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Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) xx, 1e2

CORRESPONDENCE AND COMMUNICATION

“Windmill flap”: A novel techniqueof abdominal wall reconstruction

Dear Sir,

Full thickness central abdominal wall reconstruction can bea reconstructive challenge especially if the defect is large.Microvascular free flaps have revolutionized such recon-struction. However if this option cannot be exercised (dueto non availability of microvascular facilities or patientstatus), reconstruction in such cases can prove to be verydifficult.

An 86 year old male who was a heavy smoker andknown case of diabetes, hypertension and chronicobstructive pulmonary disease presented in our outpa-tient department with recurrent ulceration in the centralanterior abdominal wall since last four months. Five yearsback patient had undergone excision of “Kangri Cancer”(squamous cell carcinoma of skin prevalent in Kashmir,India due to use of hot earthen pot as heating source tocombat harsh winter)1 in the same area followed byradiotherapy. On examination there was an ulcerativelesion measuring 8 � 12 cm in the central abdominal walladherent to the underlying musculature (Figure 1A).There was no regional lymphadenopathy. Edge biopsy ofthe ulcer revealed features suggestive of moderatelydifferentiated squamous cell carcinoma. The ulcer with2 cm healthy margin was excised leaving a full thicknessanterior abdominal wall defect measuring 12 � 16 cm(Figure 1B). Abdominal wall was reconstructed in threelayers, innermost by greater omentum (Figure 1C), middleby polypropylene mesh (Figure 2A) and skin cover bytransposing four local skin flaps (Figure 2B). Flap donorsites were split skin grafted (Figure 2C). Patient had afollow up of more than a year with no recurrence and nolocal complication.

Anterior abdominal wall is a multilayered structurewhich encases and protects vital viscera. Reconstructed fullthickness abdominal wall defects should not only haveadequate tensile strength to prevent herniation of viscerabut also have a viable skin cover.

Please cite this article in press as: Zargar HR, et al., “Windmill flap”Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/

http://dx.doi.org/10.1016/j.bjps.2014.03.0191748-6815/ª 2014 British Association of Plastic, Reconstructive and Aesthetic.

The gold standard in abdominal wall reconstruction iswith the use of autologus tissue. When autologus tissue isnot available due to any reason prosthetics or bio-prosthetics are used to assist the reconstruction.2

Greater omentum whenever available forms a goodvascularized barrier between mesh and bowel.2

The greatest challenge after reconstructing the muscu-loaponeurotic layer with the help of prosthetic mesh re-mains in reconstructing a viable skin cover. In the past largecentral abdominal defects have been usually covered usingmicrovascular free flaps3 or with large regional flaps.4

Various algorithms have been proposed for reconstructingthe abdominal wall defects based on topographic location.5

Not a single algorithm is universally applicable as theabdominal wall reconstruction depends on many issues likeavailability of local tissue, co-morbid conditions, avail-ability of expertise etc. With the advent of microvascularsurgery there is some ease in reconstruction of such de-fects. In fact these newer modalities (microvascular tech-nique, vacuum assisted closure, tissue expansion) havechanged the reconstruction guide: “The reconstructiveladder”. We tend to get lured by these newer modalitiesthere by forgetting this time honored reconstructionguideline.

Problem arises once the microvascular reconstructioncannot be done and we are left with no option but to goback to the reconstructive ladder.

We faced a similar problem in our patient while planninghis reconstruction. It initially seemed impossible to recon-struct the defect without microvascular tissue transfer, butkeeping in view his heavy smoking habit and multiple co-morbidities microvascular tissue transfer could not beconsidered.

On dividing the defect into four equal triangles by twoimaginary lines, reconstruction of the large defect suddenlyseemed to be simple. Each triangle could be reconstructedby transposing the adjacent random pattern skin flap in 1:1ratio. The plan was executed on the patient and the donorsites were grafted with split skin graft. Once the graftdressing and sutures were removed the reconstructedabdominal wall resembled a windmill so we started callingit “Windmillflap”(Figure 2C). To our knowledge this tech-nique for reconstruction of full thickness central abdominalwall defect has not been described.

: A novel technique of abdominal wall reconstruction, Journal of10.1016/j.bjps.2014.03.019

Surgeons. Published by Elsevier Ltd. All rights reserved.

Figure 1 A: Malignant ulcer anterior abdominal wall with Windmill flaps marked. B: Full thickness central abdominal wall defectfollowing wide local excision of tumor with exposed viscera. C: Greater Omentum used for reconstruction of inner layer.

Figure 2 A: Windmill flaps raised and Prolene mesh used over the omentum for reconstruction of middle musculoaponeuroticlayer. B: Windmill flaps inset. C: Postoperative photograph showing healthy transposed Windmill flaps and good split thickness skingraft take at donor sites.

2 Correspondence and communication

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Conflict of interest statement

None.

References

1. Chowdri NA, Darzi MA. Postburn scar carcinomas in Kashmiris.Burns 1996 Sep;22(6):477e82.

2. Grevious MA, Cohen M, Jean-Pierre F, Herrmann GE. The use ofprosthetics in abdominal wall reconstruction. Clin Plast Surg2006 Apr;33(2):181e97.

3. Sacks JM, Broyles JM, Baumann DP. Flap coverage of anteriorabdominal wall defects. Semin Plast Surg 2012 Feb;26(1):36e9.

4. Yezhelyev MV, Deigni O, Losken A. Management of full-thickness abdominal wall defects following tumor resection.Ann Plast Surg 2012 Aug;69(2):186e91.

5. Lowe 3rd JB. Updated algorithm for abdominal wall recon-struction. Clin Plast Surg 2006 Apr;33(2):225e40.

Please cite this article in press as: Zargar HR, et al., “Windmill flap”Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/

H.R. ZargarM.I. ZarooM. Mohsin

P.U.F. BabaDepartment of Plastic & Reconstructive Surgery, Sher-i-

Kashmir Institute of Medical Sciences (SKIMS), Soura,190011, India

E-mail address: m_mohsin@rediffmail.comS.S.A. Farooq

Chest Disease Hospital, Government Medical CollegeSrinagar, J&K, 190011, India

S.A. BashirDepartment of Plastic & Reconstructive Surgery, Sher-i-

Kashmir Institute of Medical Sciences (SKIMS), Soura,190011, India

1 December 2013

: A novel technique of abdominal wall reconstruction, Journal of10.1016/j.bjps.2014.03.019