Maxfacts

Abdomen

Postoperative problems affecting the abdomen (belly) include

• Scars. The main maxillofacial reasons for the abdomen being interfered with are
  • placement of a feeding gastrostomy tube
  • maxillofacial reconstructive surgery harvesting soft tissue in the abdominal region; either an abdominal full thickness skin graft or a rectus abdominis free flap (the rectus abdominis muscle is a long, flat group of muscles running along the whole middle front of the abdomen – the ‘six pack’ muscles).
  Each of these will leave a scar on the abdominal wall. Gastrostomy (sometimes called a PEG, percutaneous endoscopic gastrostomy) is a small puncture wound in the upper left abdominal wall. Abdominal full thickness skin grafts are usually harvested from the side of the abdominal wall (preferably not the lower right as this can be confused with an appendicectomy scar). The rectus abdominis flap for head and neck reconstruction is done in a variety of shapes but usually lies vertically on one side of the abdomen (in contrast to the transverse rectus abdominis (or TRAM) flap popular in breast reconstruction).
• It is important to be aware that of these interventions only the gastrostomy actually penetrates the abdominal wall, goes inside and connects to the contents of the stomach. This carries the risk of leakage or formation of an abnormal connection, a fistula. So, in some respects the smallest of these scars on the abdomen can be the potentially more dangerous one.
• The skin graft only affects the skin and may be itchy or prominent but has little else in the way of complications and is rarely infected.
• The rectus abdominus flap can be carried out in different ways but for maxillofacial reconstructive purposes usually takes out the muscle, fascia and blood vessel supplying the muscle and skin. This resulting defect is repaired locally and can make the abdominal wall feel very tight for weeks after. This can make it difficult to cough and thus can predispose to chest infections. Rarely hernias can occur. Sometimes a mesh is used to strengthen the abdominal wall but in very thin patients (where this flap is more often used in maxillofacial reconstruction), the mesh can work its way out of the scar. Full abdominal wall strength is very unlikely to recover in these cases.

The deep inferior epigastric free flap (DIEP flap) is an alternative but more complicated version of the operation. It attempts to reduce the issues with other types of rectus abdominis free flaps but is more often used in young women who may wish to give birth after breast reconstruction than for older maxillofacial patients with advanced head and neck cancers needing large soft tissue defects repaired after tumour excision.