Congenital lumbar hernia (LH) is a rare abdominal wall herniation and associated with lumbocostovertebral syndrome, including vertebral anomalies, costal defects and LH. There are reports using extraperitoneal placement of mesh, patches, and local flaps for repairing the LH. In this report we present a case of repair of a large recurrent congenital LH with free composite anterolateral thigh flap, tensor fascia lata flap and vastus lateralis flap (ALT-TFL-VL flap) and meshes. The patient underwent multiple cutaneous neurofibroma excisions before the treatment of LH. Recurrent neurofibroma and congenital aplasia of lumbar muscles at right flank may contribute to the patient's diffuse congenital LH development. Considering a large fascia defect (12 cm × 15 cm) with absence of lumbar muscles at the herniation site, using mesh alone is not strong enough to stop the herniation of bowel. Transposition of right pedicled ALT-TFL-VL flap (35 cm × 12 cm) with mesh was first attempted but proven to be futile, since the right lumbar wall bulged out from the distal border of previous reconstructed fascia. Thus, another free composite ALT-TFL-VL flap (35 cm × 15 cm) from left thigh was transferred on top of the previous pedicled flap, followed by delayed free flap advancement and surgical mesh addition. Post-operative course was smooth without complications. Twenty-one months after the surgery, computed tomography showed no recurrence of LH. Such case with large recurrent diffuse LH may be treated by a combination of conventional method with meshes and serial reconstruction with pedicled and free flaps for dynamic reconstruction of abdominal wall.
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