No abstract

Reconstruction of massive abdominal wall defects has long been a vexing clinical problem. A landmark development for the autogenous tissue reconstruction of these difficult wounds was the introduction of "components of anatomic separation" technique by Ramirez et al. This method uses bilateral, innervated, bipedicle, rectus abdominis-transversus abdominis-internal oblique muscle flap complexes transposed medially to reconstruct the central abdominal wall. Enamored with this concept, this institution sought to define the limitations and complications and to quantify functional outcome with the use of this technique. During a 4-year period (July of 1991 to 1995), 22 patients underwent reconstruction of massive midline abdominal wounds. The defects varied in size from 6 to 14 cm in width and from 10 to 24 cm in height. Causes included removal of infected synthetic mesh material (n = 7), recurrent hernia (n = 4), removal of split-thickness skin graft and dense abdominal wall cicatrix (n = 4), parastomal hernia (n = 2), primary incisional hernia (n = 2), trauma/enteric sepsis (n = 2), and tumor resection (abdominal wall desmoid tumor involving the right rectus abdominis muscle) (n = 1). Twenty patients were treated with mobilization of both rectus abdominis muscles, and in two patients one muscle complex was used. The plane of "separation" was the interface between the external and internal oblique muscles. A quantitative dynamic assessment of the abdominal wall was performed in two patients by using a Cybex TEF machine, with analysis of truncal flexion strength being undertaken preoperatively and at 6 months after surgery. Patients achieved wound healing in all cases with one operation. Minor complications included superficial infection in two patients and a wound seroma in one. One patient developed a recurrent incisional hernia 8 months postoperatively. There was one postoperative death caused by multisystem organ failure. One patient required the addition of synthetic mesh to achieve abdominal closure. This case involved a thin patient whose defect exceeded 16 cm in width. There has been no clinically apparent muscle weakness in the abdomen over that present preoperatively. Analysis of preoperative and postoperative truncal force generation revealed a 40 percent increase in strength in the two patients tested on a Cybex machine. Reoperation was possible through the reconstructed abdominal wall in two patients without untoward sequela. This operation is an effective method for autogenous reconstruction of massive midline abdominal wall defects. It can be used either as a primary mode of defect closure or to treat the complications of trauma, surgery, or various diseases.

Nipple-areola reconstruction represents the final stage of breast reconstruction, whereby a reconstructed breast mound is transformed into a breast facsimile that more closely resembles the original breast. Although numerous nipple reconstruction techniques are available, all have been plagued by eventual loss of long-term projection. In this report, the authors present a comparative assessment of nipple and areola projection after reconstruction using either a bell flap, a modified star flap, or a skate flap and full-thickness skin graft for areola reconstruction. The specific technique for nipple-areola reconstruction following breast reconstruction was selected on the basis of the projection of the contralateral nipple and whether or not the opposite areola showed projection. Patients with 5 mm or less of opposite nipple projection were treated with either the bell flap or the modified star flap. In patients where the areola complex exhibited significant projection, a bell flap was chosen over the modified star flap. In those patients with greater than 5-mm nipple projection, reconstruction with a skate flap and full-thickness skin graft was performed. Maintenance of nipple projection in each of these groups was then carefully assessed over a 1-year period of follow-up using caliper measurements of nipple and areola projection obtained at 3-month intervals. The best long-term nipple projection was obtained and maintained by the skate and star techniques. The major decrease in projection of the reconstructed nipple occurred during the first 3 months. After 6 months, the projection was stable. The loss of both nipple and areola projection when using the bell flap was so remarkable that the authors would discourage the use of this procedure in virtually all patients.