June 17

A.W. FARMER LECTURE

June 17, 20:35ET
Prevention and management of abdominal donor site complications
Dr. Ron Israeli
Great Neck, NY

Breast reconstruction with tissue harvested from the lower abdominal wall has been the gold standard approach to autologous breast reconstruction since the pedicled transverse rectus abdominis myocutaneous (TRAM) flap was first popularized in the 1980’s. Abdominal flaps allow for a soft, natural breast reconstruction, and provide for favorable abdominal wall contour while avoiding the risks of implant-based approaches. Unfortunately, the benefits of breast reconstruction with abdominal flaps can be tempered by the risk of potentially challenging abdominal wall complications.

Microsurgical approaches have decreased the risk of abdominal wall donor site complications while allowing for improved vascularity of abdominal based flaps. For many surgeons specializing in breast reconstruction, deep inferior epigastric perforator (DIEP) flaps and muscle-sparing free TRAM flaps, which allow for preservation of abdominal wall muscle and function, have replaced the pedicled TRAM flap approach. While this evolution has helped minimize complications at the abdominal donor site, significant risks remain.

Abdominal wall weakness, bulging, and hernias are donor site complications specific to abdominal flap breast reconstruction. Bulges and hernias occur more frequently following pedicled TRAM flap breast reconstruction as compared to free TRAM flap and DIEP flap procedures. In this presentation, the anatomy of abdominal flap donor site contour deformities and hernias is reviewed, along with strategies for avoidance of hernias and approaches to donor site hernia repair. An approach to abdominal wall reconstruction for the correction of donor site hernias is described using a technique combining an extended mesh repair with bilateral external oblique muscle advancement flaps. Additional potentially serious complications are reviewed, including the risks of abdominal wound breakdown and umbilical loss. Selective umbilical ablation is discussed as a strategy for minimizing the risk of abdominal donor site wound problems in high-risk patients. A simple and reliable technique for umbilical reconstruction in this setting is described.

LEARNING OBJECTIVES:

  • Participants will be able to explain the anatomy and pathophysiology of abdominal flap donor site bulges and hernias.
  •  Participants will be able to list approaches and strategies for the prevention of abdominal flap donor site complications.
  • Participants will be able to describe an approach for the reliable repair of abdominal flap donor site hernias.