Rectus Abdominis Muscle Flap Research Articles

Análise dos resultados estéticos na reconstrução mamária com TRAM ipsilateral vs. contralateral

Background: Breast reconstruction by using the rectus abdominis muscle (transverse rectus abdominis myocutaneous, TRAM) flaps is a common procedure that has been per ­ formed since the 1990s. Ipsilateral TRAM flaps were proven to be as safe as contralateral flaps for breast reconstruction. However, studies comparing the aesthetic outcomes of the two procedures are poorly described in the literature. The aim of this study was to com­ pare the cosmetic outcomes of ipsilateral and contralateral pedicled flaps. Methods: We prospectively evaluated 29 cases of immediate reconstruction with ipsilateral (group 1) or contralateral (group 2) TRAM flaps. The aesthetic outcomes were analyzed and the two groups were compared. Results: The average age of the patients was 43 ± 7 years. In group 1 (ipsilateral TRAM), 91.7% of the patients presented a well-defined inframammary fold, as compared to 52.9% of the patients in group 2 (contralateral TRAM). In group 1, 8.3% of patients showed xiphoid bulges, whereas they were observed in 23.5% of patients in group 2. The difference in the overall shape of the reconstructed breast was not significant; symmetry was observed in 66.7% and 70.6% of patients in groups 1 and 2, respectively. Conclusions: Ipsilateral TRAM flaps allow better preservation of the inframammary fold and cause less xiphoid bulge. However, the overall shape of the breast and the projection of its lower pole were similar between the two groups.

Single port-assisted fully laparoscopic abdominoperineal resection (APR) with immediate V-RAM flap reconstruction of the perineal defect

Abdominoperineal resection (APR) of anorectal cancers after neoadjuvant chemoradiotherapy may incur significant perineal morbidity. While vertical rectus abdominis muscle (V-RAM) flaps can fill the pelvic resection space with health tissue, their use has previously been described predominantly in association with laparotomy. Here, we describe a means of combination laparoscopic APR with V-RAM flap reconstruction that allows structural preservation of the entire abdominal wall throughout the oncological resection and of the deep parietal layers after V-RAM donation. Furthermore, a single port access device used at the end colostomy site allows a second senior surgeon assist with an additional two working instruments for the purpose of improved pelvic tissue retraction, especially useful in obese patients.

5-FUに起因した高アンモニア血症をきたした舌癌の1例

We describe a patient with tongue cancer who had hyperammonemia with impaired consciousness possibly caused by 5-fluorouracil (5-FU). The patient, a 72-year-old-man, was given a diagnosis of tongue squamous cell carcinoma (T4N2cM0). He underwent subtotal tongue resection and bilateral neck dissection, followed immediately by reconstructive surgery with a rectus abdominis muscle flap. As postoperative adjuvant chemotherapy, a regimen of TPF was started, but 2 days later, nausea and vomiting developed, which made oral intake difficult. Six days after treatment began, he experienced disturbance of consciousness. Because of respiratory arrest during cerebral computed tomography (CT) to assess these symptoms, the patient was transferred to the intensive care unit. On CT, no structural abnormalities of the brain were noted; however, blood testing revealed a high NH3 level of 536μg/dL. With intravenous fluid therapy, the NH3 gradually decreased, the level of consciousness improved, and the NH3 returned to within normal limits. On the basis of the treatment course and absence of liver dysfunction, the hyperammonemia was attributed to 5-FU.However, 4 months after surgery, the atient had an unexpected outcome due to pulmonary metastasis.

A multi‐disciplinary approach to the management of fungal osteomyelitis: Current concepts in post‐traumatic lower extremity reconstruction: A case report

Limb salvage in fungal osteomyelitis of the post-traumatic lower extremity represents a difficult clinical problem requiring aggressive management. We report lower extremity salvage by radical bony debridement, free tissue transfer, distraction osteogenesis with bone-docking, and a novel antifungal regimen in a clinical setting of infection with Scedosporium inflatum, historically requiring amputation in 100% of cases. We treated Scedosporium inflatum osteomyelitis of the tibia and calcaneus with radical debridement of infected bone, free partial medial rectus abdominis muscle flap coverage, transport distraction osteogenesis, and combination voriconazole/terbinafine chemotherapy, a novel antifungal regimen. We achieved successful control of the infection, limb salvage, and an excellent functional outcome through aggressive debridement of infected bone and soft tissue, elimination of dead space within the bony defect, the robust perfusion provided by the free flap, the hypervascular state induced by distraction osteogenesis, and the synergism of the novel antifungal regimen.

Chest Wall Reconstruction of Severe Mediastinitis With Intercostal Artery–Based Pedicled Vertical Rectus Abdominis Muscle Flap With Oblique-Designed Skin Pedicle

Recurrent poststernotomy mediastinitis has significant morbidity and mortality. Reconstructive treatment begins with pectoral muscle or omental flaps. When these options are unavailable or inadequate, surgeons resort to internal mammary artery-based vertical rectus abdominis muscle flap. If the internal mammary artery is harvested for coronary artery bypass grafting, surgeons are reluctant to use the muscle for pedicled flap because of the elevated risks. However, recent reports suggest that if enough time passes for intercostal artery collaterals to develop, they would support the viability of the flap. Moreover, recent improvements in defining flap microvasculature and proposed surgical techniques have enabled us to further refine the procedure. Although it appears that the intercostal artery-based pedicled vertical rectus abdominis muscle flap with oblique-designed skin pedicle is safe and effective for chest wall reconstruction, potential for failure remains elevated until sample size accumulates.

The versatility of the pedicled vertical rectus abdominis myocutaneous flap in oncologic patients

The vertical rectus abdominis muscle (VRAM) flap is considered a safe and simple option to cover defects of the trunk and proximal thigh. Detailed long-time follow-up studies in oncologic patients including complications and donor site morbidity are rare. In this study, complications and donor site morbidity were analysed. Data of 78 consecutive patients with oncologic disease, having received VRAM flaps, were analysed retrospectively. Patients with soft tissue sarcomas (n = 38), radiation ulcers (n = 18), carcinoma (n = 10), wound-healing difficulties after tumour resection (n = 8), breast reconstruction after ablation (n = 3) and malignant melanoma (n = 1) were included. Statistics concerning patients' satisfaction, the occurrence of wound-healing difficulties, incisional herniation, loss of abdominal wall strength in correlation to operative and (neo)adjuvant treatment and patients' history were performed. The mean follow-up time was 5.5years. No complete flap loss was observed. A body mass index over 30 was positively correlated with wound-healing difficulties; radiation had no negative effect. A contralateral cutaneous pedicle could reduce the risk of lymphoedema in groin defect patients. Incisional hernia was present in 13%. Strength endurance of the abdominal wall was reduced compared to an age-matched control. Most patients were satisfied with the postoperative result. VRAM flaps are reliable tools for defect coverage in the oncologic patient to prevent chronic ulceration, lymphangitis or more severe complications like septic rupture of femoral vessels and hip disarticulation. Donor site morbidity is tolerable, and patients' satisfaction is high.

In situ graft replacement and rectus abdominis muscle flap transfer for infected thoracoabdominal aortic aneurysm after gastrectomy

An infected thoracoabdominal aneurysm is a rare, life-threatening condition with high mortality. We performed an in situ graft replacement and applied a rectus abdominis muscle flap transfer technique in a case of infected thoracoabdominal aortic aneurysm after distal gastrectomy. A rectus abdominis muscle flap transfer might be a good alternative when the omental flap technique is not feasible.

Ventral Herniation of the Left Hepatic Lobe after Sternal Reconstruction with a Rectus Abdominis Muscle Flap

Ventral Herniation of the Left Hepatic Lobe after Sternal Reconstruction with a Rectus Abdominis Muscle Flap

Autologous Breast Augmentation With the Deepithelialized Fasciocutaneous Infragluteal Free Flap

Breast augmentation with silicone implants is frequently performed, a daily procedure in plastic surgery. Nevertheless, there are well-known risks of capsular formation and contraction leading to pain, displacement, and rupture after breast augmentation. Thus, the frequency of augmentation with autologous tissue is increasing. Most frequently used are the transverse rectus abdominis muscle flap, the deep inferior epigastric artery perforator flap, and the gracilis free flap, but in some cases, these flaps are not the first choice. Therefore, we present our experience with the free fasciocutaneous infragluteal (FCI) flap. The FCI flap is based on a constant end artery of the inferior gluteal artery and has frequently been used for various indications at our department for many years. Since 1998, 17 patients suffering from breast hypoplasia, congenital breast asymmetry, or consecutive capsular fibrosis were treated with 25 FCI flaps. In this series, no complete or partial flap loss was clinically detected. The only complaint was a discomfort at the donor site in the early postoperative period. As revealed by a final questionnaire, all patients were satisfied with the result. Our results suggest that the FCI flap should be considered as a worthy alternative for autologous breast augmentation, especially in thin patients suffering from breast hypoplasia, congenital asymmetry, or consecutive capsular formations.

Relation Between Serum Ischemia-Modified Albumin Levels and Rectus Abdominis Muscle Flap Viability

Ischemia is a major cause of flap failure in reconstructive surgery. To detect circulatory compromise, many flap monitoring methods are used; however, there is no any optimal standard method. Ischemia-modified albumin (IMA) is an ischemia marker, which has recently been investigated in many studies and largely validated for early detection of ischemia. In this study, we investigated possible relationship between muscle flap viability and serum IMA levels in experimental flap model. The rectus abdominis muscle flap model was used in 18 New Zealand white rabbits. The study was planned using 3 groups. In group 1, the rectus abdominis muscle flap was harvested as a superior pedicle-based flap in which the inferior pedicle was sacrificed. In group 2, the flap was harvested by severing the superior pedicle. Both pedicles were harvested in group 3. Serum IMA levels were measured before the procedure and 1 hour, 6 hours, and 7 days postoperatively and then compared. In group 3, in which the ischemia was evident, and in group 1, IMA levels were significantly high 1 hour postoperatively (P < 0.05). There was no other significant difference in any of the other studied parameters between the groups. In conclusion, IMA can be used as a biochemical parameter for monitoring muscle flap viability.

Free-Flap Reconstruction of the Scalp

Wide, complex defects of the scalp caused by various insults always represent reconstructive challenges for surgeons. Our study group consisted of 18 patients (14 males and 4 females) with a mean age of 40.2 years. Nineteen free-tissue transfers were used to reconstruct the scalp defects. The selected cases included 8 latissimus dorsi muscle flaps, 3 latissimus dorsi myocutaneous flaps, 2 rectus abdominis muscle flaps, 3 omental flaps, 1 scapular flap, 1 radial forearm flap, and 1 groin flap. Twelve patients had acute or subacute wounds resulting from trauma or craniotomy, 4 had primary cancer, and 2 had neurofibromatosis. Commonly used recipient vessels were the superficial temporal artery and vein. No flap procedure had morbidity due to vessel compromise, and the overall flap success rate was thus 100%. No major donor-site morbidity was observed. All cases underwent primary closure of donor sites except for one receiving split-thickness skin grafting. In cases where muscle or omental free flaps covered skin grafts, patients were more satisfied because of increased durability and well-fitted wigs. We advocate variable free-tissue transfers for the reconstruction of large defects of the scalp related to the sizes, sites, and extents of the involvement.

Präoperative CT Angiografie zur Planung freier Perforans-Lappenplastiken (DIEP-Flaps) zur Brustrekonstruktion

Preoperative Doppler ultrasonography for planning free perforator flaps is widely established to identify preoperatively perforators. The method allows one to localise the penetrating point of the perforator through the abdominal fascia. By this means it is not possible to see the intramuscular course or the position of the perforator in relation to the inferior epigastric artery. Lately the technique of computed tomographic angiography provides an opportunity for visualising the course of perforator vessels in these tissues. This paper summarises our experience with the preoperative CT angiography in our breast centre. Since spring 2009 we have reconstructed the breasts of 44 female patients by using free flaps from the lower abdominal wall. 6 of these were bilateral. In a total number of 50 breast reconstructions we used 23 deep inferior epigastric perforator (DIEP) flaps and 27 muscle-sparing transverse rectus abdominis muscle (TRAM) flaps. In addition to the preoperative ultrasonography, a CT angiography of the lower abdomen was conducted in 29 patients. On average they showed at least 2 perforators on the left as well as right abdominal sides, which could be used as flap vessels based on their signal intensity. Based on their estimated microsurgical dissection complexity, the perforator vessels could be classified into 3 groups: 1) direct perforators of category A with short intramuscular course (39%), 2) perforators with long intramuscular course of category B (50%) and 3) "turn around" perforators of category C, which pass medially around the rectus abdominis (11%). The technique of CT angiography permits a reliable preoperative visualisation of perforators in their entire course and facilitates the selection of the supplying perforator as well as the intraoperative procedure for the surgeon. The suggested classification of perforators into 3 groups simplifies the preoperative assessment of the microsurgical dissection effort. Compared to the commonly used Doppler ultrasonography there are disadvantages like the additional cost factor and the radiation exposure. However, in our experience the more detailed planning increases the safety of flap raising and reduces surgery time, so that we consider CT angiography a positive tool to facilitate free perforator flaps.

The use of free flap for limb salvage in children with tumors of the extremities

BackgroundThe purpose of this study was to evaluate long-term functional outcomes in pediatric oncology patients who underwent limb salvage using free flaps. MethodsAll 22 pediatric oncology patients treated with a free flap for extremity salvage were included in the study from 1999 to 2008. ResultsThe median patient age was 13.5 years. All but one patient had sarcoma, which involved lower extremity in 45% and upper extremity in 55%. The median bone defect length was 13.9 cm: reconstructed with vascularized free fibula in 68% (in 23% osseous allograft was also used) and used fibula growth plate transfer in 23%. The mean soft tissue defect area was 108 cm2: reconstructed with latissimus dorsi flap in 4 patients, vertical rectus abdominus muscle flap in 2, and anterolateral thigh flap in 1. The majority of the complications were nonunion (14%) and wound infection/dehiscence (14%). The median Musculoskeletal Tumor Society score was 70. Patients with tumors in the upper extremity had significantly higher Musculoskeletal Tumor Society scores compared with lower extremity tumor patients (80 vs 50, P = .04); and among those with lower extremity tumors, patients with distal defects had better outcomes than patients with proximal defects (70 vs 40, P = .03). ConclusionIn pediatric oncology patients who need limb salvage, use of free flaps can result in good long-term functional outcomes.

Induced Membranes—A Staged Technique of Bone-Grafting for Segmental Bone Loss

Chong, Keen-Wai MBBS, MRCS(Edin)MMed(Ortho)FRCS(Edin)(Ortho)1; Woon, Colin Yi-Loong MBBS, MRCS(Edin)MMed(Surg)MMed(Ortho)1; Wong, Merng-Koon MBBS, FRCS(Glasg), FAMS1 Author Information

Use of the Rectus Abdominis Muscle Flap for Repair of Enterocutaneous Fistulae: A Case Series

A fistula is considered complex when abdominal connective tissue and fascia are lost due to infection or debridement, exposure to caustic substances or retraction, as seen in the prolonged open abdomen. These fistulae are essentially enteroatmospheric, because they have no corresponding abdominal wall fat or fascia between the bowel lumen and the outside world. They often occur after bowel is exposed for a prolonged period of time and can exist as either small or large intestinal fistulae. In the literature, the mortality of these patients is noted to be as high as 80% with a nearly universal morbidity.1 Early control and characterization of the fistulae are imperative as these patients can easily become malnourished and septic. Because the spontaneous closure rate of these fistulae is exceedingly low ( 30% in some series), creative management and assistance in closure are often necessary.1,2 Although the recommended surgical management technique is resection of the involved fistulous bowel with reapproximation of the patient’s fascia, the complex fistula does not permit this occasionally.3,4 These are the cases that are more demanding in terms of both surgical and medical management. Complex wound care arrangements, skin grafting, and various devices and techniques have been identified to help gain control and assist in closure of the enterocutaneous fistula.5 When those techniques fail or the patient is deemed unable to undergo further extensive wound care and multiple attempts at closure, one option to provide a vascularized pedicle of tissue for closure of the fistula is the rectus abdominis muscle flap. The purpose of this discussion is to describe in detail the technique itself, explain its rationale for use, and present our first six consecutive cases along with their outcomes using this technique.

Stabilization of the Chest Wall: Autologous and Alloplastic Reconstructions

The goals of chest wall stabilization include maintenance of a rigid airtight cavity, protection of the thoracic and abdominal contents, optimization of respiration, and, whenever possible, an aesthetic reconstruction. Evidence suggests that bony fixation results in reduced ventilator dependence, a shorter overall hospital stay, and improved upper extremity function. We prefer to accomplish this with autologous tissue alone (such as the pectoralis major, latissimus dorsi, or rectus abdominus muscle flaps) for small to moderate defects. En bloc resection of defects larger than 5 cm or containing four or more ribs will likely benefit from chest wall stabilization. For patients previously treated with radiation, even larger defects may be tolerated owing to fibrosis. For these larger defects, methyl methacrylate composite meshes are used and covered with vascularized tissue. Contaminated wounds are generally reconstructed with bioprosthetic mesh rather than synthetic mesh. Using these principles, the reconstructive plastic surgeon can devise a comprehensive and safe plan to repair tremendous defects of the chest wall.

Workhorse Flaps in Chest Wall Reconstruction: The Pectoralis Major, Latissimus Dorsi, and Rectus Abdominis Flaps

Large and life-threatening thoracic cage defects can result from the treatment of traumatic injuries, tumors, infection, congenital anomalies, and radiation injury and require prompt reconstruction to restore respiratory function and soft tissue closure. Important factors for consideration are coverage with healthy tissue to heal a wound, the potential alteration in respiratory mechanics created by large extirpations or nonhealing thoracic wounds, and the need for immediate coverage for vital structures. The choice of technique depends on the size and extent of the defect, its location, and donor site availability with consideration to previous thoracic or abdominal operations. The focus of this article is specifically to describe the use of the pectoralis major, latissimus dorsi, and rectus abdominis muscle flaps for reconstruction of thoracic defects, as these are the workhorse flaps commonly used for chest wall reconstruction.

Versatile use of rectus abdominis muscle and musculocutaneous flaps for soft-tissue reconstruction: our clinical experiences in 25 cases

The rectus abdominis muscle and musculocutaneous flaps have contributed to the efficient reconstruction of tissue defects that require a large amount of cutaneous and muscular tissue. In this article, outcomes of soft-tissue defects after reconstruction with the rectus abdominis muscle and musculocutaneous flaps were retrospectively analyzed. From August 2003 to June 2009, 25 flaps were transferred to reconstruct a wide variety of soft-tissue defects in the breast, chest wall, groin, perineal, and head and neck regions, as well as the upper and lower extremities. The rectus abdominis muscle and musculocutaneous flaps were used as part of 11 different approaches in 25 cases. There were 13 male and 12 female patients; the mean patient age was 44.2 years. The mean follow-up period was 8 months (range, 4–15 months). The overall success rate was 100%, and all flaps healed uneventfully. All reconstructive procedures were completed without any major complications. Rectus sheets were repaired primarily, and no mesh application was used. Minor complications related to transferred flaps were wound infection and dehiscence in one case, wound dehiscence in two cases, and flap lymphedema in one case. Minor complications related to the donor site were seroma in one case and wound infection and dehiscence in another case. This study presents our experience with the rectus abdominis muscle and musculocutaneous flaps in a series of 25 cases. The indications for the use of this particular flap with other flaps are discussed.

Reconstruction of complex groin defects with inferior epigastric artery-based rectus abdominis muscle flaps: report of two cases

Because the extremities are dependent on a single vascular supply, namely the brachial and femoral arteries, injuries around the girdles are challenging, and may contribute to high morbidity rates such as extremity loss, or even mortality due to bleeding, sepsis or vascular compromise. The reconstruction or aided closure of these regions may present additional technical difficulties in the presence of a vascular injury that complicates the use of a microvascular-free transfer, which sometimes may be needed to cover the exposed vessels, bones, tendons, and cartilages whenever the neighboring skin and subcutaneous tissue are inadequate or demised. In these circumstances, pedicled regional flaps of muscular or musculocutaneous consistency (especially if a bulk or rich vascular tissue is needed) would be an alternative. In this report, we present two cases that underwent femoral artery repair via saphenous vein grafting in the vascular surgery clinic followed by our inferiorly based pedicled rectus abdominis muscle flap coverage procedure.

Breast reconstruction using deep inferior epigastric artery perforator flap

Breast reconstruction with autologous tissue has been generally accepted as a reliable procedure, the preferred donor site being lower abdominal tissue. To sacrifice the minimal amount of muscle tissue and to reduce donor site morbidity, the concept of a perforator flap was applied to the fields of breast reconstruction, such as the deep inferior epigastric artery perforator (DIEAp) flap. The DIEAp flap provides essentially the same soft tissue components as the transverse rectus abdominis muscle (TRAM) flap while significantly reducing harvesting of the rectus muscle from the abdominal wall, thereby minimizing donor site morbidity; which includes abdominal weakness, hernia, and postoperative pain, with decreased recovery time. However, there are some concerns about the tedious and risky dissection of intramuscular perforators, and the variable vascularity of the flap supplied by tiny perforators. According to our novel flap harvesting techniques, using bipolar electrocauterization for intramuscular dissection is useful in preventing injury to the tiny perforators. Including some fibers of rectus muscle and soft tissue without full isolation and skeletonization around the pedicles is also useful for prevention of vascular injury and intraoperative vessel spasms. Moreover, the flap must include 2 to 3 reliable perforators, regardless of lateral or medial rows, for prevention of postoperative fat necrosis. The superficial inferior epigastric vein can provide additional venous drainage. These surgical tips can aid in overcoming the pitfalls of the DIEA perforator flap in breast reconstruction. The DIEAp flap is an excellent choice for breast reconstruction. According to our experience, it has been shown to be a safe and reliable method for providing good results and patient satisfaction with minimal donor morbidity in breast reconstruction.