The 4 Principles of Complex Abdominal Wall Reconstruction

Abstract

Abdominal wall defects are some of the most common and challenging problems encountered by plastic surgeons. A high proportion of patients with abdominal wall defects have significant comorbidities and/or contamination, putting them at high risk for complications. In addition to advanced surgical skills and precise anatomical knowledge, the plastic surgeon needs strict discipline and medical acumen, to optimize patients before and after surgery. In this paper, we discuss the goals of abdominal wall reconstruction, and the 4 steps to successful surgery: preoperative patient selection/optimization, durable and dynamic reconstruction of the musculofascial layer, careful attention to the skin and subcutaneous tissue, and meticulous postoperative management.

Fig. 1.

Technique for Mercedes modification of the fleur-de-lis panniculectomy. A, In a patient with a large overhanging pannus and a hernia, skin excision in a vertical and a horizontal direction is needed to eliminate poorly vascularized and undermined skin. B, The Mercedes modification of the fleur-de-lis pattern improves outcomes by making the tips of the upper triangular flaps obtuse with improved perfusion. C, The T-junction is located more cranial than a classic fleur-de-lis panniculectomy, outside the pubic area, allowing for a more hygienic healing environment.