- Email: [email protected]
Complex Abdominal Wall Reconstruction with Acellular Dermal Matrix
Complex Abdominal Wall Reconstruction with Acellular Dermal Matrix C. Scott Hultman, MD, FACS, and Christopher M. Craft, MD
D
espite advances in operative technique and improvements in biomaterials for fascial replacement, complex abdominal wall defects because of recurrent hernia, tumor resection, or trauma continue to challenge the reconstructive surgeon. Successful reconstruction depends not only on restoration of abdominal wall continuity but also includes restoring abdominal wall function with minimal morbidity, while integrating abdominal wall aesthetics. Principles that have recently emerged in abdominal wall reconstruction include the following: (1) the superiority of tension-free, preperitoneal mesh versus primary suture repair for defects wider than 6 cm,1,2 (2) the decreased morbidity and quicker recovery associated with laparoscopic herniorrhaphy,3 (3) the need for vascularized tissue to provide coverage of the fascial repair,4 (4) the advantage of a functional reconstruction, in terms of abdominal wall mechanics and the effect on pulmonary function,5 (5) the combined benefits of using both myocutaneous flaps and mesh,6 and (6) the efficacy of a multi-disciplinary approach to abdominal wall reconstruction, decreasing the incidence of recurrent hernia.7 In addition to a number of pedicled, regional flaps (rectus abdominis, rectus femoris, tensor fascia lata, and latissimus) that can be used to provide coverage of the repair, a large selection of alloplastic and biologic materials is now available to replace missing fascia or restore abdominal wall continuity in patients with massive loss of domain.8,9 We utilize all of the materials outlined in the Table 1 and note that each has its own set of indications, depending on the clinical scenario. When considering which material to use for fascial replacement or for buttressing of the repair, we consider history of previous infection, degree of contamination from bowel resection or ostomy takedown, condition of the underlying viscera, presence of irradiated tissue, quality of vacularized tissue available, ease of use, and cost. Patients with massive defects (⬎200 cm2), poor soft tissue coverage, contamination, and medical comorbidities (such as morbid obesity, smoking, diabetes, steroid use, immunosuppression, and pulmonary dysfunction) represent the ex-
From the Division of Plastic and Reconstructive Surgery, University of North Carolina, Chapel Hill, NC. Address reprint requests to Dr C. Scott Hultman, Chief and Program Director, Division of Plastic and Reconstructive Surgery, 7038 Burnett-Womack Building, CB #7195, University of North Carolina, Chapel Hill, NC 27599-7195. E-mail: [email protected].
1524-153X/06/$-see front matter © 2006 Elsevier Inc. All rights reserved. doi:10.1053/j.optechgensurg.2006.11.005
tremes of difficult reconstruction. In this cohort of patients, acellular dermal matrix (AlloDerm, Lifecell, Branchburg, NJ) has emerged as a versatile and valuable bioprosthetic material in replacing deficient fascia, restoring abdominal wall continuity, and reinforcing autogenous repair.10 This regenerative matrix serves as a nonantigenic scaffold for tissue in-growth and is rapidly revascularized, protecting the material from infection whereas maintaining its tensile strength. Harvested from cadavers, AlloDerm is chemically processed via a proprietary mechanism that removes both the epidermis and the cellular components of the dermis, leaving the extra-cellular matrix intact and preserving vascular channels. Although long-term data are not available for abdominal wall reconstruction, AlloDerm has now been used in a variety of clinical settings with excellent results and essentially no morbidity. Our own clinical experience includes not only abdominal wall reconstruction but also replacement of missing dura, thoracic wall repair, and breast reconstruction with tissue expanders and implants, to provide lower and lateral pole coverage of alloplastic devices.
Components Separation and Underlay Graft for Repair of Recurrent Hernia In patients with minimal loss of domain, intact but displaced fascia, and reasonable pulmonary mechanics, acellular dermal matrix can be used in combination with components separation to provide a functional, two-layer repair of the abdominal wall. The patient shown in Figs 1A-E is a 57-yearold man who underwent open repair of an infra-renal abdominal aortic aneurysm and subsequently had a wound infection with fascial dehiscence and evisceration. Despite an attempt at primary closure during the early postoperative period, he had a recurrent hernia (Fig 1A) that was ultimately repaired, 1 year later, via components separation and implantation of acellular dermal matrix. At the time of his abdominal wall reconstruction, the patient underwent takedown of the hernia sac with lysis of adhesions, leaving him with a fascial defect that was 27 ⫻ 16 cm. Given his previous wound infection, we wanted to repair his hernia with autogenous tissue and without alloplastic materials. Bilateral components separation was performed to relocate the rectus abdominis muscles to the mid207
C.S. Hultman and C.M. Craft 4 ⴛ 16 cm Potential transmission of infectious agents from donors; limited sizes 20 ⴛ 30 cm High incidence of seroma; poor incorporation with tissues 18 ⴛ 23 cm Fluid loss through broad interstices; provides only temporary repair 30 ⴛ 30 cm Rapidly diminishing strength; provides only temporary repair
30 ⴛ 30 cm Increased incidence of adhesions, bowel obstruction, fistula
14 ⴛ 18 cm Recent recall secondary to bowel perforation from mesh scaffold
$5,472 $5,151 $976 $2,618 $5,931
ⴙⴙⴙ ⴙ $1,717 Yes Yes
ⴙⴙⴙ ⴙⴙ $244
ⴙⴙ ⴙⴙⴙ Gore ⴙⴙ ⴙⴙ
Johnson & Johnson ⴙⴙⴙⴙ ⴙ No ⴙⴙⴙⴙ ⴙⴙⴙⴙ $1,977
Manufacturer Elasticity Strength Permanence Ease of use Resistance to infection Hospital cost (UNC Hospitals) Patient charge (UNC Hospitals) Size Issues
Syneture ⴙⴙⴙⴙⴙ ⴙⴙ No ⴙⴙⴙⴙⴙ ⴙⴙⴙⴙⴙ $748
Ethicon
$6,474
ⴙⴙⴙ ⴙⴙⴙ Unknown ⴙⴙⴙ ⴙⴙⴙⴙⴙ $1,824
Lifecell
Acellular dermal matrix
Composite PTFEpolypropylene Bard ⴙ ⴙⴙⴙⴙⴙ Yes ⴙ ⴙⴙ $2,158 ePTFE Polypropylene Knitted polyglycolic acid Woven polyglactin 910 Material
Dexon Vicryl Type of Mesh
Table 1 Comparison of Prosthetic Materials in Abdominal Wall Reconstruction
Prolene
DualMesh
Composix
Alloderm
208
line as innervated, functional myofascial flaps (Fig 1B). Skin and subcutaneous fat were elevated off of the anterior rectus sheath from medial to lateral, costal margin to iliac crest. After identifying the lateral border of the rectus sheath, the tendon of the external oblique was divided with electocautery, and the external oblique was elevated off of the internal oblique, protecting neurovascular perforators deep to the area of dissection. These maneuvers permitted 10 cm of advancement of the rectus/oblique flap to the midline, for primary repair of the fascia. Acellular dermal matrix, 4 ⫻ 28 cm in dimension and 0.79 to 1.78 mm thick, was rehydrated on the back-table and implanted as an underlay patch, on the peritoneal side of the abdominal wall (Fig 1C). Care is taken to orient the matrix with the basement membrane next to viscera, to minimize adhesions and promote in-growth from the posterior fascia. The mesh is then secured to the perimeter with a series of #1.0 polypropylene horizontal mattress sutures. This maneuver also has the benefit of reducing tension on the primary fascial repair, which was completed with a series of #1.0 figure-of-8 permanent monofilament sutures (Fig 1D). Three fluted drains were placed as follows: one in each donor site, along the gutter in anterior axillary line, and one in the central area of repair. Skin and hernia sac were closed in multiple layers, completing reconstruction of the abdominal wall (Fig 1E).
Unilateral Components Separation and Interpositon Graft for Reconstruction of Abdomino-Thoracic Defect Acellular dermal matrix can also be used as an interposition graft to replace missing fascia or span defects that cannot be primarily repaired, provided that vascularized tissue can be placed in continuity with the reconstruction. The patient in Figs 2A-G is a 20-year-old woman who sustained a selfinflicted shotgun blast to the abdomen. Acute management included splenectomy, left lower lobectomy, diaphragmatic repair with a latissimus muscle flap, diverting colostomy, and abdominal closure with absorbable mesh and staged skin grafting. Nearly 1 year later, she underwent abdominal wall reconstruction via a right components separation and interposition graft of acellular dermal matrix, to restore continuity of the abdominal wall. Key to the success of her reconstruction was allowing the visceral adhesions to the abdominal wall to mature. After removal of the skin graft, adhesiolysis, and colostomy takedown (Fig 2B), the omentum was mobilized off of the transverse colon to provide a vascularized bed for placement of the interposition graft in the subxiphoid region and left upper quadrant, where superficial coverage was deficient (Fig 2C). The patient’s fascial defects essentially included both a central 15 ⫻ 25 cm region and a left chest 7 ⫻ 15 cm area, with no autologous tissue available for fascial repair. Following a right components separation to provide 10 cm of advancement of the rectus abdominis to the midline (Fig 2D), the remaining fascial defect was reconstructed with a 6 ⫻ 16 cm sheet of thick AlloDerm for the central defect (Fig 2E) and a 5 ⫻ 10 sheet of thick AlloDerm for the left upper quadrant defect (Fig 2F). Care was taken to approxi-
Abdominal wall reconstruction
Figure 1 (A–E) A 57-year-old man, with previous AAA repair, who underwent reconstruction of recurrent hernia with bilateral components separation and implantation of AlloDerm underlay mesh, to buttress the primary fascial repair. (Color version of figure appears online.)
209
C.S. Hultman and C.M. Craft
210
Figure 1 (Continued)
mate the edge of the acellular dermal matrix to viable, vascularized fascia with a permanent monofilament suture. Specific caveats of the left upper quadrant reconstruction include securing the AlloDerm to the costal margin with interrupted pericostal sutures and placing the matrix over vascularized omental tissue. A small area of exposed AlloDerm (below the left breast, 3 ⫻ 4 cm) was covered with a subatmospheric sponge dressing, resulting in granulation and secondary wound contracture and closure, without the need for a skin graft, after 3 weeks (Fig 2G).
Closure of TRAM Donor Site Defect with Inlay Graft for Fascial Replacement Another example of successful abdominal wall reconstruction with acellular dermal matrix is in closure of the fascial defect after TRAM (transverse rectus abdominis myocutaneous) flap harvest for breast reconstruction. For pedicled TRAM flap reconstruction, a 2 to 4 cm wide swatch of infraumbilical fascia is taken, to protect and preserve vital perforators from the rectus muscle to the subcutaneous fat. Primary closure of the fascia can be done, but this may relocate the umbilicus away from the midline in unilateral reconstructions and may increase intra-abdominal pressure in bilateral reconstructions. The patient shown in Figs 3A and B is a 40-year-old woman with BRCA1 and bilateral breast cancer who underwent bilateral total mastectomy, sentinel lymph node biop-
sies, and bilateral reconstruction with pedicled TRAM flaps. The abdominal fascial donor sites were closed with two sheets of thick AlloDerm, 4 ⫻ 16 cm. Three weeks later, she presented with fever, leukocytosis, cellulitis, and abdominal wall fluid on computed tomography (CT) scan. After initiation of broad-spectrum antibiotics, she was taken to the operating theater, where an abscess was drained and the wound irrigated. Her fascial repair had remained intact, despite a methicillin-resistant staphylococcus infection, and the Alloderm was completely revascularized, evidenced by the punctate capillary bleeding on the extra-peritoneal surface of the acellular dermal matrix. Had alloplastic mesh been placed at the time of her original TRAM flap harvest, she would have required explantation of the prosthetic material, resulting in probable hernia formation.
Closure of VRAM Donor Site Defect with Inlay Graft for Fascial Replacement Acellular dermal matrix has also been used in our practice to reconstruct the donor site defect after harvest of a VRAM (vertical rectus abdominis myocutaneous) flap for pelvic floor, groin, and lower extremity reconstruction. Use of AlloDerm in this setting has allowed us to harvest a much larger skin paddle, with accompanying fascia from the anterior rectus sheath, to provide more reliable tissue for distant coverage of vital structures. In general, a larger piece of fascia is needed for inferiorly based VRAM flaps, because the upper
Abdominal wall reconstruction
Figure 2 (A–G) A 20-year-old woman, with previous shotgun blast to her abdomen, who underwent colostomy takedown and abdominal wall reconstruction with a right components separation and implantation of AlloDerm interposition “inlay” graft. (Color version of figure appears online.)
211
C.S. Hultman and C.M. Craft
212
Figure 2 (Continued)
Abdominal wall reconstruction
Figure 3 (A, B) A 40-year-old woman, with BRCA1 gene and bilateral breast cancer, who underwent drainage of an abdominal wall abscess, 3 weeks after bilateral mastectomies, TRAM flap reconstructions, and closure of the abdominal donor site defect with AlloDerm. (Color version of figure appears online.)
213
214
C.S. Hultman and C.M. Craft
Figure 4 (A–E) A 62-year-old man, with a previously irradiated, recurrent liposcarcoma of the left groin and thigh, who underwent lower extremity reconstruction with an inferiorly based VRAM flap to cover the femoral canal and closure of the abdominal donor site defect with AlloDerm. (Color version of figure appears online.)
Abdominal wall reconstruction
215
Figure 4 (Continued)
quadrant skin paddle has fewer perforators, compared with the skin island of the TRAM flap. Primary closure of the fascial defect is technically possible for narrow defects but often requires prosthetic material for closure of larger defects. The patient in Figs 4 A-E is a 62-year-old golf professional who underwent radical resection of a previously irradiated, recurrent left groin and thigh liposarcoma (Fig 4A), with exposure of the femoral vessels and nerve, over an 18 cm length (Fig 4B). The lower extremity was reconstructed with a pedicled, inferiorly based VRAM flap, with a skin paddle that was 6 ⫻ 12 cm and included most of the anterior rectus sheath and all of the rectus abdominis muscle (Fig 4C). The VRAM donor site fascial defect was closed with a 4 ⫻ 12 cm sheet of thick AlloDerm, securing the matrix to the remaining fascial edges with a running, permanent monofilament suture (Fig 4D). Although he requires the use of compression garment for control of mild-tomoderate lymphedema, he has been able to maintain his golf handicap in the low single digits (Fig 4E).
Conclusion In summary, acellular dermal matrix is a versatile and valuable bioprosthetic material in the reconstruction of complex abdominal wall defects because of recurrent hernia, tumor resection, and trauma. Although autogenous repair with myofascial flaps and implantation of alloplastic mesh both yield successful, functional, and reliable results, use of acellular dermal matrix adds another technique to our approach in abdominal wall reconstruction. This material provides a
unique combination of advantages over other alloplastic and biologic prosthetics that includes tissue incorporation with revascularization, ease of use and “off-the-shelf ” availability, and resistance to infection.
References 1. Luijendijk RW, Hop WC, van den Tol MP, et al: A comparison of suture repair with mesh repair for incisional hernia. N Engl J Med 343:392398, 2000 2. Burger JW, Luijendijk RW, Hop WC, et al: Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional hernia. Ann Surg 240:578-585, 2004 3. Heniford BT, Park A, Ramshaw BJ, et al: Laparoscopic repair of ventral hernias: Nine years’ experience with 850 consecutive hernias. Ann Surg 238:391-400, 2003 4. Girotto JA, Chiaromonte M, Menon NG, et al: Recalcitrant abdominal wall hernias: Long-term superiority of autologous tissue repair. Plast Reconstr Surg 112:106-114, 2003 5. Ramirez OM, Rusas E, Dellon AL: “Components separation” method of closure of abdominal-wall defects: An anatomic and clinical study. Plast Reconstr Surg 86:519-526, 1990 6. Mathes SJ, Steinwald PM, Foster RD, et al: Complex abdominal wall reconstruction: A comparison of flap and mesh closure. Ann Surg 232: 586-596, 2000 7. Hultman CS, Pratt B, Cairns BA, et al: Multidisciplinary approach to abdominal wall reconstruction after decompressive laparotomy for abdominal compartment syndrome. Ann Plast Surg 54:269-275, 2005 8. Leber GE, Garb JL, Alexander AI, et al: Long-term complications associated with prosthetic repair of incisional hernias. Arch Surg 133:378-382, 1998 9. Diaz JJ, Gray BW, Dobson JM, et al: Repair of giant abdominal hernias: Does the type of prosthesis matter? Am Surg 70:396-402, 2004 10. Butler CE, Langstein HN, Kronowitz SJ: Pelvic, abdominal, and chest wall reconstruction with alloderm in patients at increased risk for mesh-related complications. Plast Reconstr Surg 116:1263-1277, 2005
D
espite advances in operative technique and improvements in biomaterials for fascial replacement, complex abdominal wall defects because of recurrent hernia, tumor resection, or trauma continue to challenge the reconstructive surgeon. Successful reconstruction depends not only on restoration of abdominal wall continuity but also includes restoring abdominal wall function with minimal morbidity, while integrating abdominal wall aesthetics. Principles that have recently emerged in abdominal wall reconstruction include the following: (1) the superiority of tension-free, preperitoneal mesh versus primary suture repair for defects wider than 6 cm,1,2 (2) the decreased morbidity and quicker recovery associated with laparoscopic herniorrhaphy,3 (3) the need for vascularized tissue to provide coverage of the fascial repair,4 (4) the advantage of a functional reconstruction, in terms of abdominal wall mechanics and the effect on pulmonary function,5 (5) the combined benefits of using both myocutaneous flaps and mesh,6 and (6) the efficacy of a multi-disciplinary approach to abdominal wall reconstruction, decreasing the incidence of recurrent hernia.7 In addition to a number of pedicled, regional flaps (rectus abdominis, rectus femoris, tensor fascia lata, and latissimus) that can be used to provide coverage of the repair, a large selection of alloplastic and biologic materials is now available to replace missing fascia or restore abdominal wall continuity in patients with massive loss of domain.8,9 We utilize all of the materials outlined in the Table 1 and note that each has its own set of indications, depending on the clinical scenario. When considering which material to use for fascial replacement or for buttressing of the repair, we consider history of previous infection, degree of contamination from bowel resection or ostomy takedown, condition of the underlying viscera, presence of irradiated tissue, quality of vacularized tissue available, ease of use, and cost. Patients with massive defects (⬎200 cm2), poor soft tissue coverage, contamination, and medical comorbidities (such as morbid obesity, smoking, diabetes, steroid use, immunosuppression, and pulmonary dysfunction) represent the ex-
From the Division of Plastic and Reconstructive Surgery, University of North Carolina, Chapel Hill, NC. Address reprint requests to Dr C. Scott Hultman, Chief and Program Director, Division of Plastic and Reconstructive Surgery, 7038 Burnett-Womack Building, CB #7195, University of North Carolina, Chapel Hill, NC 27599-7195. E-mail: [email protected].
1524-153X/06/$-see front matter © 2006 Elsevier Inc. All rights reserved. doi:10.1053/j.optechgensurg.2006.11.005
tremes of difficult reconstruction. In this cohort of patients, acellular dermal matrix (AlloDerm, Lifecell, Branchburg, NJ) has emerged as a versatile and valuable bioprosthetic material in replacing deficient fascia, restoring abdominal wall continuity, and reinforcing autogenous repair.10 This regenerative matrix serves as a nonantigenic scaffold for tissue in-growth and is rapidly revascularized, protecting the material from infection whereas maintaining its tensile strength. Harvested from cadavers, AlloDerm is chemically processed via a proprietary mechanism that removes both the epidermis and the cellular components of the dermis, leaving the extra-cellular matrix intact and preserving vascular channels. Although long-term data are not available for abdominal wall reconstruction, AlloDerm has now been used in a variety of clinical settings with excellent results and essentially no morbidity. Our own clinical experience includes not only abdominal wall reconstruction but also replacement of missing dura, thoracic wall repair, and breast reconstruction with tissue expanders and implants, to provide lower and lateral pole coverage of alloplastic devices.
Components Separation and Underlay Graft for Repair of Recurrent Hernia In patients with minimal loss of domain, intact but displaced fascia, and reasonable pulmonary mechanics, acellular dermal matrix can be used in combination with components separation to provide a functional, two-layer repair of the abdominal wall. The patient shown in Figs 1A-E is a 57-yearold man who underwent open repair of an infra-renal abdominal aortic aneurysm and subsequently had a wound infection with fascial dehiscence and evisceration. Despite an attempt at primary closure during the early postoperative period, he had a recurrent hernia (Fig 1A) that was ultimately repaired, 1 year later, via components separation and implantation of acellular dermal matrix. At the time of his abdominal wall reconstruction, the patient underwent takedown of the hernia sac with lysis of adhesions, leaving him with a fascial defect that was 27 ⫻ 16 cm. Given his previous wound infection, we wanted to repair his hernia with autogenous tissue and without alloplastic materials. Bilateral components separation was performed to relocate the rectus abdominis muscles to the mid207
C.S. Hultman and C.M. Craft 4 ⴛ 16 cm Potential transmission of infectious agents from donors; limited sizes 20 ⴛ 30 cm High incidence of seroma; poor incorporation with tissues 18 ⴛ 23 cm Fluid loss through broad interstices; provides only temporary repair 30 ⴛ 30 cm Rapidly diminishing strength; provides only temporary repair
30 ⴛ 30 cm Increased incidence of adhesions, bowel obstruction, fistula
14 ⴛ 18 cm Recent recall secondary to bowel perforation from mesh scaffold
$5,472 $5,151 $976 $2,618 $5,931
ⴙⴙⴙ ⴙ $1,717 Yes Yes
ⴙⴙⴙ ⴙⴙ $244
ⴙⴙ ⴙⴙⴙ Gore ⴙⴙ ⴙⴙ
Johnson & Johnson ⴙⴙⴙⴙ ⴙ No ⴙⴙⴙⴙ ⴙⴙⴙⴙ $1,977
Manufacturer Elasticity Strength Permanence Ease of use Resistance to infection Hospital cost (UNC Hospitals) Patient charge (UNC Hospitals) Size Issues
Syneture ⴙⴙⴙⴙⴙ ⴙⴙ No ⴙⴙⴙⴙⴙ ⴙⴙⴙⴙⴙ $748
Ethicon
$6,474
ⴙⴙⴙ ⴙⴙⴙ Unknown ⴙⴙⴙ ⴙⴙⴙⴙⴙ $1,824
Lifecell
Acellular dermal matrix
Composite PTFEpolypropylene Bard ⴙ ⴙⴙⴙⴙⴙ Yes ⴙ ⴙⴙ $2,158 ePTFE Polypropylene Knitted polyglycolic acid Woven polyglactin 910 Material
Dexon Vicryl Type of Mesh
Table 1 Comparison of Prosthetic Materials in Abdominal Wall Reconstruction
Prolene
DualMesh
Composix
Alloderm
208
line as innervated, functional myofascial flaps (Fig 1B). Skin and subcutaneous fat were elevated off of the anterior rectus sheath from medial to lateral, costal margin to iliac crest. After identifying the lateral border of the rectus sheath, the tendon of the external oblique was divided with electocautery, and the external oblique was elevated off of the internal oblique, protecting neurovascular perforators deep to the area of dissection. These maneuvers permitted 10 cm of advancement of the rectus/oblique flap to the midline, for primary repair of the fascia. Acellular dermal matrix, 4 ⫻ 28 cm in dimension and 0.79 to 1.78 mm thick, was rehydrated on the back-table and implanted as an underlay patch, on the peritoneal side of the abdominal wall (Fig 1C). Care is taken to orient the matrix with the basement membrane next to viscera, to minimize adhesions and promote in-growth from the posterior fascia. The mesh is then secured to the perimeter with a series of #1.0 polypropylene horizontal mattress sutures. This maneuver also has the benefit of reducing tension on the primary fascial repair, which was completed with a series of #1.0 figure-of-8 permanent monofilament sutures (Fig 1D). Three fluted drains were placed as follows: one in each donor site, along the gutter in anterior axillary line, and one in the central area of repair. Skin and hernia sac were closed in multiple layers, completing reconstruction of the abdominal wall (Fig 1E).
Unilateral Components Separation and Interpositon Graft for Reconstruction of Abdomino-Thoracic Defect Acellular dermal matrix can also be used as an interposition graft to replace missing fascia or span defects that cannot be primarily repaired, provided that vascularized tissue can be placed in continuity with the reconstruction. The patient in Figs 2A-G is a 20-year-old woman who sustained a selfinflicted shotgun blast to the abdomen. Acute management included splenectomy, left lower lobectomy, diaphragmatic repair with a latissimus muscle flap, diverting colostomy, and abdominal closure with absorbable mesh and staged skin grafting. Nearly 1 year later, she underwent abdominal wall reconstruction via a right components separation and interposition graft of acellular dermal matrix, to restore continuity of the abdominal wall. Key to the success of her reconstruction was allowing the visceral adhesions to the abdominal wall to mature. After removal of the skin graft, adhesiolysis, and colostomy takedown (Fig 2B), the omentum was mobilized off of the transverse colon to provide a vascularized bed for placement of the interposition graft in the subxiphoid region and left upper quadrant, where superficial coverage was deficient (Fig 2C). The patient’s fascial defects essentially included both a central 15 ⫻ 25 cm region and a left chest 7 ⫻ 15 cm area, with no autologous tissue available for fascial repair. Following a right components separation to provide 10 cm of advancement of the rectus abdominis to the midline (Fig 2D), the remaining fascial defect was reconstructed with a 6 ⫻ 16 cm sheet of thick AlloDerm for the central defect (Fig 2E) and a 5 ⫻ 10 sheet of thick AlloDerm for the left upper quadrant defect (Fig 2F). Care was taken to approxi-
Abdominal wall reconstruction
Figure 1 (A–E) A 57-year-old man, with previous AAA repair, who underwent reconstruction of recurrent hernia with bilateral components separation and implantation of AlloDerm underlay mesh, to buttress the primary fascial repair. (Color version of figure appears online.)
209
C.S. Hultman and C.M. Craft
210
Figure 1 (Continued)
mate the edge of the acellular dermal matrix to viable, vascularized fascia with a permanent monofilament suture. Specific caveats of the left upper quadrant reconstruction include securing the AlloDerm to the costal margin with interrupted pericostal sutures and placing the matrix over vascularized omental tissue. A small area of exposed AlloDerm (below the left breast, 3 ⫻ 4 cm) was covered with a subatmospheric sponge dressing, resulting in granulation and secondary wound contracture and closure, without the need for a skin graft, after 3 weeks (Fig 2G).
Closure of TRAM Donor Site Defect with Inlay Graft for Fascial Replacement Another example of successful abdominal wall reconstruction with acellular dermal matrix is in closure of the fascial defect after TRAM (transverse rectus abdominis myocutaneous) flap harvest for breast reconstruction. For pedicled TRAM flap reconstruction, a 2 to 4 cm wide swatch of infraumbilical fascia is taken, to protect and preserve vital perforators from the rectus muscle to the subcutaneous fat. Primary closure of the fascia can be done, but this may relocate the umbilicus away from the midline in unilateral reconstructions and may increase intra-abdominal pressure in bilateral reconstructions. The patient shown in Figs 3A and B is a 40-year-old woman with BRCA1 and bilateral breast cancer who underwent bilateral total mastectomy, sentinel lymph node biop-
sies, and bilateral reconstruction with pedicled TRAM flaps. The abdominal fascial donor sites were closed with two sheets of thick AlloDerm, 4 ⫻ 16 cm. Three weeks later, she presented with fever, leukocytosis, cellulitis, and abdominal wall fluid on computed tomography (CT) scan. After initiation of broad-spectrum antibiotics, she was taken to the operating theater, where an abscess was drained and the wound irrigated. Her fascial repair had remained intact, despite a methicillin-resistant staphylococcus infection, and the Alloderm was completely revascularized, evidenced by the punctate capillary bleeding on the extra-peritoneal surface of the acellular dermal matrix. Had alloplastic mesh been placed at the time of her original TRAM flap harvest, she would have required explantation of the prosthetic material, resulting in probable hernia formation.
Closure of VRAM Donor Site Defect with Inlay Graft for Fascial Replacement Acellular dermal matrix has also been used in our practice to reconstruct the donor site defect after harvest of a VRAM (vertical rectus abdominis myocutaneous) flap for pelvic floor, groin, and lower extremity reconstruction. Use of AlloDerm in this setting has allowed us to harvest a much larger skin paddle, with accompanying fascia from the anterior rectus sheath, to provide more reliable tissue for distant coverage of vital structures. In general, a larger piece of fascia is needed for inferiorly based VRAM flaps, because the upper
Abdominal wall reconstruction
Figure 2 (A–G) A 20-year-old woman, with previous shotgun blast to her abdomen, who underwent colostomy takedown and abdominal wall reconstruction with a right components separation and implantation of AlloDerm interposition “inlay” graft. (Color version of figure appears online.)
211
C.S. Hultman and C.M. Craft
212
Figure 2 (Continued)
Abdominal wall reconstruction
Figure 3 (A, B) A 40-year-old woman, with BRCA1 gene and bilateral breast cancer, who underwent drainage of an abdominal wall abscess, 3 weeks after bilateral mastectomies, TRAM flap reconstructions, and closure of the abdominal donor site defect with AlloDerm. (Color version of figure appears online.)
213
214
C.S. Hultman and C.M. Craft
Figure 4 (A–E) A 62-year-old man, with a previously irradiated, recurrent liposcarcoma of the left groin and thigh, who underwent lower extremity reconstruction with an inferiorly based VRAM flap to cover the femoral canal and closure of the abdominal donor site defect with AlloDerm. (Color version of figure appears online.)
Abdominal wall reconstruction
215
Figure 4 (Continued)
quadrant skin paddle has fewer perforators, compared with the skin island of the TRAM flap. Primary closure of the fascial defect is technically possible for narrow defects but often requires prosthetic material for closure of larger defects. The patient in Figs 4 A-E is a 62-year-old golf professional who underwent radical resection of a previously irradiated, recurrent left groin and thigh liposarcoma (Fig 4A), with exposure of the femoral vessels and nerve, over an 18 cm length (Fig 4B). The lower extremity was reconstructed with a pedicled, inferiorly based VRAM flap, with a skin paddle that was 6 ⫻ 12 cm and included most of the anterior rectus sheath and all of the rectus abdominis muscle (Fig 4C). The VRAM donor site fascial defect was closed with a 4 ⫻ 12 cm sheet of thick AlloDerm, securing the matrix to the remaining fascial edges with a running, permanent monofilament suture (Fig 4D). Although he requires the use of compression garment for control of mild-tomoderate lymphedema, he has been able to maintain his golf handicap in the low single digits (Fig 4E).
Conclusion In summary, acellular dermal matrix is a versatile and valuable bioprosthetic material in the reconstruction of complex abdominal wall defects because of recurrent hernia, tumor resection, and trauma. Although autogenous repair with myofascial flaps and implantation of alloplastic mesh both yield successful, functional, and reliable results, use of acellular dermal matrix adds another technique to our approach in abdominal wall reconstruction. This material provides a
unique combination of advantages over other alloplastic and biologic prosthetics that includes tissue incorporation with revascularization, ease of use and “off-the-shelf ” availability, and resistance to infection.
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