needed, it is evident that some primary
hernias are the result of a genetic predisposition, whereas
the rest may be due to acquired structural collagen
abnormalities from mechanical strain, with or without
associated predisposing risk factors, such as tobacco use,
diabetes, advanced age, male sex, sleep apnea, prostatism,
and obesity.19 Factors associated with destruction of the col-
lagen in the lung in chronic obstructive pulmonary disease
and emphysema likely result in poor wound healing and
increased hernia formation in patients with these diseases.2
Wound infection is also associated with hernia formation.20
It has been suggested that the type of suture used during
a primary operation affects incisional hernia formation, but
there is no conclusive evidence to support this notion.14
Whether the type of abdominal incision used in the primary
surgery influences the occurrence of incisional hernias also
remains controversial. A 1995 analysis of 11 publications
examining the incidence of ventral hernia formation after
various types of abdominal incisions concluded that the risk
was 10.5% for midline, 7.5% for transverse, and 2.5% for
paramedian incisions.12 A more recent prospective, random-
ized trial reported no difference in hernia formation after
1 year when comparing midline and transverse incisions,
but did note a higher wound infection rate with transverse
incisions.16
Given the likely similar rates of incisional hernia formation
after transverse and midline incisions, surgeons should plan
incisions based solely on the operative exposure desired to
safely complete procedures. A factor known to be linked to
incisional hernia formation is the manner in which the initial
midline myofascial incision is closed. Specifically, animal and
human trials have shown that a 4 : 1 suture to wound length
ratio is optimal to reduce wound-related morbidity and inci-
sional hernia formation.15,17 This suture strategy is often mis-
understood; for clarification, it typically involves 5–7 mm
fascia bites and 3–4 mm of travel. This “small-stitch” approach
results in improved healing and reduced rates of wound
infections.

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SECTION II
CHAPTER 12 • Abdominal wall reconstruction
clinically as a bulge in the midline. In this condition, the linea
alba is stretched, resulting in bulging at the medial margins
of the rectus abdominis muscles. There is no fascial ring or
true hernia sac. Unless significantly symptomatic, diastasis
recti does not generally require surgical reconstruction. In the
repair of abdominal wall defects, the surgeon must consider
a multitude of factors to identify the appropriate surgical
technique to accomplish the reconstructive goals. An indi-
vidualized approach is required and must take into account
the patient’s age, comorbidities, physiologic status, defect
size, available local tissue, and presence of contamination.
Operative considerations
The goals of ventral hernia repair, regardless of the etiology
of the defect, are to re-establish the integrity of the myofascial
layer and provide durable cutaneous coverage while mini-
mizing the risk of hernia recurrence. Although it is impossible
to restore the abdominal wall to its native state after surgical
wounding or to cure patients with hernia of their intrinsic
collagenopathies, strategies can be employed to maximize the
possibility of a successful outcome in abdominal wall recon-
struction. Restoring the layered nature of the abdominal
myofascia, the native location of key muscle groups, and the
tone and contour of the abdominal wall is often achievable
with contemporary surgical maneuvers. The importance of
a meticulous dual-layered repair, centralizing the rectus
abdominis muscle complexes, and reinforcing the repair with
mesh, especially for hernias larger than 4 cm in greatest
dimension, cannot be overemphasized.25
The description by Ramirez et al. of the surgical technique
of component separation (CS) facilitates medicalization of the
rectus musculofascia, and thus midline abdominal closure by
releasing the external oblique aponeuroses and posterior
rectus sheath bilaterally. Although CS will often allow for
midline fascial re-approximation, which is the optimal situa-
tion, occasionally this will not be possible, particularly for
larger hernias, and the myofascial edges will need to be
bridged with mesh. Data have shown that defect size reduc-
tion, especially if less than 150 cm2, will lead to the lowest
recurrence rates.26 All attempts should be made to avoid a
bridged mesh repair because there is a clear trend toward
higher recurrence rates compared with when the fascia can be
re-approximated over a mesh repair.27 There are several other
theoretic advantages to re-approximating the linea alba. If one
considers the linea alba as the tendinous insertion of the
rectus and oblique muscles and borrows from the concepts of
tendon repair, then it seems logical that the physiologic
(a branch of the external iliac artery), and the lower intercostal
arteries. The superior and inferior epigastric arteries anasto-
mose near the umbilicus. The periumbilical area provides
critical myocutaneous perforator vessels that, if preserved,
can decrease skin flap necrosis from skin undermining.21
Diagnosis/patient presentation
Abdominal wall reconstruction patients have numerous and
varied presentations. The most common presentation to
reconstructive surgeons is an incisional hernia as sequelae to
a previous laparotomy. There are three general indications
to repair an incisional hernia: the hernia is symptomatic,
causing pain or alterations in the bowel habits; the hernia
results in a significant protrusion that affects the patient’s
quality of life; and the hernia poses a significant risk of bowel
obstruction (such as a large hernia with a narrow neck).
However, the likely slow continued growth of incisional
hernias due to intra-abdominal pressure should also be taken
into consideration. In a young patient with a moderate-sized
hernia, an initial non-operative approach can result in the
need for a more complex reconstruction in the future if the
hernia becomes larger and symptomatic. Therefore most
surgeons recommend that these hernias be repaired electively
when discovered.
Correct diagnosis of abdominal wall defects is critical to
proper management. Following appropriate clinical evalua-
tion, imaging studies are a helpful adjunct for detection and
diagnosis of abdominal defects and defining the abdominal
wall anatomy. Different imaging modalities are available to
evaluate abdominal wall defects.22,23 Computed tomography
(CT) allows for visualization of intra-abdominal organs and
the abdominal wall, 3D data sets, and multiplanar reforma-
tion capabilities. CT scans may assist in detecting bowel
obstruction, incarceration, strangulation, and traumatic wall
hernias. Magnetic resonance (MR) imaging also permits the
detection of abdominal wall hernias though this modality
does not usually offer further sensitivity and therefore may
be cost prohibitive.24
Several classification systems exist that categorize ventral
hernias based on complexity, whether they are spontaneous
or acquired, or by their location on the abdominal wall (Fig.
12.1). Acquired hernias typically occur after surgical incisions
and thus are commonly referred to as incisional hernias.
Epigastric hernias occur from the xiphoid process to the
umbilicus, umbilical hernias occur at the umbilicus, and
hypogastric hernias occur below the umbilicus in the midline.
Although not a true hernia, diastasis recti can present
Grade 1
Low Risk
Grade 2
Co-Morbid
Grade 3
Potentially
Contaminated
Grade 4
Infected
• Low risk of
complications
• No history of
wound infection
• Previous wound
infection
• Violation of the
gastrointestinal
tract
• Stoma present
• Septic dehiscence
• Infected mesh
• Smoker
• Obese
• Diabetic
• Immunosuppressed
• COPD
Fig. 12.1  Ventral Hernia Working Group’s ventral
hernia grading scale. COPD, chronic obstructive
pulmonary disease. (From: Ventral Hernia Working
Group, Breuing K, Butler CE, Ferzoco S, et al.
Incisional ventral hernias: review of the literature
and recommendations regarding the grading and
technique of repair. Surgery. 2010;148(3):544–
558, © Elsevier, 2010.)

279
Operative considerations
rates when mesh is used.4,29 Mesh materials can be placed in
several different configurations: interpositional (mesh edge to
the fascial edge), inlay [or sublay] (dorsal to the rectus
muscles), or onlay (ventral to the rectus muscles). The inter-
positional technique has been largely abandoned by most
surgeons owing to an unacceptably high hernia recurrence
rate. Options for inlay mesh placement include retrorectus
(between the rectus abdominis muscles and posterior rectus
sheath), preperitoneal (between the posterior rectus sheath
and preperitoneal fat), or intraperitoneal. The location of
mesh placement plays a critical role in optimizing outcomes.
Bridging inlay repairs, in which the mesh edges are sutured
to the medial fascial edges of the defect without midline
re-approximation, give the poorest outcomes.27 The location
on the abdominal wall to which the mesh is sutured varies
between surgeons. Fig. 12.2 depicts the mesh being anchored
to the lateral aspect of the released external oblique, internal
oblique, and transversus muscles. Many surgeons prefer to
anchor the mesh to the lateral aspect of the rectus abdominis
musculofascial sheath at the semilunar line. The theoretical
advantage is that the semilunar line or lateral rectus sheath is
a strong aponeurotic buttress and may reduce the risk of
suture pull-through. An advantage of suturing the mesh
tension of the abdominal wall should be restored during
ventral incisional hernia repair. Some authors have evaluated
the functional improvement in patients in whom the midline
fascia was restored and noted a 40% improvement in the
abdominal wall function after repair.28 Although every attempt
to re-establish the midline is advisable, accomplishing that
goal is not always feasible, and not all patients can tolerate
the intraperitoneal compression required (which can result
in intraperitoneal hypertension, pulmonary compromise, or
abdominal compartment syndrome). Understanding all of the
approaches for abdominal wall reconstruction, and particu-
larly myofascial advancement flaps, is critically important to
determining the least invasive procedure to provide a long-
lasting repair with an excellent functional outcome for the
patient. An understanding of the available reconstructive
techniques and an honest assessment of his or her ability to
perform each of these techniques should also guide the
surgeon in establishing the most appropriate repair for the
patient.
Mesh reinforcement of fascial closure is advised for hernia
defects larger than 74 cm2, even when the myofascia can be
closed without tension. Randomized prospective studies have
shown significantly lower early and late hernia recurrence
Fig. 12.2  Plane of mesh placement. (A) Onlay mesh
placement. The mesh is placed superficial to the anterior
rectus sheath and the external oblique aponeurosis.
(B) Intraperitoneal inlay mesh placement. The mesh is placed
within the peritoneal cavity deep to the posterior rectus sheath
and transversalis fascia laterally. The mesh is anchored
laterally, and the anterior rectus sheaths are closed in the
midline. (C) Above the arcuate line. Retrorectus inlay mesh
placement (Rives–Stoppa technique). The mesh is placed
within the posterior rectus sheath deep to the rectus
abdominis muscle. The mesh is anchored to the linea
semilunaris, and the anterior rectus sheaths are closed in the
midline.
Dermis
Rectus sheath
Rectus abdominis
Rectus abdominis
Posterior rectus sheath
Extraperitoneal fascia
Peritoneum
Rectus abdominis
External oblique
External oblique
External oblique
Internal oblique
Internal oblique
Transversus abdominis
Transversus abdominis
A
B
C

280
SECTION II
CHAPTER 12 • Abdominal wall reconstruction
Each of the commercially available synthetic meshes has some
but not all of these properties.
Synthetic mesh materials are classified based on the weight
of the material (weight per surface area), pore size, and water
angle (hydrophobic or hydrophilic), and whether they include
an antiadhesive barrier. When mesh is placed extraperitone-
ally and there is negligible risk of bowel erosion, a macropo-
rous mesh without an antiadhesive barrier layer is appropriate.
Both polypropylene and polyester mesh have been placed
successfully in the extraperitoneal position.
Polypropylene mesh is a semirigid, hydrophobic, macropo-
rous mesh that allows for ingrowth of native fibroblasts and
incorporation into the surrounding fascia. Placing polypro-
pylene mesh in an intraperitoneal position directly against the
bowel is often avoided because of the risk of bowel adhesions
to mesh and enterocutaneous fistula formation.33 Recently,
lighter-weight polypropylene mesh has been introduced to
address some of the long-term complications of heavyweight
polypropylene mesh, particularly adhesions to the bowel. The
definition of lightweight polypropylene mesh was arbitrarily
set at less than 50 g/m2, with heavyweight mesh weighing
greater than 80 g/m2. Lightweight mesh products often have
an absorbable component that provides initial handling sta-
bility; this material is typically composed of polyglactin or
poliglecaprone mesh. Whether lightweight rather than heavy-
weight mesh results in improved patient outcomes is contro-
versial. In a randomized controlled trial evaluating lightweight
vs. heavyweight polypropylene mesh for ventral hernia
repair, the recurrence rate was more than two times greater in
the lightweight mesh group (17% vs. 7% for heavyweight
mesh; P=0.05).34 The use of lightweight polypropylene mesh
in the setting of contamination has received renewed interest
as a more cost-effective approach than bioprosthetic mesh.
Several authors have demonstrated that lightweight polypro-
pylene mesh is relatively resistant to bacterial colonization in
experimental models, and small case series have demonstrated
safety when utilized in clean-contaminated colorectal cases.35
Polyester mesh is composed of polyethylene terephthalate
and is a heavyweight, hydrophilic, macroporous mesh.
Polyester mesh has several different configurations: a 2D
flat screen-like mesh, a 3D multifilament weave, and, more
recently, a monofilamentous mesh. Uncoated polyester mesh
placed directly on the viscera is generally avoided because
unacceptable rates of erosion and bowel obstruction have
been reported.36
For intraperitoneal mesh placement, several options are
available. A laminar sheet of mesh with different porosities at
different sites and a composite mesh with one side designed to
promote tissue ingrowth and the other to resist adhesion for-
mation are available. Laminar mesh is often composed of
expanded polytetrafluoroethylene (ePTFE). It has a visceral
side that is microporous (3 µm) to resist adhesion formation
and an abdominal wall side that is macroporous (17–22 µm) to
promote tissue ingrowth. This product differs from other
synthetic meshes in that it is flexible and smooth. Some fibro-
blast proliferation occurs through the pores, but ePTFE has
limited fluid permeability. Unlike polypropylene, ePTFE is not
incorporated into the native tissue. Encapsulation occurs
slowly, and infection can occur during the encapsulation
process. When infected, ePTFE mesh almost always requires
removal. Polypropylene mesh may be used intra-abdominally
so long as the surgeon can ideally separate it from bowel with
through the lateral musculature is that there is a greater
amount of mesh surface area peripheral to the defect often
referred to as a “wide mesh underlay”. However, no studies
have directly compared these techniques.
Onlay repairs (Fig. 12.2) place the mesh superficial to the
anterior rectus sheath and external oblique aponeurosis and
re-approximate the fascia over the mesh. The major advantage
of this approach is that the mesh is placed outside the abdomi-
nal cavity, avoiding direct contact with the abdominal viscera.
However, the technique has several disadvantages: a large
subcutaneous dissection is required to inset the mesh, which
transects skin perforators; there is an increased potential
likelihood of seroma formation; the superficial location of the
mesh places it in jeopardy of contamination if the incision
becomes infected; and a skin wound dehiscence can result in
direct external exposure of the mesh. Onlay mesh is usually
placed after the fascia is closed in the midline and therefore
has little ability to “offload” the fascial tension. In contrast, an
inlay mesh inset can be placed with the appropriate physio-
logic tension to facilitate midline fascial re-approximation as
a reinforced, rather than a bridged, repair. In addition, if the
midline fascia separates in the early postoperative period, the
mesh is often exposed to abdominal viscera. No prospective
studies of this technique are available, but a retrospective
review reported hernia recurrence rates of 28% with mesh
onlay.30
Inlay mesh repairs are favorable to overlay repairs because
intra-abdominal pressure is distributed against the mesh itself
so that tension is spread across the abdominal wall. Inlay
mesh placement can be performed in any of three tissue
planes: intraperitoneal, retrorectus, and preperitoneal (Fig.
12.2). Mesh should be sutured to the lateral rectus sheath and
semilunar line. This location of suture placement can also be
used for onlay and inlay techniques. The advantage of the
intraperitoneal approach is the avoidance of injury to the
posterior sheath and rectus muscle, as well as the fact that
concomitant procedures are often performed in the same
space (e.g., ostomy takedown or fistula resection). The retro-
rectus approach has the advantages of being relatively easy
to develop (assuming no prior disruptions of this plane) and
insulating mesh from the intestines where adhesions may
form; this approach also has the theoretical advantage of
providing a broad muscle interface with the mesh to facilitate
vascularization.31,32 The preperitoneal approach is a sound
option for patients who have a well-developed preperitoneal
fat pad, which puts the mesh in direct contact with the pos-
terior sheath.
Regardless of the plane of mesh placement, appropriate
tension must be established across the mesh repair. The key
is to re-create the physiologic tension across the repair that
correlates with the tone of the abdominal wall in a resting
state while standing. If excessive tension is placed on the
mesh–myofascia suture line, this interface will attenuate and
lead to peripheral failure of the mesh repair.
When selecting the appropriate mesh for a patient, the
surgeon must consider whether the mesh will be in direct
contact with the viscera and whether infection is present or
likely. A variety of synthetic mesh products are available for
ventral hernia repair. The ideal mesh has not yet been devel-
oped but would cause minimal or no inflammatory reaction
and be chemically inert, resistant to mechanical stress, steriliz-
able, non-carcinogenic, hypoallergenic, and reasonably priced.

281
Surgical technique
than synthetic meshes, the long-term cost-effectiveness of
these materials, particularly in contaminated cases, may be
better. More recently, newer bioabsorbable protein meshes
that do not biodegrade for several months (unlike polylactic
acid-based mesh) have been introduced and proposed as less
costly alternatives to bioprosthetic meshes.44 However, further
studies are required before the exact place of these new mate-
rials in the armamentarium of the abdominal wall hernia
surgeon can be determined.
Surgical technique
Ventral hernia repair proceeds through a previously estab-
lished midline incision and occurs following adequate adhe-
siolysis when fascial edges are clearly defined. Mesh is sized
to extend at least 4 cm peripheral to the myofascial defect
edge and is secured to the musculofascia with permanent
interrupted mattress sutures. Intraperitoneal mesh placement
may be in direct contact with the abdominal contents if insuf-
ficient greater omentum is available to interpose between the
mesh and the viscera. It is therefore important to place the
sutures close together and tie sutures under direct visualiza-
tion to prevent entrapment of a loop of intestines. Another
technical challenge with this approach is to avoid buckling of
the mesh once the midline fascia is approximated. If the
midline is going to be approximated, the surgeon can measure
the amount of fascial overlap on both sides and inset the mesh
appropriately. Ideally, once the mesh is inserted peripherally
the midline fascia will be re-approximated, and the mesh and
its inset will bear the majority of the tension.
The laparoscopic approach for intraperitoneal mesh place-
ment relies on the same principles as the open technique.
Trocars are placed as far laterally as feasible based on the size
and location of the hernia. Once the hernia contents are
reduced and adhesions are lysed, the defect is measured
intraperitoneally and an appropriately sized piece of barrier-
coated mesh is fashioned with at least 4 cm of overlap around
the defect. The mesh is rolled, placed into the abdomen, and
deployed. It is secured to the anterior abdominal wall with
preplaced mattress sutures that are passed through separate
incisions, and tacking staples are placed between these sutures
to secure the mesh 4 cm beyond the defect. The laparoscopic
approach offers a significant reduction in postoperative
wound morbidity by avoiding subcutaneous tissue dissec-
tion. Postoperative pain, however, is often similar to that with
an open procedure, and in thin patients a perceptible postop-
erative bulge may be present.
Mesh can be placed extraperitoneally in either the preperi-
toneal space or retrorectus position (Fig. 12.2). This technique
was initially described by Rives and Stoppa.31,32 A large piece
of mesh is placed ventral to the posterior rectus sheath or
peritoneum. This space must first be dissected laterally on
both sides of the linea alba to the linea semilunaris. The linea
semilunaris is identified by the presence of the intercostal
nerves perforating the lateral border of the rectus muscle, as
well as the lateral reflection of the posterior sheath as it transi-
tions to the anterior sheath. These neurovascular bundles
must be maintained as they provide segmental innervation to
the rectus complex. The mesh extends 5–6 cm beyond the
superior and inferior borders of the defect. Sutures should be
placed under physiologic tension to help medialize the rectus
a tissue interposition such as omentum, hernia sack, or pro-
peritoneal tissue. To promote better tissue integration, com-
posite meshes were developed. These products combine the
attributes of both polypropylene and ePTFE by layering the
two substances. The ePTFE surface serves as a permanent
protective interface against the bowel, and the polypropylene
side faces the abdominal wall and is macroporous to promote
incorporation into the native fascial tissue. Recently, other
composite meshes have been developed that combine a mac-
roporous mesh with a temporary absorbable antiadhesive
barrier. These mesh materials are made of heavyweight or
lightweight polypropylene or polyester and an absorbable
barrier typically composed of oxidized regenerated cellulose,
hyaluronic acid, omega-3 fatty acids, or collagen hydrogels.
Studies in small animals have validated the antiadhesive
properties of these barriers, but currently no human trials exist
evaluating the ability of these composite materials to resist
adhesion formation. When used intra-abdominally, polypro-
pylene mesh can be separated from bowel by interposing soft
tissues such as omentum, hernia sac, or properitoneal tissue.
Bioprosthetic meshes are reported to have certain advan-
tages over synthetic meshes because of their potential ability
to resist infection and remodel over time, leaving behind host
cells and native regenerated collagen. Animal studies have
demonstrated a marked reduction in the strength and surface
area of adhesions with the use of acellular dermal matrices
(ADMs) compared with polypropylene mesh.37–39 Animal
studies have demonstrated rapid host cell and vascular infil-
tration into ADMs used for hernia repair. These properties are
believed to reduce the risk of bacterial infection and poten-
tially allow ADMs to be used in contaminated hernia repairs
with a lower risk of infection.40 Several bioprosthetic meshes
are commercially available for abdominal wall reconstruction
and are categorized based on the source material (porcine or
bovine), processing technique (cross-linked or non-cross-
linked), and sterilization technique (gamma radiation, ethyl-
ene oxide gas sterilization, or non-sterilized). These products
are composed mostly of acellular collagen and theoretically
provide a matrix for neovascularization and native collagen
deposition. The use of human ADMs has largely been aban-
doned within abdominal wall reconstruction due to unaccept-
able long-term elasticity particularly when used in a bridging
technique.41 Bioprosthetic meshes function best when utilized
as a fascial reinforcement rather than a bridge or interposition
graft.42 A recent meta-analysis evaluated outcomes with mesh
positions in abdominal wall repair.43 The investigators noted
hernia recurrence rates were highest for onlay (17%) place-
ment compared to either underlay (7%) or retrorectus (5%).
Seroma rates were lowest following a retrorectus repair (4%).
They postulated that this advantage might be due to the
improved local blood supply afforded by the retrorectus posi-
tion; however, larger prospective randomized studies are
necessary to confirm these findings. Few data are currently
available to assess the long-term durability of bioprosthetic
meshes, and no randomized trials have been performed to
compare the performance of different bioprosthetic meshes.
Furthermore, no data exist directly comparing the outcomes
of bioprosthetic mesh vs. synthetic mesh in a clean or clean-
contaminated field. Currently, these grafts appear to tolerate
placement in a clean-contaminated field, but their long-term
durability and role in hernia recurrence are largely unknown.
Although bioprosthetic meshes are much more expensive

282
SECTION II
CHAPTER 12 • Abdominal wall reconstruction
performed by raising large subcutaneous flaps to expose the
external oblique fascia. The cutaneous perforators emerging
from the anterior rectus sheath are ligated and divided to
facilitate exposure of the linea semilunaris in its entirety.
These flaps are carried laterally past the linea semilunaris.
This subcutaneous dissection itself can provide some medial
advancement of the abdominal wall skin (Fig. 12.3).
An anatomically precise external oblique aponeurotomy is
made 1–2 cm lateral to the linea semilunaris on the lateral
aspect of the external oblique aponeurosis from several centi-
meters above the costal margin to the pubis. It is important to
confirm that the incision is not carried through the linea
semilunaris, as this would result in a full-thickness defect of
the lateral abdominal wall, which is very challenging to repair.
The external oblique aponeurosis is then bluntly separated in
the avascular plane away from the internal oblique aponeu-
rosis to the midaxillary line, allowing the internal oblique and
transversus abdominis muscles with the rectus abdominis
muscle or fascia to advance medially as a unit. These tech-
niques, when performed bilaterally, can yield up to 20 cm of
mobilization in the midabdomen.
Once the mesh inset and fascial closure are performed, the
subcutaneous skin flaps are advanced and closed at the
midline. To reduce subcutaneous dead space, interrupted
quilting sutures should be placed between the Scarpa fascia
and musculofascial repair.47 This technique also decreases
abdominis muscles and prevent buckling of the mesh during
midline fascial re-approximation. This approach avoids
contact between the mesh and the abdominal viscera. A ret-
rospective review from the Mayo Clinic with a median
follow-up of 5 years documented a 5% overall hernia recur-
rence rate in 254 patients undergoing complex ventral hernia
repair over a 13-year period.45
Myofascial advancement flaps (Video 12.1 )
For defects that are too wide to close without undue tension,
myofascial release and advancement can be performed. These
concepts were originally described by Stoppa and Ramirez,
and several modifications have been reported.46 Myofascial
advancement techniques, or components separation, take
advantage of the laminar nature of the abdominal wall and
the ability to release one muscular or fascial layer to enable
medial advancement of another. There are few comparative
data to suggest the superiority of one myofascial advance-
ment approach over another, and likely each has a role in
abdominal wall reconstruction. If the lateral abdominal com-
partment must be released, then this can be achieved by open
or minimally invasive CS. A minimally invasive CS can be
performed various ways, but all of the techniques (to a certain
degree) maintain the blood supply to the skin from the under-
lying rectus abdominis muscles. In contrast, an open CS is
Fig. 12.3  Open component separation.
Subcutaneous flaps are elevated off the anterior
rectus sheath to expose the external oblique
aponeurosis. The external oblique aponeurosis is
released from the inguinal ligament inferiorly to
above the costal margin superiorly. This allows
exposure of the internal oblique muscle fibers once
the external aponeurosis is incised. (From: Rosen
M. Atlas of Abdominal Wall Reconstruction,
pp. 15–195. © Elsevier, 2012.)
Skin graft/scar
remnants
Bilateral division of
external oblique fascia
Internal oblique fibers
Inguinal ligament
Costal margin
Healthy edges of
anterior rectus fascia

283
Surgical technique
shear stress, which is thought to contribute to postoperative
seroma formation, and decrease the total drain output, allow-
ing the surgeon to place fewer drains and leave them in for a
shorter period. After paramedian skin perfusion is critically
assessed, a vertical panniculectomy is performed so that the
skin is re-approximated in the midline without redundancy.
Open CS often allows tension-free closure of large defects,
and recurrence rates as low as 20% have been reported with
the use of open CS and mesh reinforcement in large hernias.48
Recognizing the high recurrence rates with CS alone, several
authors have reported series of bioprosthetic or synthetic
mesh reinforcement of these repairs; although to date, no
randomized controlled trials have demonstrated lower hernia
recurrence rates with a specific mesh type. If bioprosthetic
mesh is placed, it can be secured in either an underlay or
onlay technique; no comparative data exist demonstrating the
superiority of either technique. A major limitation of open CS
is the wound morbidity associated with the large skin flaps
necessary to access the lateral abdominal wall. To avoid this
morbidity, several manuscripts have described innovative
minimally invasive approaches to CS.49,50 These approaches
are designed to gain direct access to the lateral abdominal wall
without creating large skin flaps, creating dead space, or inter-
rupting the primary blood supply to the central abdominal
skin by ligation of the rectus abdominis perforator vessels.
Laparoscopically, CS is performed through a 1 cm incision
below the tip of the 11th rib overlying the external oblique
muscle (Fig. 12.4).51 The external oblique muscle is split in the
direction of its fibers, and a standard bilateral inguinal hernia
balloon dissector is placed between the external and internal
oblique muscles and directed toward the pubis. Three laparo-
scopic trocars are placed in the space created, and the dissec-
tion is carried from the pubis to several centimeters above the
costal margin. The linea semilunaris is carefully identified,
and the external oblique aponeurosis is incised from beneath
the external oblique muscle at least 2 cm lateral to the linea
semilunaris. The muscle is released from the pubis to several
centimeters above the costal margin. This procedure is per-
formed bilaterally. Comparative data have shown laparoscopic
CS to result in a lower rate of wound morbidity than
open CS.49
A periumbilical perforator-sparing technique of CS may be
performed to preserve the blood supply to the anterior
abdominal wall skin near the midline and is based primarily
on perforator vessels from the deep inferior epigastric vessels.
Cadaver dissections and radiographic studies have confirmed
that the majority of these vessels are located within 3 cm of
the umbilicus.38 With preservation of these vessels, ischemic
complications involving the subcutaneous flaps are signifi-
cantly reduced.52 To avoid injury to the periumbilical perfora-
tor vessels, a line is marked no less than 3 cm cephalad and
3 cm caudal to the umbilicus. The periumbilical perforator
tunnels are begun at the epigastric and suprapubic regions.
Subcutaneous tunnels are created using lighted retractors to
identify the external oblique fascia. The superior and inferior
tunnels are connected using cautery and retractors while
maintaining the subcutaneous attachments of the periumbili-
cal region. The linea semilunaris is identified by palpation,
and the external oblique is incised 2 cm lateral to this junction.
The aponeurotomy is extended several centimeters above the
costal margin and to the pubic tubercle. The external oblique
muscle is separated from the internal oblique muscle in an
avascular plane toward the posterior axillary line. One series
reported a significant reduction in wound morbidity with the
periumbilical perforator-sparing technique compared with
the standard open CS technique (2% vs. 20%; P < 0.05).53 The
periumbilical perforator-sparing approach has several limita-
tions. One of the benefits of minimally invasive CS is to reduce
subcutaneous dead space. The periumbilical perforator-
sparing technique creates considerable dead space and sacri-
fices more perforator vessels to the skin than other minimally
invasive techniques. When skin mobilization is necessary,
adequate advancement occasionally can be difficult to achieve
because the midline skin is still invested in the periumbilical
region. Additionally, the placement of a wide piece of mesh
as an underlay can be difficult given the large subcutaneous
paddle that is still attached.
Butler and colleagues modified the standard open Ramirez-
style procedure that further reduces the subcutaneous dead
space and maximizes the blood supply to the abdominal skin
with rectus perforator preservation.47 The minimally invasive
components separation (MICS) technique is designed to avoid
division of the musculocutaneous perforators overlying the
rectus sheath and thus maintain perfusion to the paramedian
skin. After lysis of adhesions and identification of the fascial
edges, bilateral, 3 cm wide, subcutaneous access tunnels are
created over the anterior rectus sheath from the midline to the
linea semilunaris at the level of the costal margin (Fig. 12.5).
Through these access tunnels, the external oblique aponeuro-
sis is vertically incised 1.5 cm lateral to the linea semilunaris.
The tip of a metal Yankauer suction handle (Cardinal Health,
Dublin, OH), without suction, is inserted through the opening
in the avascular plane between the internal and the external
oblique aponeuroses, separating them at their junction with
the rectus sheath. The suction tip is advanced inferiorly to the
pubis and superiorly to above the costal margin. A narrow
incision of 2.5 cm is made inferiorly. Next, lateral dissection
between the internal and the external oblique muscles is per-
formed to the midaxillary line. Minimal subcutaneous skin
flaps are then elevated over the anterior rectus sheath circum-
ferentially to the medial row of rectus abdominis perforator
vessels, and a retrorectus or preperitoneal mesh inlay is gener-
ally used. If a preperitoneal inset is used, the preperitoneal fat
is dissected from the posterior sheath circumferentially to
allow the mesh to be inlaid directly against the posterior sheath
or rectus abdominis muscle (below the arcuate line). Mesh is
inserted to the semilunar line with #1 polypropylene sutures
via the horizontal access tunnels and the cranial and caudal
aspect of the defect. Next, the myofascial edges are advanced
and re-approximated over the mesh with sutures placed
through the myofascia and mesh. Interrupted resorbable 3-0
sutures are placed to affix the posterior sheath to the mesh,
thereby obliterating dead space and reducing the potential for
fluid collection. Closed-suction drainage catheters are placed
in each CS donor site area, in the space between the rectus
complex closure and mesh, and in the subcutaneous space.
The remaining undermined skin flaps are sutured to the myo-
fascia with vertical rows of interrupted resorbable 3-0 quilting
sutures to reduce dead space and potential shear between the
subcutaneous tissue and myofascia. A controlled study dem-
onstrated that patients had significantly fewer wound-healing
complications (32% vs. 14%, P=0.026) and skin dehiscences
(28% vs. 11%, P=0.01) with MICS than with traditional open
CS.47 These improved wound-healing outcomes are likely due

284
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CHAPTER 12 • Abdominal wall reconstruction
abdominis muscle and the peritoneum is developed as far
laterally as necessary, even to the psoas muscle if needed. This
plane can be extended superiorly to the costal margin,
retrosternally above the xiphoid, and inferiorly into the space
of Retzius. The posterior sheath is then closed, to completely
exclude any mesh from the viscera. An adequately sized piece
of mesh is then secured, similar to a standard retromuscular
repair, but with greater overlap. The midline is then
re-approximated. In a recent comparative review of open
anterior CS with posterior CS for complex abdominal wall
reconstruction, Krpata et al. reported similar fascial advance-
ment but a 50% reduction in wound morbidity with the
posterior approach when compared to an anterior CS.54
Postoperative care
In general, abdominal wall reconstruction patients have pro-
longed postoperative healing periods due to the dynamic
function and mobility of the abdominal musculature. Based
upon specific unique indications, each patient’s postoperative
to the preservation of the vascularity of the overlying skin
flaps and reduction of paramedian dead space – the surgical
principles underlying the MICS procedure.
A posterior CS is based on the retromuscular Rives–Stoppa
approach to ventral hernia repair. Unlike the Ramirez CS
focusing on external oblique aponeurosis release, the posterior
CS focuses on transversus abdominis aponeurosis release. As
previously mentioned, the transversus abdominis aponeurosis
actually forms the posterior rectus sheath in the upper two-
thirds of the abdomen. By incising this myofascial aponeurosis,
the surgeon accesses the preperitoneal space. This provides
substantial advancement of both the posterior fascial flap and
the anterior myofascial compartment. The initial release is
completed by incising the posterior rectus sheath approxi-
mately 1 cm lateral to the linea alba, and the posterior rectus
sheath is separated from the overlying rectus muscle (Fig.
12.6). The transversus abdominis muscle is incised just medial
to the intercostal nerves, and the underlying transversalis
fascia and peritoneum are identified. This myofascial release
is extended the entire length of the posterior rectus sheath
(Fig. 12.6B). The potential space between the transversus
Fig. 12.4  Endoscopic component separation.
Access to the external oblique aponeurosis is
achieved through a small incision at the costal
margin through which a balloon dissector is
placed. The external oblique aponeurosis is then
divided from the pubis to above the costal margin.
This minimally invasive approach preserves the
attachments of the subcutaneous tissue (including
myocutaneous perforators) to the anterior rectus
sheath throughout its course. (From: Rosen M.
Atlas of Abdominal Wall Reconstruction,
pp. 15–195. © Elsevier, 2012.)
External oblique
Linea semilunaris
Internal oblique
Transversus abdominis
Linea semilunaris
Standard bilateral inguinal
hernia balloon dissector,
creating space between
external and internal oblique
Caudal direction
to public tubercle
Hand pump
Camera tube inside
balloon dissector shaft
(x-sec cut)

285
Postoperative care
Fig. 12.5  Minimally invasive component separation (MICS) technique. (A) Access to the external oblique aponeurosis is achieved through a small tunnel from the midline
to the supraumbilical external oblique aponeurosis. Vertical tunnels are created dorsal and ventral to the planned release site of the external oblique aponeurosis.
Periumbilical perforators and the subcutaneous tissue overlying the anterior rectus sheath are left undisturbed. (B) The external oblique aponeurosis is then divided from the
pubis to above the costal margin. The external oblique aponeurosis in the upper abdomen is released with electrocautery as muscle is transected at, and superior to, the
costal margin. (C) Scissors are generally used to release the external oblique aponeurosis inferiorly. This MICS approach preserves the attachments of the subcutaneous
tissue (including myocutaneous perforators) to the anterior rectus sheath throughout its course. (From Rosen M. Atlas of Abdominal Wall Reconstruction, pp. 15–195.
© Elsevier, 2012.)
Xiphoid
Costal margin
Proposed line
of incision
External oblique
muscle
External oblique
aponeurosis
release:
• superior direction
• inferior direction
Umbilicus
Subcutaneous
tunnel creation
Internal oblique
muscle fibers
Linea semilunaris
Incision of external
oblique aponeurosis
Dissected space
between external and
internal oblique muscles
Rectus
muscle
Intact medial and lateral row
musculocutaneous perforators
Lateral tunnels
Access tunnels
A
B
C

286
SECTION II
CHAPTER 12 • Abdominal wall reconstruction
(mesh 2–36% vs. suture repair alone 25–54%), patient comor-
bidities, and surgical technique.1,2,4,25,29 The number of prior
attempts of hernia repair is predictive of the relative risk of
recurrence. In a study of approximately 10 000 patients, 5-year
re-operative rate was 23.8% after a primary repair, 35.3% fol-
lowing a secondary repair, and 38.7% after a tertiary repair.57
There is no standard nomenclature system to accurately
stratify ventral or incisional hernias. This has led to the use of
poorly defined, confusing terms such as “complex ventral
hernia repair”, “large defects”, and “loss of abdominal
domain”. Recently, a group of ventral hernia surgeons (the
Ventral Hernia Working Group, VHWG) attempted to develop
a classification system for ventral or incisional hernias.25 The
resulting grading system takes into account underlying
patient comorbidities and the presence of wound contamina-
tion during the repair (Fig. 12.1). In the VHWG system, grade
1 includes hernias in patients with a low risk of complications
and no history of wound infection. Grade 2 includes hernias
in patients who smoke or have chronic obstructive pulmonary
disease, and are obese, diabetic, or immunosuppressed. Grade
3 includes hernias in patients with a previous wound infec-
tion, a stoma, or violation of the gastrointestinal tract (i.e.,
hernias in potentially contaminated surgical fields). Finally,
grade 4 includes hernias in patients with infected mesh or
septic dehiscence of their wound. Based on this classification
system, the VHWG recommended the use of synthetic mesh
for grade 1 hernias and bioprosthetic mesh for grades 3 and
4. No consensus recommendations were made for grade 2
hernias. This grading system represents an important first
step in developing a classification system to improve report-
ing and allow appropriate comparative studies to be
care regimen should be individually tailored to allow for
sufficient healing of the surgical site. Perioperative manage-
ment of high-risk patients should include appropriate deep
venous thrombosis (DVT) chemoprophylaxis according to the
Caprini risk score.55,56 Sequential compression devices and
early ambulation should be utilized with low molecular
weight fractionated heparins administered postoperatively.
Perioperative antibiotics are indicated, and cases with viola-
tion of the gastrointestinal tract should be offered broader
coverage for anaerobic as well as Gram-negative bacteria. For
ventral hernia, closed suction drains are used liberally and are
kept in place for an average of 1–2 weeks until there is less
than 30 cc per day. Abdominal wall reconstruction patients
should refrain from strenuous activities and exercises that
isolate the abdominal core for at least 6–12 weeks. Patients
may gain comfort from the use on an abdominal binder for 3
months, and then with any expected heavy physical activity
thereafter. Routine follow-up includes a physical examination
in an outpatient clinic: often performed weekly for 1 month
after discharge, then every 3 months for 1 year, and then
annually thereafter.
Outcomes/prognosis
Given the wide spectrum of patient characteristics and defect
complexities, no single approach to abdominal wall recon-
struction and in particular ventral hernia repair will be the
best choice for all patients, and comparing different approaches
is difficult. Estimated incidences of hernia recurrence have a
wide range from 2% to 54%, depending on the type of repair
Fig. 12.6  Posterior component separation. (A) The initial release is completed by incising the posterior rectus sheath approximately 1 cm lateral to the linea alba, and the
posterior rectus sheath is separated from the overlying rectus abdominis muscle. Dissection is carried to the lateral border of the rectus muscle, and the perforating
intercostal nerves are identified, marking the linea semilunaris. (B) Next, the transversus abdominis muscle is incised just medial to the intercostal nerves, and the
underlying transversalis fascia and peritoneum are identified. This myofascial release is extended the entire length of the posterior rectus sheath. The potential space
between the transversus abdominis muscle and the peritoneum is developed as far laterally as necessary. (From Rosen M. Atlas of Abdominal Wall Reconstruction,
pp. 15–195. © Elsevier, 2012.)
Transversus abdominis release
(TAR)
Bilateral transversus
abdominis release (TAR)
Transversus
abdominis
Peritoneum/
transversus fascia
Reflected rectus
abdominis muscle
A
B

287
Complications
ventral hernia repair. Mesh infections are reported to occur in
0–3.6% of laparoscopic ventral hernia repairs and 6–10% of
open repairs employing mesh.61 The most common organism
infecting mesh is Staphylococcus aureus, seen in up to 81% of
cases and suggesting skin flora contamination during mesh
implantation. However, Gram-negative organisms, such as
Klebsiella and Proteus spp., have been implicated in up to 17%
of mesh infections.59 In some cases, macroporous polypropyl-
ene meshes that become infected can be salvaged with local
wound measures and antibiotics and do not require removal.
Several reports suggest that lighter-weight polypropylene
mesh might be safe in clean-contaminated environments.62
However, microporous ePTFE mesh does not tolerate infec-
tion and almost always requires excision.63,64
Seroma
Seroma formation can occur after laparoscopic or open ventral
hernia repair. During routine laparoscopic ventral hernia
repair, the hernia sac is often not excised; in such cases, a
seroma is frequently present postoperatively. It is important
to counsel patients so that they are not surprised. In most
cases, the seroma will be reabsorbed over time. If symptom-
atic, the seroma can be aspirated percutaneously. In open
ventral hernia repair, drains are often placed in an attempt to
obliterate the dead space caused by the hernia and tissue
dissection. These drains can cause retrograde bacterial con-
tamination, and seromas can form after drain removal. Long
subcutaneous tunnels, meticulous securing of drain exit sites
with drain sutures that prevent intussusception of the drain,
and meticulous drain exit site wound management using
antibiotic impregnated dressings should be utilized to reduce
the risk of retrograde bacterial infection. Seroma formation is
common after open CS owing to the extensive tissue dissec-
tion, and drains may be necessary for up to 4–6 weeks.
Intraoperative techniques, such as quilting sutures, fibrin
sealant, and postoperative abdominal binders, may help to
prevent or reduce seroma formation.65
Enterotomy and enterocutaneous fistulas
Unintentional intestinal injury during adhesiolysis can be
catastrophic. 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. 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 3–4 days. When there is gross contamination,
the use of synthetic mesh is generally contraindicated. Regard-
less of the approach taken, it is important that patients
understand preoperatively the risk of this complication and
how it might alter intraoperative decisions.
The unexpected postoperative appearance of intestinal
contents draining through an abdominal surgical incision is a
devastating event for the patient and the surgical team. The
treatment of patients with enterocutaneous fistulas (ECFs) is
complex, and most recommendations are based on expert
opinions or single-center retrospective case series.66 The
underlying cause of an ECF has significant implications as to
the prognosis for spontaneous closure or need for operative
performed. However, this grading system has not yet been
validated in a large patient cohort, and further studies are
necessary to validate these results.
Two recent systematic reviews of the use of ADMs in
abdominal wall reconstruction have echoed the difficulty of
direct comparisons between study results because of differ-
ences in patient variables, techniques, nomenclature, and
definitions of outcomes.58,59 The conclusions of these reviews
were that there is no consensus on risk factors predicting
recurrence or wound morbidity, there is limited consensus on
terminology for defect characteristics, and there is no consen-
sus on terminology for outcomes. Clearly, grading systems,
such as those described earlier, and the need to accurately
assess and report outcomes will be drivers for future studies
from multiple institutions and authors that will help define
the role of ADMs in AWR.
Several small series with short follow-up have compared
the results of laparoscopic ventral hernia repair to those of
open ventral hernia repair. A randomized trial by the Veterans
Administration compared laparoscopic and open ventral
hernia repairs in 146 patients.60 This series had several impor-
tant methodologic issues that deserve mention when inter-
preting the results. First, the authors focused on relatively
small defects, with the mean defect size in both groups aver-
aging 46 cm2. Second, the open technique involved an onlay
approach in which subcutaneous flaps are created, and the
polypropylene mesh is placed above the fascia. Finally,
the mesh placement included only 3 cm of fascial overlap. The
authors reported a significantly higher wound morbidity rate
with the open approach (23%) than with the laparoscopic
technique (6%, odds ratio [OR], 0.2; 95%, confidence interval
[CI], 0.1–0.6). Overall recurrence rates were similar in the two
groups (8.2% open vs. 12.5% laparoscopic; P=0.44). Although
the overall complication rate was lower in the laparoscopic
group, the incidence of severe or major complications was
higher in the laparoscopic group. Most notably, the rate of
enterotomy was higher in the laparoscopic group (4.1%) than
in the open group (0%). In general, the laparoscopic approach
to ventral hernia repair is a good technique for obese patients
or elderly patients with small to medium defects (up to 10 cm
wide) in which the morbidity of extensive skin flaps and
soft-tissue dissection can be avoided. However, in patients
who have severe adhesions or have undergone multiple
abdominal surgeries or both, the surgeon should exercise
caution when performing adhesiolysis laparoscopically and
have a low threshold for conversion to an open approach to
avoid bowel injury.
Complications
Infections
Surgical site infections are common after open ventral hernia
repair, although the exact incidence is difficult to determine
as most series poorly define this outcome variable. Categori-
zation of the intraoperative level of wound contamination,
based on the US Centers for Disease Control and Prevention
(CDC) criteria, into clean, clean-contaminated, contaminated,
and dirty wounds is important to appropriately stratify
patients by risk of surgical site infection. Mesh infections are
one of the most serious complications that can occur after

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CHAPTER 12 • Abdominal wall reconstruction
conjunction with our radiology team, we perform an initial
upper gastrointestinal tract X-ray series with small bowel
follow-through using water-soluble contrast material. Next,
the fistula is cannulated, and the exact anatomy of the fistula
and the remaining small bowel is documented. If necessary, a
barium enema is performed to delineate the distal anatomy.
In difficult cases, these procedures are performed under
endoscopic guidance. Once the entire gastrointestinal tract
anatomy is established, a general repair plan for the number
of anastomoses, the amount of bowel requiring resection, and
the amount of remaining bowel is made. If the fistula output
is steadily decreasing and the wound is healing, surgery
should be avoided as the fistula might heal spontaneously.64
The goals of surgical correction of ECFs are to resect the
segment of bowel involved in the fistula, re-establish gastro-
intestinal tract continuity, cover the anastomosis with well-
vascularized soft tissue, and provide a stable abdominal wall
closure. As the operation is long and difficult, we advocate a
two-team approach. The first team is responsible for re-
establishing gastrointestinal tract continuity, and the second
team performs the abdominal wall reconstruction. An autolo-
gous tissue graft or bioprosthetic mesh is preferable to syn-
thetic mesh in this population given the heavy contamination
often present as a result of the fistula. Bioprosthetic mesh has
been used to bridge the fascial defect in ECF cases with limited
success. Although bioprosthetic meshes are very expensive
and likely may not prevent a ventral hernia for a long term in
these patients, as mentioned, that is not the primary goal of
ECF repair. When planning reconstruction of an abdominal
wall in the setting of a large hernia defect and a concomitant
fistula, it is important to have all of the reconstructive options
available and utilize the option that provides the best soft-
tissue coverage with the least morbidity for the individual
case. In a series of 135 patients with ECFs, Visschers et al.66
reported successful restoration of gastrointestinal tract conti-
nuity in 91% of patients, with a 9.6% mortality rate, despite
fairly early surgical repair (mean of 53 days from ECF devel-
opment). Among 53 patients with concomitant abdominal
wall defects, 77% required surgical intervention for closure,
and the mortality rate was 15%. Among the 82 patients
without an abdominal wall defect, the mortality rate was only
6%. Malnutrition was correlated with failure of surgical
closure and increased mortality rates.
Secondary procedures
Composite reconstructions
The goals of abdominal wall reconstruction after full-thickness
composite resection are to re-establish the integrity of the
myofascial layer and provide external cutaneous coverage.
Surgical planning in abdominal wall reconstruction must
include accommodating for the loss of both skin and myofas-
cial tissue. Full-thickness loss of the abdominal wall muscu-
lofascia and overlying soft tissue – a composite defect – can
result from tumor resection, necrotizing soft-tissue infection,
or traumatic injury. These clinical scenarios represent the
most complicated abdominal wall reconstructions, some-
times requiring multiple staged procedures. Composite
defects due to en bloc tumor resection can be repaired at the
time of tumor extirpation, provided clear margin status is
intervention. By definition, an ECF is an abnormal communi-
cation between the bowel lumen and the skin. ECFs can be
classified based on their anatomy, output, or etiology. The
anatomic classification is based on the segment of the intes-
tines that is involved in the fistula: gastrocutaneous, biliocu-
taneous, enterocutaneous, or colocutaneous. The output
classification system is based on the volume of effluent from
the fistula: low output (less than 200 mL/day); moderate
output (200–500 mL/day); or high output (greater than
500 mL/day). Causes of ECFs include trauma, foreign body,
infectious disease, malignancy, and up to 20% of ECFs are
related to bowel resection in patients with Crohn’s disease.64
Approximately one-third of ECFs will close spontaneously
with appropriate wound care, nutritional support, and
medical therapy.67 Several prognostic factors have been linked
to non-healing fistulas. A common mnemonic to describe
these factors is FRIENDS of a fistula: foreign body, radiation
enteritis, inflammatory bowel disease, epithelialization of the
fistula tract, neoplasm, distal obstruction, and ongoing sepsis.
With improvements in parenteral nutrition, surgical tech-
niques, and medical care, mortality rates range from 5–25%.64,65
There are three phases of ECF management: (1) recognition
and stabilization, (2) anatomic definition and decision, and
(3) definitive operation. Published guidelines refer to the
SOWATS management algorithm: control of sepsis, optimiza-
tion of nutritional status, wound care, assessment of fistula
anatomy, timing of surgery, and surgical strategy.64 Once a
fistula is identified, four factors must be addressed simultane-
ously: (1) fluid and electrolyte repletion, (2) control of fistula
effluent and protection of the surrounding skin, (3) control of
infection and drainage of abscesses, and (4) nutritional
support. 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 bicar-
bonate, which must be adequately replaced. Diligent protec-
tion of the surrounding skin is one of the most important and
difficult aspects of ECF management. A dedicated enterosto-
mal 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, a 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 lifesav-
ing. When a proximal diversion cannot be achieved owing to
a foreshortened mesentery or extremely dilated or hostile
bowel, appropriate tube drainage can be helpful. Nutritional
supplementation is one of the most important aspects of
reducing deaths related to ECFs. Nutritional requirements
should be adjusted accordingly for patients with proximal
high-output fistulas. During initial management of an ECF,
parenteral nutritional support is preferred. However, once the
sepsis is controlled and the patient is stabilized, enteral feed-
ings are initiated. Enteral feedings preserve the intestinal
mucosal barrier, improve immunologic function, and avoid
central-line sepsis.
Initially, an abdominopelvic CT study with oral and intra-
venous contrast is performed. This provides valuable infor-
mation about undrained collections, bowel length, and the
integrity of the anterior abdominal wall. An appropriately
performed small bowel X-ray series is also helpful. In

289
Secondary procedures
confirmed. However, composite defects due to necrotizing
soft tissue loss or trauma may require serial debridements
to control the infectious process, establish the zone of injury,
or stabilize the patient before definitive reconstruction of the
abdominal wall.
Skin coverage is generally accomplished with local skin
advancement and occasionally requires a regional pedicled or
free flap with the most common donor site being the thigh or
back (Table 12.1). Options for pedicled flaps in the upper
abdomen include vertical rectus abdominis muscle flap
(VRAM), latissimus dorsi, and omental flaps. Thigh-based
flaps, such as anterolateral thigh, vastus lateralis, and tensor
fascia lata flaps, are able to reach the lower abdomen and flank
as pedicled flaps. If a pedicled flap is not available or feasible,
a thoracoepigastric bipedicled fasciocutaneous flap may
provide a local tissue alternative and avoid a free tissue
transfer. However, when the volume of tissue loss or the arc
of rotation needed precludes a pedicled flap transfer, a free
flap is required for soft-tissue coverage. The thigh can serve
as a source of fasciocutaneous flaps and myocutaneous flaps
that provide large skin paddles and significant muscle
volume.68 Recipient vessels in the lateral abdominal wall
include the deep inferior epigastric vessels, superior epigastric
vessels, internal mammary vessels, intercostal artery perfora-
tors, and thoracolumbar perforators. When no local recipient
vessels are available, vein grafts to the internal mammary or
femoral vessels may be required.
Table 12.1  Thigh-based and torso-based pedicled flaps used in abdominal wall reconstruction
Flap
Characteristics
Anterolateral
thigh flap
• Large surface area
• Minimal donor site morbidity
• Generally will reach the periumbilical area but has been reported to reach up to the costal margin
• Can reach the ipsilateral posterior superior iliac spine posteriorly and the contralateral fossa laterally
• Associated fascia may not be reliable for fascial reconstruction
Tensor fascia
lata flap
• Large skin paddle (15 × 40 cm)
• Skin can reach the periumbilical area, but distal skin necrosis is the main shortcoming when TFL is used in abdominal
wall reconstruction48,49
• Adding rectus femoris muscle to TFL with their surrounding fascia allows coverage of larger defects but is still
associated with skin necrosis50
Rectus
femoris flap
• Can be transferred as a muscle flap, musculocutaneous flap, or part of a combined thigh flap based on the lateral
circumflex femoral vessel
• Provides a long cylindrical muscle, approximately 6 cm wide, and can support a 12 × 20 cm skin island
Combined
thigh flaps
• “Subtotal thigh” flap takes advantage of the versatile lateral circumflex femoral vessel system and can include rectus
femoris, TFL, vastus lateralis, and/or ALT flap tissue
• Nearly the entire abdominal wall skin can be reconstructed with bilateral pedicled subtotal thigh flaps
• Fascial portion of these flaps can be used to repair fascial defects, but mesh is often preferred for reconstruction of
the musculofascia, with soft-tissue flaps used for coverage; thigh fascia may be less reliable and can tear along its
fibers
Rectus
abdominis
flap
• Skin paddle can be oriented vertically, horizontally, as an extended deep inferior epigastric artery flap
(musculocutaneous flap with lateral skin extension based on the periumbilical perforators), or as a flag flap (skin from
the upper abdomen with extensions to the inframammary fold and the anterior axillary line)51–54
• Useful for defects located at the periphery of the abdominal wall
• Generally should be avoided for large abdominal wall defects when the donor site would add to the primary defect
Latissimus
dorsi flap
• Arc of rotation of the flap allows coverage of superolateral abdominal wall defects
• Can be used as muscle or musculocutaneous flap
ALT, anterolateral thigh; TFL, tensor fascia lata.
(Adapted from Althubaiti G, Butler CE. Abdominal wall and chest wall reconstruction. Plast Reconstr Surg. 2014;133(5):688e–701e.)
Posterolateral abdominal defects
The anatomic boundaries of the posterior abdominal wall that
abut the posterior retroperitoneum include the paraspinous,
quadratus lumborum, and iliopsoas muscles. When these
muscular layers have been resected, divided, or denervated,
their integrity must be restored to prevent a lumbar hernia or
bulge.69 The goal is to support the retroperitoneal viscera and
redefine the retroperitoneal reflection to prevent solid organ
migration and adrenal or kidney and colon herniation. A true
mesh inlay repair may not be feasible owing to the proximity
of important neurovascular structures (posteromedial inser-
tion of diaphragm, spine, aorta, and vena cava) to the retro-
peritoneal defect. In this situation, mesh can be placed in an
onlay fashion. When significant dead space exists after rein-
forcement of the retroperitoneal boundary, a soft-tissue flap
can be included to obliterate the dead space and buttress the
mesh repair externally. In cases of prior radiation, prior
surgery, or excessive skin resection, a pedicled regional or
free flap may be required to provide adequate soft-tissue
coverage.
Parastomal hernia repair
A parastomal hernia is an incisional hernia defect at the site
where the intestine traverses the abdominal wall to create a
stoma.70 Parastomal hernias are a common early complication

290
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CHAPTER 12 • Abdominal wall reconstruction
of stoma formation, with the majority forming 1–2 years after
ostomy.71 The incidence of parastomal hernia varies from
0–39%; the smallest incidence is after loop ileostomy and the
greatest after end colostomy. The majority of parastomal
hernias are asymptomatic, causing only a cosmetic contour
deformity, and therefore can be treated conservatively. Given
the challenges in repairing parastomal hernias and the high
recurrence rates, surgical intervention should be reserved for
hernias that disrupt the ostomy appliance and cause chronic
pain, skin breakdown, or intestinal obstruction, incarceration,
or strangulation. Reinforcement (either prophylactically or in
the treatment of parastomal hernias) with inlay mesh place-
ment in a preperitoneal or intraperitoneal plane has been
adopted to further reduce the risk of parastomal hernia.
Randomized controlled trials comparing the benefits and
risks of mesh reinforcement of stomas with conventional
methods of stoma formation have shown that mesh reinforce-
ment reduces parastomal herniation (relative risk [RR] 0.23,
95% CI 0.06–0.81; P=0.02) and the percentage of parastomal
hernias requiring surgical intervention (RR 0.13, 95% CI
0.02–1.02; P=0.05) compared with conventional stoma forma-
tion.69 Surgical treatment options for parastomal hernias may
include relocation of the stoma or in situ repair of the hernia
with or without mesh reinforcement. Repair of the original
parastomal defect site with fascial closure and inlay mesh
reinforcement, as well as prophylactic reinforcement of a
newly created stomal site with mesh, are key to minimizing
the risk of parastomal reherniation. Two techniques of intra-
peritoneal mesh placement are most often used to repair
parastomal hernia defects: the keyhole technique and the
Sugarbaker technique. The keyhole technique, described in
1977 by Rosin and Bonardi,72 is performed by placing the
bowel through a circular opening in the mesh. The benefit of
the technique is that the non-yielding mesh reinforces the
attenuated myofascia. The downside of this technique is that
the bowel passes perpendicular to the mesh plane, and there
is a small area between the bowel serosa and the mesh ring
through which the intra-abdominal contents can migrate. In
1985, Sugarbaker73 described placing a single uncut piece of
mesh as an intraperitoneal patch over the parastomal defect
and then lateralizing the bowel so as to allow the stoma site
to be covered by the mesh (Fig. 12.7). Thus the stoma did not
traverse the plane of the mesh repair in a perpendicular
fashion but traveled parallel to the mesh before traversing the
Fig. 12.7  Sugarbaker parastomal hernia repair. The
parastomal hernia annulus is closed and supported
by a mesh inlay, directing the bowel laterally and
parallel with the abdominal wall. This redirection of
the end ostomy reduces the risk of other bowel
loops disrupting the plane between the end ostomy
and the posterior rectus sheath. (From Rosen M.
Atlas of Abdominal Wall Reconstruction,
pp. 15–195. © Elsevier, 2012.)
Initial closure of defect
Order of cardinal transfascial
suture placement (1–4)
Lateral mobilization
of stoma
Final mesh fixture with tacks
Bowel sutured
to lateral
abdominal wall
4
2
1
3

291
Conclusion
Conclusion
Given the ever-growing problem of obesity and the increasing
complexity of hernia defects, abdominal wall reconstruction
remains a challenging and evolving discipline for reconstruc-
tive surgeons. The development of national hernia registries
and multispecialty collaborative groups is helping to stan-
dardize outcome reporting for ventral hernias. Proper surgical
technique and patient selection are essential to the successful
and durable treatment of the abdominal wall. Further refine-
ments and prospective comparative trials of these procedures
is needed to reduce wound morbidity, minimize complica-
tions, and define optimal long-term durable repairs.
abdominal wall. Avoiding direct passage of the bowel through
the mesh led to a reduction in rates of both asymptomatic
recurrences and those requiring reoperation. The Sugarbaker
repair can be performed by open or laparoscopic approaches.
An extensive meta-analysis of more than 30 studies, both
retrospective and prospective, showed that direct suture
repair results in a significantly increased recurrence rate when
compared with the keyhole or Sugarbaker mesh repair tech-
niques (OR 8.9, 95% CI 5.2–15.1; P=0.0001).74 Recurrence rates
for keyhole and Sugarbaker mesh repairs have ranged from
6.9% to 17% and do not differ significantly. These findings
support the use of a mesh-reinforced parastomal hernia repair
technique individualized to the patient’s defect and comor-
bidities and the surgeon’s preference.
3. 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. Ramirez and colleagues
introduce the concept of musculofascial advancement flaps based upon an
anatomic understanding of the fascial planes of the abdominal wall.
Cadaver dissections of the abdominal wall were performed to determine the
amount of mobilization possible by dissecting layers vs. the entire rectus
complex as a block. Mobilization of the rectus complex allowed for the
ability to achieve complete fascial coaptation even with wide fascial defects
that previously would have been bridged or required distant muscle flaps.
This novel concept is now the standard of care and an indispensable
technique in hernia repair.
4. Luijendijk RW, Hop WC, van den Tol MP, et al. A comparison of
suture repair with mesh repair for incisional hernia. N Engl J Med.
2000;343(6):392–398. Luijendijk and colleagues performed a prospective
multi-institutional European study evaluating 200 cases of primary hernia
repair vs. repairs reinforced with mesh. Retrofascial preperitoneal repair
with polypropylene mesh was found to be significantly superior to suture
repair alone with regard to the recurrence of hernia, even in patients with
small defects, at both early and late follow-up. Mesh reinforcement of
fascial closure is now the standard for care in hernia repair based upon
this landmark article.
25. Breuing K, Butler CE, Ferzoco S, et al. Incisional ventral hernias:
review of the literature and recommendations regarding the
grading and technique of repair. Surgery. 2010;148(3):544–558.
Breuing and colleagues proposed a grading system of ventral hernias based
upon complexity as a surrogate for likelihood of recurrence. The Ventral
Hernia Working Group (VHWG) developed a grading system that takes
into account underlying patient comorbidities and the presence of wound
contamination during the repair. In the VHWG system, grade 1 includes
hernias in patients with a low risk of complications and no history of
wound infection. Grade 2 includes hernias in patients who smoke or have
chronic obstructive pulmonary disease, and are obese, diabetic, or
immunosuppressed. Grade 3 includes hernias in patients with a previous
wound infection, stoma, or violation of the gastrointestinal tract (i.e.,
hernias in potentially contaminated surgical fields). Finally, grade 4
includes hernias in patients with infected mesh or septic dehiscence of
their wound. Based on this classification system, the VHWG recommended
the use of synthetic mesh for grade 1 and bioprosthetic mesh for grades 3
and 4 hernias. The grading system has yet to be formally validated.
26. 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,
discussion 328.
40. Itani KM, Rosen M, Vargo D, et al. Prospective study of single-stage
repair of contaminated hernias using a biologic porcine tissue
matrix: the RICH Study. Surgery. 2012;152(3):498–505. Itani and
colleagues performed a prospective multi-institutional study to describe
the outcomes of ventral hernia repair in high-risk contaminated patients.
Out of 80 patients undergoing open ventral hernia repair with a porcine
bioprosthetic mesh reinforcement, defects were classified as “clean-
contaminated” (n = 39), “contaminated” (n=39), or “dirty” (n=2). At 24
months, 53 patients (66%) experienced 95 wound events. There were 28
unique, infection-related events in 24 patients. Twenty-two patients
experienced seromas, all but 5 of which were transient and required no
intervention. No unanticipated adverse events occurred, and no tissue
matrix required complete excision. There were 22 hernia (28%)
recurrences by month 24. The study advocated the use of non-cross-linked,
porcine, acellular dermal matrix in the repair of contaminated ventral
hernia in high-risk patients.
43. Albino FP, Patel KM, Nahabedian MY, et al. Does mesh location
matter in abdominal wall reconstruction? A systematic review of
the literature and a summary of recommendations. Plast Reconstr
Surg. 2013;132(5):1295–1304.
45. Iqbal CW, Pham TH, Joseph A, et al. Long-term outcome of 254
complex incisional hernia repairs using the modified Rives–Stoppa
technique. World J Surg. 2007;31(12):2398–2404.
47. Butler CE, Campbell KT. Minimally invasive component separation
with inlay bioprosthetic mesh (MICSIB) for complex abdominal
wall reconstruction. Plast Reconstr Surg. 2011;128(3):698–709.
66. 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. In a series of 135 patients with ECFs,
Visschers and colleagues64 reported successful restoration of
gastrointestinal tract continuity in 91% of patients, with a 9.6%
mortality rate, despite fairly early surgical repair (mean of 53 days from
ECF development). Among 53 patients with concomitant abdominal wall
defects, 77% required surgical intervention for closure, and the mortality
rate was 15%. Among the 82 patients without an abdominal wall defect,
the mortality rate was only 6%. Malnutrition was correlated with failure
of surgical closure and increased mortality rates. The manuscript
highlights the essential management of ECFs including control of sepsis,
optimization of nutritional status, wound care, assessment of fistula
anatomy, timing of surgery, and surgical strategy.
Access the complete reference list online at

291.e1
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study. Plast Reconstr Surg. 1990;86(3):519–526. Ramirez and colleagues
introduce the concept of musculofascial advancement flaps based upon an
anatomic understanding of the fascial planes of the abdominal wall.
Cadaver dissections of the abdominal wall were performed to determine the
amount of mobilization possible by dissecting layers vs. the entire rectus
complex as a block. Mobilization of the rectus complex allowed for the
ability to achieve complete fascial coaptation even with wide fascial defects
that previously would have been bridged or required distant muscle flaps.
This novel concept is now the standard of care and an indispensable
technique in hernia repair.
4. Luijendijk RW, Hop WC, van den Tol MP, et al. A comparison of
suture repair with mesh repair for incisional hernia. N Engl J Med.
2000;343(6):392–398. Luijendijk and colleagues performed a prospective
multi-institutional European study evaluating 200 cases of primary hernia
repair vs. repairs reinforced with mesh. Retrofascial preperitoneal repair
with polypropylene mesh was found to be significantly superior to suture
repair alone with regard to the recurrence of hernia, even in patients with
small defects, at both early and late follow-up. Mesh reinforcement of
fascial closure is now the standard for care in hernia repair based upon
this landmark article.
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review of the literature and recommendations regarding the
grading and technique of repair. Surgery. 2010;148(3):544–558.
Breuing and colleagues proposed a grading system of ventral hernias based
upon complexity as a surrogate for likelihood of recurrence. The Ventral
Hernia Working Group (VHWG) developed a grading system that takes
into account underlying patient comorbidities and the presence of wound
contamination during the repair. In the VHWG system, grade 1 includes
hernias in patients with a low risk of complications and no history of
wound infection. Grade 2 includes hernias in patients who smoke or have
chronic obstructive pulmonary disease, and are obese, diabetic, or
immunosuppressed. Grade 3 includes hernias in patients with a previous
wound infection, stoma, or violation of the gastrointestinal tract (i.e.,
hernias in potentially contaminated surgical fields). Finally, grade 4
includes hernias in patients with infected mesh or septic dehiscence of
their wound. Based on this classification system, the VHWG recommended
the use of synthetic mesh for grade 1 and bioprosthetic mesh for grades 3
and 4 hernias. The grading system has yet to be formally validated.
26. 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,
discussion 328.
27. Booth JH, Garvey PB, Baumann DP, et al. Primary fascial closure
with mesh reinforcement is superior to bridged mesh repair for
abdominal wall reconstruction. J Am Coll Surg. 2013;217(6):
999–1009.
28. Shestak KC, Edington HJ, Johnson RR. The separation of anatomic
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and limitations revisited. Plast Reconstr Surg. 2000;105(2):731–738.
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of a randomized controlled trial of suture versus mesh repair of
incisional hernia. Ann Surg. 2004;240(4):578–585.
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large midline incisional hernias with polypropylene mesh:
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2008;88(1):1–15, vii.
34. Carlson MA, Ludwig KA, Condon RE. Ventral hernia and other
complications of 1,000 midline incisions. South Med J.
1995;88(4):450–453.
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1998;133:378–382.
37. Burns NK, Jaffari MV, Rios CN, et al. Non-cross-linked porcine
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39. Butler CE, Prieto VG. Reduction of adhesions with composite
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40. Itani KM, Rosen M, Vargo D, et al. Prospective study of single-stage
repair of contaminated hernias using a biologic porcine tissue
matrix: the RICH Study. Surgery. 2012;152(3):498–505. Itani and
colleagues performed a prospective multi-institutional study to describe

291.e2
SECTION II
CHAPTER 12 • Abdominal wall reconstruction
the outcomes of ventral hernia repair in high-risk contaminated patients.
Out of 80 patients undergoing open ventral hernia repair with a porcine
bioprosthetic mesh reinforcement, defects were classified as “clean-
contaminated” (n = 39), “contaminated” (n=39), or “dirty” (n=2). At 24
months, 53 patients (66%) experienced 95 wound events. There were 28
unique, infection-related events in 24 patients. Twenty-two patients
experienced seromas, all but 5 of which were transient and required no
intervention. No unanticipated adverse events occurred, and no tissue
matrix required complete excision. There were 22 hernia (28%)
recurrences by month 24. The study advocated the use of non-cross-linked,
porcine, acellular dermal matrix in the repair of contaminated ventral
hernia in high-risk patients.
41. Blatnik J, Jin J, Rosen M. Abdominal hernia repair with bridging
acellular dermal matrix—an expensive hernia sac. Am J Surg.
2008;196(1):47–50.
42. Clemens MW, Selber JC, Liu J, et al. Bovine versus porcine acellular
dermal matrix for complex abdominal wall reconstruction. Plast
Reconstr Surg. 2013;131(1):71–79.
43. Albino FP, Patel KM, Nahabedian MY, et al. Does mesh location
matter in abdominal wall reconstruction? A systematic review of
the literature and a summary of recommendations. Plast Reconstr
Surg. 2013;132(5):1295–1304.
44. Clemens M, Downey S, Agullo F, et al. Clinical application of a silk
fibroin protein biologic scaffold for abdominal wall fascial
reinforcement. Plast Reconstr Surg Glob Open. 2014;2:e246.
45. Iqbal CW, Pham TH, Joseph A, et al. Long-term outcome of 254
complex incisional hernia repairs using the modified Rives–Stoppa
technique. World J Surg. 2007;31(12):2398–2404.
46. 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.
47. Butler CE, Campbell KT. Minimally invasive component separation
with inlay bioprosthetic mesh (MICSIB) for complex abdominal
wall reconstruction. Plast Reconstr Surg. 2011;128(3):698–709.
48. Sukkar SM, Dumanian GA, Szczerba SM, et al. Challenging
abdominal wall defects. Am J Surg. 2001;181(2):115–121.
49. Ghali S, Turza KC, Baumann DP, et al. 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.
50. 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.
51. Maas SM, de Vries RS, van Goor H, et al. Endoscopically assisted
“components separation technique” for the repair of complicated
ventral hernias. J Am Coll Surg. 2002;194(3):388–390.
52. Schaverien M, Saint-Cyr M, Arbique G, et al. Arterial and venous
anatomies of the deep inferior epigastric perforator and superficial
inferior epigastric artery flaps. Plast Reconstr Surg.
2008;121(6):1909–1919.
53. Saulis AS, Dumanian GA. Periumbilical rectus abdominis perforator
preservation significantly reduces superficial wound complications
in “separation of parts” hernia repairs. Plast Reconstr Surg.
2002;109(7):2275–2280, discussion 2281–2272.
54. Krpata DM, Blatnik JA, Novitsky YW, et al. Posterior and open
anterior components separations: a comparative analysis. Am J
Surg. 2012;203(3):318–322, discussion 322.
55. Pannucci CJ, Bailey SH, Dreszer G, et al. Validation of the Caprini
risk assessment model in plastic and reconstructive surgery
patients. J Am Coll Surg. 2011;212(1):105–112.
56. Pannucci CJ, Barta RJ, Portschy PR, et al. Assessment of
postoperative venous thromboembolism risk in plastic surgery
patients using the 2005 and 2010 Caprini Risk Score. Plast Reconstr
Surg. 2012;130(2):343–353.
57. Flum DR, Horvath K, Koepsell T. Have outcomes of incisional
hernia repair improved with time? A population-based analysis.
Ann Surg. 2003;237:129–135.
58. Janis JE, O’Neill AC, Ahmad J, et al. Acellular dermal matrices in
abdominal wall reconstruction: a systematic review of the current
evidence. Plast Reconstr Surg. 2012;130(5, suppl 2):183S–193S.
59. Zhong T, Janis JE, Ahmad J, et al. Outcomes after abdominal wall
reconstruction using acellular dermal matrix: a systematic review. J
Plast Reconstr Aesthet Surg. 2011;64(12):1562–1571.
60. 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,
discussion 328.
61. Cevasco M, Itani KM. Ventral hernia repair with synthetic,
composite, and biologic mesh: characteristics, indications, and
infection profile. Surg Infect (Larchmt). 2012;13(4):209–215.
62. Conze J, Kingsnorth AN, Flament JB, et al. Randomized clinical trial
comparing lightweight composite mesh with polyester or
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2005;92(12):1488–1493.
63. Harrell AG, Novitsky YW, Kercher KW, et al. In vitro infectability of
prosthetic mesh by methicillin-resistant Staphylococcus aureus.
Hernia. 2006;10(2):120–124.
64. Engelsman AF, van der Mei HC, Busscher HJ, et al. Morphological
aspects of surgical meshes as a risk factor for bacterial colonization.
Br J Surg. 2008;95(8):1051–1059.
65. Butler CE. Treatment of refractory donor-site seromas with
percutaneous instillation of fibrin sealant. Plast Reconstr Surg.
2006;117(3):976–985.
66. 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. In a series of 135 patients with ECFs,
Visschers and colleagues64 reported successful restoration of
gastrointestinal tract continuity in 91% of patients, with a 9.6%
mortality rate, despite fairly early surgical repair (mean of 53 days from
ECF development). Among 53 patients with concomitant abdominal wall
defects, 77% required surgical intervention for closure, and the mortality
rate was 15%. Among the 82 patients without an abdominal wall defect,
the mortality rate was only 6%. Malnutrition was correlated with failure
of surgical closure and increased mortality rates. The manuscript
highlights the essential management of ECFs including control of sepsis,
optimization of nutritional status, wound care, assessment of fistula
anatomy, timing of surgery, and surgical strategy.
67. Wind J, van Koperen PJ, Slors JF, Bemelman WA. Single-stage
closure of enterocutaneous fistula and stomas in the presence of
large abdominal wall defects using the components separation
technique. Am J Surg. 2009;197(1):24–29.
68. Lin SJ, Butler CE. Subtotal thigh flap and bioprosthetic mesh
reconstruction for large, composite abdominal wall defects. Plast
Reconstr Surg. 2010;125(4):1146–1156.
69. Baumann DP, Butler CE. Lateral abdominal wall reconstruction.
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72. Rosin JD, Bonardi RA. Paracolostomy hernia repair with Marlex
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74. Wijeyekoon SP, Gurusamy K, El-Gendy K, et al. Prevention of
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systematic review and meta-analysis of randomized controlled
trials. J Am Coll Surg. 2010;211(5):637–645.

SECTION II • Trunk Surgery
13 
Reconstruction of male genital defects
Stan Monstrey, Salvatore D’Arpa, Karel Claes, Nicolas Lumen, and Piet Hoebeke
SYNOPSIS
This chapter deals with the following topics:
■ Genital embryology and anatomy.
■ Congenital genital defects:
• exstrophy and epispadias
• disorders of sex development (DSD)
• buried penis and micropenis
• reconstructive options for penile insufficiency.
■ Post-traumatic genital defects:
• general reconstructive options: skin grafts, pedicled flaps,
microsurgical genital reconstruction
• specific indications: Fournier’s gangrene and penile cancer.
■ Reconstruction of male genitalia in the female-to-male (FTM)
transsexual:
• vaginectomy, reconstruction of the fixed urethra, and scrotoplasty
• metoidioplasty
• complete phallic reconstruction: radial forearm phalloplasty and
alternative phalloplasty techniques such as perforator flaps, fibula
flap, and muscle flaps.
Introduction
Reconstructive surgery of the male genitalia is performed
within a genitourinary reconstructive team: plastic surgeons,
urologists, colorectal surgeons, gynecologists, and orthopedic
surgeons. The essence of a reconstructive team is reflected
in this chapter, which is the collaborative work of plastic
surgeons and urologists. Plastic surgery techniques and
traditions continue to play an important role in the recon-
structive armamentarium of all who intend to repair genital
defects.
In this chapter, we first discuss the relevant (genital)
embryology and anatomy, then provide a complete overview
of congenital and acquired genital deformities, and finally
present the scope of past and current surgical techniques that
may be used to accomplish the reconstructive goals.
Basic science: genital embryology
and anatomy
Genital embryology
Genetic sex
Genetic sex of the embryo is established at conception. The
ovum, containing 22 autosomes and an X chromosome, is
penetrated by one of the surrounding spermatozoa, half of
which have an X chromosome and the other half have a Y
chromosome, and receives an X or Y chromosome, thereby
establishing genetic sexual assignment.
The embryos of both sexes develop identically for approxi-
mately 6 weeks’ gestation, the indifferent stage. During this
time, the embryo becomes tubularized as the primitive gut is
formed to terminate in the cloacal membrane. At the 6th week,
the urorectal septum begins to grow downward and inward
from the sides into the cloacal cavity, separating the cloaca
into the bladder and rectum.
Externally, a mound of mesoderm with a midline
groove, known as the indifferent genital tubercle, develops
cephalocaudal to the cloacal membrane. As the midline
mesenchyme progressively fuses in a caudal direction from
the umbilicus, the genital primordials fuse to form a genital
eminence.
Gonadal sex
Gonadal sex (differentiated stage) begins at the 7th week of
intrauterine life. Evidence suggests that a locus on the Y
chromosome (H-Y antigen) induces testicular development
by causing differentiation of the seminiferous tubules. Today,
many genes are described that play a role in male gonadal
  Access video content for this chapter online at expertconsult.com

293
Basic science: genital embryology and anatomy
erections. The tunica albuginea envelops the corporal bodies
tightly but is perforated by an intercavernosal membranous
septum that allows blood flow between the corpora. The
tunical tissues are thick over the dorsal and lateral aspects of
each corporal body but thin out in the ventral sulcus – where
the urethra and corpus spongiosum are located – and also
beneath the glans penis cap so as to have direct vascular
contact with the glans.
Overlying the tunica is the deep penile fascia (Buck’s
fascia), a strong laminar structure that tightly surrounds and
binds the corpora cavernosa together and the corpus spongio-
sum into a single-functioning entity. The urethra and its
overlying corpus spongiosum are also protected proximally
by surrounding muscles and distally by their location within
the intercorporal groove. Buck’s fascia carries important
neurovascular structures to the glans penis, including the
deep dorsal vein and arteries, the deep dorsal nerves of the
penis, the circumflex arteries and veins, and the penile lym-
phatics (Fig. 13.2).1
The penile glans itself is a vascular spongiosa containing
unique erogenous and tactile sensory endings. The glans
epithelium is a unique uroepithelium that contains sensory
Fig. 13.1  The definitive phenotypic external genital growth that occurs in utero
under the influence (or absence) of testosterone, dihydrotestosterone, and
5a-reductase. The influence of these virilizing hormones causes the genital tubercle
to enlarge, the urethral folds to meet and close ventrally, and the scrotum to
migrate medially and posteriorly. Any hormone deficit or receptor site inadequacy
leads to an external female genitalia tendency (“phenotype by default”).
Undifferentiated
Fully developed
Male
45–50 mm
Female
development, such as SRY, SOX9, AMH, SF1, DHH, ATRX,
and DMRT.
Triiodothyronine (T3) endocrine hormones explain male
differentiation. The first is Müllerian-inhibiting factor pro-
duced transiently by the Sertoli cells in the seminiferous
tubules, which causes regression of the Müllerian duct system
(9–11 weeks). The second is a testosterone homologue, pro-
duced at the same time by Leydig cells in the seminiferous
tubules, that plays two roles: (1) completion of maturation of
the seminiferous tubules, epididymides, vasa deferentia, and
seminal vesicles, and (2) extratesticular male development by
irreversible reduction to dihydrotestosterone by 5a-reductase.
The third is dihydrotestosterone, responsible for virilization
of the external genitalia and the anterior urethra.
Phenotypic sex
Phenotypic sex is determined by whether the genital tubercle
develops into a male or female pattern. In males, urogenital
swellings migrate ventrally and anteriorly to form the scrotum.
The genital tubercle develops by elongation and cylindrical
growth. The urethral folds close over the urethral groove,
thereby establishing a urethra and a midline raphe. Mesen-
chymal tissue coalesces to surround the urethra and form the
corpus spongiosum. This development is entirely under the
influence (or absence) of testosterone, testosterone derivatives
(i.e., dihydrotestosterone), and 5a-reductase and occurs
between 6 and 13 weeks’ gestation (Fig. 13.1). The prepuce
grows to cover the penile glans but is not influenced by
dihydrotestosterone.
In females, the lack of testosterone-influenced virilization
holds the urogenital sinus and the genital tubercle in a fixed
perineal position. The urethral groove remains open (folds
develop into labia minora), and the genital tubercle remains
stable in size and bends ventrally. The labia majora enlarge,
migrate caudally, and fuse to form the posterior fourchette.
This lack of closure of the ventral urethra (a nonevent) causes
the female perineum to be shorter and the introitus to be more
caudally positioned.
Genital anatomy
Male genital anatomy is unique in the human body and has
evolved phylogenetically for protection from trauma and
disease and to warrant procreation.
Genital fascia
The most obvious protective mechanism is testicular (and
penile) withdrawal on exposure to physical stress (like hypo-
thermia or blunt trauma), which causes the unique cremasteric
muscles to contract, withdrawing the testicles and shrinking
the scrotum as close to the body as possible. Otherwise, the
testicles hang free, ostensibly to provide the best environment
for sperm development. At the same time, the penile corporal
bodies and the urethra also retract and shrink in size, although
the penile skin does not have the same retraction properties
as the scrotal skin. The penis and the scrotum have redundant
skin coverage with their own separate blood supply and
underlying supportive superficial fascial system.
The penis contains specially designed tunical tissues that
surround the corporal bodies and can expand and, along with
venous valve mechanisms, prevent blood outflow during

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SECTION II
CHAPTER 13 • Reconstruction of male genital defects
continuing as common penile arteries. After exiting from
Alcock’s canal (a split in the obturator fascia that runs from
the lesser sciatic foramen to the ischial tuberosity along the
sidewall of the ischiorectal fossa), each common penile artery
gives off three branches (bulbar, urethral, and cavernosal)
and terminates in the dorsal artery of the penis, which runs
within Buck’s fascia distally to terminate in the balanic arter-
ies. Within Buck’s fascia, the dorsal penile arteries are coiled
and tortuous compared with the deep dorsal vein, which is
linear and straight. This anatomy may be related to erectile
function (Fig. 13.3).3
The perineal branch of the pudendal artery is just superfi-
cial to Colles’ fascia and has an unpredictable length, but its
central location and strong collateral supply make it a main-
stay of genitourinary flap reconstruction. The scrotal branch
of the perineal artery passes along the fold between the lateral
scrotum and the medial thigh and arborizes within the tunica
dartos (Fig. 13.4).
The superficial system originates from the superficial
external pudendal arteries – branches of the femoral arteries.
The femoral artery typically gives off a superficial external
pudendal artery and a deep external pudendal artery. The
superficial external pudendal artery supplies vascularity to
the dartos fascia and genital skin. The deep external pudendal
artery arises as a separate branch and passes into the genital
skin as the lateral inferior pudendal artery, which separates
into a dorsolateral branch supplying the dorsal and lateral
penile shaft skin and an inferior branch supplying the ventral
penile skin and the anterior plane of the scrotum (the anterior
scrotal artery) (Fig. 13.5). This arrangement allows surgeons
to elevate long axial and transverse flaps with relative safety
and still cover the shaft donor site with the adjacent skin.
The penile venous system also has a dual blood supply. The
superficial system arises from the distal penile shaft and passes
cells, particularly around the corona. The glans is naturally
covered and protected by a prepuce made of inner and outer
laminae. The inner lamina consists of uroepithelium similar
to that of the glans and, in fact, it developmentally separates
from the glans in the last trimester and after birth. The outer
lamina consists of the same epithelium as the glabrous skin
of the penile shaft. Superficial to Buck’s fascia, but beneath
the penile shaft skin and prepuce, is the superficial fascial
system, defined by Dartos fascia. This fascial layer is a con-
tinuation of Scarpa’s fascia superiorly and Colles’ fascia
inferiorly and surrounds the penis from the penoscrotal and
peno-pubic angles to the prepuce.
The Dartos contains its own vascular plexus that allows
overlying skin islands to be elevated on its independent blood
supply.
Colles’ fascia is a deep, tight, triangular fascial system that
arises laterally from the inferior pelvic rami and posteriorly
from the perineal membrane to protect the genitalia from
toxins, trauma, and infections (and envelops both testicles
circumferentially, as the Dartos). Colles’ fascia is analogous to
the Dartos on the penis, and thus skin island flaps can be
elevated on its vascular plexus (see Fig. 9.11).2
Overlying both testicles, the epididymides, and the cord
structures is a loose, well-vascularized superficial fascial
layer: the tunica vaginalis that wraps the testicles. The parietal
tunica vaginalis acts as the “vaginal space”, which can be
likened to the peritoneal cavity. Although the testicles are
anchored within the scrotum, they move separately and
independently on their cremasteric systems. The neurovascu-
lar supply to the testicles is dedicated to the viability of the
testicles, epididymides, and cord structures (vasa deferentia)
as well as to continued sperm production.
Genital blood supply
The genitalia have two separate arterial systems. The deep
system originates from the deep internal pudendal artery.
The paired pudendal arteries originate from the internal iliac
arteries, pass along the borders of the inferior pelvic rami,
and then give off the perineal and scrotal branches before
Fig. 13.2  A cross-section of the penile shaft illustrates the superficial and deep
fascial layers and their relationships to the corporal bodies and neurovascular
structures. (From: Quartey JK. Microcirculation of penile and scrotal skin. Atlas Urol
Clin North Am. 1997;5:1–9.)
Dorsal artery
Deep dorsal vein
Superficial dorsal vein
Dorsal nerves
Skin
Dartos fascia
Buck’s fascia
Tunica albuginea
Corpus cavernosum
Corpus spongiosum
Fig. 13.3  The deep arterial vascularization to the penis arises from branches of the
common penile arteries. (From: Quartey JK. Microcirculation of penile and scrotal
skin. Atlas Urol Clin North Am. 1997;5:1–9.)
Circumflex artery
Dorsal artery
Cavernosal artery
Urethral
artery
Common
penile artery
Bulbar artery

295
Basic science: genital embryology and anatomy
to the superficial dorsal vein within the dartos to drain the
penile shaft skin. In approximately 70% of anatomic studies,
the superficial dorsal vein empties into the left saphenous
vein. Other vascular patterns include connections into the
right saphenous vein (10%), left femoral vein (7%), and infe-
rior epigastric vein (3%); in 10%, the superficial dorsal veins
empty into the saphenous veins bilaterally. The deep venous
system drains the circumflex veins, the deep dorsal vein into
the prosthetic plexus and the crural and cavernosal veins into
the internal pudendal veins (Fig. 13.6).
The vasa deferentia, epididymides, and testes are vas-
cularized from the retroperitoneal blood supply, primarily
Fig. 13.5  The deep external pudendal vascular system
arises from the femoral artery and empties into the
saphenous vein. The vessel passes onto the penile shaft
and anterior scrotum to vascularize the skin and dartos
fascia. (From: Jordan GH, Stack RS. General concepts
concerning the use of genital skin islands for anterior
urethral reconstruction. Atlas Urol Clin North Am.
1997;5:23–44.)
Superficial external
pudendal vein
Superficial
external pudendal
artery
Femoral artery
and vein
Deep external
pudendal artery
Saphenous vein
Ventro-lateral
branch artery
Dorso-lateral
branch artery
Fig. 13.4  The internal pudendal artery exits Alcock’s canal and then
divides into the posterior scrotal and perineal arteries. The perineal
artery closely follows the crural reflection of Colles’ fascia. This
anatomy is favorable to dissection, elevation, and transposition of
fasciocutaneous flaps that can be rotated into the perineum. (From:
Jordan GH, Stack RS. General concepts concerning the use of genital
skin islands for anterior urethral reconstruction. Atlas Urol Clin North
Am. 1997;5:23–44.)
Posterior
scrotal artery
Perineal artery
Deep penile artery
Internal pudendal
artery
the spermatic artery, which originates from the aorta, and
the deferential artery, which supplies the vas deferens. In
addition, collateral blood supply from the retroperitoneal
cremasteric artery follows the vas to become the vasal artery.
As the spermatic artery approaches the testis, it divides into
the internal testicular artery (which supplies the testis and
the adjacent epididymal head and body) and the inferior tes-
ticular artery, which passes within the testis. The epididymal
tail is supplied by branches of the epididymal, vasal, and
testicular arteries.4
The veins form the pampiniform plexus, which coalesces
around the testis and epididymis to flow into the testicular

296
SECTION II
CHAPTER 13 • Reconstruction of male genital defects
scrotal branches of the ilioinguinal nerve, the genital branches
of the genitofemoral nerve (anterior scrotum), and the
posterior scrotal branch of the pudendal nerve (posterior
scrotum).
Genital lymphatics
Lymphatics of the glans and urethra form a plexus on the
ventral side before draining in the deep vein, passing proxi-
mally to the superficial inguinal nodes with the distal urethral
lymphatics. Some lymphatics also drain in the deep inguinal
nodes. The proximal spongy and membranous urethra drains
into the external iliac nodes. The lymphatics of the testicles
are contained in the spermatic cord and drain in the aortocaval
nodes.
Congenital genital defects
Exstrophy and epispadias
Exstrophy of the bladder is an uncommon condition (1/30 000
live births, boys/girls = 3 : 1). The defining features are an open
and protruding bladder, an open urethra, and a foreshortened
epispadiac penis (Fig. 13.7). The associated spectrum of
anomalies may extend to involve the musculoskeletal struc-
tures and the gastrointestinal tract. Classic exstrophy – defined
by bladder exstrophy, epispadias, diastasis recti, absence
of fusion of the pubic symphysis, and deformed pubic
escutcheon – occurs in 60% of cases; epispadias alone
occurs in 30% of cases, and 10% of cases are more extensive
dysmorphias including cloacal exstrophy.
The etiology of exstrophy–epispadias is controversial. It
occurs in early gestation between the 3rd and 9th week, but
veins. The testicular veins then pass in a retroperitoneal plane
to empty into the inferior vena cava on the right side and the
left renal vein on the left side.
Genital nerve supply
Genital nerves also arise from a dual source and run with the
arteries. The pudendal nerve is a mixed motor, sensory, and
autonomic nerve that originates from the sacral roots (S2–4),
and is the main penile sensory nerve: it passes through the
greater sciatic foramen and crosses the pelvic floor to enter
the pudendal canal anteriorly, after giving off the inferior
rectal nerve, supplying the rectal sphincter and anal skin and
conducting the cavernosal reflex before entering Alcock’s
(pudendal) canal. As the nerve exits Alcock’s canal and passes
close to the crural tips of the corporal bodies, it divides into
the perineal nerve and the dorsal nerve of the penis. The peri-
neal nerve supplies the perineal muscles, the deep structures
of the urogenital region, and the posterior scrotal skin. The
dorsal nerve of the penis gives off a proximal nerve to the
urethra before arborizing into its penile branches. Branches of
the nerve pass around the penile shaft within Buck’s fascia to
innervate the distal shaft and inner lamina of the prepuce and
the glans as the major tactile and erogenous source of the
penis.
The dorsal nerve of the penis does not provide sensation
to the penile shaft. Only the internal preputial plate contains
branches of the dorsal nerve of the penis.
The shaft is innervated by ancillary erogenous nerves,
including the ilioinguinal nerves, which exit through the
external inguinal rings and then innervate the anterior
scrotum and the penile shaft skin circumferentially to the
level of the prepuce, and branches of the genitofemoral
nerves. The scrotum has multiple nerve supplies: the anterior
Fig. 13.6  The superficial dorsal vein of the penis usually empties into the left
saphenous system – an anatomic fact that must be taken into account when
planning fasciocutaneous flaps. (From: Jordan GH, Stack RS. General concepts
concerning the use of genital skin islands for anterior urethral reconstruction. Atlas
Urol Clin North Am. 1997;5:23–44.)
Superficial
dorsal vein
of penis
External
pudendal
artery and vein
Fig. 13.7  Exstrophy in a boy.

297
Congenital genital defects
loss is best prevented by neonatal preservation of the umbili-
cus and transposition to an abdominal position.8,9
In some boys there just is not enough tissue due to under-
development or partial or complete loss of penile tissue after
primary closure. These patients might be good candidates for
phallic reconstruction with free (Fig. 13.9) or pedicled flaps
(see below, Fig. 13.12A–C).
Most of these patients have some form of urinary diversion
and therefore a non-functional urethra. Although ejaculatory
ducts are mostly intact, they are often abnormally positioned
as a prepubic fistula. As a consequence sperm production
is unpredictable and most of these patients are unable to
it does not represent an arrest of a normal fetal developmental
stage. It is associated with the normal formation and retrac-
tion of the cloacal membrane. In the normal fetus, a mesoder-
mal layer of tissue spreads medially to replace the thin cloacal
membrane by the 9th week in utero. According to Muecke’s
theory,5 the cloacal membrane persists and resists any medial
migration of mesoderm. The membrane then ruptures, pro-
ducing a lack of mesodermal tissue to form the anterior
abdominal wall and endodermal tissue to form the anterior
wall of the bladder. This lack of mesodermal migration also
affects the musculoskeletal system: the pubic rami are widely
separated, and the inferior pubic rami are consequently later-
ally rotated. This defect produces a widened and foreshort-
ened urethra and bladder neck, an incompletely formed penis
that remains rudimentary and, by definition, is a phallus.
According to Mitchell and Bägli,6 the anomaly is that of a fetal
abdominal wall hernia and can be recreated in the laboratory
in chickens because they have a persistent cloaca by induction
of a localized vascular accident (J. Sumfest, pers. comm. 2002).
The crural bodies are attached to the splayed pubic tuber-
cles, producing a penis that is short, wide, and with dorsal
chordee. The corpora are shorter than in a normally developed
penis and, unlike in the normal anatomy, independent of
each other with no communication through the intercorporal
septum. The neurovascular structures to the glans are laterally
displaced but move medially at the distal end of the foreshort-
ened penis; the glans is spade shaped and incomplete, and
each side is totally dependent on the respective dorsal neuro-
vascular supply. Little circulation passes through the corporal
bodies into the glans. The separated pelvic ring also produces
a widened scrotum and incompetent pelvic musculature.
Therefore the perineum is short, and there is a patulous anus
that is anteriorly displaced. The rectus muscles are widely
separated, and inguinal hernias are the rule.
Although initial postnatal diagnosis and treatment of
bladder exstrophy and epispadias remain in the realm of the
pediatric urologist and pediatric orthopedic surgeon, it is
important that the plastic surgeon is prepared, if consulted, to
help reconstruct such a child. The goals of initial closure are to
reconstruct a functional genitourinary system, reduce the risk
of bladder squamous metaplasia, and close the pelvic ring by
direct closure of the bladder and reconstitution of the pelvic
ring. After neonatal closure of the exstrophy, there are asym-
metric pubic hairlines. This can easily be reconstructed by
creating and mobilizing skin flaps and correcting the pubic
hairline.
Different techniques have been described for penile recon-
struction6,7 and although the results of urethral closure have
drastically improved, the ideal surgical approach is still con-
troversial: neonatal vs. delayed closure and one stage vs.
multistage repair. Phallic length depends on antenatal devel-
opment, and the majority of these patients end up with small
and undeveloped penises, despite the best efforts of their
treating surgeons. As they pass through their postadolescent
period, many of these young men will benefit from further
lengthening procedures or even complete penile reconstruc-
tion. In some patients, correction of unaesthetic scars and
further release of insufficiently released corpora can help to
gain length (Fig. 13.8).
Exstrophy patients miss an umbilicus and are often con-
sulting for umbilical reconstruction. Different techniques have
been described with good cosmetic outcomes, but umbilical
Fig. 13.8  A Z-plasty on the dorsal aspect of the penis extending into the prepubic
area can be useful to obtain maximal lengthening.
A
B

298
SECTION II
CHAPTER 13 • Reconstruction of male genital defects
46XY/46XX DSD
This classification refers to varying degrees of genital ambigu-
ity and presence of both male and female or dysgenetic
gonads. Reconstruction is done after gender assignment,
which is not always obvious. Multidisciplinary teams with
expertise in these pathologies are needed to guide diagnosis
and treatment in these children.
Genital conditions
This DSD classification includes conditions such as penile
agenesis, extreme penoscrotal transposition with rudimentary
penis, Mayer–Rokitansky–Kuster–Hauser with absence of
Müllerian duct derivates like vagina and uterus, cloacal
exstrophy, micropenis, and other genital malformations with
normal chromosomes and gonads. All these conditions will
eventually require genital reconstruction, although due to
their low prevalence, treatment is better centralized.
Buried penis
The buried penis deformity affects pediatric and adult popu-
lations. A buried penis is defined as a penis of normal size for
age that is hidden within the peripenile fat and subcutaneous
tissues (Fig. 13.10
).
Fig. 13.10 appears online only.
In the pediatric population, the fat deposit is often part of
the constellation of poor virilization. The abnormal mons fat
pad (gynecoid mons) may become associated with general-
ized obesity in the adolescent patient, and the buried penis
must be differentiated from a micropenis in this group. In
adults, the problem is almost always associated with obesity
and the development of pubic, scrotal, and peripubic ptosis,
which must be addressed to correct the hidden penis. Lipo-
suction and lipectomy are part of the treatment in adults,
procreate naturally. For these reasons, the urethral reconstruc-
tion may be a moot point in this group of patients, thus making
a phalloplasty, in these “boys without a penis”, much easier.
The different options and peculiarities for a phalloplasty in
an exstrophy patient will be addressed further in this chapter.
Disorders of sex development
(formerly “intersex”)
Intersex conditions are nowadays defined as disorders of
sexual development (DSD).10 DSDs are beyond the scope of
this chapter, and therefore only the conditions in which genital
reconstruction is needed will be described: genital ambiguity
and absence of Müllerian duct derived structures.
46XX DSD: over-virilized females
The most prevalent condition is congenital adrenal hyperpla-
sia (CAH) where a cortisol synthesis defect causes androgens
to be overproduced in a female. This leads to virilization of
the female genitalia with urogenital sinus formation (conflu-
ence of urogenital tracts), labioscrotal fusion, and clitoro-
megaly. Surgical correction is needed to separate the urogenital
tracts bringing the urethra and the vagina separately to the
perineum with a nerve sparing reduction of the clitoris and
labial reconstruction. Although optimal timing is controver-
sial, most surgeons agree on early reconstruction.
46XY DSD: under-virilized males
Testosterone synthesis defects and partial androgen receptor
insensitivity are among the causes. Patients in this group
present genital ambiguity with varying degrees of hypospa-
dia, penoscrotal transposition, and cryptorchidism. Surgical
treatment early in life consists of hypospadias repair, correc-
tion of penoscrotal transposition, and orchidopexy.
Fig. 13.9  (A) Bladder exstrophy patient with a severely underdeveloped penis who requested a complete penile reconstruction with a free radial forearm flap.
(B,C) Postoperative result after radial forearm phalloplasty with the small glans incorporated at the base of the reconstructed penis.
A
B
C

298.e1
Congenital genital defects
Fig. 13.10  Buried penis: retraction of the peripenile and pubic fat reveals a normal
size penis.
A
B

299
Congenital genital defects
has provided new reconstructive options with the advantage
of reducing donor site morbidity, increasing the flap’s range
of motion, and combining different tissue flaps on one single
pedicle. The pedicled anterolateral thigh (ALT) flap has been
shown to provide a valuable phalloplasty alternative specifi-
cally in patients with congenital penile insufficiency. This flap
is a skin flap based on a perforator from the descending
branch of the lateral circumflex femoral artery, a branch from
the femoral artery.
There are several reasons why in the “boys without a
penis” a pedicled ALT flap can be preferred to the standard
RFF (Fig. 13.12):
■ A pedicled flap reconstruction (the flap has a sufficiently
long pedicle) avoids the technically more complex
microsurgical procedure and might also shorten
operating time.
■ A visible donor site scar on the forearm, often considered
as the signature of FTM transsexualism, is avoided and
the donor site on the thigh can be more easily concealed.
■ Previous reconstructive surgeries at the pelvis, groin area,
and lower abdomen (e.g., in the case of bladder exstrophy)
might have altered local anatomy and vasculature making
a microsurgical anastomosis more difficult.
while in children, with puberty, the prepubic fat deposit often
decreases in size and the penis will only be released from the
fibrotic dartos tissue.11,12 Many techniques are described, but
the most important steps include keeping all available skin
from the start of the procedure, to resect all dartos tissue and
to cover the released corpora with the skin (Fig. 13.11).13
Reconstructive options for severe
penile insufficiency
A clear definition of severe penile inadequacy has not yet been
established but can be considered as an insufficient penile
length and function to obtain successful sexual intercourse.
This implies that puberty must be finished and that the patient
must be sexually active. Conditions with penile insufficiency
include aphallia or penile agenesis, idiopathic micropenis
(stretched penile length in a full-term newborn male <2.5 cm),
46XY DSD, and bladder exstrophy. Reconstructive surgery in
these mostly young patients is required because of the devas-
tating effect on psychological and sexual function.
The free vascularized radial forearm flap (RFF) (discussed
further below) is considered the gold standard technique in
penile reconstruction. The development of perforator flaps
A
B
C
Fig. 13.11  (A) Typical buried penis in an
infant. (B) Ventral incision of the skin with
maximal preservation of skin at the start of
the procedure. (C) After complete resection
of the fibrotic dartos tissue, the penis is
released from its buried position and the
skin is extendable. (D) Coverage of the
released corpora with the extended skin
creating a penis with normal length.
D

300
SECTION II
CHAPTER 13 • Reconstruction of male genital defects
children is similar to that in adults but with one added
requirement – growth through puberty to adulthood. Because
the phallus is constructed of somatic tissues (showing linear
growth) but replaces a penis that is formed by genital tissues
(demonstrating a more exponential growth), the growth rates
are temporally and quantitatively different during puberty.14
Care must be taken to accurately predict the anticipated
growth rate and to design a phallus that is larger and longer
than normal genital size for that age group.15
Another issue that we are just now beginning to address is
the “correct” age at which to proceed with penile prostheses
implantation. Once these boys have reached 18 years and the
age of majority, they must be physically and psychologically
prepared to manage a phallus that has previously been
erectionless.
There is another nagging problem with operating on
children – the lack of informed consent. Although the child’s
best interest and surgery’s best intentions are usually served
by early reconstruction, there are no long-term studies that
■ Though usually thicker than a RFF, the subcutaneous fat
layer is thinner than in a (biologically female) transman
(the most common phalloplasty patient), facilitating the
(urethral)tube-within-a-(penile)tube reconstruction of the
penis; moreover, many exstrophy patients have a
continent diversion (e.g., appendico-vesicostomy) with a
ventral ejaculatory opening left above the scrotum and do
not require urethral reconstruction.
■ Glandular, penile, and cavernosal tissues are kept at the
base of the neophallus to facilitate sexual stimulation and
pleasure (Fig. 13.9C). The lateral femoral cutaneous nerve
is connected to a dorsal penile nerve, if available, and/or
to the ilioinguinal nerve.
A preoperative 3D angio CT-scan provides detailed informa-
tion on the perforator vessel(s) and the subcutaneous tissue
layer.
There is still a lot of controversy as to whether or not to
perform a phalloplasty in children. Penile construction in
A
B
C
Fig. 13.12  The reconstruction of a penis with a pedicled anterolateral thigh (ALT) flap used as a tube-within-a-tube technique (only possible in thin “boys without a penis”
and after defatting). No real urethra was reconstructed here since the patient had a urostomy. (A) Preoperative view. (B) After flap dissection. (C) The flap is tunneled
underneath the rectus femoris muscle. (D) Suturing and nerve connection (ilioinguinal nerve to lateral femoral cutaneous nerve).
D

301
Post-traumatic genital defects
The donor site should be close to the genitalia, large enough
to produce a sheet skin graft, and well hidden. Ideally, the
skin graft should be at least 0.018–0.02 inches in thickness and
large enough to cover the whole breadth of the penile shaft
or scrotum. The skin graft should be sutured circumferentially
around the penile shaft with a ventral suture line. As men-
tioned above, this suture line will not contract, but a Z-plasty
is advisable anyway. The graft is then fixed with resorbable
sutures to the surrounding skin, the underlying Buck’s fascia,
and the tunica. Fixation with tissue sealant can improve skin
graft fixation and skin graft take in this difficult area.
Extended bed rest is important in the immediate postopera-
tive period to reduce the risk of graft shearing or movement.
Amyl nitrate and diazepam (Valium) can be administered to
control erections in the early postoperative period. However,
erections, massage, and stimulation are recommended for all
patients after grafting as soon as there is a full take of the
skin graft.
Widely meshed split-thickness skin grafts should never
be used on the penile shaft. However, with the so-called
“reversed mesh graft” (= non-expanded or 1 : 1 meshed skin
grafts) only puncture-type perforations are made with a V1
carrier (Humeca Ltd, Enschede, the Netherlands; Fig. 13.14),
which allow for better fluid evacuation and thus a better skin
graft take while still avoiding poor scarring and an unaesthetic
mesh pattern long term. These non-expanded meshed split-
thickness grafts have also become a mainstay of complicated,
staged urethral reconstruction.16,17 McAninch18 has described
the use of (not too widely) meshed split-thickness skin grafts
for scrotal reconstruction. Meshed grafts in this location may
produce “good aesthetic results”, but they will never measure
up to the functional capacity of sheet or 1 : 1 perforated
grafts.
Full-thickness skin grafts also have a place in genital recon-
struction, but mostly for smaller skin defects. Full-thickness
grafts are particularly useful for coronal sulcus design to
prevent “coronal washout” as is usually performed in FTM
transsexual patients (see below; Fig. 13.24F).
The same principles apply to scrotal reconstruction. When
primary closure is not possible, split-thickness skin grafts are
effective if they are placed and immobilized carefully. The
testicles must be fixed in an anatomically appropriate position
before proceeding with graft coverage. As already mentioned,
there is also a place for meshed, non-expanded skin grafts in
scrotal and perineal reconstruction because of the uneven and
often biconcave contours and, in addition, meshed grafts
often emulate scrotal rugae (see below; Fig. 13.18).
Buccal mucosa grafts are often used in urethral reconstruc-
tion. They can also be useful in glans reconstruction. After
partial penectomy (traumatically or for cancer treatment) the
residual corpora are sometimes still long enough to allow for
sexual intercourse, but a skin covered penis looks unnatural.
Transaction of the suspensory ligament releases the corpora,
and the tip of the corpora can be covered by free buccal
mucosa grafts that create a mucosa covered glans-like penile
tip (Fig. 13.15
).
Fig. 13.15B & C appears online only.
Genital flaps
For small penile defects, flaps based on the superficial external
pudendal system can be used for penile shaft and anterior
have evaluated the results of this surgery over a lifetime or
even a generation.
Finally, it comes as no surprise that the large majority of
these genitally compromised boys require prolonged psycho-
logical therapy to deal with genital loss, surgical trauma,
inadequacy, and scarring. These psychological issues are often
closely commingled with the need for secondary surgery to
complete reconstruction.
Nowhere in surgery is there a stronger need for parental
and family support than with these late teenage boys who
have essentially undergone years of “surgical abuse”.
Post-traumatic genital defects
Post-traumatic genital repair is an uncommon but special
chapter in surgical reconstruction. A reconstructive algo-
rithm based on the etiology, an assessment of the extent of
injury, and an anatomic inventory includes several goals and
observations. First, the anatomically protected position of the
genitalia implies that patients who have genital injuries often
have large concomitant injuries as well and are in critical
conditions. Resuscitation and life support of the patient take
precedent over any reconstruction. However, genital recon-
struction is of prime relevance, and only hand, eyelid, and lip
reconstruction are considered more important in the recon-
structive hierarchy. Second, aesthetics are foremost in genital
reconstruction. The appearance of the genitalia is important
to the self-esteem of a patient who is recovering from trauma.
What is frivolous to one person may be a lifelong obsession to
another, and genital aesthetics are as valued as other cosmetic
areas such as the face, nose, and breasts. Third, the genitalia
appear to be a “privileged site” such that the usual postrecon-
structive sequelae of scarring and contracture are often spared
in genital reconstruction. This may be due to the fact that the
average adult man has five to eight nocturnal erections every
night, thereby inherently stretching scars or skin grafts on the
penile shaft. This stretching may counteract and overcome the
tendency of myofibroblasts to contract a skin graft or scar.
General reconstructive options
Genital skin grafts
Genital skin loss occurs from burns, avulsion injuries, infec-
tions, and gangrene. As a rule, total excision of necrotic genital
tissues followed by early skin grafting produces the best
results. When the wound is contaminated or infected, adequate
debridement of necrotic tissues combined with wound bed
preparation prior to skin grafting might be required, and this
can be performed with adequate (moist) wound dressings, by
temporary coverage with skin allografts, or with the use of
topical negative pressure.
The thick split-thickness skin graft is the mainstay of penile
reconstruction. The graft should be pliable, placed onto a flat
bed, and secured with a tie-over bolus pressure dressing or
even better with a special Cavi-Care cylinder type of dressing
(Fig. 13.13
) to reduce the risk of hematoma or seroma for-
mation. Successful skin graft “take” is directly related to a
well-vascularized wound bed, meticulous hemostasis, control
of erections, an infection-free environment, and adequate
immobilization.
Fig. 13.13D–F appears online only.

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SECTION II
CHAPTER 13 • Reconstruction of male genital defects
A
B
G
Fig. 13.13  (A) A patient with a complete defect of the skin of the penile shaft. (B) The 1 : 1 perforated split-thickness skin graft is applied and sutured to the shaft. (C) A
Cavi-Care dressing is applied around the skin graft (poured out in a cylinder form around the penis), and this dressing will stay for 1 week. (G,H) A complete take of the
skin graft is obtained.
H
C
urethral reconstruction.19,20 Proximal penile flaps, vascular-
ized from the lower abdomen and pubis, are less practical for
male genitalia reconstruction.
Scrotal flaps have limited applications with the exception
of hemiscrotal reconstruction. Although the scrotum has a
wealth of well-vascularized skin and subcutaneous tissue, it
is ill-suited for genital reconstruction because of its rugous
and hairy appearance. A centrally located scrotal flap designed
along the medial raphe has been described as a reconstructive
flap option for proximal urethral repair,21 but presurgical
depilation is needed. This flap is based on the posterior scrotal
artery and can be difficult to mobilize extensively and can
cause scrotal tethering. A free oral mucosal graft is a better
choice for proximal urethral reconstruction.22
In larger defects, there often is a combined penoscrotal
defect. Any technique of tissue expansion is risky, especially
in the repair of Fournier’s gangrene defects due to the
bacteriologic environment and the multiple stages needed.
Local muscle/myocutaneous flaps, fasciocutaneous flaps,
and perforator flaps are among the options for male geni-
talia reconstruction. Nowadays, the gracilis (purely) muscle
flap is no longer considered as “the workhorse of perineal
reconstruction” but is useful to cover and vascularize urethral
anastomoses and exposed pelvic bones, to reduce the risk of
osteomyelitis, to fill the perineum after exenteration, and to
vascularize the perineum in postirradiation injuries.23
Fasciocutaneous paragenital flaps that have been used, often
with limited application, are the superficial circumflex iliac
artery flap,24 the deep circumflex iliac flap (often combined with
an osseous component),25 the superficial epigastric artery flap,26
the double-pedicled composite groin flap,27 the anteromedial
thigh flap,28 the ALT flap,29 and the pudendal thigh flap.30,31
The groin flap is based on the superficial circumflex artery, a
branch of the femoral artery, and has an unpredictable origin,
direction, and size. The flap must often be delayed, attached,
or “waltzed” into a central midline position by a secondary
procedure to be used as a genital flap. For these reasons, the
groin flap has limited primary genital use.
Medial thigh flaps may be based inferiorly on the perineal
artery system or superiorly on the external pudendal system
and branches of the profunda femoris artery. The inferiorly
based flap has been called by several names, including the
Singapore flap30 and the pudendal thigh flap.32 Originally
described to correct vesicovaginal fistulas, the flap is based
posteriorly within the crural fold between the scrotum and
the medial and extends from the posterior crural fold to the
medial groin area anteriorly. Although most flap descriptions
have focused on vaginal reconstruction and the correction of

302.e1
Post-traumatic genital defects
D
E
F
(D–F) A Cavi-Care dressing is applied around the skin graft
(poured out in a cylinder form around the penis), and this dressing will stay for 1
week.
Fig. 13.13, cont’d

303
Post-traumatic genital defects
vesicovaginal and rectovaginal fistulas, this flap has been
successfully used for male genital or male urethral
construction.31
To complete the catalogue of fasciocutaneous flaps, the
gluteal-posterior thigh flap must also be included.33, 34 This
flap is based on the inferior descending branch of the inferior
A
Fig. 13.15  (A) Penis after partial penectomy for spinocellular epithelioma,
showing residual corpora, which after release could be sufficient for sexual
intercourse.
A
B
C
Fig. 13.14  The so-called “reverse-meshed graft” or 1 : 1 perforated skin graft, obtained with a V1 mesh carrier (Humeca, the Netherlands).
D
gluteal artery. Nowadays, this flap has been replaced in most
cases by perforator flaps originating from the inferior gluteal
artery or IGAP flaps.35 Additionally, various other new (ped-
icled) perforator flaps (the so-called “lotus petal flaps”) are
based on the external pudendal artery and have been described
as possible options in the perineal area, although more in
female patients.36
The formerly more popular musculocutaneous flaps
including the vertical and transverse rectus abdominis flap
(based on the deep inferior epigastric artery),37 the gracilis
musculocutaneous flap,38 the rectus femoris musculocutane-
ous flap,39 and the tensor fasciae latae musculocutaneous
flap40 have been employed occasionally in genitourinary
reconstruction but have only limited use in the reconstruction
of male genitalia.
Nevertheless, these flaps can still be an important part of
the surgeon’s armamentarium in addressing genital injuries
after trauma, infection, and cancer and for patients with
comorbidities. The trauma, cancer, infection, and comorbid
disease that originally contributed to genital tissue loss may
also preclude sophisticated microsurgical reconstruction.
Thus these flaps are the only hope for functional, albeit sub-
optimal, genital reconstruction.
In the last decade, myocutaneous flaps have been replaced
by their “perforator-type equivalent”: the deep inferior epi-
gastric artery perforator or DIEAP flap (with its skin island

303.e1
Post-traumatic genital defects
(B) After penile elongation with release of the suspensory
ligament and coverage of the distal part of the penis with buccal mucosa.  
(C) Result of glans reconstruction using buccal mucosa.
Fig. 13.15, cont’d
B
C

304
SECTION II
CHAPTER 13 • Reconstruction of male genital defects
A
B
C
Fig. 13.16  (A) Female-to-male transsexual patient after penile reconstruction with a lack of skin to reconstruct a scrotum. (B) Design and dissection of a pedicled
anterolateral thigh (ALT) flap. (C) Transfer of the ALT flap to the pubic area. (D) Postoperative result.
D
taken either vertically or horizontally) has been reported in
a case of penile reconstruction. However, it is mainly the
pedicled anterolateral thigh or ALT flap that has become the
new “workhorse” nowadays in perineal and male genital
reconstruction.41 For the description of the use of this flap
in patients with congenital penile insufficiency we refer to
the beginning of this chapter. The pedicled ALT can also be
a valuable alternative for the reconstruction of a scrotum
(Fig. 13.16).
Microsurgical genital reconstruction
Genital replantation
Microsurgical techniques and free tissue transplantation have
become the state-of-the-art treatment for many reconstructive
problems. The first uses of the microscope in genital recon-
struction for penile reattachment after amputation were
reported independently by Cohen et al.42 and Tamai et al.43 in
1977. However, the first account of successful reattachment
long predated the introduction of microsurgical techniques.
In 1929, Ehrich44 first reported a successful penile attachment
by opposing the lacerated corporal bodies and repairing the
overlying tunica. This technique was occasionally successful
but usually associated with loss of the overlying skin, glans,
sensation, and erectile and voiding function.45
Penile replantation often mimics the algorithms of other
amputated extremities that are candidates for reattachment.
The penis is initially wrapped in saline-soaked gauze and
placed into a plastic bag, which in turn is placed in a bag
or cooler of ice with water (the so-called “bag-in-a-bag”

305
Post-traumatic genital defects
these points are considered together, the best that can be
hoped for with a reattached testicle is maintenance of testos-
terone secretion. The insertion of a testicular prosthesis com-
bined with hormonal therapy is often a much simpler and
equally effective option.
Microsurgical phallic construction
Complete reconstruction of a phallus will be described
below.
Penile transplantation
Two attempts at penile transplantation have been reported so
far. The first was performed in China and, after initial appar-
ent success, the patient had the transplant removed as he and
his wife could not manage to accept somebody else’s penis on
his body.48
The second was performed more recently (December 2014)
on a 21-year-old male in South Africa. On March 2015 press
reports stated that the patient was doing well and having
erections.49–51
Penile transplantation has raised some criticism, and to
date it is considered as the last option when autogenous
reconstruction is not appropriate.52–54
Specific reconstructive indications
Fournier’s disease
Fournier in 1883 was the first to describe a “fulminant gan-
grene” of the penis and scrotum that: (1) developed suddenly
in previously healthy young men, (2) progressed rapidly, and
(3) was idiopathic. Nowadays, every necrotizing fasciitis in
the perineum and genitalia is termed Fournier’s gangrene.55
Fournier’s disease is a true genitourinary emergency. Today
the etiology is identified in about 95% of cases. Common
sources of infection include urogenital disease and trauma
(renal abscess), urethral stones, urethral strictures, unrecog-
nized rupture of the urethra when a penile prosthesis is
inserted, colorectal causes (ruptured appendicitis), colon
cancer, diverticulitis, and perirectal, retroperitoneal, and sub-
diaphragmatic abscesses and local trauma.56
technique). Because genital amputations are often self-
inflicted, it is important to involve the psychiatrist even before
restorative surgery. After the induction of anesthesia, the
proximal and distal ends of the amputated penis are exam-
ined microscopically. Minimal debridement is followed by
mechanical stabilization of the urethra and re-approximation
of the tunica albuginea of the corpora cavernosa.
Revascularization is completed by anastomosis of the deep
dorsal arteries, the deep dorsal vein, and the superficial dorsal
vein with 9-0 and 10-0 sutures and multiple nerve coaptations
with 10-0 and 11-0 nylon sutures. The dartos fascia and skin
are then loosely approximated. A suprapubic tube is inserted
to divert the urinary flow for 2–3 weeks, and the patient is
prescribed bed rest in a warm room.
The ideal candidate for genital replantation is a patient
with a clean, sharp cut in which the amputated part has been
cooled (Fig. 13.17).
Testicular reattachment has also been reported but requires
a sharp amputation etiology for successful anastomosis of the
thin-walled arteries and veins that surround and vascularize
the testicle, seminiferous tubules, and vasa deferentia.46,47
Unfortunately, most testicular amputations are of the avulsion
or crush type and therefore are not reattachable. Clinically, the
only vessel that has adequate caliber is the testicular artery
with its venae comitantes.
Two other arteries are also involved in testicular vascu-
larization: the deferens artery, which arises from the inferior
vesicular artery and vascularizes the epididymis, and the
cremasteric artery, which arises from the inferior epigastric
artery and vascularizes the cremasteric muscle and the other
cord structures. Both of these arteries are small, flimsy, and
often unrecognizable in reattachment circumstances.
There are five factors to be considered before proceeding
with testicular reattachment. First: understanding of the three
different testicular blood supplies. Second: availability of
veins. Third: ischemia time (4–6 h). Fourth: technical feasibil-
ity of vasa deferentia anastomosis. A reattached testicle cannot
be expected to recover its sperm-producing function, and,
even if it does, the sperm count is often too low to be effective.
Fifth: maintenance of post-reattachment psychological well-
being (particularly in self-mutilation patients). When all of
Fig. 13.17  (A) Self-inflicted penile amputation. (B) Preparation of microsurgical anastomoses. (C) Immediate postoperative result. (D) Late postoperative result.
A
B
C
D

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SECTION II
CHAPTER 13 • Reconstruction of male genital defects
with circumcision. The aggressive treatments used in the past
such as partial, subtotal, or total penectomy have lost ground.
Since penile cancer involving the spongy erectile tissue of the
glans can be treated by “glansectomy”, excision can spare the
corpora cavernosa and reconstruction is limited to a redefini-
tion procedure or coverage procedure of the distal corporal
bodies. Often, just grafting the tips of the corporal bodies
provides an excellent functional as well as cosmetic result.
Buccal mucosa grafts can be used and create a natural looking
glans (Fig. 13.15).
Another surgical method for treating penile cancer involves
Mohs surgery. In Mohs surgery, sequential excisions are
Several systemic conditions have also been associated with
Fournier’s gangrene and may predispose patients to its devel-
opment: diabetes mellitus, alcoholism, heavy smoking (more
than one pack per day), human immunodeficiency virus
infection and acquired immunodeficiency syndrome, and
leukemia. Fournier’s disease is considered a synergistic nec-
rotizing fasciitis that often includes Gram-positive organisms,
Gram-negative organisms, and Clostridium perfringens anaer-
obes in the cultures. The disease often begins as a cellulitis
adjacent to an entry wound. The affected area is swollen,
erythematous, and tender as the infection begins to include
the deep fascia. There is prominent pain as well as fever
and systemic toxicity. Scrotal swelling and crepitus quickly
increase with the appearance of dark purple areas that become
gangrenous. Specific urinary symptoms include dysuria,
urethral discharge, and obstruction. A change in mental status,
tachypnea, tachycardia, hyperthermia or hypothermia, and
the presence of a typical smell indicate a potential Gram-
negative sepsis.
A high degree of suspicion is crucial to an early diagnosis.
A clinical differentiation between necrotizing fasciitis and
simple cellulitis may be difficult initially because the initial
signs of pain, edema, and erythema are not distinctive.
However, the presence of marked systemic toxicity out of
proportion to the local findings should alert the surgeon.
Once the disease is identified, intravenous fluid therapy
and broad-spectrum antibiotics should be started in prepara-
tion for surgical debridement. Once culture guided antibiotics
are begun, anaerobic coverage should be continued regardless
of culture results because of the difficulty in culturing these
organisms. Immediate surgical debridement is critical, should
be aggressive, and continue along fascial planes until all of
the devitalized tissues have been removed and viable tissue
borders the wound.
Some authors also recommend hyperbaric oxygen therapy
in conjunction with debridement and antibiotics to speed up
wound healing and minimize gangrenous spread, particularly
in patients with C. perfringens infections. In addition to hyper-
baric oxygen, mechanized wound debridement tools (i.e.,
topical negative pressure therapy) promote granulation,
wound contracture, and reduction of bacterial colonization
before reconstruction.
In most cases, reconstruction of the genitalia includes
release of the penis and testicles from surrounding granula-
tion tissue; release of scar contracture; split-thickness skin
grafts on the penile shaft and peripenile tissues and non-
expanded meshed split-thickness grafts of the scrotum,
perineum, and crural folds (Fig. 13.18). Flap reconstruction is
seldom required.
The mortality rate in Fournier’s disease averages approxi-
mately 20% but can range from 7% to 75%. Higher mortal-
ity rates are found in diabetics, alcoholics, and those with
colorectal sources of infection, who often have a greater delay
in diagnosis and more widespread extension. To reduce
morbidity and mortality, the key is early diagnosis, antibiotic
therapy, and surgical debridement.
Penile cancer
In the past, treatment of penile cancer ranged from techniques
of local excision to emasculation. Penile cancer involving the
redundant preputial and penile skin can be adequately treated
A
Fig. 13.18  Fournier’s gangrene. (A) Prior to debridement. (B) After skin grafting.
B

307
Reconstruction of male genitalia in the female-to-male (FTM) transsexual
It is recommended that the surgical oncologist contacts the
reconstructive surgeon before exenterative surgery to plan
subsequent reconstruction.
Reconstruction of male genitalia in the
female-to-male (FTM) transsexual
Reconstruction of the male genitalia in an FTM transsexual
individual is more complex than the penile reconstruction in
a biologically male patient because of the added difficulties
in reconstructing the fixed part of the urethra and the combi-
nation with a vaginectomy and a scrotoplasty.
Vaginectomy, reconstruction of the pars fixa
of the urethra, and scrotoplasty
This first part of the procedure is usually done by the urologic
team, while the team of plastic surgeons harvests the flap. The
accomplished until clean margins in all quadrants are
achieved. In classic Mohs surgery, the defect is then left to
granulate or can be skin grafted.
In patients in whom a true partial penectomy has been
performed, either local flaps or microvascular flaps are used
to lengthen the penis to incorporate prostheses at a later date.
These techniques have poor cosmetic and functional outcomes.
It is better to sacrifice the superficial penile tissue saving the
remaining corporal bodies to accomplish a true phallic con-
struction. The corporal bodies are incorporated in the base of
the microvascular free flap in the case where total penectomy
after a total phallic reconstruction is planned (Fig. 13.19). In
patients who have had extensive superficial lymph node dis-
sections, angio-CT is performed to identify adequate recipient
vessels (deep inferior epigastric vessels and the iliofemoral
system). In addition, in cases in which reconstruction is envi-
sioned, if possible, at the time of the extensive exenterative
surgery, it is preferable to place intravenous and arterial lines
in the dominant forearm, saving the vascularity of the non-
dominant forearm for subsequent use in phallic construction.
A
B
C
Fig. 13.19  (A) A hard tumor involving the whole circumference of the penis. (B,C) Magnetic resonance images (MRI) showing disruption of both corpora cavernosa.
(D) Postoperative result after total penile reconstruction with a free radial forearm flap.
D

308
SECTION II
CHAPTER 13 • Reconstruction of male genital defects
and the bladder is dissected with the electrocautery. Then
lateral dissection is started: the levator muscle is released
from the lateral vaginal wall using electrocautery for better
hemostasis. Dissection is continued until fibrotic tissue of the
former hysterectomy is reached. Lateral dissection continues
to the midline following this fibrotic plane, and the vagina is
removed.
Before urethral reconstruction starts, an 18Fr silicone drain
is inserted and a traction suture is placed to hold the enlarged
clitoris. The mucosa between the external urethral orifice
and the clitoral glans will serve as the urethral plate for the
pars fixa of the urethra (Fig. 13.20C). The incision lines are
marked (minimum width 2.5 cm), and the urethral plate is
dissected away from the inner surface of the labia minora.
Now, tubularization of the urethral plate is started at the
patient is positioned in the lithotomy position with supportive
boots to avoid compression of the common peroneal nerve
and compartment syndrome. A roman-aqueduct-like incision
is made in the prepubic area where the phallus will be
implanted and the recipient vessels and nerves will be pre-
pared (Fig. 13.20A). Division of the suspensory ligament of
the clitoris creates a prepubic space.
First the vesico-vaginal space is infiltrated with diluted
xylocaine–adrenaline solution for hydrodissection and hemo­
stasis. The vaginal introitus is incised, and the external
urethral sphincter is gently dissected away from the sub­
mucosal vaginal tissue. Four mosquito clamps hold the
vaginal mucosa (Fig. 13.20B), and the space between the
posterior vaginal wall and the rectum is bluntly dissected,
and subsequently the space between the anterior vaginal wall
A
B
Fig. 13.20  (A) Incision lines of the prepubic area (roman-aqueduct) and of the labia majora for the
scrotoplasty. (B) Incision of the vaginal introitus starts the vaginectomy. (C) Incision lines of the urethral
plate between the external urethral orifice and the tip of the clitoris.
C

309
Reconstruction of male genitalia in the female-to-male (FTM) transsexual
superficial pelvic floor muscles are now exposed and sutured
around the pars fixa of the urethra to close the superficial
perineal space (Fig. 13.22A). Abduction and flexion of the hips
are reduced in order to facilitate closure with Vicryl 1. The
labia majora flaps are now rotated 180° anteriorly towards
the base of the foreskin of the clitoris (Fig. 13.22A), and the
remains of labia minora are resected as most patients do not
want to be reminded to their former female anatomy. The
scrotum is placed in front of the patient’s legs, and the skin is
closed with 3-0 Monocryl (Fig. 13.22).
Fig. 13.22C & F appears online only.
To prepare the pars fixa of the urethra for anastomosis with
the phallic pars, 12–16 separate Vicryl 4-0 sutures are placed
in its oblique distal end through the prepubic incision. In
external urethral orifice, with inclusion of the orifices of the
paraurethral glands of Skène. Closure of the urethral plate is
continued towards the clitoral glans with a running suture in
3-0 Monocryl leaving an oblique distal end for anastomosis
with the phallic urethra (Fig. 13.21A). The preputial skin
is released from the clitoral shaft, and the clitoral glans is
denuded (Fig. 13.21B). One dorsal clitoral nerve (1 or 11 o’clock
position) is identified and prepared for later anastomosis. The
clitoris and the urethra are tunneled towards the prepubic
area and fixed to the pubic symphysis with a Vicryl 2-0 suture
(Fig. 13.21C).
Now scrotoplasty is performed: posterior borders of the
labia majora are incised (Figs. 13.20A, 13.22B
). The subcu-
taneous fat is dissected to create two flaps (Fig. 13.22C). The
A
B
Fig. 13.21  (A) Creation of the pars fixa of the urethra by tabularization of the urethral plate. (B) Release of
the foreskin of the clitoral shaft. (C) Tunneling of the clitoris and the distal end of the pars fixa to the
prepubic area.
C

310
SECTION II
CHAPTER 13 • Reconstruction of male genital defects
A
B
D
Fig. 13.22  (A) Closure of the superficial
perineal muscles over the pars fixa of the
urethra. (B) Incision lines at the labia
majora for the scrotoplasty. (D) Rotation of
the labial flaps 180° anteriorly. (E) Closure
of the skin and final result.
order to prevent fistula formation, it is advised to catch only
submucosa with the suture bite. At the end of the perineal
procedure, a suprapubic catheter is inserted.
Metoidioplasty
A metoidioplasty uses the (hypertrophied) clitoris to recon-
struct a microphallus in a way comparable with the cor-
rection of chordee and lengthening of a urethra in cases of
severe hypospadias. Eicher57 calls it “the clitoris penoid”. In
metoidioplasty, the clitoral hood is lifted and the suspensory
ligament of the clitoris is detached from the pubic bone, allow-
ing the clitoris to extend out further. An embryonic urethral
plate is divided from the underside of the clitoris to permit
outward extension and a visible erection.58–61 The urethra is
then advanced to the tip of the new penis. The technique is
very similar to the reconstruction of the horizontal part of the
urethra in a normal phalloplasty procedure. Scrotal recon-
struction and vaginectomy are performed during the same
procedure.
FTM patients interested in this procedure should be
informed preoperatively that voiding while standing cannot
be guaranteed, and that sexual intercourse will not be possible
(Fig. 13.23).
The major advantages of metoidioplasty are absence of a
donor scar, preservation of erectile function even if only in a
E

310.e1
Reconstruction of male genitalia in the female-to-male (FTM) transsexual
(C) Creation of the flaps for the scrotoplasty. (F) Closure of the
skin and final result.
Fig. 13.22, cont’d
C
F

311
Reconstruction of male genitalia in the female-to-male (FTM) transsexual
A
B
Fig. 13.23  Metoidioplasty. (A) Immediate
results. (B) Late postoperative results.
micropenis, and lower costs compared to a phalloplasty.
Complications of this procedure also include urethral obstruc-
tion and fistula.
It is always possible to perform a regular phalloplasty (e.g.,
with a radial forearm flap) at a later stage, and with the likeli-
hood of reduced risk of complications and shorter operating
time because vaginectomy, reconstruction of the pars fixa of
the urethra, and scrotoplasty have already been performed.
Complete phallic reconstruction
The term “phalloplasty” was first used in 1858 by Sprengler
to indicate reconstruction of the integument after decollement
(separation of the superficial tissue layers) of the penis.62
Bogoras, the first to report on the reconstruction of the entire
penis, labeled his procedure “penis plastica totalis”.63 He was
also the first to use a single abdominal tube, a technique later
applied by others. Subsequently, “phalloplasty” was used to
describe penile reconstruction.
Following the WWII, some leading plastic surgeons showed
an interest in phalloplasty. In 1948, McIndoe64 improved the
abdominal tubed flap by constructing a neo-urethra while
raising the tube pedicle with an inlay skin graft. Maltz65 and
Gillies and Millard66 popularized the technique adding a costal
cartilage graft as rigidity prosthesis. Further, Gillies was the first
to report the use of this technique in a transsexual patient. The
Stanford team61,67 refined the procedure by tubing an infraum-
bilical abdominal flap inside out in order to create a skin-lined
tunnel as a future urethral conduit. This method reduced the
number of stages previously necessary for phalloplasty.
Snyder described phalloplasty with a single pedicled
infraumbilical skin flap prelaminated with a superficial
skin-lined conduit.68,69 In addition, Hester performed phal-
loplasty in one stage using a vertical, superficial inferior
epigastric artery flap with a subcutaneous pedicle in a male
born with ambiguous genitalia.70 After McGregor introduced
the groin flap in 1972,24 Hoopes71 commented that “the groin
flap may prove the method of choice for phallus reconstruc-
tion”. Orticochea38 used a gracilis myocutaneous flap in a
five-stage phalloplasty procedure and claimed it produced
cosmetically and functionally superior results. The Norfolk
team also used a unilateral gracilis myocutaneous flap for
phalloplasty.39 Sometimes a combination of flaps was used.
Exner72 implanted rigidity prosthesis in a rectus abdominis
muscular flap and used bilateral groin flaps to cover the
neophallus.
Once microsurgery established a foothold in genital con-
struction, plastic surgeons began to explore and map out the
genital neurovascular supply and to consider expanding
the applications of microsurgery to elective reconstruction of
the genitalia. Chang and Hwang73 described an ingenious
adaptation of the tube-in-tube concept into a free tissue trans-
fer with the RFF originally described by Song et al.74
Since these early reports, a wide variety of other free flaps
have also been described for phalloplasty, including the dor-
salis pedis flap,29 the deltoid flap,75 the lateral arm flap,76 the
fibular flap,77 the tensor fasciae latae flap,40 the ALT,78 and the
DIEAP flap.79 The fact that so many techniques for penile
reconstruction exist is evidence that none is considered ideal.
Still, most of these articles are only case reports or small series
and even nowadays the “old” Chinese flap or RFF is by far
(>90%) the most frequently used free flap in the literature80
and is therefore often considered as the gold standard for
penile reconstruction.