Thigh-Based Flap Reconstruction for Complex Abdominal Wall Loss of Domain: A 10-Year Retrospective Cohort Study

Background: Complex abdominal wall reconstruction (AWR) is a technically demanding procedure often required in patients with large fascial defects and significant comorbidities. When primary closure is not feasible, thigh-based flaps can provide durable soft tissue coverage and structural support. However, literature on flap-based AWR remains limited. Methods: A retrospective cohort study of patients who underwent thigh-based AWR between 2014 and 2024 at a single tertiary center was conducted. All patients had significant loss of domain and underwent reconstruction with pedicled or free flaps, with or without mesh. Data on demographics, defect characteristics, comorbidities, surgical techniques, and postoperative outcomes were analyzed. Results: Fifteen patients (9 males, 6 females; mean age 53.7 ± 7 years; BMI 30.8 ± 5.9 kg/m²) underwent reconstruction. Comorbidities were common: 53% had a smoking history, 40% had diabetes, 67% had hypertension, and 93% of patients had a median of 8 previous abdominal surgeries. Defects averaged 840 cm² (fascial) and 504 cm² (skin). Mesh was used in all cases, and 67% of patients required free flaps. Flap types included anterolateral thigh (ALT), chimeric, and vastus lateralis myocutaneous configurations. The median hospital stay was 15 days. Any complications occurred in 80% of patients, with 20% experiencing Clavien-Dindo (CD) grade III events. Long-term outcomes included low rates of abdominal bulge (6.7%) and fistula recurrence (7%). Conclusions: Our 10-year experience demonstrates consistent achievement of definitive fascial closure, reliable flap survival, and manageable complication rates, even in the presence of significant comorbidities and prior surgical complexity.