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January 23, 2026

A Classification and Management Framework for Reconstruction of Acquired Massive Abdominal Wall Soft-Tissue Defects: A Scoping Review of 226 Studies

Key Points

The aim is to review and summarize repair techniques for acquired massive abdominal wall soft tissue defects (MAWSTDs) to develop a classification and management framework.
Systematic review of literature from PubMed, Scopus, Web of Science, and Google Scholar following PRISMA-ScR guidelines.
Included articles focused on flap-based reconstruction, tissue expansion, and abdominal wall transplantation for acquired MAWSTDs.
Screened 2,926 articles to identify 226 relevant studies.
Flap-based reconstruction was the most common method used (86.7%).
Mean defect size reconstructed with flaps was 342.1 cm² (S.D ± 223.0 cm², range 100–992 cm²).
Tissue expansion was used in 8.9% of cases with a mean defect size of 288.5 ± 196.8 cm² (range: 64–851 cm²).
Oncologic resection was indicated in 43% of studies, involving 612 patients.
A new definition and standard classification system for the management of MAWSTDs were developed.

Abstract

Background: Massive abdominal wall soft tissue defects (MAWSTDs) present a reconstructive challenge that usually necessitates complex repair techniques. The aim of this study was to review and summarize all the repair techniques for acquired MAWSTD ever presented in the literature and utilize these findings to develop a standardized definition, classification system, and reconstructive algorithm for MAWSTDs. Methods: A systematic review of PubMed, Scopus, Web of Science and Google Scholar was conducted according to PRISMA-ScR guidelines. Relevant articles reporting flap-based reconstruction, tissue expansion, abdominal wall transplantation (AWT) or combination(s) of these approaches for repair of acquired MAWSTD were included. Results: Of 2,926 articles screened, 226 met inclusion. Flap-based reconstruction was the most common method (86.7%), followed by tissue expansion (8.9%) and AWT (4.4%). Mean defect sizes reconstructed with flaps was (mean 342.1 cm², S.D ± 223.0 cm², range 100–992 cm²) and with tissue expansion 288.5 ± 196.8cm² (range: 64–851 cm²). Defects typically spanned zones M1–M5 and L1–L3. Oncologic resection was the most common indication (43% of studies, 612 patients). External tissue expanders are becoming increasingly common and preferred over traditional internal method of expansion. AWT (vascularized composite allotransplantation in 40%), was used for full-thickness loss following visceral transplantation or multiple prior failures. Finally, a novel definition and reconstructive classification were developed to guide the flow of management. Conclusion: Flap-based approaches are most frequently utilized (order: regional, free, local, and combination(s)). Tissue expansion and AWT are other options, though less frequently utilized. One must consider both patient-specific and defect-specific factors when determining appropriate treatment strategies.

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