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The Problem of Acquired Abdominal Wall Defects Or Contour Disturbances

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Acquired abdominal wall defects or contour disturbances may develop due to traumas, soft tissue infections, previous surgical interventions, ablative tumor resections, burns, or radiation damages. Improvements in drug technology and surgical intensive care techniques have increased the rate of encounter with patients with abdominal wall defects.One should consider that the size, location, and depth of the defect and associated problems undertake a guidance role while selecting the repair method of abdominal wall defect or contour irregularities. While in cases where the defect is greater than 15cm in size, tissue expansion or free tissue transfer is a proper choice, primary closure, local flaps or skin grafting is a favorable treatment option for the defects which are smaller than this size. Catastrophic abdominal appearance due to abdominal wall defects or abdominal wall scarring can be repaired with local abdominal flaps, tissue expansion, or abdominoplasty.

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Abdomen, is an area of the body which is located between the thorax and pelvis. It ranges from the xiphoid-costal border to the symphysis pubis, inguinal ligament, and iliac crest inferiorly, lengthens the lumbar paravertebral muscles posteriorly. The abdominal wall primarily consists of musculotendinous structure between skin-subcutaneous tissues, and the endoabdominal fascia- parietal peritoneum. It folds up the abdomen from the vertebral column posteriorly to the linea alba anteriorly

(1).Abdominal wall is a barrier for internal organs, backing the spine, contributes preserving an upright posture, aids urination, coughing or defecation so that the integrity of this structure is crucial for the body

(2).Restoration of the structural and functional support of the musculofascial portion of the abdominal wall and providing stable wound coverage with best cosmetic result and minimal morbidity are the reconstructive goals of these defects.

Abdominal wall defects must be repaired according to size, depth, and location of the defects. Every patient should be evaluated individually. They need appropriate and well-planned managements. Plastic surgeons are increasingly involved to manage or assist in managing these defects and to provide direct closure or reconstruct the defect using a series of time-honored and newly developed techniques

The difficulty of bending back and forth, the distended view of the abdomen, the scars on the abdominal wall and the disturbing appearance of the abdomen wall were the main complaints of the patients.A 23×37 cm full-thickness defect covered by a thin layer of epithelium was detected on the anterior wall of the abdomen in the one of the male patient, who underwent exploratory laparotomy due to perforated appendicitis with intraabdominal abscess. Therefore, he developed intraperitoneal sepsis after surgery, he was reoperated for preventing abdominal compartment syndrome and followed by lavages and drainage of the peritoneal cavity and left with “open abdomen that was allowed to granulate.

Six cases with perforated appendicitis were found to have retraction in the abdominal wall and hypertrophic scars causing deterioration of the contour of the abdominal wall.A male with perforated appendicitis and liver abscesses had incisional hernia and multiple scars on the abdominal wall.A female with an history of flame burn injury of back, right gluteal area, right lower abdomen, and right inguinal area 50 years ago had ulcerations on the burn scars, burn scar contracture affecting her right limb movement, and distorted view of the right lower abdomen and right inguinal area.A female who underwent wide burn scar contracture release and free DIEP application due to left leg flexion contracture had developed abdominal wall necrosis because of the position given to protect applied flap. Necrotic part of the abdominal wall excised, open wound was followed-up with dressings and after granulation defective area was grafted but by the time she had contour disturbances on the lower part of the abdominal wall.

In fifteen cases, abdominal wall contour disturbances were present in various regions of the abdominal wall, due to incisional herniation secondary to appendectomy, cholecystectomy, obesity surgery, and cesarean section.Two rectangular tissue expanders of 2000 ml volume were positioned in the subcutaneous pockets which are formed on top of the anterior rectus sheat and adjoint to the granulated abdominal wound region bilaterally to reconstruct 23×37 cm sized defect after ten months later to the male patient who left with “open abdomen. After four months, the over-expanded tissue expanders were removed, fascial defect was repaired using prosthetic mesh, enlarged skin flaps were advanced towards the mid line and covered up in layers without tightness. A more acceptable midline scar and abdominal wall contour were obtained. Demonstrated no mesh infection or extrusion signs, did not develop ulceration, enteric fistula or recurrent hernia.

In six cases, during scar tissue excision it was seen that the abdominal wall skin adhered to the peritoneum. After peritoneal repair and proper abdominal wall repair was performed by closing the wound according to the layers, local flaps were used for eliminating contour disturbances.In one case, incisional hernia was reduced by using old midline incision on the abdomen wall, fascial defect was repaired using prosthetic mesh, and scar excisions were performed to improve the contour and appearance of the abdominal wall.In fifteen consecutive cases, abdominal wall contour disturbances were corrected by classical abdominoplasty by following reduction of the hernias present in various parts of the abdominal wall and fascial reinforcements with prosthetic mesh placement.Minor wound detachements that were healed by dressings were detected in three cases, minor skin necrosis on just above the pubic region that was treated by debridement and primary suture was revealed in one case. Other patients healed without any problems.

The increase of the number of patients with structurally complex abdominal wall defects are attributed to the increasing rates of older population, obesity and diabetes, improved survival from intra-abdominal or abdominal wall tumors, and improvements in the care of the critically injured patients. A complete assessment of these patients’ history, physical and laboratory work-up are essential. Poor tissue quality, poor nutritional status, obesity, smoking, alcohol abuse, concomitant medical problems, contamination, and infection should be taken into consideration in preoperative period because they pose potential obstacles to a successful repair. To optimize outcomes, each patient should be approached individually. Because patients’ expectations and physical activities are important for desired outcomes that should be achieved both functional and aesthetic goals.

The patients have a perception of negative body images due to abdominal wall appearance that affect the sexual functions and lead to functional limitations. For that reason, these patients should be evaluated not only from the functional point of view but also from the aesthetic point of view (5, xx).The patient with defects or scarring on the abdominal wall should be evaluated on which structures are existent, absent, or unequal concerning each anatomical sheet of the abdominal wall and the former scars should also be considered before developing a reconstructive plan (5).Previous incisions can be used or extended. If this is not possible, carefully planned new incisions must be used for avoiding damage to the muscular and neurovascular structures. These incisions should enable future reconstructive options, as well (4).Repair of midline ventral defects is different from defects on the lateral just as is partial thickness defects comparatively with full thickness defects.

Abdominal wall partial thickness defects are composed of superficial tissues such as skin and subcutaneous tissue or the deeper musculofascial tissue. Full thickness defects are attributed to damage of both the superficial and the deeper structures of the abdominal wall and their repairment relies on the size and position of the defect in generally. Briefly, while repairment of the superficial abdominal wall defects relies mostly on the defect size, deep musculofascial defects relies more on the location (5). While up to 5 cm sized partial thickness defects of the skin and subcutaneous tissue can be closed primarily, local advancement flaps, split thickness skin graft, or vacuum assisted closure device can be used to close 5 to 15cm sized defects. Furthermore, larger than 15 cm sized defects can be closed with component separation technique, distant or free tissue flaps, vacuum assisted closure, tissue expansion or an integration of these procedures.

Midline full thickness defects can be repaired in a similar fashion as mentioned above. Up to 3 cm sized lateral partial defects could be closed primarily, but larger than 3 cm sized defects could be closed with local or distant muscle flaps maintain dynamic assistance by muscle contraction. While restoration of the abdominal wall integrity can be performed with primary fascial repair in the smaller than 3 cm sized myofascial defects, the larger defects can be reconstructed by using prosthetic materials or autologous tissues (4,6,7).A subset of the patients may needs specific approaches such as including complex wound closure, pannicullectomy, abdominoplasty with or without rectus plication in addition to operations such as enterostomy, and/or takedown of enterocutaneous fistula, bowel resection as in our patients.In conclusion, despite the achievements in our understanding of the complex ventral hernia repair, it is still a challenge for the plastic surgeon.

In spite of recent advances in repair technique and products, no ideal procedure exists and the recurrence and complication rates remain high. To optimize results, individualized approach should be preferred. The abdomen wall repair according to the its each anatomical layer, rectus plication when necessary, and fascial repair by using prosthetic materials or autologous tissues for strengthen the abdominal wall may increase the chances of successful outcomes that is our personal philosophy for the treatment of abdominal wall defects.

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