Technical Tip: Mark Scarpa's Fascia to Facilitate Proper Abdominal Closure During Autologous Breast Reconstruction

1 T of the main objectives of closure of the abdominal defect during autologous breast reconstruction are to maximize strength of the wound and to optimize scar appearance by reducing tension at the level of the dermis. One technical element that achieves both of these goals, and is therefore commonly utilized, is closure of Scarpa’s (superficial abdominal) fascia (SF) as a separate, strengthbearing layer.1 Unfortunately, SF can be difficult to identify (especially for trainees), and inaccurate identification of SF can lead to suboptimal clinical outcomes: inclusion of excessive amounts of subcutaneous fat in an attempt to “not miss” SF can lead to fat necrosis and its undesired sequelae,2 and inadvertent failure to include SF in the closure can lead to a widened scar and sometimes even incisional dehiscence. There are multiple factors that increase the likelihood of incorrect identification of SF during abdominal tissue–based breast reconstruction: for instance, patients who undergo autologous breast reconstruction often have large amounts of subcutaneous fat and therefore SF is particularly difficult to visualize, and the common practice of placing temporary staples that facilitate appropriate alignment in the left-to-right direction makes visualization of SF even more difficult. To decrease uncertainty regarding the exact location of SF, we have developed a simple, fast, no-cost method that facilitates reliability-effective closure of SF. After hemostasis has been confirmed and all irrigation has been completed, a surgical marking pen is used to mark the exact location of SF on both the cranial and caudal flaps (Fig. 1). Once this has been done, temporary alignment staples can be placed, and while one team completes the chest portion of the procedure, the abdominal defect is closed effectively and rapidly because the uncertainty of the location of SF has been eliminated (Fig. 2). This simple intervention has been met with enthusiasm—and a sense of relief—by the members of the surgical team at our center, and we encourage those at other centers to consider adoption of this technique, as well. Peter W. Henderson, MD, MBA Plastic and Reconstructive Surgery Service Department of Surgery Memorial Sloan Kettering Cancer Center 1275 York Avenue MRI 1007 New York, NY 10065 E-mail: [email protected]