Reconstruction of Large, Complicated Trunk Defects Using Alloderm and Flaps in Cancer Patients

Complication rates are increased in pelvic, chest, and abdominal-wall reconstructions with polypropylene mesh when the mesh is placed directly over viscera or the operative site has been irradiated or contaminated with bacteria. An alternative mesh material is Alloderm (decellularized allodermis), which becomes vascularized and remodeled into autologous tissue after implantation. When used for fascial reconstruction, it forms a strong repair, causes minimal abdominal adhesions, and resists infection.

The authors retrospectively studied cancer patients who were at increased risk for prosthetic mesh complications and who had undergone trunk reconstruction with Alloderm over a 1-year period at the M.D. Anderson Cancer Center. Risk factors for mesh-related complications included local radiotherapy, unavoidable mesh placement directly onto bowel or lung, and bacterial contamination of the operative field (enterocutaneous fistula, gross intraoperative bowel spillage, and/or a contaminated wound). The indications, defect characteristics, reconstructive techniques, and surgical outcomes were evaluated.

Nine patients (24 to 84 years old) were included in the study. Indications for reconstruction were oncologic resection (7) or a gastroesophagectomy or colocutaneous fistula repair plus repair of a large, recurrent ventral hernia (2). The operative site had bacterial contamination in 6 patients and received perioperative radiation (mean dose: 54.8 Gy) in 6 patients (preoperative 5, postoperative 1). All defects included resection of both musculofascial and cutaneous tissue and involved the abdominal wall (3), abdominal wall and pelvis (4), chest wall (1), or abdominal and chest walls (1). The mean musculofascial defect size was 470 cm² (range: 150 to 1045 cm²). Alloderm was placed directly onto viscera in all cases; a mean of 5 (6 × 12 cm) sheets were used. One to three flaps were used for coverage in 7 patients (13 pedicled and 1 free flap); two patients had skin advancement only.

With a mean follow-up of 7 months, complications occurred in 6 patients: seroma (2), hematoma (1), partial flap loss (1), enterocutaneous fistula (1), wound dehiscence (1), and cerebrospinal fluid leak (1). No clinical mesh infections, hernias, laxity, or bulges occurred. Techniques considered to improve outcome included a dual-concentric suture line inset technique, maximal mesh-musculofascial edge surface area interface, suture fixation through drill holes in adjacent bone, use of thick or extra-thick (0.8 to 2.5 mm) Alloderm, and quilting sutures for seroma prophylaxis.

Alloderm can be successfully used for large pelvic, chest, and abdominal-wall reconstructions, even when placed directly over viscera or an irradiated or contaminated operative field. This technique warrants consideration in these adverse situations.