Modified components separation technique for TRAM flap donor site closure

Abstract

Sir, Components separation is a method of abdominal closure for complex abdominal wall defects first described by Ramirez et al. in 1990 [1]. Since then several modifications have been described [2–4], and these methods achieve local fascial approximation whilst maintaining dynamic abdominal wall function. The most common method involves transection of the external oblique aponeurosis just lateral to the linea semilunaris, with separation of the external oblique from the internal oblique muscle laterally (Fig. 1). This plane is relatively aneurovascular, preserving vascularity and innervation to the anterior abdominal wall. When required, further gain can be achieved by additional separation of the posterior rectus sheath from the rectus abdominal muscle or by releasing the external oblique muscle laterally. The defect created is then usually reinforced with prosthetic mesh repair. Following transverse rectus abdominis musculocutaneous (TRAM) flap harvest, direct fascial approximation is desirable as it results in a low risk of abdominal bulge and hernia formation [5], however where this is not possible, techniques such as inlay of prosthetic mesh or acellular dermal matrix are required to achieve abdominal closure. We have found a novel technique of limited components separation to have great utility following free muscle-sparing TRAM flap harvest without any bulges or hernias occurring to date. The linea semilunaris is first incised along the lateral border of the defect and the external oblique aponeurosis mobilized (Fig. 2a, b). The extent of the undermining is sufficient to allow advancement to gain direct fascial closure without tension (Fig. 3a). The external oblique aponeurosis is then reapproximated with the anterior lamina of the internal oblique aponeurosis at the linea semilunaris with horizontal mattress nonabsorbable sutures to restore normal anatomy and to ensure that fascial closure is tensionless (Fig. 3b). The fascial defect is then closed using horizontal mattress nonabsorbable sutures. A prosthetic mesh inlay may be utilized in addition to further reinforce the closure, assessed on an individual case basis, which is fully covered with vascularized tissue, which we consider desirable and may help to reduce the potential for infection. This simple modification of the components separation technique extends the range over which direct fascial approximation at the donor site may be achieved whilst simultaneously reducing tension at the site of primary fascial repair. In addition we advocate reconstruction of M. Schaverien (*) Department of Plastic Surgery, Ninewells Hospital, Dundee DD1 9SY, UK e-mail: markschaverien@fastmail.fm