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Page 2 of 7 Patel et al. Plast Aesthet Res 2020;7:18 I http://dx.doi.org/10.20517/2347-9264.2019.15

Optimizing skin and soft tissue coverage is of utmost importance in order to reduce the risk of developing
a surgical site infection or surgical site occurrences and to expedite recovery [1-3] . This is particularly
important in the oncologic population, in which a healed wound is imperative prior to initiating adjuvant
chemotherapy or radiation therapy. Because the requirement for skin and soft-tissue reconstruction of the
abdominal wall intimates adeficiency of local tissue available for resurfacinga defect, most abdominal wall
defects are reconstructed using flaps from redundant adjacent tissue in the torso; however, certain cases
may require pedicled regional flaps or even free tissue transfer depending on the size of the defect, location,
and the patient’s body habitus. The reconstructive ladder is a useful framework for guiding abdominal soft
tissue reconstruction in most clinical scenarios. However, we have found the M.D. Anderson oncologic
abdominal wall reconstruction classification system to be particularly beneficial for the unique needs of the
[4]
oncologic population . At a minimum, planning for abdominal soft tissue reconstruction must take into
consideration the defect type, location, and the viability and perfusion of the surrounding tissues. Although
a variety of options are available to the reconstructive surgeon for abdominal soft tissue defects, there area
number of key points and technical nuances that, when implemented appropriately, can help to ensure an
acceptable result with minimal complications.

LOCAL FLAP OPTIONS
Local flapsinvolve recruiting tissue adjacent to the wound defect. Well-planned incisions and a thorough
understanding of the abdominal wall angiosomes is necessary to execute this collection of techniques.
Regarding perfusion, local flaps can be designed as having either random-pattern or axial blood supply.
There are numerous local flap types, including rotation/advancement, interpolation, V-Y advancement,
keystone flaps, propeller flaps, and bipedicled flaps. Most commonly, the flap donor site is closed primarily,
however a skin graft can alternatively be employed for this purpose, as in the bipedicled flap.

Pre-existing scars and closure tension are two important factors to consider in local flap reconstruction. For
instance, a midline laparotomy scar may preclude designing a local flap along the contralateral abdominal
wall. Regarding tension, the area of the local flap that is most important for the reconstruction is also the
area that is most vulnerable to reduced perfusion: the most distal point. Reduced perfusion is exacerbated
by excessive flap inset tension, therefore it is important to design wide-based, large local flaps, recruiting
tissue from areas of relative redundancy, in order to mitigate this possibility. In addition, the thoughtful
surgeon should account for expected postoperative edema and abdominal distention in the flap design and
inset technique.

A propeller flap is a local fasciocutaneous flap that can be rotated up to 180 degrees in relation to its
perforator. Perforator propeller flaps have been well described for extremity and chest wall reconstruction,
[5]
however their use in abdominal reconstruction is more limited . These flaps can be used to cover
abdominal defects, recruiting flap tissue from an area with relative adipocutaneous redundancy compared
to the recipient site. Propeller flaps are best used for smaller defects, as the donor site should be able to
close primarily [Figure 1]. Familiarity with perforator dissection and microsurgical technique is also
necessary, which may limit the applicability of this flap type.

[6]
A keystone flap is a fasciocutaneous flap composed of two V to Y advancements . Unlike most other local
flaps, keystone flap mobility is not facilitated by undermining. Instead, undermining should be minimized,
in order to keep all underlying cutaneous perforators intact. For any defect, unilateral or bilateral flaps can
be designed depending on the size and location of the area of skin deficit. The width of each flap should be
at least as wide as the defect and the flap and defect length should be equal. The double VY closures work
to advance the flap toward the defect, facilitating a tension-free defect closure.