Acquired defects of the abdominal wall primarily are caused by trauma, infection, ablative resection of primary or recurrent tumors, complications of surgical procedures, radiation damage, and burns. These defects can be superficial, involving only some layers of the soft tissues of the abdomen, or full-thickness, extending to the abdominal cavity. In many instances, such defects represent life-threatening conditions, because the abdominal viscera are exposed. Additionally some patients are gravely ill, with poor general health and several significant coexisting medical problems that can affect not only the outcome of the reconstructive procedure, but also place at risk the patients' lives. Others present with chronic wounds or defects with disruptions of the continuity of the musculofascial system. They also will require procedures to restore the form and function of the abdominal wall.
During recent years, several innovative concepts, reconstructive techniques, and procedures have been described; new prosthetic materials were introduced, and improved treatment protocols were presented. Thus management philosophies have changed completely, and the final outcomes improved significantly.
The contributions of plastic surgeons in the successful management of patients with complex defects of the abdominal wall are multiple and significant. Description and experience with muscle and musculocutaneous flaps provided surgeons with additional reconstructive options for tissue replacement. Well-vascularized tissues can be harvested from areas distant to the infection, trauma, tumor, or radiation damage and transferred as pedicled or free flaps to provide coverage and reconstruction of large tissue defects and obliteration, when needed, of residual cavities. They also can be used for the successful management of recalcitrant gastrointestinal fistulas.
A great, relatively new, concept is the components separation technique. This technique, initially described by Ramirez in 1990, added a new dimension to reconstructive thinking providing for functional abdominal wall reconstruction with autogenous tissues, because the vascular and motor nerve supplies to the abdominal muscles are preserved. This reconstructive technique has become accepted widely and used to manage various abdominal wall defects, replacing, in many instances, the use of prosthetic materials or flaps.
The use of the vacuum-assisted closure, initially describe by Argenta and Morykwas in 1997, revolutionized concepts and approach to wound management and allowed surgeons to optimize tissue conditions and control local infections before the reconstruction. In some instances, even spontaneous healing of full-thickness abdominal wounds has been achieved without a surgical intervention.
With close cooperation between the plastic surgeon and the referring surgeon, preoperative control of wound infections, wound preparation, appropriate timing of the definitive reconstructive procedures, extensive planning, selection and individualization of the reconstructive technique based on tissue requirements and the patient's general condition, adherence to basic surgical principles, and judicious use of prosthetic materials when needed, surgeons now are able to achieve consistently superior results with significant reduction of short- and long-term unfavorable results and complications.
This issue of the Clinics in Plastic Surgery includes an extensive update of current trends and protocols for managing defects of the abdominal wall. Available and accepted techniques and procedures are discussed in detail along with refinements of previously described modalities.
I am grateful to all contributors who devoted a great amount of their time to prepare and submit superb articles presenting cutting-edge ideas based on their vast experience and deep knowledge with this complex topic.
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