Component separation improves outcomes in VRAM flap donor sites with excessive fascial tension

BACKGROUND:: The vertical rectus abdominis musculocutaneous (VRAM) flap has numerous uses in pelvic reconstruction; however, flap harvest can result in abdominal wall morbidity. The authors hypothesized that combining component separation with fascial advancement closure would result in acceptable surgical donor-site outcomes. METHODS:: Patients were evaluated who underwent VRAM flap reconstruction for contaminated pelvic defects and component separation with fascial advancement closure or tension-bearing primary fascial closure for VRAM flap donor-site defects between 2006 and 2009. The indication for component separation was the inability to approximate fascial edges (1) at all or (2) without excessive fascial tension, creating a high risk of postoperative failure. Primary outcome indicators included wound complications, myofascial laxity, and incisional hernia. RESULTS:: Seventy-four patients were included in the study: 15 who underwent component separation and 59 who underwent primary fascial closure. The mean follow-up was 16 months (range, 6 to 39 months). The incidences of seroma, infection, and skin and fascial dehiscence were higher in the primary fascial closure group (39 percent) than in the component separation group (13 percent) (p < 0.053). There was a fourfold greater incidence of incisional hernia in the primary fascial closure group (24 percent) than in the component separation group (6 percent). There was also a trend toward a higher incidence of myofascial laxity in the primary fascial closure group (14 percent) than in the component separation group (6 percent). CONCLUSIONS:: Component separation was effective in allowing closure of VRAM donor sites that were otherwise impossible to reapproximate without excessive fascial tension. Component separation closures resulted in fewer postoperative wound complications, hernias, and bulges, despite a more difficult closure, and should be considered when fascial closure tension would be excessive.