Abdominal wall expansion in congenital defects

Reconstruction of Large Full-Thickness Abdominal Wall Defects Using a Free Functional Latissimus Dorsi Muscle

Introduction

The large full-thickness abdominal wall defect has to be treated by considering anatomical and functional requirements. The abdominal wall must regain total physiological function, which means that the full thickness abdominal wall defect must be reconstructed anatomically, not only according to the anatomical requirements but also maintaining the functional dynamic voluntary movement. Defects in the abdominal wall alter respiratory mechanics and can impair the diaphragm function. Additionally, muscles of the anterolateral abdominal wall increase the stability of the lumbar region of the vertebral column by tensing the thoracolumbar fascia and by increasing intraabdominal pressure.

Materials and Methods

The timing and method of reconstruction must be chosen depending upon the etiology of the defect. Severe traumatic injuries, abdominal wall infections, necrotizing soft tissue loss, or sepsis needs to undergo staged reconstruction following adequate debridement to control the infectious process, establish the zone of injury, and for proper treatment of intraabdominal pathology, thereby achieving temporary primary closure using split-thickness skin grafting to the viscera. At the time of definitive reconstruction, deep skin graft dermabrasion give us a facial-like layer with adequate strength to stabilize the static abdominal wall. This dermal layer is supported by free functional (innervated) latissimus dorsi muscle (fLDM), giving full anatomical coverage and functional stability. After oncologic resections full-thickness abdominal wall reconstruction was performed immediately with a combination of fLDM flaps and meshes.

Results

A total of 14 patients underwent abdominal wall reconstruction using the fLDM flap. Staged reconstruction was applied in 8 cases. In the remaining six cases, two had no mesh support, three had synthetic mesh, and one had a fascial graft, which were covered with fLDM flap. There were no free flaps failure. One flap revision due to venous anastomosis thrombosis was performed. Donor site seromas occurred in 5 cases and were treated with punction and direct doxycycline injection. Electromyographic testing postoperatively confirmed reinnervation of transplanted LDM.

Conclusion

Using fLDM as a definitive solution, we are not only able to repair soft tissue defects, but also reconstruct voluntary contractility and dynamic natural functional abdominal wall. Transplanted LDM offers enough contractile capacity and strength to replace the function of the missing abdominal wall muscles.

Systematic Review of Tissue Expansion: Utilization in Non-breast Applications

Background

Tissue expansion is a versatile reconstructive technique providing well-vascularized local tissue. The current literature focuses largely on tissue expansion for breast reconstruction and in the context of burn and pediatric skin/soft tissue replacement; however, less traditional applications are also prevalent. The aim of this study was to systematically review the utilization of tissue expansion in such less well-characterized circumstances.

Methods

The authors conducted a systematic review of all publications describing non-breast applications of tissue expansion. Variables regarding expander specifications, expansion process, and complications were collected and further analyzed.

Results

A total of 565 publications were identified. Of these, 166 publications described tissue expansion for "less traditional" indications, which fell into 5 categories: ear reconstruction, cranioplasty, abdominal wall reconstruction, orthopedic procedures, and genital (penile/scrotal and vaginal/vulva) reconstruction. While lower extremity expansion is known to have high complication rates, tissue expander failure, infection, and exposure rates were in fact highest for penile/scrotal (failure: 18.5%; infection: 15.5%; exposure: 12.5%) and vaginal/vulva (failure: 20.6%; infection: 10.3%; exposure: 6.9%) reconstruction.

Conclusions

Tissue expansion enables index operations by providing additional skin before definitive reconstruction. Tissue expanders are a valuable option along the reconstructive ladder because they obviate the need for free tissue transfer. Although tissue expansion comes with inherent risk, aggregate outcome failures of the final reconstruction are similar to published rates of complications without pre-expansion. Thus, although tissue expansion requires a staged approach, it remains a valuable option in facilitating a variety of reconstructive procedures.

Role of tissue expansion in abdominal wall reconstruction: A systematic evidence-based review

BACKGROUND

Tissue expanders (TEs) can be used to assist primary closure of complicated hernias and large abdominal wall defects. However, there is no consensus regarding the optimal technique, use, or associated risk of TE in abdominal wall reconstruction.

METHODS

A systematic search of PubMed and Embase databases was conducted to identify articles reporting abdominal wall reconstruction with TE techniques. English articles published between 1980 and 2016 were included on the basis of the following inclusion criteria: two-stage TE surgical technique, >3 cases, reporting of postoperative complications, hernia recurrence, and patient-based clinical data.

RESULTS

Fourteen studies containing 103 patients (85 adults and 18 children) were identified for analysis. Most patients presented with a skin-grafted ventral hernia (n = 86). The etiology of the hernia was from trauma or prior abdominal surgery. The remaining patients had TE placed before organ transplantation (n = 12) or for congenital abdominal wall defects (n = 5). The location for expander placement was subcutaneous (n = 74), between the internal and external obliques (n = 26), posterior to the rectus sheath (n = 2), and intra-peritoneal (n = 1). Postoperative infections and implant-related problems were the most commonly reported complications after Stage I. The most common complication after Stage II was recurrent hernia, which was observed in 12 patients (11.7%). Five patients with TE died. Complications and mortality were more prevalent in children, immunosuppressed patients, and those with chronic illnesses.

CONCLUSIONS

Tissue expansion for abdominal wall reconstruction can be successfully used for a variety of carefully selected patients with an acceptable complication and risk profile.

Combined submuscular tissue expansion and anterior component separation technique for abdominal wall reconstruction: Long-term outcome analysis

BACKGROUND

We report the long-term outcome analysis of 12 patients who underwent two-stage abdominal wall reconstruction using combined submuscular tissue expansion and anterior components separation (CS) technique.

METHODS

Outcome measures were (1) the patients were assessed for the presence or absence of recurrence; (2) patient-reported outcomes on physical functioning in relation with the abdominal wall reconstruction were evaluated using the SF 36-item health survey.

RESULTS

The mean age, average expansion volume, and mean time expansion were 37.5 years, 1250 cc, and 9.5 weeks, respectively. The average soft tissue deficiency size was 15.5 (width) × 19.5 (length) cm². The average fascial defect was 17 (width) × 21.5 (length) cm². No mesh-assisted technique was required. Primary closure was obtained in all. The average follow-up was 39.6 months. Hernia recurrence was noted in one patient (8.3%). All 12 patients completed the SF 36-item health survey. Moreover, 75% of the patients reported 100%, indicating "Not limited in vigorous activities," and 25% indicated "limited a little." All patients reported 100% "not limited at all" in lifting or carrying groceries, climbing several flights of stairs, climbing one flight of stairs, bending, kneeling, stooping, walking more than a mile, walking several blocks, walking one block, bathing, or dressing.

CONCLUSIONS

Parietal laxity obtained with tissue expansion increases the possibility of direct closure of the fascial layer, skin, and subcutaneous tissue components. Combined use of tissue expansion and CS may result in favorable long-term outcomes as evidenced by patient-reported physical functioning data and low rate of hernia recurrence.

The role of osmotic self-inflatable tissue expanders in intestinal transplant candidates

Intestinal transplantation (ITx) is often associated with decreased abdominal domain, rendering abdominal closure difficult. Pre-transplant placement of tissue expanders (TE) can overcome this challenge; however it can be associated with life-threatening complications. This review aimed to comprehensively summarize all available literature on TE in ITx candidates and include the technical details of osmotic, self-inflatable TE -a technique undescribed before. PubMed, EMBASE and CCTR were searched until April 30, 2016. Based on structured data abstraction and detailed analysis, eighteen cases of TE (inflatable) in ITx candidates were found. Localisation of placement was: subcutaneously in 11; intraperitoneally in 4; 1 patient had 1 TE placed retromuscularly and 1 intraperitoneally; 1 patient had biplanar TE (intraperitoneally placed and extending retromuscularly) and in 1 localisation was unreported. Complication rate was high (61%), injection- or intraperitoneal-related, resulting in life-threatening infections/hematoma. With successful expansion, physiological graft protection -by skin+/-fascia- was always achieved. In completion of this review, we describe our own experience with two patients (7.5-, 34-year-old females), in whom osmotic TE were placed subcutaneously pre-ITx. No TE-related complications occurred and both patients underwent uncomplicated ITx with respectively primary skin and skin + fascia closure. The pros and cons of each TE type and placement are discussed, resulting in the overall conclusions that TE offer an important benefit in graft-protection following ITx. Osmotic TE are safer than conventional prostheses by avoiding percutaneous injections. Subcutaneous placement seems to be safer and more reliable.

Abdominal wall dysfunction in adult bladder exstrophy: a treatable but under-recognized problem

PURPOSE

Bladder exstrophy is defined by urogenital and skeletal abnormalities with cosmetic and functional deformity of the lower anterior abdominal wall. The primary management objectives have historically been establishment of urinary continence with renal function preservation, reconstruction of functional and cosmetically acceptable external genitalia, and abdominal wall closure of some variety. The literature has focused on the challenges of neonatal approaches to abdominal wall closure; however, there has been a paucity of long-term followup to identify the presence and severity of abdominal wall defects in adulthood. Our goal was to characterize the adult disease and determine effective therapy.

METHODS

A retrospective review of a consecutive series of six patients was performed.

RESULTS

We report and characterize the presence of severe abdominal wall dysfunction in these adult exstrophy patients treated as children. We tailored an abdominal wall and pelvic floor reconstruction with long-term success to highlight a need for awareness of the magnitude of the problem and its solvability.

CONCLUSIONS

The natural history of abdominal wall laxity and the long-term consequences of cloacal exstrophy closure have gone unexplored and unreported. Evaluation of our series facilitates understanding in this complex area and may be valuable for patients who are living limited lives thinking that no solution is available.

Role of tissue expanders in patients with loss of abdominal domain awaiting intestinal transplantation

Abdominal closure is a complex surgical problem in intestinal transplant recipients with loss of abdominal domain, as graft exposure results in profound morbidity. Although intraoperative coverage techniques have been described, this is the first report of preoperative abdominal wall augmentation using tissue expanders in patients awaiting intestinal transplantation. We report on five patients who received a total of twelve tissue expanders as a means to increase abdominal surface area. Each patient had a compromised abdominal wall (multiple prior operations, enterocutaneous fistulae, subcutaneous abscesses, stomas) with loss of domain and was identified as high risk for an open abdomen post-transplant. Cross-sectional imaging and dimensional analysis were performed to quantify the effect of the expanders on total abdominal and intraperitoneal cavity volumes. The overall mean increase in total abdominal volume was 958 cm(3) with a mean expander volume of 896.5 cc. Two expanders were removed in the first patient due to infection, but after protocol modification, there were no further infections. Three patients eventually underwent small bowel transplantation with complete graft coverage. In our preliminary experience, abdominal tissue expander placement is a safe, feasible, and well-tolerated method to increase subcutaneous domain and facilitate graft coverage in patients undergoing intestinal transplantation.

Components Separation Combined with Abdominal Wall Plication for Repair of Large Abdominal Wall Hernias following Bariatric Surgery

BACKGROUND

Abdominal wall hernias frequently occur after open bariatric surgical procedures. Standard repair with synthetic mesh may be suboptimal, with a recurrence rate as high as 50 percent. Patients often seek hernia repair in conjunction with abdominal body contouring procedures following substantial weight loss.

METHODS

In 66 consecutive patients undergoing abdominal surgery after open bariatric surgery, abdominal wall hernias of some size were found in 50 patients. In 65 of these patients, panniculectomy was performed simultaneously. The majority of these hernias could be closed primarily in conjunction with abdominal wall plication [38 of 50 (76 percent)]. In 12 patients (24 percent of hernias), the defects were too large (median, 10.8 cm) or located too close to the xiphoid to permit primary closure without undue tension.

RESULTS

Using a components separation technique, primary fascial closure was achieved in all 12 patients. The technique was modified to include abdominal wall plication above and below the repaired hernia defect and the use of an absorbable mesh onlay. Although these patients had a high rate (50 percent) of minor or major superficial wound complications, all wounds closed subsequently without additional operative procedures. Despite the high-risk nature of this group, ventral hernia recurred in only one of 12 patients (8.3 percent) after a median follow-up of 16 months. The single recurrence occurred in one of the two patients with the largest diameter (15 cm) hernias in the series.

CONCLUSIONS

The components separation technique combined with abdominal wall plication was assessed as the preferred technique for the repair of large hernias not amenable to primary repair in the massive weight loss patient following open bariatric procedures. Because this technique avoids placement of permanent mesh, it is particularly advantageous in the post-bariatric surgery patient at high risk for wound dehiscence and infection.

Aesthetic aspects of abdominal wall and external genital reconstructive surgery in bladder exstrophy-epispadias complex

Long-term follow-up of patients born with classical bladder exstrophy-epispadias complex (EEC) reveals that many of them suffer from poor self-image, and the aesthetic aspects of the genitalia and lower abdomen acquire greater significance with age. In this article, we review the aesthetic outcomes in performing puboplasty, umbilicoplasty, and genitoplasty in patients born with EEC. Retrospective review of the cosmetic and functional outcomes in 116 patients born with EEC treated by puboplasty, umbilicoplasty, or genitoplasty was performed. Satisfaction with the cosmetic and functional outcomes of these three reconstructive surgeries was high following initial reconstructive efforts (> 90%). Attention to cosmesis during abdominal wall and genital reconstruction for EEC helps to improve a patient's perception of body image and self-esteem. Our experience with these procedures over the past 25 years demonstrated that the efforts directed toward aesthetics have been well worthwhile.

Updated algorithm for abdominal wall reconstruction

Like any clinical regime, the algorithm for abdominal wall reconstruction requires routine updating as new options and techniques become available. Increased experience and understanding of new applications have allowed for improvements to the approach to complex abdominal wall defects. These improvements have increased efficiency and decreased risk, particularly in the area of staged reconstruction. Surgeons have continued to rely heavily on autologous reconstruction and local tissue advancement for long-term dynamic support. The current approach to abdominal wall reconstruction is based on understanding the literature, clinical experience, and the type of patients seen in practice. This article provides surgeons with the basic guidelines to follow when faced with complex abdominal wall defects and the tools necessary to solve these difficult problems in a responsible and reliable way.

Separation of Anatomic Components Method of Abdominal Wall Reconstruction—Clinical Outcome Analysis and an Update of Surgical Modifications Using the Technique

This article describes some of the benefits and complications of the components separation technique. It additionally highlights some of the modifications that have been made to the technique over the years.

Hepatic omphalocele in an adult

The finding of an untreated omphalocele in adulthood is extremely rare. We report the case of a 29-year-old patient, who presented to us with a congenital defect of the abdominal wall and protrusion of underlying viscera.

The use of tissue expanders in the closure of a giant omphalocele

Giant omphalocele is associated with a high degree of visceroabdominal disproportion, which prohibits safe primary closure. Conventional treatment options include (1) topical therapy with epithelialization followed by secondary ventral hernia repair and (2) staged reduction using a SILASTIC(R) (Dow Corning, Midland, MI) chimney. The authors report a case in which staged reduction of a giant omphalocele was facilitated by the use of crescent-shaped tissue expanders positioned in the potential space between the internal oblique and transversus abdominis layers of the abdominal wall.

Abdominoplasty repair for abdominal wall hernias

The objectives of abdominal hernial repair are to reconstruct the structural integrity of the abdominal wall while minimizing morbidity. Current techniques include primary closure, staged repair, and the use of prosthetic materials. Techniques for abdominoplasty include the use of the transverse lower abdominal incision and the resection of excess skin. By incorporating these aspects into hernial repairs, the procedures are made safer and the results are improved. The medical records were reviewed of 123 consecutive patients who underwent hernial repair. Seventy-six of these patients underwent a total of 82 herniorrhaphies using an abdominoplasty approach. This included using a transverse lower abdominal incision with or without extending it into an inverted-T incision. The hernial defect was then identified and isolated. Repair was obtained with primary fascial closure and plication, primary fascial approximation and reinforcement with absorbable Vicryl mesh, or placement of permanent mesh with or without fascial approximation. Overall, 8 of 82 hernias recurred. Most complications were minor and could be managed with local wound care only. Major complications included one enterocutaneous fistula, one occurrence of skin flap necrosis requiring operative debridement and skin grafting, and one delayed permanent mesh extrusion 2 years after repair. The abdominoplasty approach isolates the incision from the hernial defect and repair. This technique is safe with a low risk of complications and a low rate of recurrence. It is particularly helpful in obese patients, in patients with multiple hernias, and in those patients with recurrent hernias.

Risks associated with "components separation" for closure of complex abdominal wall defects

The reconstruction of complex abdominal wall defects can often pose a significant challenge to surgeons and their patients. Complex ventral hernias may result from large tumor resections, trauma from gunshot wounds, or infections following routine abdominal surgery. "Components separation" of the abdominal musculature uses advancement of local autologous tissue, when available, to close large ventral wall defects. The authors report on a retrospective chart review of 30 patients who underwent components separation for the closure of complex abdominal defects. The study group was 50 percent female, with a mean age of 45 years, body mass index of 33.2 kg/m2, and abdominal defect size of 240 cm2. On average, 20 percent of patients had preoperative wound infections, 30 percent had intraoperative bowel enterotomies, and 33 percent required prosthetic mesh for closure. Total surgery time averaged 4.8 hours, with a mean postoperative stay of 12.5 days and follow-up of 9.5 months. The recurrence rate was 10 percent; postoperative complications included midline ischemia, infection, and dehiscence occurring at rates of 20, 40, and 43 percent, respectively. This study provides a comprehensive review of the risks and complications associated with the treatment of complex ventral hernias and those associated with abdominal "components separation."

Massive Ventral Hernias: Role of Tissue Expansion in Abdominal Wall Restoration following Abdominal Compartment Syndrome

Massive ventral hernias may result from a variety of clinical situations. One such clinical situation, a common problem in trauma patients, is abdominal compartment syndrome. Abdominal compartment syndrome frequently results in a massive abdominal defect when primary closure after surgical decompression is not possible. We offer a technique for repairing these massive ventral hernias by first expanding the lateral abdominal wall muscles, fasciae, and skin with tissue expanders and then closing the defect with elements of the “components separation” method. Additionally we present other clinical situations resulting in a massive ventral hernia that were repaired using this technique.

Bladder preservation in adult classic exstrophy: early results of four patients

OBJECTIVES

To report our experience with the treatment of classic exstrophy of the bladder in a small series of adult patients using ileocystoplasty, bladder neck reconstruction, and abdominal wall closure with flaps. The presentation of exstrophy of the bladder in adulthood is rare. The problems encountered include difficulty in abdominal closure, malignant potential, and upper tract dysfunction. The treatment of choice has been cystectomy with urinary diversion in all reported cases.

METHODS

We treated 4 adult male patients with classic exstrophy of the bladder and complete epispadias. They had not received any previous treatment. Multiple random bladder biopsies revealed nonspecific inflammatory changes with focal areas of keratinization. Three patients were treated in two stages. The first stage included ileocystoplasty, bladder neck reconstruction, and abdominal wall closure with the use of flaps. The epispadias was repaired in the second stage. In 1 patient, the reconstruction was completed in a single stage.

RESULTS

All patients were continent at the last follow-up visit, with three using self-catheterization and one voiding spontaneously. The renal parameters and ultrasound scans were normal at a follow-up of 2 to 48 months. Cystoscopy performed at 6 months postoperatively revealed normal-looking mucosa in 2 patients and mild inflammation in 1 patient. Three patients were satisfied with the cosmetic results and one complained of the small size of his penis. All patients were evaluated by psychiatrists and revealed anxiety disorders preoperatively. After surgery, all demonstrated improved social interaction.

CONCLUSIONS

Vesical preservation with primary reconstruction of bladder exstrophy in adults is safe and feasible in the absence of significant histologic changes in the bladder mucosa. Abdominal closure can be achieved without difficulty with the use of transposition flaps. However, these patients require strict follow-up to detect malignant transformation at an early stage.

Scrotal Reconstruction Using Tissue Expanders

Tissue expansion has been used successfully for reconstruction following many congenital and acquired deformities. This report outlines the use of tissue expansion for reconstructing the scrotum in a pseudohermaphrodite with undescended testes and a hypoplastic scrotum. Tissue expanders were placed in the scrotum to create space for the testes. Relative to other reconstructive options in the scrotum, tissue expansion resulted in an excellent cosmetic appearance with the advantage of providing the desirable space for the testes with no donor site morbidity.

Endoscopically assisted "components separation" for closure of abdominal wall defects

The repair of ventral hernia defects of the abdominal wall challenges both general and plastic surgeons. Ventral herniation is a postoperative complication in 10 percent of abdominal surgeries; the repair of such defects has a recurrence rate as high as 50 percent. The "components separation" technique has successfully decreased the recurrence rates of ventral abdominal hernias. However, this technique has been associated with midline dehiscence and a prolonged postoperative stay at the authors' institutions. The purpose of this study was to determine whether endoscopically assisted components separation could minimize operative damage to the vasculature of the abdominal wall and decrease postoperative wound dehiscence. The study group consisted of seven patients who underwent endoscopically assisted components separation; the control group consisted of 30 patients who underwent open components separation. The two groups were similar regarding demographic data and defect size. The endoscopic group had a higher initial success rate than the open group (100 versus 77 percent). Recurrence rates were not significantly different between the two groups. However, the endoscopically assisted components separation patients had fewer postoperative and long-term complications. In the authors' experience, endoscopically assisted components separation has proved to be a safe and effective method for the repair of complicated and recurrent midline ventral hernias.

An algorithm for abdominal wall reconstruction

Acquired abdominal wall defects result from trauma, previous surgery, infection, and tumor resection. The correction of complex defects is a challenge to both plastic and reconstructive and general surgeons. The anatomy of the abdominal wall, as well as considerations in patient assessment and surgical planning, are discussed. A simple classification of abdominal wall defects based on size, depth, and location is provided. Publications regarding the various abdominal reconstruction techniques are reviewed and summarized to familiarize the reader with the treatment options for each particular defect. Finally, an algorithm is presented to guide the surgeon in selecting the optimal reconstructive technique.

Free innervated latissimus dorsi muscle flap for reconstruction of full-thickness abdominal wall defects

Full-thickness abdominal wall defects continue to be a challenge for the reconstructive surgeon. The most frequently used reconstructive techniques are transfer of a pedicled, local abdominal flap or a distant flap from the thigh region. The purpose of this paper is to present a new approach to full-thickness abdominal wall reconstruction using an innervated free latissimus dorsi musculocutaneous flap. Four patients with large full-thickness abdominal wall defects underwent reconstruction with a free innervated latissimus dorsi muscle flap. In two patients, staged abdominal wall reconstruction was performed. Primary closure was first obtained with a skin graft. During the subsequent definitive reconstruction (with an innervated free latissimus dorsi muscle flap), this skin graft was not excised. Instead, deep dermabrasion of the skin graft was performed, leaving a residual dermal layer. This layer was then covered with a free innervated latissimus dorsi muscle flap. In these two cases, there was no need for the use of a prosthetic mesh. A single stage reconstruction was performed in the other two cases. After abdominal wall sarcoma resection, Prolene mesh was placed and subsequently covered with a free innervated latissimus dorsi muscle flap. There were no free flap failures. The average time of surgery was 4 hours, 50 minutes. The average hospital stay was 14 days. No significant complications occurred except for one donor site seroma. No hernias have occurred postoperatively. The mean follow-up was 21 months. Postoperatively, electromyographic testing was performed regularly in all patients to document reinnervation of the latissimus dorsi muscle flap. With reinnervation and intensive muscle training, the transplanted latissimus dorsi muscle offers enough contractile capacity and strength to adequately replace the function of the missing abdominal wall muscles. In complicated staged reconstructions, dermabrasion of the temporary skin graft allows for the use of a residual dermal layer as a fascia-like substitute to aid in the restoration of structural integrity. The combination of the dermal layer with an innervated free latissimus dorsi muscle provides a strong, vascularized fascial repair as well as an overlying vascularized soft-tissue coverage. In conclusion, adequate functional dynamic reconstruction of full-thickness abdominal wall defects is possible using an innervated free latissimus dorsi muscle flap. The reinnervated latissimus dorsi muscle is suitable for reconstitution of the missing functional and anatomic components of complex abdominal wall defects.

Massive abdominal-wall hernia reconstruction with expanded external/internal oblique and transversalis musculofascia

We describe a technique for expansion and primary closure of massive and large recalcitrant abdominal-wall hernias in the middle and lower abdomen utilizing expanders placed in the lateral abdominal wall between the external oblique and the deeper complex of the internal oblique and transversalis fasciae. Since this technique describes expansion of the lateral abdominal wall, insertion incisions are made in the lateral abdominal wall away from the primary zone of injury surrounding the abdominal hernia and without interrupting the blood supply or innervation to the abdominal-wall muscle, fascia, or skin. This technique, described in four patients with massive abdominal-wall hernias, has been used successfully for primary closure with vascularized autogenous abdominal-wall fascia, obviating the need for interposition of prosthetic material or extraabdominal flaps.

Use of tissue expanders in final reconstruction of infrapubic midline scar, mons pubis, and vulva after bladder exstrophy repair

Two patients following bladder exstrophy repair presented for final cosmetic reconstruction with the characteristic lower abdominal midline scar, bisected mons pubis, and laterally displaced labia majora. Tissue expanders were used to obtain additional skin and subcutaneous tissue. After adequate serial expansion, the expanders were removed, scar tissue excised, and primary approximation of healthy tissues performed. A tension-free closure and esthetically pleasing midline incision, mons pubis, and vulva were obtained.

Wound closure at the trunk by microvascular free flap transfer

Defects of the thoracic or abdominal wall can be congenital or caused by trauma or tumour resection. There may be other problems, such as infection and irradiation effects. In most cases those defects can be closed by local cutaneous and fasciocutaneous or by muscle and myocutaneous flaps. In some rare instances, the use of pedicled flaps may be limited. The size of the defect, the impossibility of closing the donor site, an impaired blood supply, or poor quality of local tissues represent such limitations. In these cases microvascular flap transfer has enlarged our choice of alternative methods. Advantages of this method are the one-stage procedure and the wound coverage by well-vascularized tissue. This is especially beneficial in areas of infected or irradiated tissue. On the other hand microvascular flap transfer requires high technical skill and extensive perioperative and postoperative care.