Ipsilateral Component Separation Improves Outcomes of VRAM Flap Donor Sites with Excessive Fascial Tension

INTRODUCTION: The Vertical Rectus Abdominis Musculocutaneous (VRAM) flap has numerous indications in pelvic, vaginal and perineal soft tissue reconstruction. However, there can be considerable donor site morbidity associated with the muscle and fascial harvest of a VRAM flap owing to excessive fascial closure tension including myofascial laxity, fascial dehiscence and incisional hernia. Ipsilateral component separation (CS) with release of the external oblique aponeurosis can be used to reduce tension and facilitate fascial closure. We hypothesize that component separation can be used to close VRAM donor site abdominal wall defects, in patients where primary fascial closure is impossible or would result in excessive fascial closure tension.

METHODS: We evaluated surgical outcomes of all consecutive patients who underwent CS with VRAM donor site closure for difficult fascial closures and compared them to a control group of standard, primary fascial closure (PFC) VRAM donor site closures without excessive fascial tension at M. D. Anderson Cancer Center between June 2006 and May 2009. The indication for use of ipsilateral CS with VRAM donor site closure was the inability to approximate the fascial edges together or fascial closure tension deemed by the attending surgeon to be excessive and at extremely high risk for postoperative failure. Primary outcome indicators included surgical outcomes at the donor site, particularly wound complications, myofascial laxity (bulge) and incisional hernia.

RESULTS: Seventy-four patients were included in the study; 15 CS and 59 PFC patients. Mean follow-up was 16 months (range 6-39 months). The incidence of early postoperative complications including, seroma, infection, skin dehiscence and fascial dehiscence; was higher in the PFC (39%) group compared to the CS (13%) group (p<0.05). There was a four-fold greater incidence of incisional hernia in the PFC (24%) group compared to the CS (6%) group. There was also a non-statistically significant trend towards a higher incidence of myofascial laxity (bulge) in the PFC (14%) group compared to the CS (6%) group.

CONCLUSION: CS was effective in allowing closure of VRAM fascial donor sites that were otherwise impossible to re-approximate or resulted in excessive tension. CS closures resulted in fewer postoperative wound complications, hernias and bulges despite a more difficult closure. CS facilitates fascial closure of VRAM donor sites by reducing fascial closure tension and should be considered when fascial closure tension is excessive.