RECONSTRUCTION OF EXTENSIVE ABDOMINAL WALL DEFECTUSING AN ECCENTRIC PERFORATOR-BASED PEDICLEDANTEROLATERAL THIGH FLAP: A CASE REPORT

JOONCHUL JANG, M.D., SEONG-HO JEONG, M.D., Ph.D.,* SEUNG-KYU HAN, M.D., Ph.D., and WOO-KYUNG KIM, M.D., Ph.D.

Reconstruction of extensive abdominal wall defects is a challenge for reconstructive surgeons. In this report, a case of reconstruction of alarge abdominal wall defect using an eccentric perforator-based pedicled anterolateral thigh (ALT) flap is presented. A 30-year-old manpresented with recurrent desmoid-type fibromatosis in the abdominal wall. The recurrent tumor was radically excised, and the en blocexcision resulted in a full-thickness, large abdominal wall defect (25 cm 3 20 cm). An eccentric perforator-based pedicled ALT flap, includ-ing wide fascial extension, was transferred to the abdominal defect; fascial portions were sutured to the remnant abdominal fascia. Plica-tion of the fascia along the sutured portion was performed to relieve the skin tension between the flap and the marginal skin of theabdominal defect. Eight months after surgery, the reconstructed abdomen had an acceptable esthetic appearance without tumor recur-rence or hernia. The use of an eccentric perforator-based pedicled ALT flap may be an alternative method for the reconstruction of exten-sive abdominal wall defects. VC 2013 Wiley Periodicals, Inc. Microsurgery 33:482-486, 2013.

Reconstruction of extensive abdominal wall defects is a

challenge for reconstructive surgeons. Various approaches

to this type of reconstruction based on the use of skin

grafts and skin flaps, with or without concomitant incor-

poration of prosthetic materials, have been advocated in

the past. In recent years, the anterolateral thigh (ALT)

flap has been used extensively for the reconstruction of

various soft tissue defects.1 It is a versatile flap that has

gained popularity because of its ease of dissection, vari-

able composition and volume availability, long vascular

pedicle, and durable skin paddle.2 Since the introduction

of the ALT flap by Song et al.,3 the flap has evolved,

and the pedicled-type ALT flap has been used in the

reconstruction of defects in the groin and lower abdo-

men.2–5 Free ALT/fascia lata composite flaps have been

described as the ideal surgical option for various poston-

cological resection defects in the abdominal and thora-

coabdominal regions.4,5 These flaps have been used for

the reconstruction of defects that are not amenable to

direct primary repair or when stable reconstruction of the

fascial layer, adequate skin coverage, and restoration of

the contour of the abdominal wall are required.6 How-

ever, the pedicled ALT flap could be the option of

choice in certain cases such as the presence of recipient

vessel damage resulting from a primary operation or

other procedures and the presence of a high potential for

tumor recurrence that could lead to large abdominal wall

defects. Here, we report a case of reconstruction of an

extensive abdominal wall defect using the eccentric per-

forator-based pedicled ALT flap with an extended

fascial cuff.

CASE REPORT

A 30-year-old man presented with a recurrent palpa-

ble mass in the abdominal wall. Radical resection of the

abdominal mass and reconstruction using a local

advancement flap and umbilicoplasty had been performed

2 years earlier (Fig. 1A). The patient was histologically

diagnosed with desmoid-type fibromatosis after the previ-

ous surgery. Physical examination revealed a huge, solid,

indolent, recurrent mass within the infraumbilical rectus

abdominis muscle (Figs. 1B and 1C). Magnetic resonance

imaging showed a huge, lobulated, partially infiltrating,

local, recurrent mass extending into the entire lower ab-

dominal wall; the mass was mainly intramuscular in the

bilateral rectus abdominis (Fig. 2).

An en bloc resection with a wide curative margin

was performed, which resulted in a full-thickness abdom-

inal wall defect of 25 cm 3 20 cm. Before reconstruc-

tion of the abdominal wall defect, an intraoperative

frozen section was obtained for margin evaluation, and

histologically clear margins were confirmed. The abdomi-

nal fascia was repaired using a synthetic Marlex net

(Phillips Petroleum Company, Bartlesville, OK) (Fig. 3),

and a fasciocutaneous pedicled ALT perforator flap (20

cm 3 15 cm) was designed for the closure of the defect.

The perforator was located using a 5-MHz hand-held

Doppler probe. To maximize the rotation arc, the flap

was raised subfascially on the basis of two very distal

eccentric septocutaneous perforators (diameter, 1.5 mm);

the more proximal perforator was cut to obtain a maxi-

mal length pedicle (Fig. 4A). The flap with a 20 cm 3

15 cm skin paddle was raised, and a large piece of

Department of Plastic Surgery, Korea University Guro Hospital, Guro-Gu,Seoul, Korea

*Correspondence to: Seong-Ho Jeong, M.D., Ph.D., Department of PlasticSurgery, Korea University Guro Hospital, 97 Guro-Dong, Guro-Gu, Seoul152–703, Korea. E-mail: surgilearn@korea.ac.kr

Received 11 December 2012; Revision accepted 27 February 2013;Accepted 4 March 2013

Published online 9 July 2013 in Wiley Online Library (wileyonlinelibrary.com).DOI: 10.1002/micr.22117

� 2013 Wiley Periodicals, Inc.

vascularized fascial extension was included. Extended

fascial harvesting was performed by excavating �5 cm

beyond the cutaneous perimeter of the flap and then

incising around the larger area of fascia. During the har-

vest, the fascial margin showed good bleeding from its

subfascial and prefascial vascular plexus. The pedicle

was dissected to the level of its origin from the profunda

femoris with a division of the transverse branch. The

pedicled ALT perforator flap was then elevated and

delivered into the abdominal defect through the tunnel

beneath the rectus femoris and sartorius muscle (Fig.

4B). The deep fascia of the flap was sutured onto the

deep fascia of the abdomen. Then these fasciae were pli-

cated together to reduce skin tension. Release of the ten-

sion between the flap and the margin of the defect

facilitated suturing of the skin (Fig. 5).The donor site

was closed by sutures and a split-skin graft. Congestion

developed at the distal tip of the flap, which was

resolved after 5 days by the application of medical

leeches. Partial necrosis of fat tissues at the distal flap

portion and wound dehiscence (length, 4 cm) occurred.

However, the dehiscence healed well by secondary inten-

tion 1 month after the operation using conservative dress-

ings. Eight months after the surgery, the reconstructed

abdominal wall was stable without herniation of the in-

traperitoneal organs, and the esthetic result was good

(Fig. 6). The patient reported transient numbness within

the distribution of the lateral femoral cutaneous nerve.

However, there were no reports of donor-site complica-

tions, such as wound dehiscence, bulging, or herniation

of the thigh.

DISCUSSION

In the past, large, full-thickness abdominal wall

defects required staged repairs.4 The abdominal organs

were first covered with a synthetic mesh, and granulation

tissue was induced. Skin grafts were then performed.7

However, this technique of abdominal wall reconstruction

did not provide durable results. To overcome this draw-

back, pedicled or free flaps (sometimes accompanied by

prosthetic reinforcement) have been used for abdominal

reconstruction.8,9 In particular, the ALT perforator flap is

considered as a useful option. The free ALT perforator

flap (alone or in combination with a vascularized fascia

lata flap) has been used for the reconstruction of large

abdominal wall defects; however, the pedicled ALT per-

forator flap has not been used for this purpose because of

the limited rotation arc and relatively small dimension of

the skin paddle.6 Posch et al.10 showed that the combina-

tion of the skin paddle and the vastus lateralis muscle is

useful for reconstruction with an ALT flap and can be

used in cases of extensive defects. Sasaki et al.11

described the use of a combination of the tensor fasciae

Figure 1. Clinical aspects of a 30-year-old man with a solid mass

in the lower abdominal wall: (A) initial preoperative mass; (B) sec-

ond preoperative mass (anterior view); and (C) second preopera-

tive mass (lateral view). [Color figure can be viewed in the online

issue, which is available at wileyonlinelibrary.com.]

Figure 2. Contrast-enhanced magnetic resonance imaging scan showing a huge (15 cm 3 15 cm 3 9.2 cm) lobulated, partially infiltrating,

local recurrent mass extending to almost the entire lower abdominal wall; the mass is mainly intramuscular in the bilateral rectus abdomi-

nis: (A) coronal view and (B) transverse view.

Treatment of Abdominal Wall Defect Using ALT Flap 483

Microsurgery DOI 10.1002/micr

lata musculocutaneous flap and the ALT flap for the

reconstruction of a large abdominal wall defect.

Recent reports have described the use of the pedicled

ALT perforator flap for the reconstruction of various

defects despite some limitations such as a limited rota-

tion arc and the relatively small dimensions of the skin

paddle.1,2,12–14 The pedicled ALT perforator flap can

have a long pedicle and can reach 8 cm above the umbil-

icus. Moreover, the pedicled ALT flap is associated with

a shorter operation time than the free ALT flap. Kayano

et al. found no significant differences between free and

pedicled ALT flaps in the rate of flap complications. The

only significant difference was a significantly longer

reconstructive time for free ALT flaps because of the

time required for microvascular anastomosis.15 Therefore,

we selected the pedicled ALT perforator flap attached to

the fascia lata and used perforators to reconstruct the ab-

dominal wall.

In this case, the reconstruction of the large abdominal

wall defect was limited by the size of the ALT skin flap.

We solved this problem by using an eccentric perforator

and placating the extended fascia. The careful selection

of perforators allows the flap to reach the subcostal area;

however, if the selection is not appropriate, it may be a

limiting factor in pedicle extension.14 The entire length

of the vascular pedicle and consequently the radius of

the rotation arc increases when the perforator is distally

Figure 3. Desmoid-type fibromatosis resection with wide margins

that resulted in a full-thickness defect (25 cm 3 20 cm). Defect

coverage was performed using a synthetic Marlex mesh for fascial

stabilization. [Color figure can be viewed in the online issue, which

is available at wileyonlinelibrary.com.]

484 Jang et al.

Microsurgery DOI 10.1002/micr

Figure 4. A (from the lateral side): A pedicled ALT perforator flap was elevated on the basis of two very distal perforators (black arrows).

The more proximal perforator was cut to maximize the arc of rotation. The lateral circumflex femoral artery is indicated with an orange

arrow. B: The flap was delivered to the abdominal defects through the submuscular and subcutaneous tunnels. Attached fascia (black

arrow). C: Eccentric perforator (black arrow) is shown. D: Schematic of the arc of rotation, and pedicle (dotted lines) are shown. [Color fig-

ure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]

located in the case of a proximally based flap. Gravvanis

et al.1 showed that a pedicled ALT flap could be trans-

ferred proximally or distally from the umbilicus to the tib-

ial tuberosity. We used the distal eccentric perforator,

which improved the distal reach of the flap. The absence

of distal perforator pedicles in flap elevation procedures

prevents the transfer of the flap to the subcostal area. In

this case, the pedicled ALT flap might be transferred to a

free ALT flap.5 Potential recipient vessels are the superfi-

cial circumflex iliac artery or the deep circumflex iliac ar-

tery. Another possible method is plication of the extended

fascia. Using this method, the skin paddle of the flap in

the remaining abdominal wall can be approximated.

Therefore, the size of the defect can be reduced as much

as possible and skin repair between the remaining abdomi-

nal wall and skin-flap paddle can be performed with ease.

In this case, we achieved excellent functional and es-

thetic results using this method. Functionally, we pre-

vented herniation by plicating the extended fascia, which

resulted in a tight abdominal wall. Esthetically, the color

and thickness of the flap and those of the abdomen were

satisfactory. In addition, a very important advantage of

this method is that the opposite thigh can be saved for

managing a recurrent tumor. Salas et al.16 described three

unfavorable prognostic factors of desmoid-type fibroma-

tosis: age< 37 years, tumor size> 7 cm, and extra-ab-

dominal tumor location. In the current case, age and

tumor size were relevant as unfavorable prognostic fac-

tors. With regard to tumor recurrence, the saved opposite

thigh can provide useful tissue for the reconstruction of

abdominal defects. However, before the adoption of this

method, several disadvantages should be considered. Do-

nor-site issues such as pain, weakness, wound dehis-

cence, and scarring can develop because the deep fascia

is sacrificed.17 The method may not be performed

because of the anatomic variations of perforators. More-

over, congestion at the distal portion of the flap may de-

velop because of insufficient venous drainage. To test if

the distal part of flap gets enough perfusion, it can be

helpful to clamp the more proximal perforator before

complete flap elevation. If the distal perfusion is found

poor after clamping the proximal perforator, we suggest

two possible options. Supercharging procedure can be

considered as one choice.18 In other words, anastomosis

between proximal perforator vein and the superficial cir-

cumflex iliac vein may be possible. Free ALT flap could

be another option in case of failure in supercharging.5

Other methods to overcome the flap-size limitation

for the reconstruction of large defects have been

reported. Kulahci et al.19 used a pre-expanded pedicled

flap to reconstruct a large defect. Fujiwara et al.20

reported the use of a free flap in combination with a

Figure 5. A: Schematic of the pedicle ALT flap set into the abdominal defect. B: Schematic horizontal section of dotted lines: (a) fascial

suture, (b) plication of fascia, and (c) skin suture. [Color figure can be viewed in the online issue, which is available at

wileyonlinelibrary.com.]

Figure 6. The clinical result after 8 months shows a well-contoured,

stable abdominal wall: (A) anterior view and (B) lateral view. [Color

figure can be viewed in the online issue, which is available at

wileyonlinelibrary.com.]

Treatment of Abdominal Wall Defect Using ALT Flap 485

Microsurgery DOI 10.1002/micr

delayed procedure. The use of a tissue expander or

delayed reconstruction could be applied to our technique.

Further research is necessary to evaluate pre-expanded

pedicled ALT flaps and an eccentric perforator-based

pedicled ALT flap in delayed reconstruction. This will be

the focus of our future investigations.

Despite some drawbacks, we believe that the eccen-

tric perforator-based pedicled ALT flap with an extended

fascial cuff can be a very useful alternative for recon-

structing extensive abdominal wall defects.

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Microsurgery DOI 10.1002/micr