259
CLINICS IN
Anterior Abdominal
Wall Reconstruction
Roshini Gopinathan, MD, Mark Granick,
& Anatomy of the anterior abdominal wall
& Indications for abdominal wall
reconstruction
& Preoperative evaluation
& Operations
Primary closure
Vacuum-assisted closure
The anterior abdominal wall serves several func-
tions. It contains and protects the abdominal
viscerae. The muscles of the abdominal wall assist
in pulling down on the ribs during forced expira-
tion and coughing. When the thoracic cage is fixed,
the muscles of the abdominal wall assist with defe-
cation, micturition, and child birth. The rectus
muscle helps in flexion of the spine and the rectus,
and lateral obliques assist in rotation of the torso.
Anatomy of the anterior abdominal wall
The paired rectus abdominis muscles are enclosed
by the rectus sheaths. The sheath is formed by the
aponeuroses of the internal and external obliques
and the transversus abdominis muscles. The apo-
neurosis of the internal oblique splits at the lateral
border of the rectus muscle. The anterior layer fuses
with the aponeurosis of the external oblique to
form the anterior wall of the rectus sheath while
the posterior layer merges with the transverse ab-
dominis aponeurosis to form the posterior sheath.
The posterior rectus sheath ends midway between
the umbilicus and symphysis pubis, at the arcuate
line. Inferior to this line, the aponeuroses of all
Division of Plastic Surgery, Department of Surgery, New Jersey Medical School–University of Medicine and
Dentistry in New Jersey, 90 Bergen Street, Suite 7200, Newark, NJ 07103, USA
* Corresponding author.
E-mail address: mgranickmd@umdnj.edu (M. Granick).
0094-1298/06/$ – see front matter © 2006 Elsevier Inc. All rights reserved.
plasticsurgery.theclinics.com
PLASTIC
SURGERY
Clin Plastic Surg 33 (2006) 259–267
MD*
Skin and fascial grafts
Fascial release
Components separation
Tissue expansion
Mesh and biomaterials
Pedicled muscle and myocutaneous flaps
& References
three muscles pass anterior to the rectus muscle.
The thigh is also a rich source of donor tissue.
Surgeons performing abdominal wall repair must
know the neurovascular anatomy and arc of rota-
tion of the thigh muscles.
Indications for abdominal wall
reconstruction
The clinical problems that require abdominal wall
reconstruction are congenital abdominal wall de-
fects, including omphalocele, gastroschisis, and blad-
der or cloacal exstrophy; and infection, including
necrotizing fasciitis and clostridial myonecrosis.
Other indications include: tumor resection, includ-
ing desmoid tumors, dermatofibrosarcoma protu-
berans, sarcomas, metastatic tumors, and radiation
ulcers; ventral hernia; trauma; and loss of abdomi-
nal domain.
Preoperative evaluation
Each abdominal wall defect should be evaluated
individually. The extent of the defect and whether
it includes skin, subcutaneous tissue, or fascia
doi:10.1016/j.cps.2005.12.006
260 Gopinathan & Granick

Fig. 1. (A, B) Radiation ulcer extending from anterior abdomen to back. (C ) Anterior defect was fixed with rectus
abdominis flap and skin graft. (D) Posterior defect was fixed with gluteus maximus myocutaneous flaps.

should be assessed. Previous abdominal surgeries,
history of radiation, and medical comorbidities
should be evaluated. The presence or absence of
infection should be noted.
Radiation causes progressive obliterative endar-
teritis leading to tissue ischemia. Low tissue oxygen
tension leads to lack of function of fibroblasts
and leucocytes. In the presence of a minimal chal-
lenge leading to increased metabolic demands, the
wound breaks down with secondary bacterial in-
fection. Such wounds require wide excision and
importing of well-vascularized tissues from non-
irradiated areas. Hyperbaric oxygen therapy has
been shown to be useful in these patients [1] [Fig. 1].
Soft tissue infections such as necrotizing fasciitis
and clostridial myonecrosis are mixed infections

Fig. 2. (A, B) Necrotizing fasciitis of lower abdomen and thigh. (C, D) Following serial debridement, wound cov-
erage was achieved with skin grafts.
 Anterior Abdominal Wall 261

Fig. 3. (A) Osteomyelitis following open reduction internal fixation for pelvic fracture (B) Arteriogram demon-
strating patent inferior epigastric vessels. (C ) Rectus femoris flap following debridement and removal of hardware.

Fig. 4. (A) Open abdomen with loss of domain; vacuum assisted closure was used to reduce size of defect. (B) Vicryl
mesh placed over viscerae. (C ) Widely meshed skin graft. (D) Skin grafts have matured and can be separated
from the viscera. (E ) Separation of components. (F ) Skin closure.
262 Gopinathan & Granick
Box 1: Various modalities used for abdominal
wall reconstruction
Primary closure without tension
Vacuum-assisted closure
Skin and fascial grafts
Mesh
Skin graft over mesh/omentum/viscerae
Fascial release
Components separation
Tissue expansion
Pedicled muscle and myocutaneous flaps
Free flaps
with aerobic and anaerobic organisms. Aggressive
soft tissue debridement and intravenous antibiotics
are essential. Once the infection is controlled, de-
finitive coverage can be achieved. The presence of
osteomyelitis requires removal of all foreign bodies
and sequestra [Figs. 2, 3].
Trauma to the abdominal wall can result in injury
to the abdominal viscerae with subsequent con-
tamination. Staged abdominal wall repair is often
necessary and may be complicated by other se-
quelae of major trauma. Loss of domain is treated
similarly. In these patients, a visceral insult such
as ischemic bowel prevents ultimate closure of the
abdominal wall. Gastrointestinal dysfunction in-
cluding intestinal fistulae may complicate the situa-
tion further. Mesh repair of the abdominal wall
with skin grafts placed over mesh or omentum, or
even directly over viscerae may be a good tempo-
rizing measure, although a massive ventral hernia
results. Definitive reconstruction is performed 6 to
Fig. 5. (A) Necrotizing fasciitis of lower abdomen. (B) Following debridement. (C ) Closure using pannus.
12 months later, once the skin grafts are mature
and can be separated from the viscerae [Fig. 4].
Operations
The techniques used for abdominal wall recon-
struction run the gamut from simple skin grafting
to free flap reconstruction. Treatment needs to be
optimized to provide the best functional and cos-
metic result with minimal morbidity. Modalities
are highlighted in Box 1.
Primary closure
Use of local tissues may be feasible, particularly if
the patient has a pannus. It is important to avoid
tension on the fascia and skin [Figs. 5, 6].
Vacuum-assisted closure
Vacuum-assisted fascial closure has been helpful
in management of the open abdomen. Suction is
applied to polyurethane foam under an occlu-
sive dressing, pulling the fascia medially. Miller
and colleagues described use of this technique in
45 patients and showed significantly higher fascial
closure rates, obviating the need for hernia repair
later [2].
Skin and fascial grafts
Skin grafts are very useful for covering extensive
wounds resulting from invasive infections such as
necrotizing fasciitis. Once the wound is healthy and
granulating well, meshed skin grafts can be used
to provide coverage. Skin grafts can be applied di-
rectly over viscerae or omentum. The disadvantage
 Anterior Abdominal Wall 263

Fig. 6. (A) Unstable scar following liver transplant. (B) Osteomyelitis of rib. (C ) Following debridement. (D) Lower
abdominal wall used as a flap.

Fig. 7. (A) Ventral hernia. (B) Tensor fascia lata facial graft was harvested. (C ) Fascial repair.
264 Gopinathan & Granick

of using skin grafts is poor cosmesis. Autogenous
fascia lata grafts have been used to reconstruct the
abdominal wall in patients with ventral herniae.
Disa and colleagues reported on a series of
32 patients who underwent abdominal wall recon-
struction with autologous fascia lata grafts [3]. Indi-
cations included exposed mesh, enteric fistulae,
enteric contamination, wound infection, and im-
munosuppression alone. Recurrent hernia was seen
in 9% of patients. Good incorporation of fascia was
noted in three patients who required laparotomy
for unrelated reasons [Fig. 7].
Fascial release
Closure without tension is paramount in achiev-
ing stable closure. Relaxing incisions through the
transverse abdominis and external oblique muscles
and subsequent medial advancement can achieve
closure without tension. Thomas used bilateral
parasagittal incisions to achieve repair of ventral
herniae [4].
Components separation
Ramirez described the components separation
technique to close large defects [5]. The rectus ab-
dominis muscle is dissected from the posterior
sheath, and the external oblique is separated from
the internal oblique. The rectus muscle and anterior
sheath with attached internal oblique and trans-
verse abdominis muscles are advanced medially
towards the midline. The undermined external
oblique is left in its original position. Up to 20 cm
of advancement can be achieved in the umbilical
area with bilateral advancement. Previous surgical
procedures can limit use of this technique by de-
stroying tissue planes [Fig. 8].
Tissue expansion
Tissue expanders can be placed either above the
fascia, between the external and internal oblique
muscles, or between the internal oblique and
transverse abdominis muscles. Use of the intermus-
cular plane avoids use of mesh to achieve fascial
integrity. Use of tissue expanders provides good cos-
metic results at the expense of prolonged, multi-
stage therapy. Infection may require removal of
expanders and further delay of treatment. Carlson
and colleagues described tissue expansion in four
patients with large skin grafted ventral herniae [6].
In the first stage, tissue expanders were placed
under the skin and subcutaneous tissues lateral to
the defect. In the second stage, following adequate
tissue expansion, the expanders were removed,
Polypropylene mesh was used to reconstruct the
fascial defect, and the expanded skin was closed
over the mesh.
Mesh and biomaterials
Various synthetic materials have been used to re-
construct deficient fascia. Some of them, notably
polypropylene have been associated with high rates

Fig. 8. (A) Sarcoma of anterior chest and abdomen. (B) CT scan showing the lesion. (C ) Separation of components.
(D) Rearrangement of components with subsequent closure of skin envelope.
 Anterior Abdominal Wall 265

of enteric fistulization and erosion of the mesh.
The use of Vicryl (Ethicon, Somerville, New Jersey)
and Gore-tex mesh (W.L. Gore, Flagstaff, Arizona)
has been associated with fewer fistulae. The inter-
position of omentum or absorbable mesh between
viscerae and polypropylene mesh reduces adhe-
sions and fistulization. Danino and colleagues [7]
described the use of a Gore-Tex (PTFE) polypro-
pylene sandwich, with the Gore-Tex forming a
neoperitoneum, polypropylene used to reconstruct
the fascia, and a superficial flap for skin closure.
More recently, Danino and colleagues described
use of the scanning electron microscope to evaluate
both sides of the mesh construct [7]. At the time of
2-year delayed reconstruction in 15 patients, frag-
ments of the mesh were removed and analyzed.
They showed stability of the PTFE graft at the deep
surface with formation of an intermediate layer be-
tween the PTFE and polypropylene layers. The poly-
propylene mesh was seen to have dense adhesions
to the surrounding tissue.
Acellular cadaveric dermis (AlloDerm, Lifecell,
Branchburg, New Jersey) recently was used for ven-
tral hernia repair and reconstruction of abdominal
fascial defects. Buinewicz and Rosen described the
use of Allo-derm for reconstruction of fascial
defects in 44 patients who had ventral herniae or
who were undergoing TRAM flaps [8]. Successful
repair of defects was reported, even in infected
patients. Animal models have shown good in-
corporation of Allo-derm into native tissues. Kolker
and colleagues used Allo-derm in a multi-layer

Fig. 9. (A) Full thickness recurrence of abdominal wall tumor. (B) Abdominal wall defect following radical
resection. (C ) AlloDerm was used to reconstruct the abdominal wall. Contralateral rectus abdominis and ipsilat-
eral TFL flaps were harvested. (D) Wound closure. (E ) Patient developed acute abdomen secondary to volvulus.
(F ) Flaps remained viable following repair of volvulus.
266 Gopinathan & Granick

Fig. 10. (A) Open abdomen treated with skin graft over viscera. (B) Separation of components was not adequate
for closure. (C ) TFL flap harvested for successful closure.

fascial repair with components separation in 16 pa-
tients who had recurrent herniae; they reported no
recurrences [9] [Fig. 9].
Pedicled muscle and myocutaneous flaps
Pedicled muscle flaps are sometimes necessary in
contaminated fields or to provide coverage of
mesh. The choice of flap depends on the location
of the defect and available donor tissue. Frequently
used options for the lower abdomen are tensor
fascia lata and rectus femoris flaps. Latissimus
dorsi, external oblique, and rectus abdominis flaps
are good options for the upper abdomen.
The tensor fascia lata is a small muscle that origi-
nates from the anterior superior iliac spine and the
greater trochanter. It has a large fascial extension
and inserts into the lateral aspect of the knee. The
muscle is supplied by the lateral femoral circumflex
artery, and perforators supply the skin. It has a large
skin territory, up to 15 × 40 cm [Fig. 10].

Fig. 11. (A) Epigastric hernia at lower end of sternotomy incision. (B) Proximal rectus muscle was freed proximally
and rotated medially to cover the defect. (C ) Completed closure.

The rectus femoris muscle flap can provide mus-
cle, fascia, and skin to cover suprapubic and lower
abdominal areas. It originates from the anterior
inferior iliac spine and inserts into the patellar ten-
don. The muscle is supplied by the lateral femoral
circumflex vessels.
Once the muscle is harvested, the vastus medialis
and lateralis are sutured together to preserve termi-
nal knee extension.
The latissimus dorsi muscle flap can provide cov-
erage for upper abdominal defects. It is supplied
by the thoracodorsal vessels.
The rectus abdominis muscle is supplied by supe-
rior and inferior epigastric vessels. It can be used as
a pedicled flap based on either vessel [Fig. 11].
Free tissue transfer may be necessary if pedicled
flaps do not reach the defect, as in epigastric de-
fects. They also may be necessary in case of prior
surgery or radiation-destroying muscle pedicles.
Sometimes free flaps are necessary when dead
space needs to be filled up [10]. The choice of
free flap would depend on the size and loca-
tion of the defect and the condition of the recipi-
ent vessels.
Reconstruction of the anterior abdominal wall is
based on six basic principles. First, the anatomy of
the abdominal wall and adjacent donor sites must
be understood clearly. This includes a complete
knowledge of the neurovascular anatomy and the
arc of rotation of each subunit. The defect then has
to be exposed completely before the definitive clo-
sure is attempted. Once the defect is established,
abdominal domain is restored with some sort of
support. The next phase of the repair involves reas-
signing local tissue to close the defect. Distant
tissue then is imported from donor sites such as
the thigh, if needed. Finally, the skin envelope is
readjusted and closed. These principles help opti-
mize function and restore form, hence achieving
the best possible result.
Anterior Abdominal Wall 267
References
[1] Bennett M, Feldmeier J, Hampson N, et al.
Hyperbaric oxygen therapy for late radiation tis-
sue injury. Cochrane Database Syst Rev 2005;
20(3):CD005005.
[2] Miller PR, Meredith JW, Johnson JC, et al. Pro-
spective evaluation of vacuum-assisted fascial clo-
sure after open abdomen: planned ventral hernia
rate is substantially reduced. Ann Surg 2004;
239(5):608–14 [discussion 614–6].
[3] Disa JJ, Goldberg NH, Carlton JM, et al. Restor-
ing abdominal wall integrity in contaminated
tissue-deficient wounds using autologous fascia
grafts. Plast Reconstr Surg 1998;101(4):979–86.
[4] Thomas WOI, Parry SW, Rodning CB. Ventral /
incisional abdominal herniorraphy by fascial
partition/release. Plast Reconstr Surg 1993;91:
1080–6.
[5] Ramirez OM, Ruas E, Dellon AL. Components
separation method for closure of abdominal
wall defects: an anatomic and clinical study. Plast
Reconstr Surg 1990;86:519–26.
[6] Carlson GW, Elwood E, Losken A, et al. The role
of tissue expansion in abdominal wall recon-
struction. Ann Plast Surg 2000;44(2):147–53.
[7] Danino AM, Malka G, Revol M, et al. A scanning
electron microscopical study of the two sides of
polypropylene mesh (Marlex) and PTFE (Gore
Tex) mesh 2 years after complete abdominal
wall reconstruction. A study of 15 cases. Br J Plast
Surg 2005;58(3):384–8.
[8] Buinewicz B, Rosen B. Acellular cadaveric dermis
(Allo-Derm): a new alternative for abdominal
hernia repair. Ann Plast Surg 2004;52(2):188–94.
[9] Kolker AR, Brown DJ, Redstone JS, et al. Multi-
layer reconstruction of abdominal wall defects
with acellular dermal allograft (Allo-Derm) and
component separation. Ann Plast Surg 2005;
55(1):36–41 [discussion 41–2].
[10] Netscher DT, Valkov PL. Reconstruction of on-
cologic torso defects: emphasis on microvascular
reconstruction. Semin Surg Oncol 2000;19(3):
255–63.