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.
Large supraumbilical full-thickness defects of the abdominal wall present a difficult reconstructive challenge.1 They can occur after acute trauma, following resection of soft tissue tumors, or result from peritonitis.1–4 Three major issues need to be addressed when reconstructing such defects that are not amenable to direct, primary closure: stable reconstruction of the fascial layer, adequate skin coverage, and restoration of the contour of the abdominal wall. Although small defects can be closed directly with local tissues or pedicled flaps, large abdominal wall defects (>40 cm2) frequently require a staged repair.4–5 Using conventional methods, a temporary abdominal closure can be accomplished with a variety of synthetic coverings, followed by skin grafting directly onto visceral granulation tissue.6–7 Subsequently, the resulting abdominal wall defect is reconstructed by fascial closure, prosthetic reinforcement, tissue rotation, pedicled flaps, or free tissue transplantation.8–10 However, such multiple stage reconstructions are time- and cost-consuming, and the results are usually not satisfying.4,11,12,13 Therefore, one-stage reconstruction with vascularized fascia has been proposed to overcome such disadvantages.14–17
The anterolateral thigh (ALT) flap is used for reconstruction of various types of defects.13,18–21 In a previous report, the ALT flap with vascularized fascia lata was successfully employed for reconstruction of composite Achilles tendon defects.16 The fascia lata receives sufficient blood supply via the prefascial and subfascial vascular plexus when attached to the ALT flap.16,22 The excellent blood supply makes the composite ALT flap a valuable tool that resists infection and reduces recovery time, when used for reconstruction of complex abdominal wall defects. However, possible donor site morbidity needs to be considered. The vastus lateralis is the largest compartment of the quadriceps femoris muscle, which is the prime extensor of the knee.19,23,24 Harvest or injury of this muscle might subsequently lead to weakness of the knee function.
This paper presents our approach to reconstruct a composite full-thickness abdominal wall defect by using a free composite ALT flap with vascularized fascia lata. Objective assessment of the strength of the reconstructed abdominal wall and of the donor thighs was performed using Cybex kinetic dynamometer machines.25–28