Background: A team approach is essential to properly restore the integrity and function of the complete abdominal wall defect. If additional vascularized tissue coverage following this reconstruction is imperative, knowledge of all potential flap alternatives to achieve this goal becomes critical to ensure healing and reduce the risk of recurrent hernia.
Methods: A historical review of algorithms for the management of complex abdominal wall defects was undertaken. Numerous schemas have been suggested as guidelines for flap selection, if needed, and each was carefully scrutinized to determine its contemporary appropriateness.
Results: The method for closure of any abdominal wall defect depends on its size, depth, and location. Previous schemas divided the abdomen into subunits with an inventory of available flaps for each region. Traditionally, muscle or musculocutaneous flaps were most commonly suggested. With the advent of perforator flaps, a new set of options is available to augment the possibilities apropos to the specific abdomen zone.
Conclusions: Complete restoration of even basic function of the abdominal wall requires an intact and contractile musculofascial supporting system. Any incisions or flaps that denervate functioning muscle should be avoided. Perforator flaps have proven to be another reasonable option with which to restore any skin deficiencies whether as pedicled or free flaps and, because by definition no muscle is ever included, maximum function preservation of the abdominal wall will also thereby be achieved.