Closure of the donor defect for breast reconstruction with rectus abdominis myocutaneous flaps.

The abdominal muscles not only constitute a multidirectional cinch that holds the abdominal contents in place, but they also determine the flexion and rotational movements of the trunk. The rectus is mainly responsible for flexion and the obliques are responsible for rotating the trunk. It is therefore important to maintain the tone and direction of pull of the oblique muscles. The key to closure of the fascial defect is to replace the same area of anterior rectus fascia (tendon of both obliques and transversus muscles) as has been removed with the rectus abdominis flap pedicle. This replacement, done with a double Merselene mesh, should extend up to the costal margin and should be of the same width as the fascia taken with the muscle pedicle. This technique was drawn from experience with 186 patients. Of these, 31 were simply approximated, and 43 percent developed weakness, bulging, or hernias, of which 5 required secondary repair. A total of 155 patients were closed with Merselene mesh, and only 4 percent developed bulging that was later repaired and attributed to technical mistakes. There were two cases of infection and three cases of exposed mesh due to necrosis (mesh did not need removal). Seromas were common (14 percent), but the incidence was reduced to 5 percent after tacking stitches were done from the mesh to the subcutaneous fascia.