The tensor fascia lata free flap in abdominal-wall reconstruction

Bioengineering of vascularized porcine flaps using perfusion-recellularization

Large volume soft tissue defects greatly impact patient quality of life and function while suitable repair options remain a challenge in reconstructive surgery. Engineered flaps could represent a clinically translatable option that may circumvent issues related to donor site morbidity and tissue availability. Herein, we describe the regeneration of vascularized porcine flaps, specifically of the omentum and tensor fascia lata (TFL) flaps, using a tissue engineering perfusion-decellularization and recellularization approach. Flaps were decellularized using a low concentration sodium dodecyl sulfate (SDS) detergent perfusion to generate an acellular scaffold with retained extracellular matrix (ECM) components while removing underlying cellular and nuclear contents. A perfusion-recellularization strategy allowed for seeding of acellular flaps with a co-culture of human umbilical vein endothelial cell (HUVEC) and mesenchymal stromal cells (MSC) onto the decellularized omentum and TFL flaps. Our recellularization technique demonstrated evidence of intravascular cell attachment, as well as markers of endothelial and mesenchymal phenotype. Altogether, our findings support the potential of using bioengineered porcine flaps as a novel, clinically-translatable strategy for future application in reconstructive surgery.

Open Complex Abdominal Wall Reconstruction

This article provides an approach to open complex abdominal wall reconstruction. Herein, the authors discuss the purpose of component separation as well as its relevant indications. The techniques and anatomical considerations of both anterior and posterior component separation are described. In addition, patient selection criteria, preoperative adjuncts that may assist with fascial or soft tissue closure, and complications of component separation will be discussed.

Reconstruction of infected trunk wounds with pedicled rectus abdominis musculocutaneous flaps: a retrospective case series

OBJECTIVE

To completely treat and cover extensively infected trunk defects, reconstruction should be performed using a sufficiently vascularised flap, such as a muscle or musculocutaneous flap after perfect debridement. These reconstructive surgeries are challenging in patients with severe comorbidities. In this case series, we describe extensively infected trunk defect reconstruction, in patients with severe comorbidities, using a pedicled rectus abdominis musculocutaneous flap and suggest an algorithm for reconstruction.

METHOD

Between March 2011 and March 2015, participating patients underwent reconstruction of extensively infected trunk defects using a pedicled rectus abdominis musculocutaneous flap. All patients had diabetes and hypertension, and several patients had severe comorbidities, including heart and renal failure. Bacterial cultures revealed that meticillin-resistant Staphylococcus aureus (MRSA) was present in seven patients (with concurrent Pseudomonas aeruginosa in two patients), multidrug-resistant Acinetobacter baumannii in one patient and Mycobacterium tuberculosis in two patients.

RESULTS

A total of 10 patients underwent the procedure. The pedicled rectus abdominis musculocutaneous flaps survived completely in all 10 patients. There were no complications related to the flaps, although two patients developed minor wound dehiscence, which may be due to their comorbidities. There were no signs of recurrent infection during the follow-up period in each case.

CONCLUSION

Reconstruction using the pedicled rectus abdominis musculocutaneous flap is a good treatment option for extensively infected three-dimensional trunk defects, even for patients with severe comorbidities.

Planned hernia repair and late abdominal wall reconstruction

Planned ventral hernia is a management strategy in which the abdominal fascial layer has been left unclosed and the viscera are covered only with original or grafted skin. Leaving the fascia open can be deliberate or unavoidable and most commonly results from staged repair of the abdominal wall due to trauma, peritonitis, pancreatitis, abdominal vascular emergencies, or abdominal compartment syndrome. The abdominal wall defects can be categorized as type I or II defects depending on whether there is intact, stable skin coverage. In defects with intact skin coverage, the most commonly used methods are the components separation technique and a prosthetic repair, sometimes used in combination. The advantages of the components separation technique is the ability to close the linea alba at the midline, creating a better functional result than a repair with inert mesh. Although the reherniation risk seems higher after components separation, the risk of infection is considerably lower. With a type II defect, with absent or unstable skin coverage, fascial repair alone is inadequate. Of the more complex reconstruction techniques, the use of a free tensor fasciae latae (TFL) flap utilizing a saphenous vein arteriovenous loop is the most promising. The advantages of the TFL flap include constant anatomy of the pedicle, a strong fascial layer, large-caliber vessels matching the size of the AV loop, and the ability to use large flaps (up to 20 × 35 cm). Whatever technique is used, the repair of complex abdominal wall defects requires close collaboration with plastic and abdominal surgeons, which is best managed in specialized centers.

Reconstruction of extensive abdominal wall defects with microvascular tensor fasciae latae flap

Background

Most abdominal wall defects can be repaired with a mesh, components separation technique or pedicle flaps, but a free flap reconstruction might be the only option for large epigastric or non-midline defects. This retrospective study reviewed the results of consecutive patients who had extensive full-thickness abdominal wall defects reconstructed with a large, microvascular tensor fasciae latae (TFL) flap.

Methods

A 30–35 × 15–20-cm TFL flap was harvested and microvascular anastomoses were performed using a saphenous arteriovenous loop.

Results

From 1995 to 2009, 20 patients were operated on with a TFL flap. The repair was combined with a mesh in nine patients, components separation in one patient, and both techniques were used in one patient. The median follow-up was 2 (range 0·5–13) years. There were no perioperative deaths, or intra-abdominal or deep surgical-site infections. The flap failed in one patient, two patients had minor distal tip necrosis of the flap and one developed a recurrent hernia 3 months after TFL repair.

Conclusion

A microvascular TFL flap is a feasible option for reconstruction of exceptionally large abdominal wall defects if other means of reconstruction have already been used or are insufficient. It can also be combined with other methods of reconstruction. A close collaboration between plastic and abdominal surgeons is important.

Immediate repair of major abdominal wall defect after extensive tumor excision in patients with abdominal wall neoplasm: a retrospective review of 27 cases [corrected]

BACKGROUND

The treatment of abdominal wall neoplasm continues to present a challenging problem because it is not easy to repair the giant defect which is resulted from extensive tumor excision. Some techniques and materials have been reported, but most report a certain technique or material for abdominal wall reconstruction. Therefore, we retrospectively reviewed the treatment of such patients in our department and assessed the reconstruction algorithm in such a situation.

METHODS

We studied 27 patients undergoing immediate abdominal wall reconstruction between 1999 and 2008 who sought care for major defects after extensive tumor excision of malignancy. We categorized the defects into three types: type I, defects involving only the loss of skin (15 cases); type II, myofascial defects with intact skin coverage (6 cases); and type III, myofascial defects without skin coverage (6 cases). Different techniques and materials were used. Postoperative morbidities, sign of herniation, and other follow-up data were recorded.

RESULTS

The immediate abdominal wall reconstruction was successful in all patients. There was no severe morbidity after the operation. Only one patient developed hernia.

CONCLUSIONS

Most type I defects can be corrected with primary suture. For type II defects, a prosthetic or biological mesh, or alternatively an autologous fascial substitute, may be used. For type III defects, the resulting full-thickness defect will require a myocutaneous flap, such as the tensor fascia lata flap, with or without a mesh for abdominal wall reconstruction. Human acellular dermal matrix, a biological mesh, is an ideal alternative for synthetic mesh, especially in situations of infection or contamination.

Abdominal Wall Reconstruction with Free Flaps

This article addresses the clinical applications of free tissue transfer for abdominal wall reconstruction. Details of indications, techniques, and clinical examples for the coverage of complex abdominal wall defects are presented.

[Total abdominal wall reconstruction. Management of full-thickness losses of the abdominal wall after a long ischemic compression]

The authors report an original case of a 70-year-old male with large musculocutaneous necrosis area of the abdominal wall following a long ischemic compression. Initial treatment was done using a wide excision of the abdominal wall necrosis and insertion of synthetic prosthesis to protect bowels. After 4 weeks of further surgical revisions, two splits thickness skin grafting were performed. The grafts were placed directly on granulations around and over the mesh and the healing was complete. Postoperative course was uneventful. In our experience, this technique allowed a good cicatrisation and a good esthetical result.

Free tensor fasciae latae musculofasciocutaneous flap in reconstructive surgery: a series of 85 cases

The use of tensor fasciae latae was first described as a rotation or island flap and evolved into a free flap in the late 1970s. This series of 85 patients undergoing free tensor fasciae latae transfer includes complex head and neck, abdominal wall and lower limb reconstruction. The overall success rate was 93% (79 patients), partial flap loss, 5% (four cases), and flap failure, 2% (two patients). Twelve patients (14%) required unplanned return to theatre for exploration resulting in a 75% salvage rate. We believe this series demonstrates the great versatility of this flap and highlights particular indications for its use.

Incisional hernia repair: abdominoplasty, tissue expansion, and methods of augmentation

Incisional hernia repair without mesh mainly consists of tissue transfer to bridge or close the defect. Bridging includes rotational or free musculocutaneous flaps, rendering acceptable short-term results but a rather disappointing long-term outcome. Abdominal wall closure where there has been significant loss of domain, with intraperitoneal organs residing permanently outside the abdominal cavity, can only be achieved using the patients' own tissue if preoperative expansion of the abdominal cavity is performed using artificial expanders or pneumoperitoneum. From a scientific point of view, however, evidence supporting any treatment option is weak because prospective randomized controlled trials are virtually impossible to conduct owing to the inhomogeneity of the patient population being considered. Treatment of this condition by the above-mentioned means should therefore be proposed on an individual basis utilizing one or more of the many possible techniques described.

Reconstruction of a wide abdominal defect using an extended groin flap

We present reconstruction of a wide anterior abdominal defect measuring 30 x 45 cm(2), the result of necrotising pancreatitis. After serial debridements and reconstruction of the peritoneum using a Prolene mesh support, a delayed extended groin flap was transposed. No complications were encountered afterwards. An extended groin flap can be used safely to cover a full-thickness defect of the abdominal wall encompassing all of the anatomic subunits.

Use of autogenous fascia lata graft for perineal herniorrhaphy in dogs

OBJECTIVE

To evaluate the effectiveness of a herniorrhaphy technique, using an autogenous fascia lata graft (FLG) for perineal hernia (PH) repair in dogs.

STUDY DESIGN

Prospective clinical study.

ANIMALS

Twelve dogs with PH.

METHOD

PHs were repaired with FLG harvested from the dog's ipsilateral thigh and sutured directly into the perineal defect. Correction of associated conditions, and castration were performed. Surgical time, pain, inflammation, pattern of defecation, lameness, hospitalization time, postoperative complications, and owner satisfaction were recorded. Histopathologic examination was performed in 1 dog euthanatized 10 months after repair.

RESULTS

Hernia did not recur (mean follow-up, 5.8 months). Lameness was the most frequent minor complication, and was resolved within a few days. Transient rectal prolapse occurred in 2 dogs with bilateral PH. The mean (+/-SD) hospitalization was 1.8+/-0.9 days, and the surgical time was 76.5+/-9.8 minutes. Histopathologic examination in 1 dog revealed perfect integration of FLG into adjacent tissues without substantial tissue reaction.

CONCLUSIONS

FLG reconstruction of PH is a simple, effective method of treatment.

CLINICAL RELEVANCE

FLG can be used without major complications for primary repair of PH, as an augmentation procedure when the internal obturator muscle is thin or friable, or when herniation has recurred after another repair technique.

Reconstruction of traumatic transposition of the penis and scrotum and associated complex open abdominoperineal pelvic deformity with free innervated tensor fascia latae osteomyocutaneous flap

Guidelines for the repair of full-thickness defects of the lower abdominal wall have been established. However, lower abdominal defects associated with traumatic bladder herniation and pubic symphyseal diastasis or bony loss have not been addressed. Poor abdominal wall contour, protuberance, and recurrent hernias are likely when there is discontinuity of the midline pelvis in association with full-thickness lower abdominal defects and visceral herniation. We devised an operation that would not only restore bony continuity by providing a vascularized bone flap but also simultaneously maintain the integrity of the attachment of the tensor fascia latae muscle to the iliac crest and reestablish musculofascial continuity.

One-stage reconstruction of large midline abdominal wall defects using a composite free anterolateral thigh flap with vascularized fascia lata

OBJECTIVE

Large midline abdominal wall defects are continuously a challenge for reconstructive surgeons. Adequate skin coverage and fascia repair of the abdominal wall is necessary for achieving acceptable results. The purpose of this paper is to present a new approach to abdominal wall reconstruction using a free vascularized composite anterolateral thigh (ALT) flap with fascia lata.

METHODS

Seven patients with large full-thickness abdominal wall defects were successfully reconstructed by means of a composite ALT flap combined with vascularized fascia lata. The size of the skin islands ranged from 20 to 32 cm in length and 10 to 22 cm in width, and the vascularized fascia lata sheath measured 14 to 28 cm and 8 to 18 cm, respectively. Functional outcome of the abdominal wall strength and donor thigh morbidity were investigated by using a Cybex kinetic dynamometer.

RESULTS

All flaps survived. No postoperative ventral hernia occurred except for one mild inguinal incision hernia. Subjectively there were no significant donor site problems. Objective assessment was performed in 4 patients 2 years postoperatively. In the reconstructed abdomen, isokinetic concentric and eccentric measurements of extension/flexion ratios of the abdominal wall strength showed no apparent decrease compared with other references. Functional evaluation of quadriceps femoris muscle contraction forces after free ALT composite flap harvest showed an averaged deficit of 30% as compared with the contralateral legs. However, no difficulties in daily ambulating were reported by the patients.

CONCLUSION

The free composite ALT myocutaneous flap with vascularized fascia lata provides an alternative option for a stable repair in complex abdominal wall defects.

[Principles and possibilities of reconstruction with microsurgical flaps]

Microsurgical reconstructions are considered an integral art of modern reconstructive concepts, especially in the fields of trauma, tumor reconstruction, and correction of congenital deformities. Patient expectations regarding function and aesthetics of plastic surgical reconstructions are satisfied with permanently improved flap designs that also lead to a significant reduction in donor site morbidity. Together with steadily decreasing complication rates, these options have made microsurgical reconstructions a prime choice in plastic surgery, in contrast to the past, where they were considered the "last line of defense."

Reconstruction of the hand and upper limb with free flaps based on musculocutaneous perforators

Since the advent of perforator flaps, a wide variety of applications have been documented. This study focuses on free flaps based on musculocutaneous perforators, because they have not been well-described in the literature of upper-limb reconstruction. They can be trimmed to be thin and pliable, and may provide large flaps with multiple components on the same pedicle to facilitate three-dimensional inset of flaps. Microvascular free flaps based on musculocutaneous perforators were performed in 36 cases for reconstruction of the thumb and thenar web, palm, dorsum of the hand, wrist, and forearm. They included the anterolateral thigh perforator flap (27 cases), thoracodorsal perforator flap (5 cases), and deep inferior epigastric perforator flap (4 cases). In 2 other cases not included in this series, the thoracodorsal perforator flap could not be elevated due to anatomical variations. There was no failure in this series, but complications included: 1) hematoma in 2 cases, and 2) infection in 2 cases with flap rim necrosis which was treated by a local rotation flap and skin graft. The thin flaps facilitated secondary reconstructive procedures, and only minor effort was required for the debulking procedure of the flaps. On average, these patients required 2.3 occasions of secondary procedures for further reconstruction following coverage with a perforator flap. The perforator flaps provide medium-thickness flaps for coverage of large defects in the upper limb with improved aesthetics and function. With careful dissection of the musculocutaneous perforators and primary thinning of the flaps, the use of a perforator flap is quite safe. Preservation of the muscles leads to better preservation of donor-site functions. Less requirement of secondary debulking procedures is a great advantage. However, caution should be taken in the presence of wound infection.

Anterolateral thigh flap: an ideal soft tissue flap

Microsurgical reconstruction has evolved to a stage where a nearly 100% success rate has been achieved. Therefore, refinement of the functional and aesthetic result, as well as a decrease in donor site morbidity have become the major concerns. The anterolateral thigh flap meets these requirements; its wide application to various fields is based on the following charateristics. Its reliable vascularity. Its vascular pedicle is long and large, at least 8 cm (can be 20 cm). Flap territory is large and easy to design. The pedicle can be at the periphery of the flap. Its length can be 40 cm and its width can be half of the thigh, with the maximal dimension as large as 40 x 20 cm (800 cm2). Primary trimming of the flap to 3 mm to 5 mm in thickness does not compromise its vascularity. The subcutaneous fat can be included to facilitate gliding of the underlying tendons. To harvest chimeric flaps, the following components can be included: muscles, fascia and bone (an osseous flap can be joined to the flap with microvascular anastomoses). A two-team approach is possible, because the recipient site is usually far away from the donor site. Usually it does not require that the patient change position. It can be closed primarily without skin graft if its width is less than 8 cm. The donor site is easily covered with clothes, and the motor function is least affected. Care should be taken in flap dissection, inset, and postoperative care, as well as strategies for re-exploration.

Dynamic reconstruction of large abdominal defects using a free rectus femoris musculocutaneous flap with normal motor function

Reconstruction of large abdominal wall defects with conventional reconstruction including the component separation technique is difficult because of strong transverse tension and loss or weakness of the rectus abdominis muscle. To overcome this problem, dynamic reconstruction of the abdominal wall using a free innervated rectus femoris musculocutaneous flap was performed for large defects with separation of the bilateral rectus abdominis muscles. The intact motor nerve of the rectus femoris muscle was transferred without transection, and only the pedicle vessels were anastomosed to the omental vessels. Four and one-half years after surgery, the rectus femoris muscle had voluntary strong muscle contraction and there was no abdominal protrusion, herniation, or donor morbidity. This new method with dynamic function can replace conventional techniques for large abdominal defects without rectus muscle function.

Use of Abdominoplasty Technique and Marlex for Closure of a Major Abdominal Wall Defect

Surgical resection of extensive primary or secondary abdominal wall tumours leads to major defects requiring reconstruction. The present case report describes the use of Marlex (polypropylene) mesh (CR Bard Inc, USA) with Mitek GII suture anchors (Mitek Products, USA) and an abdominoplasty technique to close a defect involving the entire lower half of the abdominal wall.

Resection of talocalcaneal middle facet coalition. Interposition with a tensor fascia lata allograft: a case report

Tensor fascia lata is utilized in the management of complex soft-tissue injuries and defects, but has not been described in the literature in the use of tissue interposition with resection of talocalcaneal middle facet coalitions. This article is a case presentation of a resection of a middle facet coalition with interposition of an allograft of tensor fascia lata. At 14 months postoperative follow-up, range of motion of the subtalar joint was noted to be 20 degrees, and without pain or crepitus. There was no radiographic evidence of degenerative changes in Chopart's joint. The patient returned to all routine and sports activities without pain. He was satisfied with the outcome of the procedure.