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

Original article

Reconstruction of extensive abdominal wall defectswith microvascular tensor fasciae latae flap

E. Tukiainen1 and A. Leppaniemi2

Departments of 1Plastic and 2Abdominal Surgery, Helsinki University Hospital, Helsinki, FinlandCorrespondence to: Dr E. Tukiainen, Department of Plastic Surgery, Helsinki University Hospital Toolo, PO Box 266, 00029 HUS, Finland(e-mail: [email protected])

Background: Most abdominal wall defects can be repaired with a mesh, components separation techniqueor 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 extensivefull-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 performedusing a saphenous arteriovenous loop.Results: From 1995 to 2009, 20 patients were operated on with a TFL flap. The repair was combinedwith a mesh in nine patients, components separation in one patient, and both techniques were used inone patient. The median follow-up was 2 (range 0·5–13) years. There were no perioperative deaths, orintra-abdominal or deep surgical-site infections. The flap failed in one patient, two patients had minordistal 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 largeabdominal wall defects if other means of reconstruction have already been used or are insufficient. Itcan also be combined with other methods of reconstruction. A close collaboration between plastic andabdominal surgeons is important.

Presented to the Annual Meeting of the European Surgical Association, Budapest, Hungary, May 2009

Paper accepted 31 January 2011Published online 8 April 2011 in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.7489

Introduction

A defect in the abdominal wall may result from tissueloss after tumour resection or infection, or retraction ofthe abdominal wall with a planned ventral hernia treatedpreviously by skin grafting after an open abdomen. Inaddition, failed attempts at ventral hernia repair may haveresulted in giant hernias, sometimes associated with aninfected and exposed mesh. The defects may be categorizedas type I or II depending on the type of skin coverage overthe hernia defect. In type I defects there is intact orstable skin coverage, whereas type II defects have absent orunstable skin coverage1.

Large abdominal wall defects that cannot be closedprimarily require abdominal wall repair. Bridging thefascial gap with prosthetic material or autologous tissueis the method most frequently used for type I defects

with stable skin coverage. In the components separationtechnique, initially described in 1990, the externaloblique muscle is divided on both sides vertically about2 cm lateral to the lateral edge of the rectus sheath,and the muscle is separated along the avascular planefrom the internal oblique muscle; this creates tworectus abdominis–transversus abdominis–internal obliquemuscle flap complexes that can be advanced medially upto approximately 10 cm at the waistline on each side, andsutured together at the midline2,3. This technique hasrecently been shown to compare favourably with meshrepair4.

Mesh repair alone is inadequate for type II defectswith absent or unstable skin coverage, and the useof components separation for large defects may createexcessive tension with a risk of tissue necrosis orabdominal compartment syndrome. The criteria for special

2011 British Journal of Surgery Society Ltd British Journal of Surgery 2011; 98: 880–884Published by John Wiley & Sons Ltd

Microvascular tensor fascia latae flap for abdominal wall reconstruction 881

reconstruction techniques include a large defect (40 cm2),absence of stable skin coverage, recurrence of the defectafter previous closure attempts, infected or exposed mesh,systemic compromise (intercurrent malignancy), localtissue compromise (irradiation, corticosteroid dependence)and concomitant visceral complications (enterocutaneousfistula)1.

Vascularized flaps provide healthy autologous tissuecoverage without implantation of foreign material at theclosure site. Pedicled flaps can be used in small andmid-sized defects within the arch of rotation of the flap.In contrast, extensive upper midline abdominal wall andthoracoabdominal defects usually require a free flap, whichoffers a completely autologous, single-stage reconstructivesolution. Following the first description of the tensorfasciae latae (TFL) myocutaneous free flap in 19785, ithas been used not only in reconstructing large abdominalwall defects but also for reconstruction of complex headand neck, composite extremity and perineal defects6–18.

The aim of this study was to evaluate the resultsof microvascular TFL repair for extensive and complexabdominal wall defects at a tertiary referral centre.

Methods

Hospital records of consecutive patients who underwentabdominal wall reconstruction with microvascular TFLflaps between 1995 and 2009 were reviewed. Thesurgical technique for harvesting and reconstruction ofthe abdominal wall with a TFL flap was a modificationof previously published techniques15,16,19. The TFL flapconsisted of a musculofasciocutaneous flap with a skincomponent measuring 30–35 × 15–20 cm and underlyingfascia as well as including the TFL muscle. The flap washarvested from the thigh and its pedicle dissected freetowards the deep femoral artery and vein. In patients witha large defect, the rectus femoris muscle was included inthe flap to ensure adequate perfusion of the distal tip. Theipsilateral great saphenous vein was divided distally abovethe knee and its distal end was reflected proximally andanastomosed end-to-side to the common femoral artery,creating an arteriovenous loop (Fig. 1). The loop wastunnelled subcutaneously to the edge of the defect anddivided at its apex. Arterial and venous anastomoses withthe flap vessels were created with continuous 7/0 or 8/0vascular sutures.

The flap fascial edges were sutured to the fascialedges of the original defect, carefully avoiding anyobstruction or kinking of the flap vessels. Drains wereplaced subcutaneously, and the subcutaneous space andskin were closed with interrupted sutures or staples (Fig. 2).

Fig. 1 Saphenous vein loop used for tensor fasciae latae flap incombination with components separation and mesh

Fig. 2 Tensor fasciae latae flap used for a large abdominal defect;previous skin graft donor site marks are visible on the flap

In all patients the donor site was closed directly as far aspossible and the remaining defect was covered with a split-thickness skin graft. After surgery, the viability of the flapwas monitored clinically every hour, with inspection offlap colour, temperature and capillary refill. The intra-abdominal pressure was measured every 4–6 h.

Results

The clinical characteristics of the patients, indications andflap sizes are summarized in Table 1. Six of 12 patients

2011 British Journal of Surgery Society Ltd www.bjs.co.uk British Journal of Surgery 2011; 98: 880–884Published by John Wiley & Sons Ltd

882 E. Tukiainen and A. Leppaniemi

Table 1 Clinical characteristics of 20 patients undergoingabdominal wall reconstruction with a microvascular tensorfasciae latae flap

No. of patients*

Age (years)† 53 (43–78)Sex ratio (M : F) 18 : 2Indication for TFL flap

Tumour resection 12Sarcoma 8Carcinoma 4

Planned abdominal hernia 6Trauma 3Acute pancreatitis 2Peritonitis 1

Infected mesh 2Flap size (cm)†

Vertical 32 (30–35)Horizontal 17 (15–20)

Additional visceral proceduresClosure of enterostomy or colostomy 4Small bowel resection 3

*Unless indicated otherwise; †values are median (range). TFL, tensorfasciae latae.

with abdominal wall tumours required extension of theresection to the chest wall. In another six patients, thevisceral organs had been covered temporarily with split-thickness skin grafts as part of a planned hernia strategy.The skin graft was allowed to mature for 9–12 monthsuntil it could be rolled freely over the bowel.

In 18 patients, an arteriovenous loop was createdbetween the ipsilateral great saphenous vein and thecommon femoral artery. In two patients, the deep inferiorepigastric vessels were used as recipient vessels.

Owing to a large midline defect or thin fascialcomponent of the TFL flap, an additional componentsseparation procedure was used in one patient, meshenforcement in nine patients and a combination of bothtechniques in one patient (Fig. 1). An additional visceralprocedure was performed in seven patients.

The median postoperative follow-up time was 2 (range0·5–13) years. Clinical outcomes are summarized inTable 2. The only complete flap loss was caused by arterialthrombosis, and the necrotic flap was replaced with thecontralateral TFL flap. Postoperative bleeding from thearterial anastomosis required resuturing in one patient. Intwo patients with distal skin tip necrosis of the flap, thenecrotic skin area was removed and the defect covered byeither direct closure or a skin graft. There was no initialmorbidity at the donor site, but two patients required minorsurgical revision of the donor area during follow-up. Nosignificant loss of force in knee extension was recorded, butfunctional assessment was not performed systematically.

Table 2 Outcome after abdominal wall reconstruction with amicrovascular tensor fasciae latae flap

No. of patients*

Perioperative death 0Flap failure 1Partial flap loss 2Postoperative bleeding 1Postoperative infection 0Length of hospital stay (days)† 19 (11–27)Early donor-site morbidity 0Late donor-site morbidity 2Recurrent hernia 1

*Unless indicated otherwise; †values are median (range).

One patient developed a recurrent incisional hernia atthe inferolateral side of the flap 3 months after surgery thatwas later repaired with a mesh placed under the healed andhealthy flap.

Discussion

The overall results of a free TFL flap procedurefor abdominal wall reconstruction in this series of 20consecutive patients with large abdominal wall defectswere satisfactory. There was only one total flap failure andtwo instances of distal tip necrosis.

Total loss of the flap is rare; even in a large seriesof 85 patients undergoing free TFL transfer for complexhead and neck, abdominal wall and leg reconstruction,the overall success rate was 93 per cent (79 of 85), withonly two flap failures and four partial flap losses15. Earlytechnical complications, such as kinking or thrombosis ofthe vein requiring re-exploration, have been reported inthree instances8,10,17. The only flap loss in the present serieswas thought to have been caused by an arterial thrombosisfollowing the manipulation of an atherosclerotic vesselduring reconstruction.

Distal tip necrosis of the flap occurred in two patientsin the present series. This probably reflects an insufficientarterial supply with respect to the large flap size. Among33 patients from five reports in the literature, distal tipnecrosis was reported in seven patients8,9,12,14,17. For largedefects requiring extensive flaps, the rectus femoris musclecan be included in the flap to ensure adequate perfusion ofthe distal flap tip. During the latter part of this study, therectus femoris muscle was included in large flaps in threepatients, and no distal tip necrosis occurred.

The arteriovenous loop technique, used in 18 patientshere, has been described previously as either a one- or atwo-stage procedure17,19. It allows the flap to reach the


Microvascular tensor fascia latae flap for abdominal wall reconstruction 883

epigastrium or chest wall, and provides a constant large-calibre, high-flow vessel to the flap. An additional benefitis the location of the anastomoses outside the abdominalcavity, reducing the risk of vessel compression or herniarecurrence. Other advantages of the free TFL flap in thesecritically ill patients include the ability to harvest the flapwithout changing the position of the patient, allowinga two-team approach and reduction in total duration ofoperation. In contrast to use of a latissimus dorsi flap, thelocation of the donor site in the thigh does not compromiserespiratory function.

The use of microvascular TFL flaps in abdominalwall reconstruction, sometimes in combination with ananterolateral thigh flap, has been reported in more than70 patients5–18. The most commonly used recipientvessels are the deep inferior epigastric vessels. The use ofintraperitoneal vessels, mainly the gastroepiploic vessels,allows the use of flaps with shorter pedicles and tight,continuous, circumferential fascial closure between theflap and native abdominal wall13. Compared with ananterolateral thigh flap, the anatomy of the TFL pedicleis constant and it offers large-calibre vessels matching thevessel size of the great saphenous vein loop. Furthermore,the size of the flap can be large, up to 20 × 35 cm. However,the relative thinness of the anteromedial portion of thefascia in very wide flaps, especially in women, sometimesrequires mesh enforcement, as was necessary in ten patientsin this series.

The TFL flap is functionally passive, resembling a mesh.An innervated free latissimus dorsi musculocutaneous flaphas been used to create a functional dynamic reconstructionof full-thickness abdominal wall defects20.

In general, the majority of patients with largeabdominal wall defects can be treated with componentsseparation or mesh repair alone (type I defects). Complexreconstruction techniques are required mainly for extensiveor recurrent defects. Among 954 patients undergoingautologous tissue repair of large abdominal wall defects,the majority (94 per cent) underwent either local tissuerepair (components separation, rectus sheath) or repairwith autologous grafts (free fasciae latae, autodermal graft).Pedicled or free vascularized flaps were used in only59 patients, including rectus femoris in 11 patients andlatissimus dorsi in 13. A TFL flap was used in 35 patients,pedicled in 15 and microvascular in 20 patients21.

The repair of complex type II abdominal wall defectsrequires a multispecialty approach and is best managedin specialized units22. Close collaboration between plasticand abdominal surgeons is particularly useful, and allowsadaptation of the visceral procedure and abdominal wallreconstruction to the needs of the individual patient.

Acknowledgements

The authors declare no conflict of interest.

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