Innovative Reconstruction of Depressed Abdominal Scars Using Adipofascial Flaps and W-Plasty

Introduction

It is estimated that approximately 100 million people annually in developed countries acquire scars because of elective surgeries and trauma-related procedures. Among these individuals, about 15% develop excessive or aesthetically unfavorable scars [1]. This clinical challenge is particularly relevant to pediatric populations, as longitudinal data demonstrate that childhood surgical incisions undergo significant expansion during growth, frequently exceeding their original dimensions [2]. Such pathological scar progression helps explain the high incidence of depressed abdominal scars following common childhood procedures like appendectomies and abdominal trauma repairs [3].

Current treatments for depressed scars include subcutaneous excision [4], autologous fat grafting [5,6], scar release surgery [7], and pedicled fascial flap surgery [8]. Pedicled flaps are widely used for the reconstruction of skin defects [9], often involving the placement of expanders beneath the skin of the forehead and chest to obtain well-vascularized pedicled flaps [10,11]. However, the use of bilayered adipofascial flaps derived from both Scarpa’s and Camper’s fascia for in situ volumetric restoration of depressed abdominal scars remains poorly documented in the literature.

This report describes a 22-year-old woman with a post-appendectomy depressed scar and abdominal wall reconstruction using scar tissue release, abdominal wall reinforcement, bilayered adipofascial flaps, and a W-plasty suture to the anterior rectus sheath.

Case Report

A 22-year-old woman presented to our clinic in Shanghai with scar in the right lower abdomen. Fourteen years prior to her visit, she had undergone an appendectomy for acute purulent appendicitis, which was complicated by a postoperative purulent infection.

Seeking further treatment for the abdominal wall scar, the patient presented to our hospital for assessment. Physical examination revealed an adherent scar located in the right lower abdomen, with a size of 8×2 cm. The scar was conspicuously depressed, firm in texture, and exhibited no manifestations of ulceration, tenderness, nor hyperpigmentation. An additional scar was noted at the drainage site on the lower right side.

Preoperative computed tomography (CT) and ultrasonography at our institution identified a depressed scar in the right lower anterior abdominal wall accompanied by significant subcutaneous tissue loss. The imaging findings demonstrated fibrotic adhesions tethering the dermis to the anterior rectus sheath, with deeper extensions involving the peritoneal layer. Of particular significance was the complete structural disruption of the right rectus abdominis muscle (Figure 1A, 1B).

Under general anesthesia, the patient was placed in the supine position and the scar was visibly depressed (Figure 2A). The scarred epidermis was completely excised, resulting a defect measuring 8 cm in length (Figure 2B). Subsequently, the superficial adipose layer (Camper’s fascia) was elevated to expose the underlying Scarpa fascia (Figure 2C). After complete lateral scar release, the intraoperative view revealed the exposed anterior rectus sheath (Figure 2D).

Next, a medial dissection was performed along the scar margin until reaching the Scarpa fascia plane (Figure 2E). Meticulous circumferential release of fibrotic adhesions around the scar tissue was then performed (Figure 2F). Subsequently, the medial and lateral scar margins were sutured to the corresponding edges of the rectus sheath for reinforcement of the abdominal wall using 2-0 interrupted monofilament nylon suture (Figure 2G).

The medially-based adipofascial flap (Scarpa’s fascia) was sutured over the repaired defect using 2-0 interrupted monofilament nylon suture (Figure 2H). In the second-layer reconstruction, the laterally-based adipofascial flap was overlapped onto the medial flap and sutured in place (Figure 2I). Finally, the adherent scars on both sides of the skin were excised, and a W-plasty suture was performed (Figure 2J).

Preoperative evaluation revealed a depressed, adherent scar with characteristic skin dimpling and contour deformity (Figure 3A, 3B). Two weeks postoperatively, the incision exhibited primary healing without evidence of scar contracture or hypertrophy (Figure 3C). The 1-year follow-up demonstrated maintained contour restoration with absence of recurrent depression or adhesion, with satisfactory aesthetic and functional outcomes (Figure 3D).

Discussion

This case demonstrates that complex abdominal scars with deep tissue involvement require a comprehensive surgical approach addressing 3 critical aspects: adhesion release, structural reinforcement, and volumetric restoration. The technique’s success stems from utilizing vascularized adipofascial flaps (Scarpa’s and Camper’s fasciae) rather than non-vascularized fat grafts, combined with tension-reducing closure.

Chronic infection during the healing process can induce subcutaneous tissue loss and pathological scar formation. In severe cases, this can result in depressed and adherent scars [12]. The adhesions observed in our case demonstrated a distinct anatomical pattern compared to typical post-surgical abdominal adhesions, being strictly localized between the scar tissue and anterior rectus sheath without peritoneal or visceral organ involvement. Current standard management options for such depressed scars include surgical scar release and pedicled flap reconstruction [13].

While subcision remains a common treatment for depressed scars [14], its utility is constrained by several limitations. The technique demonstrates optimal efficacy only for small, superficial scars [15], whereas larger depressed scars often require more extensive interventions, such as layered dermal support or fascial reinforcement [16]. Subcutaneous excision, while effective in some cases, can lead to increased skin tension and cause anatomical distortion [17]. In our patient, the 8×2 cm scar exhibited firm adhesions to the anterior rectus sheath, rendering conventional subcision or excision inadequate. Consequently, we implemented a surgical strategy comprising scar tissue release, abdominal wall reinforcement, and correction of the depressed scar.

Autologous fat grafting has traditionally been used for scar depression correction, offering temporary volumetric improvement through subcutaneous augmentation [18,19]. However, this method also has limitations: significant fat resorption rates frequently necessitate multiple procedures, elevated local pressure in severe depressions can displace grafted fat into adjacent tissues, and the lack of structural support fails to address underlying fascial defects. Our technique overcomes these challenges through a novel combination of scar dermal flaps and bilayered adipofascial flaps, which provides several advantages. Firstly, tension redistribution to deeper fascial planes significantly reduces dermal stress, a critical factor in hypertrophic scar formation [20]. Secondly, it ensures durable volume restoration with minimal tissue migration risk. Thirdly, the dual-layer design addresses both volumetric restoration and abdominal wall reinforcement, overcoming the structural deficiencies of traditional local flaps. Additionally, the W-plasty closure enhances aesthetic contouring.

Although our approach shows superior scar revision outcomes compared to conventional methods, it does have limitations in extremely wide defects due to restricted Scarpa fascia mobility. For such cases, Fong et al demonstrated that combining bilayered fascial flap with interpositional omental flaps could effectively reconstruct even large contaminated abdominal defect [21], suggesting a potential solution for these challenging cases.

Conclusions

Depressed abdominal scars with deep adhesions require reconstruction addressing both structural support and volume restoration. This report demonstrates that bilayered adipofascial flaps combined with tension-reducing techniques overcome limitations of traditional subcision and fat grafting, providing durable functional and aesthetic outcomes in complex cases. The approach offers an effective solution for scars involving muscular disruption and significant tissue deficiency.