TRUNK RECONSTRUCTION

Christopher W Conner MD

ACQUIRED DEFECTS OF THE associated bronchopleural fistulas. To close the

pleural spaces the authors used, in order of
THORAX
decreasing frequency, ipsilateral latissimus dorsi, ser-
ratus anterior, and pectoralis major muscles, omen-
The repair of acquired chest wall defects is predi-
tum, and rectus abdominis muscle (Fig 1).
cated on the type and extent of the missing ele-
ments. Design of the reconstructive procedure
must take into account the status of the pleural
cavity, the requirement for skeletal support, if any,
and the soft tissue defect. The reconstructive
sequence begins with the deepest tissues and pro-
ceeds to the most superficial.

Pleural Cavity
The bronchopleural and tracheoesophageal fis-
tulas that arise after intrathoracic surgical proce-
dures have plagued chest surgeons for years. In
1911 Abrashanoff1 reported intrathoracic muscle
transposition for closure of bronchopleural fistula,
but it was not until the late 1970s that musculocuta-
neous flaps from the trunk became popular for
soft-tissue reconstruction of the chest, to obliterate
post-pneumonectomy empyema spaces, and to
close fistulas.2-6
Today it is generally accepted that an air-tight
pleural cavity is essential to the success of any pro-
cedure designed to restore the anatomy and physi-
ology of the chest. To produce negative intratho-
racic pressure, both an air-tight seal of the pleural
cavity and skeletal stability over the thorax are
needed. If the visceral pleura is intact, it will readily
form adhesions to the autogenous or alloplastic
materials used to reconstruct the rib cage.7
In severely debilitated patients, an intermediate
step to control the sepsis can be the creation of an
Eloesser flap, whereby the pleural cavity is drained
and the infection washed out.8 After the sepsis is
controlled, the cavity is closed and irrigated with
antibiotic solutions, as suggested by Clagget.9
Miller and colleagues10 report single-stage com-
plete closure of the postpneumonectomy empy-
ema space with extrathoracic muscle and omental
flaps in 5 consecutive patients, 2 of whom had
Fig 1. Optional muscle flaps and omentum for filling a
postpneumonectomy empyema cavity. (Reprinted with per-
mission from Miller JI et al: Single-stage complete muscle flap
closure of the postpneumonectomy empyema space: A new
method and possible solution to a disturbing complication. Ann
Thorac Surg 38:227, 1984.)
Other authors have championed the use of
omentum earlier in the sequence.11,12 The omen-
tum and muscles not located on the lateral thoracic
wall are important alternatives when a thoracotomy
incision has devascularized and injured portions of
the latissimus dorsi and serratus anterior muscles.
The extrathoracic muscle flaps enter the chest
through an incision 4-5 cm long in a double-rib
resection. The exact site of entry depends on the
muscle being transposed and its blood supply, so
that the transfer can be accomplished without ten-
sion or torsion of its vascular pedicle. Before clo-
sure, chest tubes are inserted for drainage. These
SRPS Volume 9, Number 31
are unnecessary if an Eloesser flap is left in place, in
which case the wound is packed. In Miller’s series
all procedures were done in a single stage and the
wounds were closed primarily with no permanent
chest tubes or wall openings.
Miller10 lists six basic principles for obtaining com-
plete flap closure of empyema:
• Administer appropriate antibiotics.
• Enter the cavity through the original incision.
• Debride widely and thoroughly.
• Identify all bronchopleural fistulas and close
them primarily using omental flap or other
muscle flap.
• Fill the entire pleural cavity with appropriate
muscles or omental flaps.
• Use as many flaps as necessary to obliterate the
cavity, maintaining a regional flap hierarchy that
begins with the latissimus dorsi and is followed
by the serratus anterior, pectoralis major, omen-
tum, and rectus abdominis.
Unlike Miller, Arnold and Pairolero13 introduce
the muscle flaps through a second smaller thorac-
otomy, and where no pneumonectomy has been
performed they do not insist on complete oblitera-
tion of the pleural space. Bronchopleural fistulas
are packed with muscle, irrigated with an antibiotic
solution, and dressings are changed frequently. The
chest is closed secondarily. The serratus anterior
muscle was the most commonly transferred flap,
followed in frequency by the latissimus dorsi and
pectoralis major muscles, with only a few patients
receiving pectoralis minor or rectus abdominis
muscle transfers. Serratus transfer was associated
with postoperative shoulder discomfort and occa-
sional scapular flare.
In the combined review of their extensive expe-
rience, Arnold and Pairolero13 reported intratho-
racic transposition of extrathoracic muscle for chest
reconstruction in 22 patients with postneumo-
nectomy empyema and in 40 patients with
bronchopleural fistula (17 of whom were also
included in the empyema group). Continued infec-
tion was the most frequent cause of reconstructive
failure and accounted for most of the deaths. Over-
all, treatment was successful in 63.6% of patients
with empyema and 72.5% of patients with fistula.
Hammond, Fisher, and Meland14 reported the
results of reconstruction in 7 patients with complex
2
intrathoracic defects. The wounds were repaired
with free flaps of latissimus dorsi (3), rectus
abdominis (3), or omentum (1). The anastomoses
were done extrathoracically to the thoracodorsal
artery and vein in 5 patients. When the thoraco-
dorsal vessels were unavailable, the common
carotid and transverse cervical vessels were used
in one case each. Free flap transfer was the recon-
structive method of choice in patients with previ-
ous resection of chest wall muscles or failed pedicle
flap in the presence of a bronchopleural fistula.
Free flaps offered abundant, well-vascularized tis-
sue, tension-free closure, and the possibility of a
complete muscle wrap around the pleural defect.
A recurring theme in surgery for empyema and
intrathoracic catastrophe is the high rate of success
of therapy when treatment is instituted early, before
infection becomes established.15,16 In instances
where lung tissue has not been completely resected
(lobectomy as opposed to pneumonectomy), early
intervention for treatment of empyema may avert
future decortication. During the initial stages of
empyema, the fibrous material in the thoracic cav-
ity is less organized and therefore more easily sepa-
rated from the lung and chest wall. The remaining
lung is more likely to fully expand, which enhances
immediate postoperative and long-term respiratory
function and creates fewer restrictive lung prob-
lems than if treatment were delayed.15,16 This is
contrary to the teachings of some thoracic sur-
geons who prefer to delay treatment until the
empyema cavity has matured. Delayed treatment
increases the risk of subsequent breathing prob-
lems and fistula and decreases the lung’s ability to
expand. 15,16 Procedures for early drainage of
empyema are described by Hood17 in Techniques
in General and Thoracic Surgery.
Thoracoplasty is rarely reported in the modern
literature but continues to serve well in many clini-
cal situations.18-22 Numerous techniques for thora-
coplasty were well known to thoracic surgeons
who treated tuberculosis in the days before anti-
bacterial therapy. In general, multiple ribs are
resected to allow collapse of the chest wall and
obliteration of the remaining pleural cavities. As
resistant strains of tuberculosis have emerged, we
may have to go back and relearn these techniques.
Hood17 details the surgical steps of thoracoplasty
in simple and understandable terms.

The chief indications for thoracoplasty are
chronic, long-standing empyema caused by antibi-
otic-resistant organisms, and long-standing pleural
space infections secondary to extensive resections
such as pneumonectomy.18-22 Unlike therapy for
acute empyema, the reconstruction should be
delayed “until the volume of the empyema cavity is
reduced in size to a relatively narrow space by
contraction of the chest wall and diaphragm and
shifting of the mediastinum to the diseased side. If
the procedure is attempted early when the hemitho-
rax is essentially normal in volume, the transplanted
musculature will not even begin to fill the obliter-
ated space.”17 As mentioned above, an intermedi-
ate step may be an Eloesser flap with external drain-
age. The wound is packed and dressings are
changed frequently until the sepsis is resolved. Many
of these patients can be managed at home by a
family member, with excellent results and improved
overall volume of the hemithorax.
The Sternum and Rib Cage
The most important feature in the contour of
the anterior chest is the arch formed by the costal
cartilages and the sternum.7 The keystone to this
arch is the junction of the manubrium and the body
of the sternum where it connects to the clavicles
and the first rib.1 Sternal defects are classified
according to their location and associated func-
tional consequence, as follows:7
Grade 1 Loss of upper body of sternum and
adjacent ribs – minimal physiologic
effect.
Grade 2 Loss of entire body of sternum and
adjacent ribs – moderate physiologic
effect.
Grade 3 Loss of manubrium and upper body of
sternum with adjacent ribs – severe
physiologic effect.
The integrity of the diaphragm and accessory
muscles of inspiration—the intercostal, submastoid
and scalene muscles—must be considered when
assessing the severity of the skeletal defect. Infected
sternal wounds repaired with muscles or musculo-
cutaneous flaps typically produce only minor im-
pairment of pulmonary function.23,24
SRPS Volume 9, Number 31
Azarow and colleagues25 review the preopera-
tive evaluation and general preparation of patients
for chest wall procedures. They recommend
assessing the pulmonary, cardiovascular, and nutri-
tional status of the patient. Spirometry and mea-
surement of forced vital capacity and forced expi-
ratory flow at 1 second (FEV1) guide the surgeon
in estimating a patient’s ability to tolerate the resec-
tion of all or part of the lung (Table 1).
TABLE 1
Assessment of Pulmonary Resectability
(Adapted from Azarow KS, Molloy M, Seyfer AE, Graeber GM:
Preoperative evaluation and general preparation for chest-wall
operations. Surg Clin N Amer 69:899, 1989.)
The results of the pulmonary function tests will
consign patients to one of five risk categories (Table
2).
TABLE 2
Assessment for Risk of Postoperative
Respiratory Complications
(Adapted from Azarow KS, Molloy M, Seyfer AE, Graeber GM:
preoperative evaluation and general preparation for chest-wall
operations. Surg Clin N Amer 69:899, 1989.)
The need to reconstruct the skeletal deficit
resulting from chest wall resection is relative. Gen-
erally a two-rib segmental loss may be overcome
by soft-tissue reconstruction alone,26 but rigid
reconstruction should be considered in the event
of loss of skeletal support over a larger area (eg,
from combined anterior-posterior defect or major
sternal resection). Dingman26 stated that removal
of four ribs usually results in a flail condition.
Pairolero and Arnold,24 on the other hand, state
that almost all patients can have a sternectomy or
resection of four to six ribs at the cartilage level
without experiencing either a flail chest or respira-
tory insufficiency.24 More extensive skeletal resec-
3
SRPS Volume 9, Number 31
tion may be possible in the radiated thorax because
the consequent radiation fibrosis stiffens the soft
tissues.
A third point of view is offered by McCormack,27
who stated that any defect >5 cm requires stabiliza-
tion. Picciocchi and colleagues28 believe that pros-
thetic reconstruction is not indicated in the pres-
ence of parietal defect <5 cm in diameter or involv-
ing fewer than three ribs. In their series larger
defects located posteriorly or superiorly were not
reconstructed either because of shielding of these
areas by the scapula. All these viewpoints should
be taken into account and weighed against the
individual patient’s pulmonary status and overall
condition. The better functioning patients may not
be debilitated by resection without rigid reconstruc-
tion, whereas more compromised patients might
have to have rigid skeletal reconstruction to pre-
vent respiratory problems postoperatively.
Alloplastic Reconstruction
Autogenous costal reconstruction with contralat-
eral ribs was the standard in the past, but has now
been supplanted by the use of alloplasts in patients
with major skeletal defects. In noncontaminated
wounds, defects of both the sternum and rib cage
are reconstructed in general with prosthetic mate-
rial.24,29 Arnold and Pairolero24, 29-32 as well as Mor-
gan et al33 are proponents of double-knit Prolene
mesh. Boyd et al34 and McCormack27,35 prefer
Marlex. Prolene mesh is double-knitted and is flex-
ible in two dimensions and also resists fraying.
Marlex is a single-stitch product and is rigid in one
direction but stretchable at right angles. When
sutured under tension, both Prolene and Marlex
become semi-rigid and provide satisfactory tempo-
rary support, usually without the need for further
skeletal reconstruction even if the mesh is removed
at a later date.35
McCormack27 reviews his experience with the
Marlex-methylmethacrylate composite in chest wall
reconstruction. Infection is the most frequent com-
plication encountered and generally necessitates
removal of the mesh. Fortunately, if the Marlex
graft is allowed to remain intact for at least 6 to 8
weeks, the thick fibrous capsule that results is rigid
enough to prevent a flail segment in the area
involved. The main disadvantage of Marlex is a
4
tendency to fragment, especially in response to
the frequent movements of the chest wall.
Kroll et al36 reviewed the postoperative course
of 101 patients with and without Marlex mesh sta-
bilization. The use of Marlex mesh decreased the
time required for mechanical ventilation by a mean
of 0.8 days and subsequently shortened hospital
stays. Postoperative wound infections were more
common when Marlex mesh was used: 5% with
Marlex mesh vs 0% without Marlex mesh. Infec-
tion was preceded in each case by ischemic necro-
sis of the overlying flaps. The authors speculate
that infection would have been avoided if better
vascularized coverage had been provided.
Steel mesh has also been used in conjunction
with methylmethacrylate, but is now relatively
rare.27,35 When more than half of the anterior or
posterolateral chest wall is involved, Larsson, Al-
Khaja, and Roberts37 use steel bars as rib substi-
tutes. These bars are superimposed on a double
layer of Marlex mesh and covered with vascular-
ized flaps for contouring. The authors report satis-
factory long-term function and cosmesis with no
infection and no subsequent removal of prosthetic
material.
Hyans, Moore, and Sinha38 describe chest wall
reconstruction with expanded polytetrafluoro-
ethylene (e-PTFE) soft-tissue patch (Gore-Tex). They
also used vascularized flaps in 9 patients after major
chest wall resections. Their patients’ thoracic defects
ranged from 60-400 cm2 and resulted from resec-
tion of tumor in 7 patients and radiation in 2. There
was a single postoperative infection that prompted
removal of the implant without replacement. The
authors prefer Gore-Tex over Marlex because of
its flexibility, its imperviousness to air and fluids, and
its superior durability and strength.
Puma, Ragusa, and Daddi39 studied the perfor-
mance of a grid constructed of polydioxanone
bands (PDSTM; Ethicon) for chest wall construction
in 11 patients and report no complications and
excellent long-term stability. Reber and colleagues40
report excellent results in post-traumatic flail chest
(11) and painful nonunion of two ribs (1) after
open reduction and chest wall stabilization by
osteosynthesis with 3.5 mm plates and screws using
the AO technique. There was good pain relief,
improved ventilatory mechanics, and no second-
ary dislocation.

In the past, silicone41 and Proplast42 were used
for rigid stabilization of the chest wall. Both materi-
als were plagued with problems, however, and cur-
rently synthetic meshes are the standard alloplasts
for thoracic reconstruction.29 In their most recent
update of their extensive experience, Arnold and
Pairolero 29 reached the following conclusion:
“Prosthetic materials available today are reliable and
provide reasonable stability. Thus we have not
used rib grafts in recent years and rely totally on
synthetic meshes when reconstructing the thoracic
skeleton.”
Reconstruction with Autologous Tissue
Infected wounds present a formidable recon-
structive challenge in that it is not safe to introduce
foreign bodies into the wound. In the event of
infection, therefore, autogenous materials are pre-
ferred even though they increase the complexity
of the repair. A popular option is a split-rib graft
covered by a musculocutaneous flap. Hirase et
al43 used a composite multiple split-rib latissimus
dorsi osteocutaneous pedicled flap for chest wall
reconstruction in infected patients. They harvested
the entire 9th, 10th, and 11th ribs in one case and
split ribs where the posterior half was left intact,
and report no postoperative weakness at the donor
site and stable chest wall reconstruction.
Van Geel and colleagues44 employed grafts of
dura mater overlaid by pedicled omentum and cov-
ered with a split-thickness skin graft. The obvious
disadvantage of this approach is the two different
extrathoracic donor sites.
Sternal Osteomyelitis
In 1957 Julian described the median sternotomy
incision that has since become the standard access
route to midline thoracic structures.45,46 Mortality
rates in subsequent sternal infections approached
70%. Uncontrolled infection of the sternum may
involve underlying vascular and cardiac suture lines
as well as prosthetic valves and grafts which rup-
ture under stress.
Management of the postoperative sternum
should be aggressive to prevent further deteriora-
tion and promote healing. The modern trend in
the U.S. toward shorter hospital stays has led to
potential delays in diagnosis. In cases where the
SRPS Volume 9, Number 31
diagnosis is equivocal, CT scan will not only help
make the diagnosis but define the extent of
involvement of the sternal bones, retrosternal tis-
sues, and cartilages.47
In the past, the management of infected sternal
incisions consisted of open treatment with granula-
tion. This is a course associated with considerable
morbidity, mortality, and lengthy hospital stays. Then
in 1963 Shumaker and Mandelbaum48 successfully
treated mediastinitis with debridement and
reclosure of the sternum followed by closed irriga-
tion of the mediastinum. After further modifica-
tion,49 this regimen was associated with a decrease
in mortality from poststernotomy infection to 20%.
Another significant advance in the management
of infected sternal wounds occurred in 1976, when
Lee50 introduced wide debridement of bone and
cartilage followed by greater omentum transposi-
tion to fill the mediastinal dead space with vascular-
ized tissue. Jurkiewicz and associates51 subsequently
expanded on this idea to include muscle flap clo-
sure for patients in whom catheter irrigation had
failed. Later still, this muscle flap reconstruction
was used as primary therapy for deep mediastinal
infections. By eliminating closed irrigation and using
wide debridement and muscle flap reconstruction,
the authors were able to decrease the mortality
rate in their series of patients with mediastinal infec-
tions to 0.
Nahai and coworkers45 reviewed 211 consecu-
tive cases of mediastinitis following median sterno-
tomy (1.6% overall incidence) treated at Emory
University Hospitals according to the regimen
defined by Jurkiewicz. Of 377 muscle flaps trans-
ferred, 212 were pectoralis major and 145 were
rectus abdominis muscles. Over the last 2 years of
the study, 73% of patients were treated with single
pectoralis major or rectus abdominis turnover flaps
for closure of the sternal defect.45 Technical details
of these transfers are given in the article (Fig 2).
Use of the internal mammary artery (IMA) in
lieu of vein grafts did not predispose to infection in
their series, but did influence the choice of flap for
reconstruction (Table 3).45
When the mammary vessels have been taken
from both sides of the chest, the lower half of the
pectoralis major muscle is perfused by intercostal
perforators lateral to the IMA perforators. The flap
is advanced medially and turned over in the usual
manner to cover the infection portion of the ster-
5
SRPS Volume 9, Number 31
TABLE 3
Local Flap Selections Following Reversed Saphenous
Vein and Internal Mammary Artery Bypass Grafts
(Reprinted with permission from Nahai F et al: Primary treatment
of the infected sternotomy wound with muscle flaps: A review of
211 consecutive cases. Plast Reconstr Surg 84:434, 1989.)
num. The upper half of the pectoralis is mobilized
laterally, elevated on its thoracoacromial pedicle,
and transposed in the wound. This segmental muscle
transfer allows complete coverage of the sternum
with one muscle, even when the IMA has been
harvested bilaterally.
6
Fig 2. The pectoralis turnover and
rotation-advancement flaps and the
rectus abdominis flap. (Reprinted
with permission from Nahai F et al:
Primary treatment of the infected
sternotomy wound with muscle flaps:
A review of 211 consecutive cases.
Plast Reconstr Surg 84:434, 1989.)
Another option elevates a composite bipedicled
pectoralis-rectus unit.52,53 Blood supply is by the
thoracoacromial vessels superiorly and the deep
inferior epigastric arteries inferiorly. The flap is
elevated medially to laterally and sutured to a simi-
lar flap from the other side. Recurrent osteomyeli-
tis and chondritis are thought to be the result of
inadequate debridement.
Arnold and Pairolero’s 54,55 algorithm is only
slightly different from Nahai’s45 in their updated
series of 100 consecutive patients.55 The authors
report transposing 175 muscles, including 169 pec-
toralis major, 3 rectus abdominis, 2 external oblique,
and 1 latissimus dorsi. There were 2 postoperative
deaths and 26 recurrent infections. The recurrences
were caused by retained infected cartilage in 16
patients, bone in 6, and foreign body in 4. The
authors stress the importance of removing all
exposed healthy cartilage because it is prone to
infection due to its relatively poor blood supply.
The indication for the use of omentum was exposed
epicardium. Of 19 patients who had omental trans-
fer, 5 developed hernias through the tunnel but
remained asymptomatic, and no surgery was
required for correction.

Reports of the use of the greater omentum in
the treatment of infected mediastinitis have appeared
recently. Wening et al56 detailed the technique of
omental transposition in the treatment of infected
wounds of the anterior chest wall and described
their experience in 8 patients. Because of varia-
tions in vascular anatomy of the omentum, the
authors recommend preoperative laparoscopy
under anesthesia to ascertain the vascular pattern
of the greater omentum.
Initial debridement of the sternum with the
vacuum-assisted closure device serves as a bridge
to eventual sternal wound closure. Hersh et al57
treated 16 patients with the device, changing it every
2-3 days until quantitative biopsy showed resolution
of the infection. The wound was subsequently
closed with a regional muscle flap. Obdeijn et al58
used the vacuum-assisted closure device in 3 patients
to prepare a wound for secondary closure without
a muscle flap. This may be an option in high-risk
patients who cannot withstand a second large re-
constructive procedure after the initial debridement.
The frequency of poststernotomy mediastinitis
in children will likely increase along with the rising
popularity of pediatric thoracic surgery. The treat-
ment is essentially the same as for adults, and
includes thorough sternal debridement and muscle
flap closure.59-61 The small size of the infant’s medi-
astinum accommodates a limited amount of
edema,59 which hinders recovery. More than one
flap is often needed to completely close the sternal
defect. Other technical points to be remembered
when operating on children include the following:59
• The cartilage and minimally ossified bone of
infants can desiccate readily and may be easily
contaminated, dictating an aggressive approach
to promote reossification.
• The muscles are extremely delicate, necessitat-
ing the use of loupes and even microsurgical
techniques for magnification.
• The rectus sheath is very thin but wide, occupy-
ing two thirds of the anterior abdominal wall.
This allows successful vertical division of the
muscle.
Stahl and Kopf59 report their experience in 8
patients with congenital heart disease who were
operated on at ages 1 day to 7 months. Five of
these infants had subsequent flap reconstruction
SRPS Volume 9, Number 31
of their sternal wounds because of infection or in-
ability to close the chest at the initial procedure.
These 5 children underwent bilateral pectoralis
major muscle flap with preservation of the humeral
insertion, and 3 required additional unilateral rec-
tus abdominis flaps for closure. A silicone sheath
was used to reinforce the closure of the chest wall
and temporarily seal the thorax when the chest
could not be closed directly immediately after car-
diac surgery. Septic complications and recurrent
cardiac tamponade are expected in these babies,
and definitive reconstruction should be postponed
until the child is stable.
Hester60 wrote of the Emory University experi-
ence with sternal wound infection in children. In
their series of 13 patients aged 10 days to 4 years,
conservative treatment yielded a 25% mortality
from sepsis, compared with only 1 death (8%) when
the wound was closed with flaps. This outcome
mirrors the surgical team’s experience with adult
patients. Muscle flap reconstruction was associ-
ated with a reduction in ventilatory support from
25 days to 4 days and of intensive nursing care
from 33 days to 6 days. Hester60 warns against
aggressive cartilage and sternal debridement in
small children, debriding only obviously infected
and nonviable sternum and no costal cartilage.
Backer and colleagues62 report their experience
with 8 patients treated for mediastinal infection after
cardiac surgery at Children’s Memorial Hospital in
Chicago. All 8 patients healed completely with the
use of muscle flaps—10 pectoralis major, 3 rectus
abdominis, and 1 cervical strap. There was 1 death
secondary to Candida sepsis from an exposed
Gore-Tex graft.
Soft-Tissue Reconstruction
Soft-tissue coverage may be as simple as a skin
graft or as complicated as a microvascular flap. The
choice of coverage method depends on the spe-
cific defect and the patient’s options.26 Arnold and
Pairolero29 identify four indications that require tho-
racic and plastic surgeons to combine efforts in
chest wall resection and reconstruction.
• tumor, primary or recurrent
• infection
• radiation injury
• trauma
7
SRPS Volume 9, Number 31

To this list we would add intrathoracic defects abdominis. Palmer and Taylor69 define the vascular
that necessitate space-filling procedures and territories of the anterior chest wall in an elegant
bronchopleural fistulas, which are special cases of anatomic study that should aid in the planning of
infection. A close working relationship between flaps in this area (Fig 3). The authors note “a close
the plastic surgeon and thoracic surgeon early in relationship between the musculoskeletal territory
the patient’s management can prevent damage to supplied by a parent artery and the territory sup-
tissues which might be employed in the recon- plied by its cutaneous perforators.”
struction later. On the balance side, thoracic sur-
geons can be more aggressive in their ablative
efforts when they are informed of the alternatives
for repair and are confident of the reconstructive
outcome by their plastic surgery colleagues.
Muscle-sparing posterolateral thoracotomy tech-
niques can be applied quite successfully. These
incisions do take longer to create and offer a slightly
more limited exposure than traditional incisions,
but the time can be made up during closure of the
wound. Bethencourt and Holmes63 describe their
experience in 43 patients undergoing a variety of
intrathoracic procedures by muscle-sparing thorac-
otomy. They report faster recovery and less post-
operative pain and dysfunction. Of note is the fact
that the latissimus dorsi and serratus anterior muscles
are spared with this technique, and therefore are
available if later reconstruction is indicated.
Partial-thickness defects involving the chest wall
are relatively straightforward to repair. Skin grafts Fig 3. Interconnecting vascular territories of the cutaneous
provide adequate temporary closure of thoracic perforators of the anterior chest wall. Territories of the (a)
defects and in some cases have survived for years. transverse cervical; (b) internal thoracic; (c) acromiothoracic;
(d) posterior circumflex humeral; (e) lateral thoracic; (f) deep
For skin grafts to be successful, they must be applied inferior epigastric; and (g) posterior intercostal arteries. (Re-
to a well-perfused bed and therefore are limited to printed with permission from Palmer JH, Taylor GI: The vascular
coverage of superficial wounds over healthy muscle. territories of the anterior chest wall. Br J Plast Surg 39:287, 1986.)
Despite reported take of grafts applied directly to
the pleura and pericardium,26 flaps are preferred
for long-term chest wall reconstruction because Latissimus dorsi
the potential complications of a failed graft can be Several studies attest to the versatility and reli-
disastrous. ability of the latissimus dorsi musculocutaneous
Small full-thickness defects of the thorax are (LDM) flap for anterior thoracic wall reconstruc-
closed following the usual reconstructive echelon. tion.24,30-33,70-72 The flap has a predictable blood
Large full-thickness defects are usually repaired with supply on a sturdy vascular pedicle so it can be
flaps of skin, muscle, muscle and skin, or fascia and tunneled safely to emerge anteriorly. Its arc of
skin. All the muscles of the thorax can be elevated rotation allows it to reach all areas of the ipsilateral
and rotated for a considerable distance with or chest and across the anterior midline up to the
without skin. The choice of flap for anterior chest contralateral axillary fold.
wall reconstruction is based on the skin require- McCraw and coworkers70 detail the technique
ments of the defect, stability of the thoracic wall, of latissimus dorsi musculocutaneous flap transfer
need to protect the thoracic viscera, and donor for chest wall reconstruction. The anterior two
site considerations.64-68 The muscles most com- thirds of the muscle is supplied by the thoracodorsal
monly employed in chest wall reconstruction are vessels, but the entire muscle is also perfused via
latissimus dorsi, pectoralis major, and rectus multiple collaterals and may be transferred

8

undelayed when based proximally. If the entire
cutaneous territory of the flap is needed for recon-
struction, the authors70 recommend a delay proce-
dure. The maximum length of the skin paddle that
allows primary closure is approximately 7 cm. A
larger skin paddle requires skin grafting of the donor
site.
Matsuo and colleagues73 report uncomplicated
chest wall reconstruction in 11 patients by con-
tralateral LDM flap designed along the long axis of
the muscle with a skin island overlying the
lumbodorsal fascia. They chose this reconstruc-
tion because of previous ipsilateral axillary radia-
tion that might have injured the thoracodorsal ves-
sels. By placing the island of skin over the
lumbodorsal fascia, the flap reach was extended to
cover the contralateral clavicular region, the ante-
rior axillary area, and even the axilla proper. They
report only one partial loss of the tip of the flap.69
Salmon, Razaboni, and Soussaline74 found the
neurovascular bundle to the LDM flap to be intact
in patients who had been irradiated. Extensive axil-
lary fibrosis as a result of the radiation and axillary
dissection did cause difficulties during flap eleva-
tion. Maxwell and colleagues75 and Fischer et al76
transferred latissimus dorsi flaps based on the ser-
ratus anterior branch in patients who had prior liga-
tion of the thoracodorsal vessels. May, Tooth, and
Cohen77 report a case where no identifiable vascu-
lar pedicle was present due to prior surgery. They
SRPS Volume 9, Number 31
incorporated the teres major and its collateral ves-
sels into the latissimus dorsi flap and report suc-
cessful transfer of a double musculocutaneous
unit.77
Depending on the specific circumstances, the
thoracodorsal nerve can be either left intact or
divided after transfer. Ligation of the neurovascu-
lar pedicle will cause flap atrophy and shrinkage.71
Salvin78 increased the transferable size of a latissi-
mus dorsi flap with preharvest tissue expansion.78
Moelleken, Mathes and Chang79 found minimal
functional impairment from transfer of a latissimus
dorsi muscle. The only measurable deficit was a
minor decrease in backward extension and adduc-
tion of the ipsilateral arm.
Pectoralis major
Arnold and Pairolero3,5,6,13,24,30-32 demonstrated
the versatility of the pectoralis major as a muscle or
musculocutaneous flap in the repair of anterior chest
wall defects. The origin and insertion of the pecto-
ralis major muscle can be divided, leaving the
muscle attached only by the thoracoacromial ves-
sels and the lateral pectoral nerve (Fig 4). The
muscle is rotated on the neurovascular pedicle to
cover the defect.
Small cutaneous paddles can be carried with the
muscle to allow primary closure of the donor site.
When dealing with larger defects, it is preferable to
Fig 4. The pectoralis major
muscle flap in chest wall recon-
struction. (Reprinted with per-
mission from Arnold PG, Pairolero
PC: Use of the pectoralis major
muscle flaps to repair defects of
the anterior chest wall. Plast
Reconstr Surg 63:205, 1979.)
9
SRPS Volume 9, Number 31
apply a split-thickness skin graft to the transposed
pectoralis major muscle.24,30-32
Sisson et al80 covered a mediastinal wound with
the medial portion of a pectoralis major muscle
based on perforators from the internal mammary
vessels. Brown, Fleming and Jurkiewicz81 used
bilateral pectoralis major muscle flaps to cover a
large defect in the manubrial region.
Tobin82 discusses the role of pectoralis major
musculocutaneous flaps in chest wall reconstruc-
tion. When the muscle is taken from the non-
dominant side of the chest, there is minimal func-
tional impairment to the patient.
Rectus abdominis
Moon and Taylor83 detail the vascular anatomy
of the rectus abdominis musculocutaneous flap
based on the deep superior epigastric system. They
describe four different designs for skin paddles and
their respective merits. The vertical and upper trans-
verse flaps have the best blood supply.84 Boyd,
Taylor and Corlett85 elucidated the location of per-
forating vessels from the rectus abdominis muscle
to the overlying skin paddle, and found them to be
more numerous in the paraumbilical region. When
the rectus abdominis is raised as a musculocutane-
ous flap, the skin paddles should incorporate these
periumbilical perforators to enhance blood supply.
Boyd and associates,34 Miyamoto et al,86 and
Hartrampf87 all have reported the transfer of the
rectus abdominis based on the superior epigastric
vessels and carrying a transverse skin paddle for
chest wall reconstruction—the TRAM flap. When
based superiorly, the rectus abdominis has an arc
of rotation that encompasses the nipple on either
side.87
Miller and coworkers88 emphasize the impor-
tance of the costal marginal artery that enters the
rectus muscle laterally as a major potential source
of blood supply to the flap. They stress that division
of the costal marginal artery to gain additional length
for the flap pedicle can seriously compromise flap
perfusion. The costal marginal artery may be sacri-
ficed only after the specific configuration of the
superior epigastric artery has been established.
Ueda and coworkers89 employ a transverse rec-
tus abdominis musculocutaneous flap that comprises
the anterior rectus sheath, external oblique fascia
10
on the ipsilateral side, and a skin component from
the contralateral side. Fascia is used to reconstruct
the pleura, while the rectus abdominis, ribs and
intercostal muscles restore musculoskeletal integ-
rity, and the skin paddle covers the cutaneous defect.
Takayanagi and Ohtsuka 90 report using an
extended TRAM flap for coverage of large defects
of the chest wall. The vascularity of zones 2 and 4
is enhanced by including the superficial epigastric
vessels and superficial circumflex iliac vessels with
the flap and anastomosing these vessels to the
thoracodorsal vessels of the recipient site—a super-
charged TRAM.91 This modification is a way of
dealing with large defects of the upper chest wall.
Coleman and Bostwick67 review the role of the
rectus abdominis muscle in chest wall reconstruc-
tion. Their recommendation is to use the latissi-
mus dorsi or pectoralis muscles, in the belief that
the rectus abdominis muscle poses a greater risk
than either of the other flaps, particularly with regard
to late hernia formation in the lower abdomen.87 If
the TRAM flap is used, selective harvesting is rec-
ommended, preserving as much rectus sheath and
rectus muscle as possible in each case. When
these guidelines are followed, the incidence of her-
nia is minimal.
External oblique
Hodgkinson and Arnold92 describe anterior chest
wall reconstruction with an external oblique muscle
flap that is based laterally on its segmental blood
supply and is rotated superiorly. The upper limit of
this flap’s reach is the 4th intercostal space.
Serratus anterior
Arnold and Pairolero93 have used the serratus
anterior to repair small through-and-through defects
of the chest wall and for intrathoracic reconstruc-
tion of, for example, bronchopleural fistulas.
Triceps brachii
Hartrampf, Elliott, and Feldman94 report chest wall
reconstruction in 7 patients with a triceps brachii
musculocutaneous flap. This is an ancillary flap in
breast reconstruction when the TRAM flap is the
primary flap, and can also be used secondarily for
coverage of open wounds after partial TRAM flap

loss. The donor scar and limited skin paddle are the
obvious drawbacks of the triceps flap. The func-
tional deficit resulting from transfer of the long head
of the triceps is negligible.
Intercostal
The intercostal flap has been employed by Daniel
and colleagues95 in chest wall reconstruction. The
flap can include ribs and has sensory capability.
The limited arc of rotation and difficult posterior
dissection are drawbacks of this method.
Fasciocutaneous flaps
Regional fasciocutaneous flaps96-98 have been
used for soft tissue reconstruction in the chest and
to bolster the vascularity of muscle flaps. Maruyama
et al99 elevated vertical abdominal fasciocutaneous
flaps with the anterior rectus fascia in 8 patients to
successfully close thoracic wounds without com-
plication. Preservation of the superficial epigastric
vessels during proximal dissection is crucial to flap
vascularity but tedious to carry out. In addition,
one or two perforating vessels from below the
costal margin should be included in the flap to
ensure adequate perfusion.100 Flaps with a base-to-
length ratio >1:3 have survived.
Teich-Alasia and coauthors101 report 80 cases of
chest wall reconstruction with subscapular-pubic
fasciocutaneous flaps up to 40 cm in length. Exten-
sive undermining of the donor site allows primary
closure.
Chiu and Barone102 describe microvascular trans-
fer of circumferential forearm fasciocutaneous flaps
based on the cephalic vein and brachial artery for
coverage of a massive chest wall defect in a single
patient. The flap extended from above the elbow
to the wrist. The flap was harvested from the trau-
matically amputated ipsilateral extremity.
Fascia lata103 and dura mater44 have also been
suggested to stabilize the rib cage. Soft-tissue bulk
and surface coverage are achieved with other flaps.
Deltopectoral flap
The deltopectoral flap can reach the anterior
chest surface and is easily and quickly elevated.64
Inclusion of the underlying fascia results in a more
reliable blood supply.104
SRPS Volume 9, Number 31
Osteocutaneous flaps
A composite flap consisting of latissimus dorsi
muscle, the 11th and 12th ribs, and the posterior
pleura was described by Bobin, Crozet, and
Ranchere.105 The blood supply to this flap is proxi-
mal and based on a thoracodorsal pedicle and per-
forating segmental vessels. Bone scan confirmed
good uptake in the transferred ribs and stable tho-
racic coverage.
Hirase et al106 report the use of a similar flap in 2
patients. Yamamoto and coworkers107 extended
the latissimus dorsi-rib flap to include the subscapu-
lar muscle. These alternatives are to be consid-
ered in cases of wound infection or an otherwise
compromised patient when reconstruction with
alloplastic material is contraindicated.
Random flaps
Researchers at the Sloan-Kettering Memorial In-
stitute7 report using random rotation flaps in chest
wall reconstruction. Disadvantages of these flaps
are their small size, difficulty with flap harvest and
transfer, and unreliability of results.
Free flaps
Because of the abundance of well-vascularized
regional flaps, microvascular transfers have been
infrequently used in chest wall reconstruction.
Hidalgo et al108 list two indications for free flap
coverage of thoracic wounds: 1) unavailability of
appropriate local musculocutaneous flaps: either
the blood supply or local flaps have been divided
or prior regional flaps have failed; or 2) the defect
is too large or extends past the reach of local flaps.
They report reconstruction by microvascular
transfer in 7 patients, 6 with free rectus abdominis
flaps and 1 with latissimus dorsi. Large defects
were reliably covered with these flaps.
Omentum
Like microvascular transfers, omental transposi-
tion for soft-tissue reconstruction should be
reserved for the unlikely event where muscle or
musculocutaneous flaps are not available or have
failed. In chest wall reconstruction, the omentum
is best suited for partial-thickness wounds, as it does
not contribute any structural stability to the tho-
11
SRPS Volume 9, Number 31
racic cage. Omental flaps are often used in intratho-
racic reconstruction, such as in closure of a broncho-
pleural fistula, filling an empyema space, or padding
of the sternum. Fix and Vasconez109 review the use
of the omentum in chest wall reconstruction.
RADIATION WOUNDS
Radiation wounds are far ranging and ill con-
tained. Planning the reconstruction in the irradi-
ated chest wound is complicated by the indistinct
boundaries of the scarred, fibrotic tissue, which
makes it difficult to accurately project the extent of
the surgical defect. Reconstruction options are lim-
ited by necrosis in the recipient bed, osteoradio-
necrosis in bony structures, and the likelihood of
damage to blood vessels in potential donor areas.
Skin grafts and regional flaps are tenuous and prob-
ably useless.110,111 In the words of Arnold and
Pairolero, “chest wall reconstructive problems
associated with previous irradiation are some of
the most awesome of all defects reconstructive
surgeons confront. Irradiated tissues are prone to
infection, and synthetic materials tend to fail in these
circumstances.”29,32
Granick, Larson, and Solomon112 discuss the cur-
rent management of chronic radiation wounds.
Arnold and Pairolero32 recommend aggressive de-
bridement of all infected and ischemic tissue, usu-
ally to include a portion of the thoracic skeleton,
and coverage with well-vascularized muscle flaps
without prosthetic mesh if possible, especially if the
wound is contaminated. The fibrosis resulting from
radiation provides stiffness to the soft tissues and
aids in stabilizing the chest wall.
Samuels and coworkers113 support the practice
of aggressive debridement and vascularized local
flap coverage of radiation-induced chest wall lesions.
They report on 24 patients who were reconstructed
with the following flaps: latissimus dorsi (12), TRAM
(8), and pectoralis major muscle (3). Complete
healing was noted in all but 2 patients, who were
left with small chronic wounds. The overall compli-
cation rate was 29%.
A contralateral breast flap for chest wall recon-
struction in irradiated wounds was first reported by
Whalen114 and revisited by Hughes et al.115 This
method has been basically abandoned unless there
is absolutely no other reconstructive alternative.
12
Jurkiewicz and Arnold116 report using a pedicled
omentum flap overlaid with skin graft in 10 patients.
The foremost complication was gastric outlet
obstruction, which occurred in 30% of patients.
Alday and Goldsmith117 discuss the use of omen-
tum in chest wall reconstruction and suggest a tech-
nique for lengthening the vascular pedicle to make
more omentum available for the reconstruction.
Woods et al118 describe their experience with
random chest wall flaps in 30 patients. Complica-
tions developed in 44%.
Musculocutaneous flaps remain the mainstay of
reconstruction in irradiated chest wounds. Heinz
and Lee119 reported satisfactory healing when the
latissimus dorsi musculocutaneous flap was used with
or without ribs and with or without Marlex mesh.
Crowe and coworkers120 reviewed the reconstruc-
tive results at M D Anderson Hospital in 96 patients
with postradiation wounds of the thorax. Patients
whose chest was stabilized with synthetic mesh suf-
fered a 50% complication rate, compared with 46%
complications when mesh was not used.
BACK WOUNDS
Most wounds of the back are secondary to
trauma, tumor resection, radiation, and spinal
instrumentation/stabilization procedures. The fol-
lowing flaps are particularly useful in reconstruc-
tion of these cases:
• the trapezius muscle for upper third wounds
• the latissimus dorsi muscle for middle third
wounds
• the gluteus maximus muscle for lower third
wounds
To this list we can add pedicled perforator flaps
as described by Roche and associates.121 “Reverse”
latissimus dorsi muscle flaps can also be used to
advantage in large wounds of the lower back.122
The blood supply of the reverse LDM flap is through
perforating branches from the 9th, 10th, and 11th
posterior intercostal arteries. These vessels enter
the deep surface of the muscle 4-5 cm from the
midline and approximately 5 cm caudal to their
respective origins in the intercostal vessels (Fig 5).122
The transverse back flap described by Hill, Brown
and Jurkiewicz123 is an option for closure of lower
thoracic and sacral defects, although grafting of the
donor site is required. For small back wounds, the
 SRPS Volume 9, Number 31

Hochberg and colleagues126 report muscle and

musculocutaneous flap coverage of exposed spi-
nal fusion devices. Eight patients with complex
wounds due to metal implants and skin dehiscence
had complete healing without removal of the
implants. Multiple flaps were necessary in several
patients. The flaps used included latissimus dorsi, a
bipedicled flap of latissimus dorsi and gluteus maxi-
mus, a trapezius flap, and paraspinus turnover flaps.
The use of free flaps has also been described in
hostile midline back wounds, with good success.127
Stephens and Grotting128 review surgical methods
for coverage of the chest wall and spine (Tables 4-
7). The authors offer sensible guidelines for the
management of these very difficult problems.

TABLE 4
Flaps for Defects in the Sternum and Medial
Chest Wall
Fig 5. Blood supply of the “reverse” latissimus dorsi flap. (Re-
printed with permission from Stevenson TR et al: More experience
with the “reverse” latissimus dorsi musculocutaneous flap: Precise
location of the blood supply. Plast Reconstr Surg 74:237, 1984.)

serratus anterior, serratus posterior, and paraspinus

muscles have also been suggested.
Roche and others121 use large skin and fascial
flaps, as follows:
• The fourth lumbar perforator flap, which is
located 5-9 cm from the midline. This flap car- (Reprinted with permission from Stephens DR, Grotting JC: Soft
ries skin from the posterior midline all the way tissue reconstruction. Coverage of the chest wall and spine.
to the rectus muscle. Orthop Clin North Am 24:449, 1993.)

• Superior gluteal artery perforator flaps. These

flaps are based on the superficial branch of the TABLE 5
superior gluteal artery. The blood supply enters Flaps for Defects in the Lateral Chest Wall
the flap above the piriformis muscle at a point
between the greater trochanter and halfway to
the sacrum.
• Intercostal artery flaps based on a perforator
overlying the 9th or 10th intercostal space.
Their paper describes the anatomy and surgical
technique of flap elevation and transfer. Recon-
struction in 4 patients gave excellent results.
The intercostal flap has been suggested by Daniel
and associates.124,125 This is a sensory flap useful in
paraplegic patients. Fasciocutaneous flaps are par-
ticularly valuable in patients who are mobile and in
(Reprinted with permission from Stephens DR, Grotting JC: Soft
whom the use of muscle flaps creates functional tissue reconstruction. Coverage of the chest wall and spine.
deficits. Orthop Clin North Am 24:449, 1993.)

13
SRPS Volume 9, Number 31
TABLE 6
Flaps for Shoulder and Axilla Reconstruction
(Reprinted with permission from Stephens DR, Grotting JC: Soft
tissue reconstruction. Coverage of the chest wall and spine.
Orthop Clin North Am 24:449, 1993.)
TABLE 7
Flaps for Spine Reconstruction
(Reprinted with permission from Stephens DR, Grotting JC: Soft
tissue reconstruction. Coverage of the chest wall and spine.
Orthop Clin North Am 24:449, 1993.)
Yuan-Innes et al 129 described use of the
vacuum-assisted device in spinal wounds with
exposed hardware. Wounds were initially
debrided and vacuum therapy initiated as an
inpatient. Patients were subsequently discharged
from hospital and therapy was completed on an
outpatient basis without flap surgery. The wounds
were stabilized in 42 days in one case and in 70
days in the other. Despite these long therapy
periods, good healing was achieved and most of
the care was delivered outside the hospital.
14
THORAX — CONGENITAL DEFECTS
POLAND’S SYNDROME
In 1841 and based on findings from a single
autopsy, Poland130 described a patient with tho-
racic wall deformities that appeared to be restricted
to the musculature on one side of the chest. Sir
Alfred noted ipsilateral upper extremity anomalies
in this individual, but he failed to recognize that the
hand deformities were part of the symptom com-
plex that bears his name. Sixty years later, de Haan131
linked the skeletal anomalies of the trunk and hand
in Poland’s syndrome.
Anatomy
The essential features of Poland’s syndrome are
the following (Fig 6):132-135
• absence of the sternal head of the pectoralis
major muscle
• hypoplasia or aplasia of the breast or nipple
• deficiency of the subcutaneous fat and axillary
hair
• anomalies of the costal cartilages and anterior
rib ends
• sundry anomalies of the ipsilateral upper
extremity, including shortening and brachy-
syndactyly
Less commonly there may also be
• absence of the pectoralis minor
• variable degrees of deformity of the serratus,
infraspinatus, supraspinatus, latissimus dorsi, and
external oblique muscles
• total absence of the anterior lateral ribs with
herniation of the lung
• symphalangism with syndactyly and hypoplasia
or complete absence of the middle phalanges
• foreshortening and hypoplasia of the forearm
Because of the wide spectrum of anomalies of
the hemithorax and ipsilateral upper extremity,
some authors refer to this symptom complex as
“Poland’s sequence”.

Fig 6. The deformity in Poland’s sequence.
Epidemiology
Poland’s syndrome often goes undiagnosed and
therefore is probably underreported. Freire-Maia
and associates136 found the prevalence of Poland’s
syndrome in Brazil to be 1 in 30,000. There appears
to be no gender preference, although more
women present to plastic surgeons because of the
breast deformity. The right side is affected twice as
often as the left. The majority of cases appear to
be sporadic; genetic transmission has been
reported only in about 15 families to date.137-143
The pedigrees of affected families “are consistent
with either an autosomal dominant gene or low
penetrance or delayed mutation. It seems reason-
able to accept the hypothesis that most cases result
from developmental vascular accidents, nongenetic
in nature, leading to highly variable effects on the
phenotype, and that in some cases a predisposi-
tion to developmental vascular instability is pro-
vided by a mutant gene.”139
Combined Poland’s syndrome and congenital
bilateral facial paralysis with inability to abduct the
eyes (Moebius’ syndrome) is seen in approximately
1 in 500,000 patients.144-146 Poland’s syndrome also
has been associated with hematopoietic malignancy
(leukemia and non-Hodgkin’s lymphoma).147
Etiology
Current thinking favors a vascular etiology for
Poland’s syndrome. This theory holds that the mus-
SRPS Volume 9, Number 31
culoskeletal malformations stem from hypoplasia of
the subclavian artery on the affected side148,149 oc-
curring at approximately the 6th week of gestation.
As the ribs gradually grow forward and medially,
the vessel is shaped into a U, with the vertebral
artery originating at the center of the curve. If
either vessel is distorted at this critical time, it may
lead to kinking and occlusion in a process called
“subclavian artery supply disruption sequence”
(SASDS).145 The clinical manifestations of this phe-
nomenon are specific for the location of the
blocked flow—ie, whether the patient develops
Poland’s, Klippel-Feil, or Moebius’ syndrome. The
more proximal the point of occlusion, the more
severe the anomaly.
Merlob and coworkers150 analyzed subclavian
arterial diameter and flow velocity by Doppler scan-
ning in 4 patients with various degrees of Poland’s
syndrome. Flows were diminished by approxi-
mately 50% compared with the normal side in all
patients, independent of severity of deformity. The
authors propose that subclavian hypoplasia should
be listed as one of the main components of Poland’s
syndrome.150
Treatment
Despite the hand deformities, the functional dis-
ability in Poland’s syndrome is mild. The abnormal
anatomy should be defined with CT scanning151,152
and the status of the latissimus dorsi muscle should
be noted, as it will affect reconstructive efforts.153
Any history of maternal drug use should be docu-
mented. Hematologic irregularities (leukemia, non-
Hodgkin’s lymphoma) should be ruled out.
Surgical reconstruction of the breast deformity
of Poland’s syndrome was significantly advanced
by the development of silicone breast prostheses
and custom-made Silastic implants.154,155 Augmen-
tation by implants alone, however, does not
address the underlying chest wall deformity, the
absence of the pectoralis fold and rib cage, and
these must be corrected with muscle and muscu-
locutaneous flaps.
Hester and Bostwick135 introduced latissimus
dorsi muscle transposition to correct the chest
wall deformities in Poland’s syndrome in their
series of 11 patients. They transferred the inser-
tion of the muscle anteriorly to aid in reconstruc-
tion of the anterior axillary fold, and covered the
15
SRPS Volume 9, Number 31
implant entirely with muscle. The prosthesis is
inserted through a lateral inframammary fold inci-
sion (Fig 7).
Seyfer and associates156 believe mild to moder-
ate deformities can be managed with latissimus dorsi
transposition without skeletal reconstruction. Other
authors believe that women with more severe
deformities of the skeletal base require bony
reconstruction of the chest wall to prevent subse-
quent dislodging of the prosthesis, adequate pro-
jection of the breast mound, and symmetry with
the normal side.
A variety of materials has been used for this
purpose, such as Marlex mesh, Prolene mesh, and
synthetic dura.157-159 Urschel et al159 report excel-
lent results with Marlex mesh and artificial dura to
correct skeletal deformity. Breast implants were
covered with latissimus dorsi muscle flaps at a later
date. Haller et al158 use autogenous rib grafts and
later prosthetic meshes to replace deficient chest
wall skeletal structure. Anderl and Kerschbaumer160
report early correction of Poland’s anomaly in two
cases, one aged 5 years and the other 8 months.
Anterior thoracic reconstruction employing latissi-
mus dorsi muscle flap produced excellent results,
with a normal-appearing rib cage and a straight
spine.160
Shamberger, Welch, and Upton161 report a 75-
patient experience with the correction of Poland’s
syndrome. Reconstruction of the rib cage was
16
deemed necessary in 13 patients. They particularly
noted rotation of the sternum toward the involved
side, with contralateral carinate deformity (Fig 8).
These abnormalities were addressed with subperi-
chondrial split-rib cartilage resection, grafting, and
sternal osteotomy, which allowed anterior displace-
ment and orthorotation of the sternum.
The authors believe that esthetic breast recon-
struction is difficult if the chest wall deformity is not
corrected. They did not treat Poland’s syndrome in
males unless a rib cage deformity was present.161
Marks et al162 report their results in 8 patients
treated for Poland’s syndrome. Early in the series
treatment consisted only of a muscle flap, but sub-
sequently a custom silicone implant was added
because of dissatisfaction with postoperative muscle
atrophy and conventional implant displacement.
Most surgeons agree that aplasia of the rib cage
in Poland’s anomaly should be corrected regard-
less of patient sex. The posterior thoracic defor-
mity created by harvest of the latissimus dorsi
muscle is an acceptable tradeoff for correction of
the anterior axillary fold. Some authors believe
that surgery in girls should be postponed until after
breast maturity at age 18 or 19 to ensure breast
symmetry.163 Earlier correction is sometimes indi-
cated for psychological reasons.
Asymmetry of nipple position (the affected side
is typically too high) can be corrected by reposi-
tioning the areolar complex lower on the breast
mound.134 Alternatively, mastopexy can be per-
formed on the contralateral breast. 135 Tissue
expansion has been employed by Argenta et al163
and Versaci et al.164,165 The expander is inserted
Fig 7. The latissimus dorsi muscle
flap for reconstruction in Poland’s
sequence. (Reprinted with permis-
sion from Hester TR, Bostwick J III:
Poland’s syndrome: Correction with
latissimus dorsi muscle transposition.
Plast Reconstr Surg 69:226, 1982.)

Fig 8. The spectrum of rib cage abnormality seen in Poland’s
sequence. Most frequently there is an entirely normal rib cage
with only absent pectoral muscles, as in A. (Reprinted with
permission from Shamberger RC, Welch KJ, Upton J III: Surgical
treatment of thoracic deformity in Poland’s syndrome. J Pediatr
Surg 24:760, 1989.)
through a small incision in the axilla and placed just
superior to the nipple. Expansion begins in child-
hood and continues through puberty and adoles-
cence at a pace to match breast growth on the
normal side. Later the expanders are replaced with
a permanent implant covered by a latissimus dorsi
flap.163,164 Ohjimi and coworkers166 prefer a turn-
over modification at the insertion of the latissimus
flap to enhance the thickness of the flap in the
axillary fold and produce a more esthetic result.
PECTUS EXCAVATUM
Pectus excavatum is the most common congeni-
tal deformity of the chest wall, accounting for 90%
of all chest wall anomalies. The etiology is unknown.
Boys outnumber girls 3:1, and occasionally there is
a positive family history.167
Pectus excavatum is usually noted in the first
weeks of life.168 Ravitch169 gave the first detailed
description of the deformity in 1949: a depressed
sternum; rounded sloping shoulders; mild dorsal
kyphosis; a “potbelly”; and abnormal breathing char-
acterized by retraction of the sternum on deep
inspiration. Severe pectus excavatum is associated
with stress intolerance and evidence of respiratory
and cardiac dysfunction.170-172 Associated anoma-
lies include Marfan’s syndrome in 25%, lumbodorsal
scoliosis, broad thin chest, hypomastia, cardiac
murmurs, and EKG changes.173
SRPS Volume 9, Number 31
In 1939 Ochsner and DeBakey proposed that
the sternum in pectus excavatum was sunken and
held posteriorly by rib cartilage overgrowth. This
theory was recently validated by Feng et al174 and
accounts for the increasing severity of the defor-
mity as the child grows.173-175
The indications for surgery are not well defined.
The overwhelming majority of children are asymp-
tomatic176 and the main reason to have surgery is
cosmesis. Patients who have had surgery appear
to breathe better, although objective corrobora-
tion of physiologic improvement is lacking. Winn
and coworkers177 measured total lung capacity and
cardiac output with exercise in 12 children (mean
age 13.8 years) with pectus excavatum, 8 of whom
had operative correction. All patients reached 86%
of their maximal predicted heart rate with exercise,
and there was no change with surgery. In fact, the
operated patients had a decrease in total lung
capacity from 80.3% to 72.8%.
Investigators from Japan178 evaluated the degree
of severity of pectus excavatum and pulmonary
function before and after surgical repair. In 138
patients who were tested preoperatively and 40-42
months postoperatively, the severity of the chest
deformity correlated directly with respiratory physi-
ology. The preoperative vital capacity averaged
86% of predicted and forced expiratory flow was
85% of predicted. In the first 2 months after repair
there was approximately a 10% decrease from
baseline, which recovered to the preoperative level
by 1 year. Excellent cosmetic results were obtained
in all patients but the authors could not document
improvement in respiratory function as a result of
surgical correction.
Morshuis et al179 demonstrated increased restric-
tion of pulmonary function in postoperative patients
despite subjective improvement in the patients’ stud-
ies. There was approximately 10% decrease in total
lung capacity after surgery, and vital capacity
decreased from 78.3% to 70.7% postoperatively.
The authors concluded that “the satisfactory, sub-
jective long-term results of most patients justify sur-
gery for psychological/cosmetic reasons”.
Fonkalsrud et al180 advocate correction of pectus
excavatum with substernal support at an early age.
The 207 patients in their series had excellent cos-
metic results as well as subjective improvement in
exercise tolerance, endurance, and respiratory
17
SRPS Volume 9, Number 31
symptoms. Once again these physiologic benefits
were unsupported by objective measurements.
Haller et al181 describe the course of 12 children
with pectus excavatum who showed severe car-
diopulmonary symptoms postoperatively second-
ary to failure of growth of the thoracic wall after
extensive surgical repair. All patients were oper-
ated on before age 4, and each had resection of
five or more rib cartilages with perichondrium. The
physiologic restriction was theorized to be due to
the extensive nature of the surgical procedure and
removal of the cartilaginous growth centers.
Haller’s group182 report the effects of repair on
exercise tolerance and pulse oximetry tests. Their
patients had a mild restrictive lung disorder which
was not affected by surgical repair. Postopera-
tively there was slight increase in exercise toler-
ance and improvement in pulse oximetry, suggest-
ing enhanced cardiac function with exercise. Pos-
sibly the single-breath testing done in prior studies
was unable to demonstrate the physiologic improve-
ment from surgical repair manifested on exercise
testing as done here.
Shamberger183 reviewed the literature for evi-
dence of improvement in work-related capacity after
pectus excavatum repair. He concluded that
. . . results of studies in cardiac functions have at
times been in conflict, and additional studies are
needed to further define the relationship between
pectus excavatum and cardiac function. Recent
dynamic or exercise studies have been most
promising in this regard. What are required are
reproducible and simply-measured parameters to
measure patients with excavatum to assess the
level of cardiorespiratory impact of the deformity
and [to gain] a better understanding of which
patients would physiologically benefit from repair.
Shamberger (2000)
Less extensive surgery such as the Nuss proce-
dure may be able to improve cardiac function with-
out producing the scarring that leads to restriction
of the chest wall and limits respirations.
Treatment
There are three categories of corrective proce-
dures for pectus excavatum: 1) those that camou-
flage the defect with silicone implants; 2) those that
involve sternal or costal cartilage resection; and 3)
18
those that involve no resection but include place-
ment of a retrosternal bar (Nuss procedure).
Camouflaging Techniques
Adolescents who are beyond their final growth
spurt and are asymptomatic are probably best
treated with silicone implants.173 Customized sili-
cone implants were first proposed by Murray 184
in 1965 and subsequently popularized by oth-
ers.185-189 Implant placement was initially subcuta-
neous, but now submuscular implantation is pre-
ferred to reduce palpability of the edges and ante-
rior displacement of the prosthesis.167 Fixation is
facilitated by a Dacron patch on the posterior aspect
of the implant. Prefabricated implants are tailored
to the individual patient’s deformity.167
Reconstructive Procedures
Infants with severe chest wall deformity as well
as older individuals with cardiac and respiratory
symptoms or stress intolerance should be consid-
ered for reconstruction. These procedures begin
by resecting the costal cartilages involved in the
deformity. Once this is corrected, the sternum is
realigned as necessary—many authors employ a
transverse osteotomy—and stabilized—eg, with a
retrosternal metal bar.190
Ravitch and associates169,191,192 give technical
details of reconstructive procedures for numerous
chest wall deformities, including pectus excavatum,
pectus carinatum, and Poland’s syndrome.
Haller et al193 use CT scans to assess the preop
status of pectus excavatum patients. The largest
transverse diameter of the chest is measured and
plotted against the narrowest AP diameter. A ratio
>3.25:1 signifies moderate to severe deformity and
was an indication for surgical correction in their
series. This degree of pectus excavatum was asso-
ciated with a significant decrease in heart and lung
function during vigorous exercise. The authors
believe that the physiologic impairment is revers-
ible if the repair is completed before puberty, and
recommend operation at age 4-6 years to 1) “re-
lieve structural compression of the chest and allow
normal growth of the thorax”, 2) avert cardiopul-
monary dysfunction later in life, and 3) improve
cosmesis.193 They recommend correction with a
modified Ravitch procedure, which involves

removal of three to four overgrown cartilages and
anterior repositioning of the sternum through a
transverse osteotomy. Internal support is provided
by the child’s lowest normal ribs; no prosthetic
mesh is used. A temporary bar is inserted beneath
the sternum and prevents depression postopera-
tively. Their series encompassed 664 patients who
were followed from 1 to 40 years. The results
were excellent in 95% and the other 5% had mild
to moderate recurrence.
Hayashi and Maruyama194 use a vascularized
rib strut in the repair of pectus excavatum. They
employ the 7th rib, usually from the left side, which
is harvested based on the anterior intercostal
branch of the internal mammary artery and is trans-
posed beneath the sternum to stabilize the chest
wall (Fig 9).
Fig 9. Internal fixation using a vascularized rib strut. IM=internal
mammary artery; R=rib strut; S=sternum. (Reprinted with
permission from Hayashi A, Maruyama Y: Vascularized rib strut
technique for repair of pectus excavatum. Ann Thorac Surg
53:346, 1992.)
Matsui and colleages195 recount their experience
with a bioabsorbable strut made from poly-L-lactide
(P-L-LA) for chest wall reconstruction in 56 patients,
including 33 cases of pectus excavatum. The P-L-
LA material biodegrades but retains 90% of its
mechanical strength for approximately 3 months
after implantation. There were no wound infec-
SRPS Volume 9, Number 31
tions, respiratory complications, and no recurrence
of the deformity in 4 years of follow-up. The authors
recommend the use of a P-L-LA strut at least 2.5
mm thick for chest wall reconstruction.
Fonkalsrud et al180 make a horizontal incision,
resect the lower four to five costal cartilages bilat-
erally, and cut a transverse wedge osteotomy
through the anterior table of the sternum. The
posterior table is cracked with a greenstick frac-
ture. In children <5 years of age, the periosteal
sheath from the 5th rib on each side is brought
retrosternally and sutured together for support. In
older children, a thin steel strut is implanted for 6
months for sternal support.
Bentz and colleagues196 prefer rigid plates for
sternal fixation in children and adults. Wada et al197
report an even more aggressive approach in 271
patients. When the deformity is bilaterally sym-
metrical, the deformed cartilages are transected,
the internal mammary artery vessels are divided,
and the sternum is removed. The entire complex is
then reversed, contoured, and stabilized to the
anterior chest wall with wire sutures. 197 The
devascularized sternum is potentially subject to avas-
cular necrosis and infection.
Doty and Hawkins198 leave one internal mam-
mary vessel intact on the left and even leave both
vessels intact in the turnover type procedure.
Ishikawa and colleages199 report a similar turnover
procedure that leaves the internal mammary arter-
ies intact. These turnover procedures appear to
be quite extensive, and excellent results have
apparently been achieved with less dramatic and
extensive surgeries.
Golladay and Wagner200 report a 15-year expe-
rience comprising 177 patients with pectus
excavatum. The sternum is approached through a
transverse incision in boys and a modified gull-wing
incision in girls. Subcutaneous dissection is mini-
mal. All involved cartilages are resected, usually
the 3rd through 8th, as well as the xiphoid. A metal
strut (Atkins) is inserted presternally and the ster-
num is suspended to this bar with wire sutures.
The strut is typically removed 12-18 months later.
A number of authors recommend less extensive
surgery with fixation. Wolf et al201 report the surgi-
cal outcome of 191 patients operated on for pec-
tus excavatum and carinatum over a 16-year period.
Their technique involves resection of cartilages,
wedge osteotomy of the sternum, and maintenance
19
SRPS Volume 9, Number 31
of sternal position with transcutaneous wire and a
modified Jewett brace. The patient is fitted with the
brace preoperatively and wears it for 6 weeks post-
operatively. The brace is connected to the
transcutaneously placed wire, which is removed in
the surgeon’s office. Excellent results were reported
in both pectus excavatum and carinatum except in
patients with scoliosis or Marfan’s syndrome. The
obvious drawback of this technique is the neces-
sity to wear the brace for 6 weeks.
Reports of endoscopic repair of pectus
excavatum and carinatum are beginning to appear.
Kobayashi and colleagues202 describe a thoraco-
scopically assisted procedure through a 2.5-4 cm
incision just above the xiphoid process. This inci-
sion is supplemented with small stab wounds,
approximately 3 mm long, that are made for inser-
tion of the surgical instruments. The ribs and rib
cartilages are exposed through the prexiphoid inci-
sion under endoscopic control. A retrosternal strut
is used to fixate the sternum after the cartilages are
transected and displaced anteriorly. An anterior
wedge osteotomy is performed at the point of
maximum curvature of the sternum, leaving the
posterior cortex intact (greenstick).
Nuss and his group from Norfolk203 devised a
minimally invasive technique for the correction
of pectus excavatum. The procedure begins with
a transverse incision 2.5 cm long made on the
lateral chest wall between the anterior and pos-
terior axillary lines. Skin tunnels are raised ante-
riorly and the intercostal space is entered using a
Kelly clamp which is slowly advanced across the
mediastinum immediately under the sternum. The
dissection is carried over to the contralateral
chest, umbilical tape is passed through this tun-
nel, and a metal bar is passed between the two
sides (this bar has been molded to the patient’s
anterior chest preoperatively). Initially the metal
bar is introduced in an inverted, upside-down
position, and then turned over 180 degrees to
correct the deformity. Neither cartilage nor ster-
num is resected, and patients were allowed to
return to full activity after 1 month. Nuss reports
excellent long-term results with minimal side
effects. In their series of 42 patients followed
for 1-9.2 years (mean 4.6 years), bar removal
was possible in 30 patients. The early excellent
results were maintained in 22, declined to good
in 4, were fair in 2, and poor in 2. The surgeon’s
20
experience influenced the outcome, and most of
the less-than-optimal results occurred early in the
series. A poor result was thought to be due to a
bar that was too soft (3), a sternum that was too
soft (1), or associated complex thoracic anoma-
lies (1).
An excellent review of the Nuss technique with
step-by-step details is presented by Hebra.204 An
overview of the author’s experience in 251 patients
reveals 96.5% satisfaction with the results of sur-
gery.205 Later in the series they added a vertical
metal bar attached to the extrathoracic ends of the
transverse bar to prevent movement of the strut.
PECTUS CARINATUM
Pectus carinatum results from abnormal costo-
chondral overgrowth of unknown cause. Pena et
al206 presume that pectus excavatum and carinatum
are two different morphologic manifestations of
the same disease. If the overgrowth of the costal
cartilages generates a downward, inward force, it
produces pectus excavatum; if the force is out-
ward, pectus carinatum is the result. Pectus
carinatum has been reported in association with
numerous developmental conditions such as
Noonan syndrome207 and Leopard syndrome, an
autosomal dominant disorder characterized by len-
tigo, sensorineural deafness, retarded growth, ocu-
lar hypertelorism, prognathia, kyphosis, winged
scapula, valvular pulmonary stenosis, and pectus
carinatum or excavatum.208
The degree of deformity seems to worsen as
the child undergoes the juvenile growth spurt. Most
children remain asymptomatic. Surgical treatment
of pectus carinatum was developed over the years
by Ravitch209 and Shamberger,210 and ultimately
improved upon by Robicsek and Fokin.211 Their
technique involved
• Exposure of the sternal deformity by subperi-
osteal dissection and elevation of pectoralis
major muscles bilaterally.
• V-shaped transverse osteotomy performed high
on the sternum above the level where the
abnormal forward curvature begins. The
osteotomy is through the anterior table of the
sternum leaving the posterior lamina intact. The
resection is done in the intercostal space rather
than at the sternocostal junction.

• Below the transverse osteotomy, the involved
cartilages are resected subperiosteally. This
resection may need to be more extensive than
in patients with pectus excavatum. The pectora-
lis muscles are brought together across the mid-
line and sutured to one another.
Morales and coworkers212 find that midline ster-
nal defects are frequently associated with ectopia
cordis. Of the 4 patients reported by Morales, 3
had intracardiac defects. Other associated defects
are noted by Amato and associates,213 who noted
a single patient with pectus carinatum, ectopia cordis,
anterior diaphragmatic hernia, and omphalocele.
The patient also had a patent ductus arteriosus and
persistent left superior vena cava. Hochberg et
al 214 report similar findings in a patient with
thoracoabdominal ectopia cordis and omphalocele.
Closure with muscle flaps was successful in this
case.
The embryology of the sternum is reviewed by
Sadler. 215 An excellent review of the surgical
anatomy and reconstruction of the cleft sternum
and sternal foramina is presented by Fokin.216 Sur-
gical repair is accomplished through a midline verti-
cal incision. The pericardium and skin are dissected
off. Periosteal flaps are created and left attached
on the underside. The flaps are subsequently closed
across the midline. The fresh edges of the sternum
are approximated and wedge osteotomies are cre-
ated inferiorly. This is a superior surgical primer for
management of these unusual conditions.
ABDOMEN — ACQUIRED DEFECTS
Acquired defects of the abdominal wall are usu-
ally secondary to tumor resection, trauma, or infec-
tion. The goals of abdominal wall reconstruction
are to protect the intraabdominal structures, pre-
vent herniation, and provide a well-vascularized
cover.
Gottlieb and associates217 analyze their experi-
ence in the repair of large upper abdominal wall
defects with specific reference to the frequency of
complications and timing of the repair. They found
one-stage reconstruction with mesh or musculocu-
taneous flaps appropriate and largely successful in
SRPS Volume 9, Number 31
uncomplicated cases such as ventral hernia or pri-
mary tumor resections. Complex wounds and
operations involving extensive lysis of adhesions,
excisions of fistulas, or other considerable manipu-
lation of abdominal viscera were difficult and com-
promised the reconstructive outcome. In these
cases the authors recommend abandoning the plan
of one-stage repair and opting instead for tempo-
rary closure with mesh, skin grafts, or skin flaps
until definitive reconstruction at a later date. Yeh
and colleagues218 concur on the basis of their
experience with 36 patients treated for major
abdominal trauma.
Rohrich and coauthors219 offer algorithms for
abdominal wall reconstruction in partial and through-
and-through defects (Figs 10 and 11). The authors
classify defects according to size, depth, and loca-
tion. Like Gottlieb, they recommend delayed
reconstruction with skin graft or vacuum-assisted
closure device.
Spontaneous Healing
Small full-thickness defects can sometimes be
managed successfully by gauze packing kept moist
with antibacterial solutions. Healing by secondary
intention follows removal of the wick.
Skin Grafts
External wound coverage by skin grafts is sim-
plest and should be considered as long as the
underlying tissue has good perfusion and there is
adequate support of the abdominal wall. Split thick-
ness skin grafts can be applied directly to abdomi-
nal viscera,220,221 although they are associated with
breakdown, adhesions and hernia formation and
ultimately require replacement with more complex
tissues to provide support and protection.
Direct Approximation
Massive intraperitoneal and gynecologic tumors
distend the anterior abdominal and pelvic wall, caus-
ing diastasis of the rectus muscle and subsequent
hernia formation. Matory and colleagues222 rec-
ommend selective, transverse, elliptical excision of
the attenuated rectus abdominis and oblique
muscles and sheaths, plication of the recti, and pri-
mary layered closure at the time of tumor resec-
21
SRPS Volume 9, Number 31

Fig 10. Algorithm for repair of partial abdomonal wall defects. TFL, tensor fasciae latae; RF, rectus femoris; FTT, free tissue transfer;
TE, tissue expansion. (Reprinted with permission from Rohrich RJ, Lowe JB, Hackney FL, et al: An algorithm for abdominal wall
reconstruction. Plast Reconstr Surg 105:202, 2000.)

tion. This technique improved visualization of the
surgical field, reduced the risk of ventral herniation,
and facilitated hygiene in their series. The lower
abdominal wall tone and function were better after
resection of the redundant muscles than in cases
where plication alone was employed.
Ramirez, Ruas, and Dellon223 describe abdomi-
nal wall reconstruction in 11 patients by the tech-
nique of “components separation”, in which the
rectus muscle is peeled off the posterior rectus
sheath and the external oblique is separated from
the internal oblique muscle. The plane of dissec-
tion is relatively avascular. Once separated from
the external oblique muscle, the compound flap of
rectus muscle with anterior rectus sheath and
attached internal oblique and transversus abdominis
muscle can be advanced medially approximately 5
cm in the epigastrium, 10 cm at the waist line, and 3
cm in the suprapubic region, allowing direct clo-
sure of some abdominal wall defects (Fig 12). Bilat-
eral mobilization doubles these figures.
Lowe and associates224 and Shestak and cowork-
ers225 advocate a similar technique. Shestak reports
his results in 22 patients with complex, full-thickness,
midline abdominal wall wounds (Fig 13). Defects
ranged in size from 84 cm2 to 375 cm2. Results

22

Fig 11. Algorithm for repair of complete abdominal wall defects. TFL, tensor dasciae latae; RF, rectus femoris. (Reprinted with
permission from Rohrich RJ, Lowe JB, Hackney FL, et al: An algorithm for abdominal wall reconstruction. Plast Reconstr Surg 105:202,
2000.)
were excellent, with only 1 long-term hernia noted.
There were no other abdominal wall complications.
One patient died secondary to multiple organ sys-
tem failure.
Thomas, Parry, and Rodning226 suggest a modi-
fied dissection involving parasagittal incisions in
the external oblique and transversus abdominis
fascia to facilitate coaptation of the linea alba. This
fascial partition-release allows medial translation
of the muscle fascias to the level of the umbilicus
for 7-10 cm in the case of the external oblique
and 2-4 cm for the transversus abdominis, per
side. Closure is reinforced with a layer of syn-
thetic mesh applied to the external surface of the
abdominal fascia to prevent adhesions to viscera
and diminish the risk of fistula.
SRPS Volume 9, Number 31
Fabian and others227 report the results of staged
management of acute abdominal wall defects in 88
patients. This treatment is indicated when the
abdomen cannot be closed primarily because of
massive edema, diffuse peritonitis, planned reexplor-
ation, or partial tissue loss (eg, necrotizing fasciitis).
Stage I consists of placement of a prosthetic mate-
rial (Prolene, Vicryl, Gor-Tex, or plastic from an IV
fluid bag). Two to 3 weeks later, when the wound
shows granulation, the prosthetic material is
removed (stage II). If the wounds can be approxi-
mated, they are closed secondarily at this time.
Stage III takes place 2 to 3 days after prosthetic
removal, and involves closure by either a split-thick-
ness skin graft directly on viscera or full-thickness
mobilization of skin and subcutaneous tissue and
23
SRPS Volume 9, Number 31

Fig 12. Dissection of the abdominal wall musculature into

components for medial advancement of separate muscle lay-
ers. (Reprinted with permission from Ramirez OM, Ruas E, Dellon
AL: “Components separation” method for closure of abdominal-
wall defects: An anatomic and clinical study. Plast Reconstr Surg
86:519, 1990.

closure (a planned ventral hernia). Stage IV occurs

6 to 12 months after discharge. The patient is
returned to the operating room, where the
abdominal wall is reconstructed with prosthetic
mesh or by components separation. Of the 20
patients available for follow-up (mean 11 months,
range 3 to 65 months), infection and recurrent
hernias developed in 33% of those reconstructed
with mesh and in 11% of those treated with the
components separation method. Despite these
high complication rates, the authors defend their
staged management approach on the grounds that
these were huge defects that sometimes extended
from xiphoid to pubis.
Tissue Expansion
Several authors have advocated tissue expan-
sion for repair of partial thickness, anterior abdomi-
Fig 13. Above, maximum defect dimension that can be recon-
structed in upper, middle, and lower abdominal area. Separa-
tion of the rectus muscle from the posterior rectus fascia yields
an additional 2 cm of medial muscle advancement. Below,
Separated external oblique and internal oblique muscles. (Re-
printed with permission from Shestak KC, Edington HJD, Johnson
RR: The separation of anatomic components technique for the
reconstruction of massive midline abdominal wall defects:
anatomy, surgical technique, applications, and limitations revis-
ited. Plast Reconstr Surg 105:731, 2000.)
nal wall defects.228-229 In 1989 Byrd and Hobar230
described a technique of tissue expansion of the
musculofascial layer for reconstruction of the
abdominal wall in infants with congenital defects.
Later the authors231 reviewed the anatomic consid-
erations in abdominal wall expansion and report

24

successful use of the technique in an adult with a
posttraumatic defect. Technical details are as fol-
lows:231
The innervation and blood supply of the abdomi-
nal muscles arise from the 7th to 12th intercostal
and 1st lumbar vessels and nerves and travel
between the layers of the internal oblique and
transversus abdominis [muscles]. . . . Bilateral
incisions are made on either side of the hernia, and
dissection is carried between the rectus abdominis
muscle and anterior rectus sheath to the lateral
aspect of the sheath, where the internal oblique
aponeurosis splits into an anterior and a posterior
lamina. A vertical incision is made in the posterior
leaf of the internal oblique aponeurosis to gain
access to the plane between the internal oblique
and transversus abdominis. . . . The pocket is
dissected bluntly and the expander inserted (Fig
14). . . . Expansion is carried out slowly over several
weeks as an outpatient office procedure.
Hobar et al (1994)
Fig 14. Plane of dissection for placement of tissue expanders
between internal oblique and transversus abdominis muscles.
(Reprinted with permission from Hobar PC, Rohrich RJ, Byrd HS:
Abdominal-wall reconstruction with expanded musculofascial
tissue in a posttraumatic defect. Plast Reconstr Surg 94:379,
1994.)
Expansion of the muscular and fascial layers of
the abdominal wall brings autogenous, innervated,
well vascularized, and contractile tissue to the
reconstruction. The technique seems most appli-
cable in cases where the components separation
method would not be sufficient and the use of
mesh would pose an unacceptably high risk of com-
plications. The expansion technique yields excel-
lent color match and contour and minimal morbid-
ity of the donor site.
Jacobsen and colleagues232 modified Hobar and
Byrd’s technique to avoid violating the anterior rec-
tus sheath. They recommend placement of the
expander through a lateral oblique incision extend-
ing across the external oblique muscle. The large
SRPS Volume 9, Number 31
anterior abdominal wall defects were initially grafted
and bilateral expanders were placed and expanded
to large volumes (3000-4000 mL). At the conclu-
sion of expansion it was possible to advance the
medial rectus sheath from either side toward the
center and close the defect directly. Their tech-
nique avoids injury to the neurovascular bundles
of the anterior wall musculature and dissection
through the rectus area, which is often scarred
from prior abdominal procedures in these cases.
Coelho and colleages233 use air insufflation intra-
peritoneally to achieve superficial tissue expansion.
Air is injected through a 19-gauge needle on a 50-
100 mL syringe with a 3-way stopcock. They be-
gan by injecting 500-2000 mL of air at the first
session, gradually increasing the amount daily or
on alternate days for 6 to 15 days. Average vol-
umes insufflated were 7700 mL (range 4500-18,500
mL). Of the 36 patients treated, 30 had direct
closure without tension and 6 had their wounds
closed with polypropylene mesh. Recurrences
occurred in 2 patients and wound infections devel-
oped in 3. The mean follow-up was 10 months.
The concept of vacuum-assisted closure of
abdominal wall defects was introduced by Argenta
and Morykwas.234,235 This proprietary device has
been used in the repair of chronic and acute wounds
in various regions of the body, including abdomi-
nal wall dehiscence and exstrophy. Although not
recommended by the manufacturer for use in
patients with enterocutaneous fistulas (eg, Crohn’s
disease), the device appears to be beneficial in that
setting too.236 Erdmann236 reports a single patient
with a 30-year history of Crohn’s disease and high-
output enterocutaneous fistula which had not
responded to bowel rest and TPN. Recurrent fis-
tula formation after an initial operation presented
them with a very difficult management problem. At
the time of publication the fistula had not closed
completely, but drainage had markedly decreased
and the patient was much improved.
Alloplasts
The strength of the closure in full-thickness losses
of the abdominal wall is often reinforced with syn-
thetic mesh, fascial flaps, or a combination of the
two. Prosthetic material is often an alternative to
autogenous tissue in the acute period. Alternate-
day dressings stimulate granulation over synthetic
25
SRPS Volume 9, Number 31
mesh, and a skin graft is applied for cover.218 An
abdominal wall prosthesis must be: a) noncarcino-
genic; b) sterilizable; c) biologically inert; d) chemi-
cally stable; e) pliable (so as to minimize erosion
into vital structures); f) porous (so as to permit
drainage of exudate); and g) long lasting (with
respect to mesh integrity and strength).218, 237-240
Morris et al240 studied carbon fibers for the repair
of abdominal wall defects in rats. Compared with
Marlex, carbon fibers induce significantly more tis-
sue ingrowth at 6 and 12 months postoperatively.
The authors reported no fragmentation of the
implants nor debris in the regional lymph nodes,
but did not address the potential adherence of car-
bon fibers to bowel structures and viscera.
Voyles et al241 reviewed their experience with
polypropylene mesh (PPM or Marlex) for the
immediate closure of abdominal wall defects. Of
the wounds that were skin grafted (9) or allowed
to heal secondarily (6), mesh extrusion occurred in
all but one. In contrast, when prosthetic mesh was
placed beneath a reconstructive flap (3), there was
no extrusion.
Adloff and Arnaud242 reviewed the management
of large incisional hernias with intraperitoneal poly-
ester fiber mesh (Mersilene) covered by a flap of
anterior rectus sheath in 130 patients. Follow-up
was longer than 3 years in 80% of cases and as
long as 8 years in some, during which time there
were no obstructive complications. Six hernias
recurred (4.5%) from lateral detachment of the
mesh early in their series. The authors believe
Mersilene mesh gives the best results in terms of
tissue tolerance and wound healing.
Bauer et al243 described incisional hernia repair
with e-PTFE in 28 patients, 12 of whom had failed
primary repair. Wound infections developed in 2
patients, one with intercurrent pelvic abscess; both
had intestinal stomas. No complications were noted
related to adhesions or erosion of the patch mate-
rial into the viscera or skin, bowel obstruction, or
fistula formation. The authors believe Gore-Tex Soft
Patch represents an advance in synthetic abdomi-
nal wall substitutes because it elicits little foreign
body reaction, has a low rate of bacterial coloniza-
tion, produces very few adhesions, and supports
fibrous tissue ingrowth.
Van der Lei and colleagues226 report a similarly
favorable clinical experience with Gore-Tex in the
repair of 11 large abdominal wall defects. Brown
26
and colleagues239 evaluated Marlex and Gore-Tex
for abdominal wall reconstruction in experimen-
tally created, contaminated wounds. The authors
found no difference between the materials in terms
of numbers of intraperitoneal bacteria, but Gore-
Tex produced fewer adhesions and was more eas-
ily removed than Marlex in all cases.
Murphy and Freeman245 prefer Gore-Tex over
Marlex when prosthetic material and viscera are in
close proximity. Their study found equal strength
of the repair with either substance in uncontami-
nated abdominal wounds in rats. Law246 compared
prosthetic materials for the repair of experimental
abdominal wall defects and found that wound
strength was the same whether Marlex or Gore-
Tex was used. The fibrous response induced by
polyglycolic acid (PGA or Dexon) was insufficient
to produce a strong enough support for abdomi-
nal wall reconstruction. Because of the different
patterns of collagen infiltration into each material
(dense, irregular, whorled fibers in Marlex vs fine
fibrils in Gore-Tex), Gore-Tex required a larger over-
lap than Marlex to achieve the same strength of
repair.
Hallock and Altobelli247 cite a study by Jenkins248
showing identical bursting strength of full-thickness
abdominal wounds repaired with Marlex, Gore-
Tex, silicone rubber, and polyglactin-910 (Vicryl) at
8 weeks, and proposed the use of Vicryl for sup-
port of the donor defect after a double-pedicle
rectus abdominis flap transposition. One and 2 years
after surgery, there was no bulge or discomfort in
2 patients. Nevertheless, eventual herniation should
be expected following abdominal wall closure with
any absorbable mesh.
Current research focuses on composite meshes
that promote incorporation of the prosthesis into
the abdominal wall without adhering to the intes-
tines.249 In a recent comparison of intraperitoneal
prosthesis for repair of abdominal wall defects in
rats, Pans and Pierard250 noted that a mesh made of
Dacron (Mersilene) coated with Vicryl induced an
excellent fibrotic response to the surrounding fas-
cia. Gore-Tex was too slow to induce fibrosis, and
thus was associated with the lowest wound strength
of all the materials. This delayed fibrotic reaction
was particularly noticeable during the first 2 weeks
of the wound repair process. In terms of fibrosis,
prostheses made of Mersilene alone ranked some-
where between Vicryl-Mersilene and Gore-Tex. In

terms of adhesions, Mersilene was noted to be con-
sistently nonadherent, whereas adhesions to the
omentum were fairly common with Vicryl-
Mersilene and frequent with Gore-Tex.
Meddings et al251 tested a collagen-coated Vicryl
mesh for the repair of defects of the abdominal
wall in rats. After 2 weeks the implant collagen
could not be distinguished from the host collagen,
and at 6 months the wounds had reached 70% of
the control tensile strength. This was attributed to
the increased collagen content of the repair.
In another experimental comparison of Gore-
Tex and Marlex for abdominal wall repair, this time
with specific attention to wound strength, Law and
Ellis252 found that both materials were equally satis-
factory in uninfected wounds. In wounds contami-
nated with Staphylococcus aureus, Gore-Tex cre-
ated a weak interface between the patch and the
abdominal wall fascia that inhibited collagen
ingrowth and weakened the strength of the repair.
In contrast, the wound strength of Marlex repair
was unaffected by the presence of bacterial con-
tamination.
Subsequent reports253,254 confirm poor ingrowth
of fibrocartilaginous tissue into expanded Gore-
Tex patches used to close abdominal wounds. Fre-
quent wound infection (16/21) and recurrent her-
niation (14/21) made Gore-Tex unsuitable for
abdominal wall repair, particularly in contaminated
wounds. Prolene mesh was suggested as an option
for the reconstruction.
Dayton and colleagues255 report their experience
with absorbable Dexon mesh for the closure of
contaminated abdominal wall defects. Of 8 patients
treated, 4 had direct wound approximation over
the absorbable mesh and 4 had packing of their
wounds and subsequent skin grafting. During a
postoperative observation period of 3-18 months,
6 patients developed hernias despite a healed
wound. Clearly, mesh should not be used in an
infected wound.
In small- to moderate-size defects, the most
appropriate option for repair seems to be either
the components separation technique or its fascial
partition/release modification. In large contami-
nated wounds, where closure of the defect is a
primary concern because of sepsis and protein loss,
Dexon mesh may play a role, but only in the short
term. Definitive wound repair with permanent mesh
SRPS Volume 9, Number 31
implantation is more likely to succeed after the in-
fection has resolved.
Stoppa256 describes treatment of large, compli-
cated groin and incisional hernias prone to recur-
rence by prosthetic material placed in a retroparietal,
preperitoneal position. The key to his technique is
the ample size of the patch material. In large
incisional hernias he frequently uses progressive
preoperative pneumoperitoneum, which enlarges
the abdomen and decreases the risk of postop
respiratory distress. The pneumoperitoneum also
facilitates intraoperative dissection of adhesions and
aids in diaphragmatic function by producing a higher
intraabdominal pressure. Stoppa believes respira-
tory preparation in these patients is essential to the
success of a repair. Technical features of his
operation include a subumbilical medial approach
and placement of the mesh material preperitoneally
behind the deep fascia (Fig 15). The mesh is held
in place by sutures and abdominal pressure.
Fasciocutaneous Flaps
The advantage of fasciocutaneous flaps in
abdominal wall reconstruction is the ability to
restore structural stability and cutaneous cover with
autogenous tissue in a single operation. Unlike
reconstruction with muscle flaps, the integrity and
contour of the abdomen are unimpaired.
As early as 1934, Wangensteen257 used long
pedicled flaps of fascia lata to repair large or recur-
rent abdominal hernias. Subsequent reports showed
no wound breakdown, abdominal wall weakness,
or donor site problems.258,259 Others260 prefer the
use of fascia lata as a source of onlay grafts for
abdominal hernia repair. In 1981 Ponten 261
described two true fasciocutaneous flaps in lower
leg reconstruction, then 2 years later Tolhurst and
colleagues262 expanded the use of fasciocutaneous
flaps to the chest and abdomen. Deep subcutane-
ous fascia is carried with the flap to augment the
vascularity of the overlying skin (Fig 16).
Iwahira et al98 report using two simultaneous
fasciocutaneous flaps based on the superior and
inferior epigastric perforators to close a massive
defect of the abdominal wall resulting from exci-
sion of recurrent tumor. Terashi and associates263
report using a groin flap, a tensor fascia lata flap,
and an anterolateral thigh adipofascial flap for
reconstruction of a wide lower abdominal wall
27
SRPS Volume 9, Number 31

Fig 15A. Retroparietal preperitoneal prosthesis for subumbilical median elevation. (Reprinted with permission from Stoppa RE: The
treatment of complicated groin and incisional hernias. World J Surg 13:545, 1989.)

Fig 15B. Prosthesis between the rectus abdominis muscle and its posterior sheath for supraumbilical median eventration. (Reprinted
with permission from Stoppa RE: The treatment of complicated groin and incisional hernias. World J Surg 13:545, 1989.)

28

Fig 16. Blood supply of deep fascia:
(1) perforating arteries, (2) subcuta-
neous arteries, and (3) subfascial
arteries. (Reprinted with permission
from Tolhurst D, Haeseker B, Zeeman
RJ: The development of the fascio-
cutaneous flap and its clinical appli-
cation. Plast Reconstr Surg 71:597,
1983.)
wound in a single patient. The result was satisfac-
tory.
Kimata and coworkers264 used a free or pedicled
anterolateral thigh flap based on perforators from
the lateral circumflex femoral artery in 7 patients.
The flap’s pivot point is approximately 2 cm below
the inguinal ligament on the femoral artery. The
cutaneous territory of the anterolateral thigh flap
extends from the level of the greater trochanter
to just above the patella, and may encompass half
the surface area of the thigh. It includes the ili-
otibial tract but not the tensor fascia lata muscle.
The island flap and its vascular pedicle are passed
underneath the rectus femoris and sartorius
muscles to reach the anterior abdominal wall
defects. Defects up to 20 x 20 cm were so
repaired, and the pedicled thigh flap reached as
high as 8 cm above the umbilicus. To resurface
larger wounds, the thigh tissue was transferred as
a free flap.
Still et al265 report using a massive pedicled flap
from the back to cover the anterior abdominal wall
in a patient with severe burns. As initial manage-
ment they covered the bowel with Gore-Tex placed
deep to the peritoneal membrane and covered the
peritoneal membrane with a split-thickness skin graft.
Tissue expanders were placed in the back to cre-
ate a large posterior flap, which was eventually
transferred to the abdominal wall. The skin graft
was removed at that time.
SRPS Volume 9, Number 31
Matloub and coworkers266 evaluated the use of
Marlex mesh, Gore-Tex, and autogenous fascia for
abdominal wall reconstruction in a rat model. One
year after implantation, the materials were removed
and tensile strength of the repair and rate of adhe-
sions were measured. There was no change in
tensile strength of any material with time, and both
synthetic materials were stronger than autogenous
fascia. Suture line tensile strength was greater for
autogenous fascia and Marlex mesh than for Gore-
Tex. Marlex mesh was associated with the greatest
number of adhesions. The authors concluded that
autogenous fascia was the material of choice
because it showed virtually no adhesions and good
suture line strength. While it was the weakest of
the three materials examined, the strength was still
within the normal range and adequate for abdomi-
nal wall reconstruction.266
Musculocutaneous Flaps
Rectus abdominis
The contralateral or ipsilateral rectus abdominis
musculocutaneous flap may be transferred in either
a superior or inferior pedicle for abdominal recon-
struction as dictated by the location of the
defect267,268 (Fig 17). When the flap is based supe-
riorly, care must be taken to preserve the superfi-
29
SRPS Volume 9, Number 31
cial epigastric vessels during dissection. Based
inferiorly, the flap is supplied by the deep inferior
epigastric vessels85,269,270 and has a wide arc of rota-
tion that lends itself quite well to reconstruction of
the lower abdomen, groin, and perineum.
Fig 17. Arc of rotation of the rectus abdominis musculocuta-
neous flap based superiorly (left) and inferiorly (right). (Re-
printed with permission from Bostwick J III, Hill HL, Nahai F:
Repairs in the lower abdomen, groin, or perineum with
myocutaneous or omental flaps. Plast Reconstr Surg 63:186,
1979.)
Lineaweaver and colleagues271 extend the flap’s
reach by passing the inferior rectus island over the
transversalis fascia to the posterior pelvic rim. This
maneuver necessitates pre- and retroperitoneal tun-
neling as well as a V-shaped wedge of the iliac
crest.
The rectus muscle can also be used as a turn-
over flap, incorporating the anterior rectus sheath
along with the rectus muscle, which is extensively
mobilized and then turned over bilaterally. Mesh is
placed on the superficial side of the muscle to rein-
force the closure and prevent adhesions. DeFranzo
and colleagues 272 report successful repair of
abdominal wall hernias in 15 patients using rectus
turnover flaps.
Weakness of the lower abdominal wall after rec-
tus muscle transposition has been addressed by
various authors. Kroll273 describes two techniques
for preserving the midline fascia when raising double
pedicled TRAM flaps. The more appealing method
approaches the midline fascia from inside the rec-
30
tus sheath underneath the muscle. Flap dissection
on one side proceeds along the posterior rectus
sheath from lateral to medial borders of the muscle,
sparing as much of the lateral fascia as possible.
The muscle is separated from its bed up to the
medial border of the sheath. At this point the dis-
section continues in retrograde fashion from medial
to lateral until the medial perforators of the muscles
are met. The midline fascia is incised just medial to
these perforators, leaving as much fascia as pos-
sible attached to the linea alba medially. On the
opposite side, dissection is carried from medial to
lateral until the medial perforators are located, and
the midline fascia is incised just medial to them.
From this point onward the flap is elevated in stan-
dard fashion. The technique harvests only a strip of
fascia attached to muscle through which perfora-
tors travel to the skin paddle. All of Kroll’s patients
had direct approximation of the fascia without mesh.
Other authors routinely employ mesh in abdomi-
nal wall repair. Drever and Hodson-Walker274
believe that the key to closure of the fascial defect
is to replace the same area of anterior rectus fascia
(tendons of both obliques and transversalis muscles)
as is removed when the rectus abdominis flap is
harvested. This replacement is done with a sheet
of double Mersilene mesh extending up to the
costal margin and as wide as the fascia taken with
the muscle pedicle. In their series, fascial
reapproximation without mesh reinforcement
resulted in weakness, bulging, or frank hernia in
43% of patients. In contrast, only 4% of wounds
closed with Mersilene mesh developed bulging
postoperatively.
Hartrampf275 writes that the technique of rectus
muscle harvest itself determines the likelihood of
abdominal wall complications. Three supporting
structures are all important: the two linea semilunaris
ligaments and the linea alba. The full width of rec-
tus muscle and sheath should never be taken below
the lowest transverse tendinous inscription, for with-
out this fixation point, the remaining muscle retracts
toward the pubis and starts the erosion that leads
to lower abdominal weakness and herniation.275
Hartrampf finds the use of mesh necessary in only
25% of bipedicled flap repairs.
Spear and Walker276 used an external oblique
flap for reconstruction of the rectus sheath in 33
patients who had undergone double pedicled
TRAM flap for breast reconstruction. All wounds

were closed primarily. If there was evidence of
excessive tension, external oblique flaps were used
to reinforce the closure. Bilateral relaxing inci-
sions made into the external oblique fascia
extended for up to 12 cm, coursing in the direc-
tion of the muscle fibers, to allow superomedial
advancement of the external oblique muscle.
Mesh was needed in 7/33 patients whose clo-
sure appeared too tight. Uneventful healing with
normal abdominal wall strength was documented
in 32/33 patients.
Latissimus dorsi
Houston and colleagues277 describe the use of
an extended latissimus dorsi flap for the repair of
abdominal wall defects. The standard latissimus dorsi
flap was enhanced by inclusion of the thoracolum-
bar and gluteal fascia, which increased the flap’s
arc of rotation to cover ipsilateral upper and mid-
line abdominal defects and to cross the midline.
Their patients healed without evidence of lumbar
hernia.
Tensor fascia lata
Potential advantages of extraabdominal muscles
in abdominal wall reconstruction are that they 1)
produce a dynamic repair, 2) avoid herniation, 3)
relieve scoliosis resulting from previous muscle
loss, and 4) assist in the expulsive effort of bowel
movements.278 As a musculocutaneous flap, the
tensor fascia lata is appealing because of its reli-
able blood supply, large size, strength, and ease
of dissection.278-281 The tensor fascia lata has also
been transferred as a free flap for abdominal wall
repair.282-284
Silberman, Elliott and Hoffman285 lengthened
the reach of tensor fascia lata and rectus femoris
musculocutaneous flaps by including the sur-
rounding fascia. This modification allowed them
to cover defects in the upper quadrants of the
abdomen. Although dye injection studies in a
fresh cadaver showed adequate perivascular fill-
ing, partial flap loss was noted in 2 patients, both
of whom required subsequent split-thickness skin
grafts.
The tensor fascia lata is often used in conjunc-
tion with other flaps for coverage of the abdominal
wall, and can be used, of course, bilaterally.
SRPS Volume 9, Number 31
Rectus femoris
Ger and Duboys278 prefer the rectus femoris
muscle flap for closure of abdominal wall defects
because of its free medial and lateral borders
and ease or harvest. They extended flap reach
by turning the muscle over instead of rotating it.
In a discussion of this paper, Nahai286 agrees that
there is minimal, if any, resultant defect following
transposition of the rectus femoris muscle as long
as the remaining distal tendinous portion is
secured to the vastus lateralis. Nahai prefers the
tensor fascia lata to the rectus femoris because
of the large amount of fascia available with the
TFL.
Brown and associates287 report two cases of near
total abdominal wall reconstruction with bilateral
rectus femoris musculocutaneous flaps with
fasciocutaneous extensions of the superficial thigh,
fascia, and skin. There was loss of skin over the
fascial extension in one patient. The authors found
the extended rectus femoris flap to be reliable and
versatile, and its donor defect to be of little func-
tional significance.
Caulfield and colleagues288 assessed donor leg
strength after unilateral rectus femoris muscle flap
transfer in 7 patients. Comparing the donor knee
to the normal side during flexion, they found 24%
to 28% loss of strength on the operated side. Only
one patient required physical therapy to regain
presurgical strength.
Gracilis
Bostwick and associates268 describe and illustrate
the arc of rotation of the gracilis musculocutane-
ous flap. This flap may be indicated for limited
coverage of lower abdominal and perineal wounds.
Miscellaneous Flaps
Other flaps from the torso that can be applied to
abdominal wall reconstruction are the groin flap
described by Bogart, Rowe, and Parsons. 289
Although limited to lower abdominal wall defects,
the groin flap has the potential for primary closure
of the donor site.
Little and coworkers290 report use of an upper
quadrant flap similar to the intercostal flap.95 Despite
the small skin paddle, the upper quadrant flap is
useful because it is a sensory flap.
31
SRPS Volume 9, Number 31
Free Flaps
A lack of adequate recipient vessels may be a
problem in free flap reconstruction of the abdomi-
nal wall. Earle, Feng, and Jordan291 create an A-V
loop with the long saphenous vein to reach the
xiphoid superiorly and the sacrum posteriorly. Ten-
sor fascia lata can be transferred as a free flap for
total abdominal wall reconstruction. Recipient ves-
sels may be the superior epigastric artery or the
gastroepiploic vessels from the greater omen-
tum.292-295 Advantages of the free flap technique
include a wide arc of rotation and improved perfu-
sion of the distal flap. Transferred as a free flap, the
tensor fascia lata can reach to above the umbilicus.
In addition, the flap can be oriented transversely to
increase tensile strength of the repair, which is not
possible with the pedicled TFL flap.283,284
Omentum
The omentum is highly regarded in the repair of
abdominal wall defects because of its size (approxi-
mately 25 x 35 cm) and its capacity for further
lengthening.296 Skin grafting over the omentum pro-
vides durable cutaneous cover but little abdominal
wall strength.
ABDOMEN — CONGENITAL
DEFECTS
The abdominal wall is formed by four separate
embryologic folds, one cephalic, one caudal, and
right and left lateral folds. These structures are
covered by an outer layer of amnion, and the entire
unit comprises the umbilical cord. Between the 5th
and 10th weeks of fetal development, the intestinal
tract undergoes rapid growth outside the abdomi-
nal cavity within the proximal portion of the umbili-
cal cord. As development nears its end, the intes-
tine gradually returns to the abdominal cavity, and
contraction of the umbilical ring completes the pro-
cess of abdominal wall formation. Failure of clo-
sure of any segment results in a congenital defect
of the anterior abdominal wall.297
The vast majority of congenital deformities of
the abdominal wall fall into one of four categories:
1) diaphragmatic hernias; 2) umbilical hernias; 3)
32
omphaloceles; or 4) gastroschisis. By means of ul-
trasound, prenatal diagnosis of congential abdomi-
nal wall defects is possible in approximately 60% of
patients. This figure would be higher were it not
that ultrasonic techniques are very technician
dependent.298
Diaphragmatic Hernias
With the increasing use of extracorporeal mem-
brane oxygenation (ECMO), a number of infants
with partial and even total agenesis of the diaphragm
are now able to survive who would have perished
in the past. Diaphragmatic defects too large to
repair primarily require the use of either an autog-
enous or synthetic prosthesis.299 Muscle flaps300,301
are technically demanding and risk perioperative
bleeding, since many of these infants require ECMO
with systemic anticoagulation. Alloplastic mesh and
patches, on the other hand, have no capacity for
growth, and may lead to deformity of the chest as
the child grows and the thorax is tethered.
Lally, Cheu, and Vazquez299 compared absorb-
able versus nonabsorbable materials as a diaphrag-
matic substitute in growing rats. The study animals
had resection of the left hemidiaphragm and
reconstruction with oxidized cellulose, polyglactin
mesh, or Gore-Tex patch. Weekly PA chest radio-
graphs were taken until the animals weighed 400
g, at which time they were killed and necropsies
performed. Eventration was common in the
polyglactin group. Both cellulose and polyglactin
led to some chest deformity, but this was not sig-
nificantly different from controls. In contrast, 50%
of rats in the e-PTFE group had considerable rib
deformity and smaller thoraces, a significant differ-
ence. All e-PTFE patches had pulled away from the
ribs at the time of necropsies. The authors con-
clude that none of the materials studied are ideal
diaphragmatic substitutes, and suggest using a nar-
row-mesh absorbable prosthesis initially, followed
by a muscle flap as the infant grows.
The chest wall deformities seen in rats correlate
with those in humans, as reported by Vanamo and
coauthors.302 They describe the outcome of 164
patients operated on between 1948 and 1980 who
survived diaphragmatic hernia repair as infants.
Chest asymmetry was present in 48%, pectus
excavatum in 18%, and one (0.6%) had pectus
carinatum. Significant scoliosis was also noted in

27% of patients. The authors recommend long-
term surveillance in these cases.
Atkinson and Poon303 report using ECMO in the
management of large, severe congenital diaphrag-
matic hernias. Historically, mortality was extremely
high when arterial pH was <7, decreasing only to
50% with pH of 7-7.2.304 With the use of ECMO,
survival rose to 83%. Most patients were repaired
with silicone mesh and less commonly with Marlex
mesh or Gore-Tex. Reherniation was common in
patients who required patch repair.
Wung et al305 challenged the concept that a dia-
phragmatic hernia should be repaired as soon as
the diagnosis is made. They prefer to stabilize the
patient with ECMO and nasal intubation; no chest
tube. Infants who had corrective surgery no ear-
lier than 100 hours after birth had a 94% survival
rate, compared with 82% survival when the child
was operated on 6 hours after birth.
Umbilical Hernias
Failure of closure of the umbilical ring at the
appropriate time in the embryologic sequence
leaves a central defect in the linea alba. Small (<1
cm) umbilical hernias usually close spontaneously
by age 1 to 2 years. Larger defects may require
longer times to close on their own, or may be
surgically repaired after the age of 2 if persistent.
The hernia is approached through a small, curving,
infraumbilical incision parallel to the relaxed skin
tension lines, and the fascial defect is repaired with
permanent sutures. Bowel incarceration is rare.
Omphaloceles
An omphalocele represents a perpetuation of
the existing intrauterine defect connecting the mid-
gut to the yolk sac. Omphaloceles are usually >4
cm in diameter and frequently contain liver and
midgut as well as a hernia sac. Emergency treat-
ment of affected infants aims at resuscitation and
stabilization by establishing lines for intravenous
hyperalimentation. Surgical intervention is indicated
when the patient is receiving adequate nutrition
and developing normally.
Traditional methods of repair involve fascial clo-
sure and undermining of abdominal skin to allow
skin approximation. If fascial closure is not pos-
sible, such as in defects 6 cm or larger, Teflon or
SRPS Volume 9, Number 31
silicone mesh is sutured to the margins of the fascial
defect to reduce postoperative respiratory prob-
lems and to accommodate subsequent growth and
enlargement of the abdominal wall.306 The alloplast
is removed at a later time for definitive reconstruc-
tion. In these large omphaloceles, a silastic silo can
be created where material is sutured around the
periphery of the defect to allow temporary hernia-
tion of the intestines and liver into the silo, which is
then closed at its apex. Over a period of days, the
silo is twisted from the top to gently push the
abdominal contents back into the abdominal cav-
ity. After 3 to 4 days, the silo is removed in a
second procedure.307
Analysis of the combined data on omphaloceles
from 11 large clinics308 reveals a 67% incidence of
anomalies, including cloacal exstrophy and
Beckwith-Wiedeman syndrome. Byrd and Hobar230
outline a technique of tissue expansion developed
to treat congenital absence of the lower abdomi-
nal musculature in children with cloacal exstrophy.
A single expander is placed between the musculo-
fascial layers of the abdomen anterior to the recti
and between the internal oblique and transversus
abdominis muscles. The authors report a 200%
increase in the outer layer of muscle and fascia
(both oblique muscles) and approximately 50%
increase in the inner layer (transversus abdominis
muscle, transversalis fascia, and peritoneum). The
histologic changes brought about by tissue expan-
sion—eg, thinning of the muscle and abnormal
arrangement of the sarcomeres309—were not evi-
dent after 2 years.
The prune belly syndrome is a rare abnormality
that consists of congenital hypoplasia or aplasia of
the abdominal musculature with marked wrinkling
of the skin over the lower part of the abdomen.
The condition is largely confined to male infants
and is associated with cryptorchidism, an enlarged
bladder, dilated and tortuous ureters, and hypo-
plastic kidneys. Appropriate management involves
temporary ureter revision followed by staged
reconstruction.
Ehrlich, Lesavoy, and Fine310 delay surgery until
after the first year of life, but stress the need for
early abdominal wall reconstruction to enable nor-
mal psychosocial growth of the patients. Surgical
correction involves dissection of the muscle fascia
remnants to the midaxillary line, followed by medial
advancement and overlapping in a double-breasted
33
SRPS Volume 9, Number 31
fashion. The double thickness fascia is closed and
the excess skin and subcutaneous tissues are
excised via the midline incision. The abdominal
wall reconstruction is performed simultaneously
with bilateral cryptorchidopexy and GU reconstruc-
tion.
Gastroschisis
Gastroschisis represents a congenital defect of
the abdominal wall to the right of the normal loca-
tion of the umbilical cord that permits escape of
the intestines from the abdominal cavity. The intes-
tines are edematous and matted, indicating the
loops have been floating freely in the amnion for
some time. Treatment is as in omphalocele, except
that prompt return of the intestines to the abdomi-
nal cavity is indicated, together with secure abdomi-
nal closure by primary suture.
Spina Bifida
Spina bifida denotes incomplete fusion of the
vertebrae dorsally. The overall incidence of spina
bifida is 1 in 800 live births. The etiology is unknown,
but parents of an affected child are at much higher
risk of having subsequent children with the defor-
mity (1 in 25).
Spina bifida may be of the occulta or cystica
type311 according to the severity of associated symp-
toms. Spina bifida occulta commonly goes undiag-
nosed, for it has no outward manifestations. It is
generally found incidentally on x-ray examination
of the adult patient. Vertebral involvement is often
limited to one vertebra in the lumbar or sacral
region. Neurologic abnormalities are rare. Cuta-
neous changes sometimes overlie the bony defor-
mity and range from skin atrophy to nevoid in-
volvement or a hairy patch.
Spina bifida cystica includes four variants, all of
which have the clinical expression of a cystic struc-
ture overlying the bony and neural defects:
Meningocele is a relatively benign form of spina
bifida cystica, comprising 14% of all cases. There is
no neurologic deficit, only meninges in the cystic
herniation. There is an atrophic cutaneous cover-
ing that ruptures readily, leading to CNS contami-
nation.
Meningomyelocele is the most common vari-
ant. It has a neural element consisting of spinal
34
nerve, cauda equina, or spinal cord within the
meninges-lined cystic structure. The tenuous cuta-
neous covering is easily damaged. There is usually
some degree of motor and sensory deficit, fre-
quently including the bladder and rectal sphincters.
Associated hydrocephalus is present in 50% of
cases.
Syringomyelocele is a rare form of spina bifida
cystica that differs from the more frequent menin-
gomyelocele only in that there is dilatation of the
central canal of the cord.
Myelocele is characterized by an open central
nervous system without any bony, meningeal, or
cutaneous covering. Epithelialization is sometimes
possible when neonates are given appropriate
antibiotics and wound therapy.
Neurologic evaluation to include ventriculog-
raphy helps in differentiating among the variants
and identifying the salvageable cases. When the
neural elements have intact epithelial covering, as
is the case in all the variants except myelocele,
there is no need for early emergency surgery.
The tenuous skin over the cystic mass is easily
rent, however, and cord contamination has omi-
nous consequences, so reconstruction with a
stable, sturdy, and well-vascularized cover is indi-
cated to prevent epithelial tears and subsequent
infection as well as to preserve any existing func-
tional neural tissue.312
The surgical team should consist of a neurosur-
geon and a plastic surgeon. Care should be taken
to safeguard all neural elements before closing or
imbricating the meninges.313 Cutaneous coverage
of small defects can be accomplished with simple
rotation or interposition flaps. In large defects, the
ambulatory status of the patient should be consid-
ered when selecting a procedure for the recon-
struction—eg, sacrifice of the latissimus dorsi
muscle(s) may be contraindicated in paraplegic
patients who rely on their upper shoulder muscula-
ture for getting about.
Luce and Walsh314 trace their experience with
myelomeningocele correction. They abandoned
wide undermining and skin advancement early in
the series because of frequent wound breakdown.
Latissimus dorsi muscle closure was associated with
longer operative times and increased blood loss,
and was likewise discarded after a few trials. In
their last 32 patients, the authors performed imme-
diate dural closure overlaid by skin graft, and report

good graft take and a low incidence of CSF leak or
sepsis.
DesPrez et al313 recommend bilateral flaps of
skin, muscle, and bone based on the sacrospinalis
muscles and extending vertically on either side of
the defect to incorporate the bifid spinous pro-
cesses.
McCraw and colleagues70 as well as Stevenson
et al122 have advanced bilateral latissimus dorsi mus-
culocutaneous flaps based on their distal perfora-
tors to cover a spinal defect. The lumbar fascia
overlying the intercostal perforators is incised to
allow medial advancement of the flap when repair-
ing deficits of the posterior midline. Unfortunately,
this approach suffers from having the suture line
over the original defect. Moore et al315 used bilat-
eral bipedicled LDM flaps and skin-grafted the flap
donor sites.
Blaiklock and associates316 rotated bilateral LDM
flaps on their thoracodorsal vascular pedicles and
successfully covered spina bifida defects as low as
L-4, while placing the scar away from the original
defect. Subsequently Ramirez and associates317
described successful repair of lumbosacral
meningomyeloceles by en bloc advancement of
bilateral latissimus dorsi and gluteus maximus mus-
culocutaneous flaps. The neurovascular supplies
to the flaps are not altered, but rather the muscle
origins are redefined. The muscles as well as the
intervening fascia are elevated as a unit and
advanced medially to be sutured in three layers
over the midline defect. No skin grafts or relaxing
incisions are needed for closure.
Important technical points during the procedure
are 1) no undermining of the skin during the initial
neurosurgical closure, and 2) taking care to pro-
tect the retroperitoneal structures during lateral dis-
section, because the quadratus lumborum muscle
is poorly developed in infants. The average opera-
tive time in their series of 9 large meningo-
myeloceles was 1½ hours. Blood loss was
approximately 20 mL, and no drains were neces-
sary. No complications ensued. Flap vascularity
was confirmed clinically as well as by injection stud-
ies in cadavers.
Mustoe, Gifford, and Lach318 describe rapid skin
expansion in 2 patients undergoing spinal fusion
for correction of kyphoscoliosis secondary to
myelomeningocele. Expansion in the first patient
was carried out over 2½ weeks and resulted in
SRPS Volume 9, Number 31
partial necrosis of the expanded skin. In the sec-
ond patient expansion was more gradual over a
period of 3½ weeks, and the injections were halted
when a pressure of 40 cm of water was reached.
The authors state that rapid tissue expansion in a
carefully controlled setting can achieve satisfactory
skin coverage without unduly lengthening hospital-
ization.
Jaworski and coauthors319 close large defects in
30 infants with lower latissimus dorsi musculocuta-
neous flaps. The skin incision was designed like a
rhomboid with a superior pedicle. The authors list
the following advantages of this method: 1) it allows
effective closure of large defects in myelo-
meningocele cases; 2) the covering flap is of nor-
mal vitality; 3) the flap covers the spine and dura
very satisfactorily; and 4) there is little tendency to
develop pressure sores at a later date.
Ultimately, the reconstruction of these tragic
defects may fall to future surgeons approaching
the problem in utero. In utero coverage might
spare deterioration of the exposed spinal cord dur-
ing the pregnancy. Meuli-Simmen et al320 experi-
mented with lumbar myelomeningocele in sheep.
On day 25 after the surgical insult, the spinal defect
was covered with a reverse latissimus dorsi flap.
The surviving experimental subjects had normal
hind-limb function.
The role of tissue expansion in the treatment of
myelomeningocele is controversial. Implantation
of a foreign body into an open wound should
always be approached with caution, but particularly
so in an already compromised infant population
where the risk of infection and meningitis is ever-
present and would have disastrous consequences.
Tissue expansion has an advantage over flap meth-
ods using upper back and anterior chest muscles
that are of critical importance to future mobility of
wheelchair-bound patients, but one must question
the safety of a 3- to 4-week delay in closing many
of these complicated meningocele wounds. In a
setting where the wounds are not acute or have
been previously closed, however, tissue expansion
may be a reasonable approach.
CARDIOMYOPLASTY
One of the most innovative applications of muscle
flaps in recent years has been the development of
the “dynamic cardiomyoplasty” procedure. The
35
SRPS Volume 9, Number 31
gist of the technique is to replace damaged heart
muscle with stimulated skeletal muscle—in this in-
stance, latissimus dorsi.321 The first successful clini-
cal case was performed in Paris in 1985 and in-
volved a 37-year-old man with severe right and left
cardiac insufficiency. The patient was found to
have a large tumor that involved both ventricles
and invaded the diaphragm. The extensive fibroma
was resected and the cardiac muscle was replaced
with latissimus dorsi muscle.
Since this original report, various refinements in
the cardiomyoplasty technique and measures to
enhance the extramyocardial collateral blood flow
have been described. To reduce fibrosis of the
distal end of the LDM and improve its function
after transfer, the muscle can be chronically stimu-
lated. 322 Mannion and colleagues 323 report
increased latissimus-derived collateral blood flow
after cardiomyoplasty when the transferred muscle
was electrically stimulated. Heparin infusion, on
the other hand, fails to enhance collateral blood
flow. In another experiment, Mannion et al324 found
36
that LDMs conditioned by continuous electric stimu-
lation were more resistant to fatigue, even though
blood flow during stimulation was lower than in
nonconditioned control muscle.
Chiu325 describes and illustrates the modern tech-
nique of dynamic cardiomyoplasty (Fig 18).
Acker326 believes dynamic cardiomyoplasty is at
the crossroads. In a meta-analysis encompassing
600 patients, he notes that 80% to 85% of survi-
vors showed improvement in New York Heart
Association Class. Over the course of the studies
included in his review, operative mortality decreased
from 31% to 3%. Future modifications of the tech-
nique to include preoperative tissue expansion of
the latissimus dorsi and simultaneous pacemaker
implantation to prepare the muscle for transfer
might enhance the results—that is, generate more
forceful muscular action early in the immediate
postoperative period and prevent fibrosis of the
distal muscle. The jury is out on this procedure, but
it may well be an option in lieu of cardiac transplan-
tation for severely debilitated patients.
 SRPS Volume 9, Number 31

Fig 18. Surgical technique of left latissimus dorsi muscle for dynamic cardioplasty. (Reprinted with permission from Chiu RC-J:
Cardiomyoplasty. In: Edmunds LH Jr, Cardiac Surgery in the Adult. New York, McGraw-Hill, 1997. Ch 52, pp 1491-1504.)

37
SRPS Volume 9, Number 31
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SRPS Volume 9, Number 31
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SRPS Volume 9, Number 31

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