Dynamic reconstruction of complex abdominal wall defects with the pedicled innervated vastus lateralis and anterolateral thigh PIVA flap.

BACKGROUND AND AIM: Reconstruction of large and chronically infected recurrent abdominal wall defects with exposed bowel in a scarred wound environment, when component release has been previously performed but failed, is a veritable challenge. We use a pedicled innervated vastus lateralis muscle with a fasciocutaneous anterolateral thigh flap (PIVA flap) to restore the continuity of the abdominal wall with vascularised tissues and create a dynamic component that improves the functional outcome. MATERIALS AND METHODS: A one-stage PIVA flap was used in 15 patients with grade 4 transmural chronically infected defects. They had a mean of 4.53 previous laparotomies and important co-morbidities. We determined post-operative reconstructive abdominal wall strength using a validated quality-of-life (QoL) hernia-related questionnaire and modified it to quantify donor-site morbidity at the thigh. We measured the maximal force generated at 60°/s and the force velocity at 120°/s by isokinetic dynamometric analysis at 3 and 12 months. Electromyography (EMG) was performed 12 months after the reconstruction to analyse the contractile integrity of the vastus lateralis segment. A two-sided sign test was used to analyse data. RESULTS: All transmural chronic wounds healed without recurrence. Dynamometric strength increased significantly in the abdominal wall musculature (p < 0.016) and in the donor thigh (p < 0.023) between 3 months and 12 months after the intervention, which reflected in the EMG outcome and the high scores in the QoL measurements after 12 months. CONCLUSIONS: The PIVA flap revascularises the scarred milieu, adds a dynamic component to improve function and may reach up to the xiphoid process. Donor-site morbidity is limited.

[Degloving injuries of the lower limb]. / Die Décollementverletzung im Bereich der unteren Extremität.

Although seldom dangerous to life, these degloving injuries are all potentially infected and, unless treated as acute surgical emergencies, inevitably lead to serious complications. Diagnostic is done according to a standardized protocol, which eventually must be integrated in the standard polytrauma management. Multidisciplinary (orthopedic surgery, plastic surgery, dermatology, physiotherapy) defect management is of utmost importance and requires an "integrated therapy concept". The success or failure of primary treatment of degloving injuries is determined by an adequate primary care including debridement, osteosynthesis (if necessary) and soft tissue and skin management. If the skin is no more vascularised, it should be thinned out and refixed as a full thickness skin graft at the day of injury. Still vascularised skin flaps should be replaced and fixed with few stitches. A second look operation 24 to 72 hours later should be planned. Secondary surgery is necessary in almost every patient in order to improve the functional or aesthetic result. Adjuvant procedures such as physiotherapy, standardized scar treatment, orthesis, orthopedic shoes, etc. may be useful at any time of treatment.