Purpose: Bladder exstrophy is defined by urogenital and skeletal abnormalities as well as cosmetic and functional deformity of the lower anterior abdominal wall. We report two cases of severe abdominal wall dysfunction in adult exstrophy patients that drastically improved following use of our unique method of reconstruction. Methods: Two patients with disabling abdominal wall defects preventing performance of their occupations underwent reconstruction using wide dissection of the lipocutaneous layer from the myofascial layer to allow tension free primary closure. Acellularized human dermis reinforced this closure and, in one case, bridged a residual pubic diastasis. A quilted mesh onlay was applied over the entire abdominal wall prior to closure in layers of skin and subcutaneous tissue. Results/Conclusions: Following our repairs, our patients have been clinically and radiologically recurrence free for 18 and 33 months, respectively, and can carry out “heavy lifting” duties. Most authors have reported neonatal approaches to abdominal wall closure with an underestimation of the need for abdominal wall component reconstruction. The natural history of abdominal wall laxity and dysfunction, secondary to the syndrome and primary closure, has largely not been reported. We suspect many patients would benefit from complex abdominal wall reconstruction in adulthood.