Rotational and Free Flap Closure of the Abdominal Wall

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Chapter 15 Rotational and Free Flap Closure of the Abdominal Wall image

Christopher G. Zochowski, MD, Hooman Soltanian, MD, FACS

1 Preoperative Considerations

1 Comorbidities

image Skin and subcutaneous fat may be of varying thicknesses and qualities in patients because of body habitus, scarring, steroid use, malnutrition, advanced age, and other factors.
image Bleeding tendencies should be addressed preoperatively.
image Conversely, a thrombogenic state will put any flap at risk and may warrant a hematologist to assist in the pre- and postoperative care.

2 Open Wound Management

image The timing of the closure of abdominal wounds is on a case-by-case basis.
image Appropriate dressings should be applied to the wound before surgery to prevent desiccation of the soft tissues and intraabdominal contents.
image Negative pressure dressings allow for easier management of large abdominal wounds, but the wound must be monitored closely when the dressing is applied over exposed bowel.
image Some wounds require frequent debridements to determine the extent of viable tissue and clearance of infection.
image Open wounds increase the nutritional and fluid requirements of the patient.
image Chronic open wounds should be converted to acute clean wounds before closure.

3 Timing

image Optimize the patient before closure of the abdominal wall in regard to nutrition, cardiovascular status, and pulmonary function. The closure may lead to prolonged intubation, and this risk is increased in patients with chronic obstructive pulmonary disease (COPD) and smokers.
image Closure should be timed after bowel edema has subsided (stage if needed).
image Avoid intraoperative nitrous oxide use. Consider a nasogastric tube.

4 Defect Assessment and Flap Selection

image Assess the extent of missing or aberrant structures and define the anatomical region of the tissue loss.
image Assess the quality of remaining structures and loss of domain.
image Take note of an ostomy position if present.
image Assess for enterocutaneous fistulae.
image Rule out previous damage to the blood supply of any potential flaps.
image Pedicled flaps are limited by their arc of rotation and the size and location of the defect.

2 Muscular Flaps (Table 15-1)

image Figure 15-1 shows the cross-sectional anatomy of the thigh demonstrating the possible muscles for coverage of abdominal wall defects

TABLE 15-1 Flap Types

image

image

Figure 15-1

1 Tensor fascia lata

image Anatomy

image The flap can be musculocutaneous.
image Sensory innervation includes the lateral cutaneous branch of the twelfth thoracic nerve and the lateral cutaneous sensory nerve of the thigh (L2 and L3). Motor innervation is supplied by the distal branch of the superior gluteal nerve (L4 and L5).
image Arterial blood supply is from the ascending branch of the lateral femoral circumflex artery, which is 1.5 to 2.5 mm diameter. The vein is slightly larger than the artery when traced to the origin on the lateral femoral circumflex.
image Pedicle length can be up to 10 cm. The pedicle enters the tensor fasciae lata (TFL) muscle at the level of the junction of the proximal and middle thirds of an axis drawn from the anterior superior iliac spine (ASIS) to the lateral aspect of the patella. It emerges from beneath the rectus femoris muscle, anterior to the vastus lateralis and enters the muscle via the deep surface medially 6 to 8 cm from the ASIS.
image The descending branch of the lateral femoral circumflex artery continues beyond the TFL muscle to supply the skin of the anterolateral midthigh and the lower thigh. It can be harvested with the anterolateral thigh skin to enlarge the perfused vascular territory.
image The TFL muscle (Fig. 15-2) is a short, flat muscle that is approximately 12 to 15 cm long. It acts as an accessory flexor and medial rotator of the thigh. It originates from the anterior iliac crest and the deep surface of the fascia lata. At the origin, it lies between the gluteus medius and sartorius, and superficial to the vastus lateralis. It inserts into the iliotibial tract, which inserts distally on Gerdy’s tubercle on the lateral aspect of the tibia.
image The fascia lata is the deep fascia of the thigh. It thickens to form the iliotibial tract laterally and attaches distally to the lateral condyle of the tibia. The TFL muscle is enclosed by the fascia lata, and distally, the muscle fibers coalesce with the iliotibial tract in the middle third of the thigh. The thickness of the fascia lata over the TFL muscle makes it a strong fascial donor site suitable for reconstructing abdominal wall defects.
image

Figure 15-2

image Flap Design

image Skin territory can be up to 15 × 40 cm. A line from the ASIS 10 to 15 cm posteriorly marks the origin of the TFL muscle, with the skin territory extending 2 cm cranial to this line (Fig. 15-3). The lower skin territory is 8 cm above the lateral femoral condyle. Posterior skin territory is a line drawn from the greater trochanter to the fibular head or approximately along the axis of the femur. The anterior border is a line drawn from the ASIS to the lateral aspect of the patella.
image The entry point of the pedicle is at the level of the junction of the proximal and middle third of the line or 6 to 8 cm from the ASIS.
image The rotation arc of the pedicled flap reaches the costal margin if the tensor muscle is completely detached from its origin and raised as an island flap.
image

Figure 15-3

image Marking and Dissection

image The flap is marked as an ellipse over the axis of the TFL muscle and to incorporate the pedicle proximally.
image The patient is prepped and draped supine with a bump under the ipsilateral hip.
image The flap is elevated from distal to proximal.
image The skin and deep fascia are incised together in a plane deep to the iliotibial tract fascia.
image As dissection proceeds cranially, the space between the rectus femoris and vastus lateralis is retracted with a self-retaining retractor to identify the descending branch of the lateral femoral circumflex artery.
image The ascending branch is then identified as one proceeds in a superior direction (Fig. 15-4).
image With the ascending branch identified, its course to the TFL can be isolated
image The proximal flap is then divided by electrocautery while protecting the pedicle.
image The pedicle can be traced to the origin of the lateral femoral circumflex vessels to gain length.
image If more length is needed, flex the patient at the hip.
image

Figure 15-4

image Variations

image Variations include a free flap, chimeric flap, and an osteomusculocutaneous flap.
image Chimeric flaps are on a common pedicle with the anterolateral thigh and/or the rectus femoris flap.
image In an osteomusculocutaneous flap, a portion of the external table of iliac crest can be harvested with the proximal flap.

image Postoperative Care

image The donor site can be closed primarily if planned appropriately. Skin graft may be needed for larger flaps including skin.
image Close the donor site in layers over closed suction drains.
image Ambulation can begin postoperatively.

image Pitfalls

image This procedure results in a long incision on the leg.

2 Latissimus dorsi

image The latissimus dorsi can be used to as a functional free flap, muscle flap, or myocutaneous flap.
image The latissimus dorsi is the largest muscle in the body (up to 20 × 40 cm), but it is quite thin (<1 cm thick). It acts as a humeral adductor and internal rotator, and no significant functional deficit results from harvest. It has six origins, from the lower six thoracic spines and supraspinatus ligaments, posterior layer of lumbar fascia, tendinous attachments of the iliac crest, strips of muscle interdigitating with the external oblique, muscular slips from lower four ribs, and muscular slips from the scapula. The upper and anterior borders are free. The latissimus is deep to the trapezius. It inserts at the floor of bicipital groove of the humerus behind the tendon of the long head of the biceps. The latissimus forms the posterior fold of the axilla with the subscapularis tendon.

image Innervation

image Motor innervation is supplied by the thoracodorsal nerve, a branch of the posterior cord of the brachial plexus (C7); this nerve closely accompanies the thoracodorsal artery.

image Blood Supply

image Arterial blood is supplied through a terminal branch of the subscapular artery (2 to 5 mm diameter), a branch of the axillary artery.
image After 5 cm, the subscapular artery gives off the circumflex scapular branch posteriorly and the thoracodorsal artery (2 to 4 mm diameter) (Fig. 15-5).
image The thoracodorsal artery courses along the posterior aspect of the axilla for 8 to 14 cm and gives off 1 to 2 branches to the serratus before it enters the latissimus dorsi muscle on its deep surface. The serratus branch can be kept to include the serratus as part of a chimeric flap. The artery divides in the substance of the muscle into vertical and transverse branches and can facilitate a split flap.
image Thoracic intercostal and lumbar perforating arteries enter the deep surface of the muscle 8 cm from the posterior midline at the level of the seventh, ninth, and eleventh vertebral spines. They perfuse the inferior and medial latissimus.
image There is usually a single vena comitans with the artery that is slightly larger than the artery.
image If the pedicle is based on the subscapular artery; a length of five to 10 cm is possible.
image

Figure 15-5

image Contraindications

image There is no absolute contraindication as long as the pedicle is patent.
image Relative contraindications include radiation to the site, prior axillary dissection, a patient who is reliant on shoulder function for crutches or who is wheelchair bound, or if a functioning spinal accessory nerve is absent from prior neck dissection.

image Flap Design

image The flap design can cover ipsilateral abdominal defects. If raised as an “extended” variant, it can cross the midline by incorporating the rim of supragluteal fascia.
image If based at the muscle insertion, the pivot point is at the level of the midposterior axillary line.
image If the insertion is incised, the island flap pivot point is 1.5 to 2 cm inferior to the pectoral humeral junction.
image The skin paddle can be 12 × 20 cm and may allow for primary closure of the donor site.
image The skin paddle can be as large as 5 cm anterior and inferior to the muscle without delay and can be made larger with a delay procedure.
image The skin paddle can be made in a transverse or oblique fashion in women so that the scar is hidden under a brassiere.

image Marking and Dissection

image The outline of the anterior and superior edges of the muscle is made. This can be facilitated by having the patient contract the latissimus.
image If a muscle only flap needed, the incision is marked extending from the posterior axillary fold, then inferiorly and posteriorly over the anterior boarder of the latissimus muscle as dictated by the length of the muscle.
image If it is a myocutaneous flap, the skin island can be designed anywhere over the muscle.
image The upper two thirds of the latissimus dorsi muscle contain a higher density of myocutaneous perforators
image The donor site can be usually closed primarily if the skin paddle width is less than 10 cm.
image To determine location of the skin island, the distance from the surgical defect to the pectoral-humeral junction is measured.
image A line is then drawn from the anterior border of the latissimus dorsi to its origin along the posterior iliac crest, and the prior distance is transferred to this line.
image The patient is placed in a lateral decubitus position on a beanbag, with an axillary roll. The ipsilateral arm is prepped completely and left in the operative field abducted and resting on a Mayo stand, placed anterosuperiorly to the patient.
image After incision, anterior and posterior flaps are raised superficial to the muscle to expose the latissimus. The flaps are elevated enough to gain adequate exposure for the required muscular harvest.
image The superior edge of the latissimus is identified at the inferior angle of the scapula and is then elevated. The serratus muscle can be identified, and dissection deep to it should be avoided. This areolar plane is easy to dissect, and some perforators are encountered and ligated.
image The dissection continues toward the midline, and the areas of origin of the muscle are divided.
image The dissection proceeds inferiorly, freeing the medial muscle origin. At the inferior/terminal portion of the muscle, there is not a clear plane, and the muscle must be divided with electrocautery.
image Dissection then proceeds toward the axilla in the areolar plane (Fig. 15-6).
image The pedicle can be approached directly by dissecting the latissimus from the axilla, or it can be found by following the undersurface of the muscle in a distal to proximal approach.
image As the axilla is neared, the branch to serratus is ligated and the circumflex scapular branch can be as well if more length is needed.
image The thoracodorsal nerve is divided, and the artery and vein can be ligated and divided when the recipient area is ready if a free flap is being used.
image Closure is in layers and over drains. Mattressing sutures can be used to coapt the potential space in addition to drains.
image The ipsilateral arm can be used postoperatively.
image Postoperative inspection must be vigilant for seroma or hematoma formation. Drains often remain for a relatively long time. If a clinical seroma develops, aspiration should be done.
image

Figure 15-6

image Free Flap

image The procedure for the free flap proceeds similarly as described previously.
image The pedicle is completely isolated, and the flap elevation completed before ligating the pedicle.
image The positioning in the lateral decubitus position makes a two-team approach difficult in preparing the recipient site.
image Deep inferior epigastric, omental vessels, right and left gastroepiploic vessels have been used as recipient vessels.
image The use of bilateral latissimus dorsi muscles as pedicled flaps or free flaps provides a substantial surface area for coverage.

3 Rectus Femoris

image Anatomy

image Blood supply: The descending branch of the lateral circumflex artery (1.5 to 2 mm diameter) (Fig. 15-7) from the profunda femoris is located 8 cm below the inguinal ligament and enters the muscle on its deep surface. It also supplies the tissue of the anterolateral thigh flap.
image Three to four musculocutaneous perforators are at the proximal portion of the muscle, and fasciocutaneous perforators from the intermuscular septum supply the skin. There are usually two venae comitantes.
image Muscle: It is the most anterior muscle of the quadriceps group. One can harvest muscle flap with tendinous portions both proximally and distally.
image Its origin is the anterior inferior iliac spine and the ilium just superior to the acetabulum. It inserts at the patellar tendon along with Vastus muscles.
image Function is the terminal 20 degrees of knee extension.
image Nerve: Motor innervation is supplied by a branch of the femoral nerve, which enters the muscle at the same point as the artery. It can be >20 cm long.
image It has been described as a functional flap with anastomosis to an intercostal nerve for abdominal wall reconstruction. The native innervation can be maintained and the vascular pedicle trasnferred to recipient vessels closer to the abdominal wall defect (e.g. deep inferior epigastric vessels)
image Sensory innervation to the skin is by the intermediate cutaneous nerve of the thigh.
image

Figure 15-7

image Flap Design

image The flap reconstructs the lower abdominal wall, with the umbilicus as the superior limit.
image The design can be a muscle flap, myocutaneous flap, functional flap, or sensate flap.
image Flaps as large as 15 × 40 cm have been described.
image The donor site can be closed primarily with a myocutaneous flap if the skin paddle is <7 cm wide. The skin paddle is designed directly over the muscle, keeping in mind the proximal perforators.
image The pivot point is at the entrance of the neurovascular pedicle 8 cm below the inguinal ligament. This low pivot point limits the use of the muscle in abdominal reconstruction as a pedicled flap. This limitation can be overcome by using the muscle as a free flap.

image Marking and Dissection

image The muscle falls on a line drawn from the ASIS to the middle aspect of the patella and terminates approximately 6 cm superior to the patella (Fig. 15-8).
image A proper skin flap is drawn, keeping in mind the limitations described previously.
image A pinch test may demonstrate the ability to close primarily before incision.
image If muscle only, the incision is made in a lazy “S” or a longitudinal fashion down to muscular fascia.
image The rectus femoris and sartorius muscles are identified deep to the muscular fascia.
image The sartorius is retracted medially and away from the leg to expose the areolar plane underneath and to identify the lateral femoral circumflex vessels. The femoral nerve and branches are also identified at this level.
image If a skin paddle is to be used, the skin edges of the myocutaneous flap are sutured to the fascia to prevent shearing during harvest. Cutaneous perforators can be determined with the pencil Doppler.
image The pedicle can be located by measuring 8 cm from the inguinal ligament or just proximal to the junction of the proximal and middle thirds of the muscle (Fig. 15-9).
image Ensure that the proper muscle is releasd from the other muscles conjoining at the patellar tendon, usually 6 cm proximal to the patella.
image The musculotendinuous unit should be elevated from distal to proximal and from lateral to medial.
image Once the pedicle is identified on the deep surface, the muscle can then be divided proximal to the pedicle.
image The nerve to the muscle is ligated and divided, as needed.
image The muscle can either be rotated or turned over for coverage.
image The muscle fascia can be split or “pie crusted” for further advancement of the flap.
image The wound is closed in layers over a suction drain.
image The remaining musculotendinuous junctions are medialized with larger figure-of-eight sutures. Suture vastus medialis and vastus lateralis to the cut rectus femoris tendon. Redirecting the remaining muscles will replace some of the lost force of the rectus femoris.
image Ambulation is allowed according to the protocol for the muscle recipient area.
image A knee immobilizer is used for approximately 2 weeks. Physical therapy is usually needed for strengthening of the knee extensors.
image

Figure 15-8

image

Figure 15-9

image Extended Rectus Femoris Flap (“Mutton Chop Flap”)

image An extended area of the anterior thigh fascia can be harvested with the rectus femoris. This would allow for coverage of larger defects with autologius tissue.
image The disadvantage of harvest from this donor site is loss of muscle strength of the thigh.
image Some report weakness in terminal extension of the knee, but more recent studies denounce this.

3 Fasciocutaneous Flaps (Fig. 15-10, see Table 15-1)

image Many flaps can be created in the trunk and torso. As depicted in Figure 15-10, on the right side of the torso are axially based flaps, including the deltopectoral, thoracoepigastric, groin, and hypogastric flaps. On the left side of the torso are depictions of bipedicled and laterally based cutaneous flaps.
image

Figure 15-10

1 Groin flap

image Anatomy

image Blood is supplied by the superficial circumflex iliac artery (SCIA) from the external iliac/superficial femoral artery at the level of the inguinal ligament (Fig. 15-11). The artery may arise directly from the femoral vessel or from the trunk of a parent vessel supplying the SCIA and the deep circumflex iliac artery (DCIA). The artery also can arise from a common trunk that gives off the superficial inferior epigastric artery (SIEA).
image The SCIA, which is 1 to 2 mm in diameter, pierces the fascia just lateral to the fossa ovalis at or close to the lateral border of the sartorius muscle and runs in the subcutaneous plane cranially and laterally 2 to 3 cm below the inguinal ligament. This course is maintained to the level of the ASIS and has many connections with branches of the superficial epigastric artery (SEA), DCIA, and lateral femoral circumflex artery.
image The superficial epigastric artery (SEA) runs parallel to the SCIA and may be dominant. If this is the only vessel delineated by Doppler, design the flap to incorporate this vessel.
image It is drained by the cutaneous vein to the saphenous system, which is usually a discrete vein along with artery as it courses medially. The vein will arise from the saphenous vein or from a branch off the superficial femoral vein.
image Pedicle length depends on size and position of the skin paddle and can range from 2 to 5 cm.
image

Figure 15-11

image Flap Design

image The sartorius muscle, inguinal ligament, and iliac crest are all identified and marked.
image Doppler is used to localize the arterial pedicle, usually approximately a fingerbreadth below the inguinal ligament. If not present, seek the SEA by passing the Doppler probe superior to the inguinal ligament.
image The medial aspect of the flap is marked at the lateral border of the sartorius.
image The upper and lower borders can be 5 cm above and below the axis of the vessel, but the maximum width of the design is determined by pinching the skin.
image The length is determined by the defect to be covered.
image A non-delayed groin flap will survive even with the distal tip placed 5 cm beyond the ASIS. This will cover most ipsilateral lower abdominal defects. If the upper abdomen needs coverage, then the groin flap may require a delay procedure.

image Marking and Dissection

image The patient is placed supine.
image A bump under the ipsilateral hip may be used if the skin paddle extends far laterally.
image Dissection can be begun medially or laterally.
image The incision is carried down to the deep fascia and the dissection begun over the deep fascia, identifying and ligating perforating vessels as one proceeds medially.
image At the level of the ASIS, the interval between the tensor fascia lata and the sartorius muscle is identified.
image In addition, the lateral femoral cutaneous nerve (LFCN) of the thigh is identified as it exits the deep fascia to enter the subcutaneous tissue in its inferior course. The LCFN may need to be transected.
image At the lateral aspect of the sartorius, the muscular fascia is incised along the lateral aspect, and the flap elevation plane is now conducted deep to the muscular fascia.
image Proceeding medially, the superficial circumflex iliac vessels become visible in the plane above the sartorius heading into the muscular fascia.
image Branches to the muscle are ligated. At the medial aspect of the sartorius, the fascial plane around the pedicle is incised, and the artery and vein are dissected free to their origin (Fig. 15-12).
image The flap is mobilized on the vascular pedicle.
image The donor area is closed after slight undermining superficial to the deep fascia.
image Layered closure is used over suction drains.
image If there is tension on the closure, slight hip flexion may be needed.
image

Figure 15-12

2 Extended Deep Inferior Epigastric Perforator Flap

image Anatomy

image The course and connections of the deep inferior epigastric artery (DIEA) have been previously covered.
image If the DIEA is dissected free from the rectus abdominis muscle, a pedicle of 10 to 15 cm is possible. The pedicle can be dissected to the takeoff at the external iliac artery (Fig. 15-13).
image It usually has two venae comitantes (2-3 mm in diameter).
image The greatest concentration of perforating vessels is in the periumbilical region. These usually radiate cranially and laterally.
image The diameter of DIEA is approximately 2-3 mm at its proximal end.
image

Figure 15-13

image Flap Design

image Borders are the groin and anterior axillary fold.
image A large skin paddle can be designed on the perforating vessel.
image A muscle flap alone can be used with a split thickness skin graft after insetting.
image An axial skin flap can be designed in any direction with its base at the umbilicus, but the longest can be obtained along a line from the umbilicus to the inferior angle of the scapula.
image The width of the flap can be determined by a “pinch test” based on the laxity of the skin.

image Markings and Dissection

image The markings are determined by the defect, with the length of the pedicle obtainable; many variations of shape and size are possible, as long as perforators are included.
image Incision and dissection in the areolar layer on the deep surface of the subcutaneous fat begins at the distal end of the flap.
image Dissection proceeds until the lateral border of the rectus abdominis.
image Care is taken to protect desirable perforators leading to the designed skin paddle.
image Then a disk of the rectus abdominis and its sheath that encircle the perforators are isolated.
image The sheath and muscle at the superior border are divided and the connections to the superior epigastric system are ligated.
image A sparing amount of muscle and fascia is taken to facilitate closure and reduce donor site morbidity.
image Care is taken to incise the sheath above the arcuate line.
image The sheath is then incised longitudinally and the rectus abdominis is dissected free.
image The DIEA is dissected from the undersurface of the muscle.
image The pedicle will then course inferolaterally to the external iliac and is ligated at this level.
image The rectus sheath is repaired to prevent hernia formation or bulge.

3 Thoracoepigastric Flap

image Anatomy

image The DIEA supplies the majority of the major perforating vessels leaving the rectus abdominis muscle and running laterally to the area of the latissimus in a suprafascial plane.
image The superior epigastric artery is smaller than the DIEA, but it supplies the upper abdominal and thoracic flaps (Fig. 15-14, A).
image The superior epigastric is derived mainly from the internal mammary artery but receives contributions from the terminal branches of the intercostals and the SIEA.
image

Figure 15-14

image Flap Design

image The flap includes skin, subcutaneous tissue, and muscular fascia of the lateral thoracic and upper abdomen.
image It can be delayed for larger flaps (Fig. 15-14, B).
image The base of the flap is the lateral border of the rectus sheath, and this is the point of rotation.
image The lateral border is the posterior axillary line or anterior edge of the latissimus dorsi muscle. A delayed flap may extend to 5 cm within the dorsal midline.
image The upper limit in men is the base of areola; in women, the upper limit is the inframammary fold (IMF).
image The base can be moved cranially or caudally as long as a perforator is included.
image Flap width can be 10- to 15 cm, with some descriptions of up to 30 cm.
image The donor site can be closed with a width of 16 cm in an obese patient and 10 cm in a thin patient.

image Marking and Dissection: (Fig. 15-14 C)

image The lateral border of the rectus abdominis is palpated and marked.
image The flap is elevated in a lateral to medial fashion.
image At the lateral aspect, the muscular intercostal perforators (usually over the serratus anterior) are divided.
image The elevation from axillary line to the lateral border of the rectus is in a subfascial plane to protect the perforators.
image There is no dissection medial to the lateral border of the rectus.
image The perforating vessels may not ever be visualized, and a Doppler may be used for confirmation of perforator inclusion.
image Posterolaterally, the flap is more random and can be suprafascial.
image Closure is layered and over drains.
image If the donor site cannot be closed, a split thickness skin graft can be used.

4 Anterolateral Thigh

image Anatomy

image The skin and subcutaneous fat in the anterolateral thigh (ALT) can be thin.
image The artery’s anatomy is variable with size ranging from 1 to 3 mm in diameter. The pedicle can be as long as 7 or 8 cm. It is supplied by the descending branch of the lateral femoral circumflex artery from the profunda femoris. The descending branch travels deep within the space between the rectus femoris muscle and the vastus lateralis muscle.
image The major draining vein is slightly larger than the artery. Two venae accompany the artery and merge into one at their apex.
image A major branch of the lateral cutaneous nerve of the thigh enters the flap at the superior aspect.

image Flap Design

image The anterolateral thigh flap lies on the axis of the septum dividing the vastus lateralis and the rectus femoris muscles.
image The skin paddle can be as large as 8 × 25 cm with possible primary closure.

image Marking and Dissection

image The axis of the septum between the rectus femoris and the vastus lateralis is marked by a line connecting the ASIS and the lateral patella (Fig. 15-15).
image This line is divided into thirds. The junction of the proximal and middle third is often the site of a perforator that pierces the TFL. It is incorporated for the rare circumstance when the distal perforators are of poor quality or injured during dissection.
image The junction of the middle and distal third is marked and is also incorporated into the flap (Fig. 15-16).
image The middle third of the axis line generally encompasses all substantial perforating vessels.
image A pencil Doppler exam can confirm that perforators are present.
image The anterior flap is elevated first, noting any vessels perforating the rectus femoris. Vessels near the septum are preserved until the posterior flap is elevated.
image Two perforators are found and preserved. The superior perforators may arise from the rectus femoris muscle. The inferior perforators may arise either via the septum or through the medial aspect of the vastus lateralis muscle.
image The posterior flap is elevated toward the septum only after localization of a substantial perforator. If there is no usable perforator or if it is damaged during dissection, the flap is sutured back down to the donor bed.
image The lower perforator can be seen to travel through the vastus and should be dissected toward the descending branch of the lateral circumflex femoral artery (LCFA).
image The septum is identified and any septal perforators are noted. If an adequate perforator is noted, then the flap can be based upon it. Anterior elevation can continue until the septum is isolated both medially and laterally.
image If the blood supply is entirely septal, the descending branch of the LCFA is found at the base of the septum between the rectus femoris and vastus lateralis and dissected proximally (Fig. 15-17).
image If the perforator courses in a transmuscular course, it must be dissected through to the descending branch.
image A light circumferential pressure dressing can be applied to the thigh postoperatively.
image Closed suction is used.
image The patient is allowed to ambulate as soon as clinically indicated for the flap reconstruction.
image

Figure 15-15

image

Figure 15-16

image

Figure 15-17

image Flap Variations

image Flap variations include an anterolateral thigh adipofascial flap and an anterolateral thigh fascial flap.

4 Postoperative Care

image Patients are allowed to ambulate at differing times, depending on the type of flap used. Free tissue transfer may preclude earlier ambulation to protect the anastomosis.
image Support by an abdominal binder may be used if applied properly. A binder that is too tight may cause perfusion problems.
image Diets are advanced as tolerated, based on the amount of intestinal manipulation required during opening of the hernia and lysis of adhesions.
image Drains are maintained until their drainage is <20 to 30 mL per drain per 24-hour period depending on the site.
image The patient may require monitoring in an intensive care unit for free tissue monitoring and increased pulmonary restriction after decreasing the abdominal volume. In addition, many patients requiring closure of the abdominal wall have other severe comorbidities.

5 Pearls/Pitfalls

image If a pedicled flap is not adequate, then free tissue transfer may be the next step.
image As previously stated, not all the described pedicled flaps are good options for free tissue transfer. There are limitations in vessel match, length of pedicle, size and type of tissue to be transferred.
image For perforator based flaps, such as the ALT flap, the size and location of the perforator determines whether an additional vessel is needed.
image Vessels can be temporarily clamped with micro clamps to determine inflow dominance.
image Closure of the abdominal defect with a combination of flap and synthetic or biologic mesh may be required.
image Each flap choice needs to be assessed for potential morbidity.

Selected References

Gottlieb J.R., Engrav L.H., Walkinshaw M.D., Eddy A.C., Herman C.M. Upper abdominal wall defects: immediate or staged reconstruction? Plast Reconstr Surg. 1990;86(2):281-286.

Mansberger A.R.Jr., Kang J.S., Beebe H.G., Le Flore I. Repair of massive acute abdominal wall defects. J Trauma. 1973;13(9):766-774.

Mathes S.J., Steinwald P.M., Foster R.D., Hoffman W.Y., Anthony J.P. Complex abdominal wall reconstruction: a comparison of flap and mesh closure. Ann Surg. 2000;232(4):586-596.

Rohrich RJ, Lowe JB, Hackney FL, Bowman JL, Hobar PC: An algorithm for abdominal wall reconstruction. Plast Recon Surg 105(1): 202–216.

Steinwald P.M., Mathes S.J. Management of the complex abdominal wall wound. Adv Surg. 2001;35:77-108.

Strauch B., Vasconez L.O., Hall-Findlay E.J., editors. Grabb’s Encyclopedia of Flaps, ed 2, Philadelphia: Lippincott- Raven, 1998.

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