Rectus Abdominis Myocutaneous Flap Research Articles

Breast reconstruction with autologous tissue following mastectomy: two case reports of a delayed conventional transverse rectus abdominismyocutaneous (TRAM) and latissimus dorsi myocutaneous (LDM) flap surgery

Breast cancer is the most common malignant tumor and the leading cause of death among females. Most women with breast cancer will undergo breast-conserving surgery (BCS) or lumpectomy, simple or total mastectomy, modified radical mastectomy or bilateral mastectomy. Breast reconstruction solves many of the problems. The goal is to return the patient to a near-normal state so that she is not handicapped in her daily living. Breast reconstruction is also intended to offer psychological benefits to women treated by mastectomy following a diagnosis of possibly terminal cancer. In these case reports, we reported two successful cosmetic reconstruction cases. The first case was a 39-years-old female with non-recurrent breast cancer consulted and was referred by the oncology surgeon to the Plastic Reconstructive, and Aesthetic Surgery Division, Department of Surgery, Dr. Sardjito General Hospital. She wanted to undergo breast reconstruction. We planned to operate three years following mastectomy. She was diagnosed with 3B-stage of right breast cancer before. After the surgery, the patient received six series of chemotherapy. She also underwent radiotherapy 25 times and hormonal therapy. We decided to perform a transverse rectus abdominis myocutaneous (TRAM) flap surgery on her with 22 months follow up. The procedure provided good results, and the patient was satisfied. The second case was a 32-year-old woman who after excision of a phyllodes tumor and wanted breast reconstruction. Reconstruction was performed four years after tumor removal using latissimus dorsi myocutaneous (LDM) flap. The surgery provided good results, and the patient was satisfied. We reported two successful cosmetic reconstruction cases of non-recurrent 3B-stage of right breast cancer post-mastectomy after pedicled TRAM flap surgery and left breast post excision of phyllodes tumor after LDM flap surgery.

A shark attack treated in a tertiary care centre: Case report and review of the literature

Although uncommon, shark attacks can lead to devastating outcomes for victims. Surgeons also face unique challenges during operative management such as exsanguination, shock, specific injury patterns and infections. This case report presents the management of a 39-year-old previously healthy female attacked by a shark while on vacation in Mexico. The patient sustained severe injuries to her left arm and her left thigh. She was transferred to a Canadian institution after ambiguous operative management in Mexico and presented with no clear antibiotic coverage and a Volkman’s contracture of the left upper extremity. In total, the patient underwent four washouts of wounds, two split-thickness skin grafts, one free anterolateral thigh flap, and one free transverse rectus abdominus myocutaneous flap for the reconstruction and salvage of the left lower extremity. This article highlights the specifics of this case and describes important points in managing these devastating injuries.

Breast Reconstruction with Free Transverse Rectus Abdominis Myocutaneous Flap Complicated by Deep Vein Thrombosis-associated Pulmonary Thrombo-embolism

Breast Reconstruction with Free Transverse Rectus Abdominis Myocutaneous Flap Complicated by Deep Vein Thrombosis-associated Pulmonary Thrombo-embolism

Evaluation of the effects of radiotherapy on breast reconstruction with a transverse rectus abdominis myocutaneous flap

Evaluation of the effects of radiotherapy on breast reconstruction with a transverse rectus abdominis myocutaneous flap

Patient selection and transverse rectus abdominis myocutaneous flap complications: a literature review

Patient selection and transverse rectus abdominis myocutaneous flap complications: a literature review

Costal osteo-chondral autograft in hand and wrist surgery

Previous studies have described osteo-chondral costal vascularized autograft with a pedicled myo-osteous serratus anterior, a transverse rectus abdominis myocutaneous flap combined with vascularized costal cartilages and a case of vascularized osteochondral costal graft to replace the proximal pole of the scaphoid, partially successful. This study evaluates the feasibility of vascularized osteo-chondral costal autografts in the treatment of hand and wrist degenerative and post traumatic arthritis+ and describe the different types of possible grafts adapted to this specific indication. Sacrifice of the a rib cartilage to access the internal mammary vessels for breast reconstruction has become frequent and safe, with very few thoracic complications. This piece of cartilage resected and thrown away could be kept to reconstruct other deficient part of the body, with minimal complications. This study is based on thorax CT scans with intravenous contrast injection, wrist and hand CT scans, anatomic cadavers’ dissections data and information obtained in the literature. Random patients were included from the imaging software database of public hospitals of Marseille, we selected ten (five women and five men) normal thoracic injected CT- scans and ten normal hand and wrist CT-scans (five women and five men). Precise measures of ribs and carpal bones size and vessels’ (internal mammary arteries) position and size were taken on these scans. We then did dissections to put into practice the alternatives deducted from CT scans studies. The morbidity of previous costal vascularized autografts is important, and the vascularization not very reliable (based on anastomoses, secondary vessels). A myo-osteous flap implies a large and bulky tissue, which is difficult to manage in hand and wrist surgeries. Degenerative and post-traumatic arthritis of hand and wrist joints are still difficult to treat with generally bad outcomes, in certain situations other vascularized grafts (femoral condyle graft, iliac crest graft) are proposed. This work points out different possible safe sites of osteo-chondral costal vascularized autograft's harvest. These possible grafts have strong vascularization's reliability, large vessels’ caliber, long pedicle, and very low donor site morbidity. The third or fourth rib either cartilage only or osteo-chondral graft can be harvested on the internal mammary vessels (with direct branches to the periosteum). Another ideal location, even more for women (scar in the inframammary fold), is the sixth rib, more prone to cartilaginous harvest only, based on the musculo-phrenic artery.

Reconstruction of Pelvic Exenteration Defects Using the Combined Method With Extended Vertical Rectus Abdominus Flap and Vacuum-Assisted Suction Drainage

Introduction: Pelvic exenteration is a highly invasive procedure, with a reported rate of 20%–80% for serious complications. Thus, the prevention of postoperative complications is a major issue. Many previous reports have emphasized the importance of filling the dead space to prevent postoperative complications. In addition to filling the dead space, we believe that achieving sufficient drainage is extremely important. In this paper, we present a new combined method of the extended rectus abdominis myocutaneous flap and vacuum drainage with multiple drains, which achieved a lower frequency of complications. Case Presentation: The subjects were 6 patients who underwent reconstruction following pelvic exenteration during a 7-year period between April 2005 and September 2013. We retrospectively measured the volume of the pelvic cavity and that of the rectus abdominis flap on lateral computed tomography (CT) scans to calculate the percentage of the dead space that was filled by the flap. There were no problems with flap engraftment in any of the patients. There were no serious complications, and no patient required additional surgery. The percentage of the dead space filled ranged from 25% to 46% (mean: 32%). Conclusion: The rectus flap + vacuum drainage method, which uses an extended rectus abdominis myocutaneous flap to decrease the pelvic dead space and multiple vacuum suction drains, was associated with the prevention of serious complications.

Flap monitoring with continuous oxygen partial tension measurement in breast reconstructive surgery: A preliminary report.

The best method for the postoperative monitoring of flaps in reconstructive surgery is still a matter of debate. The aim of this study is to evaluate the usefulness of an oxygen partial tension monitoring system for the postoperative follow-up of a series of breast flaps, in addition to the traditional periodical clinical evaluations. Twenty-one consecutive female patients (mean age: 61 years) who underwent free- or pedicled-flap reconstruction of the breast were included in the study. Fifteen patients had a deep inferior epigastric perforator flap breast reconstruction, while the remaining six patients underwent a transverse rectus abdominus myocutaneous flap reconstruction. The Licox® Recon (Integra LifeSciences Corp, Plainsboro, New Jersey) system was used for the monitoring of the flaps. The oxygen partial tension (PtO2 ) values were displayed on the system monitor and registered with appropriate software for statistical analysis. A decreasing trend in the mean PtO2 values was observed over the first five postoperative days. The mean values registered in the first postoperative day were higher than those observed in the subsequent four days. Three patients were lost due to misplacement of the probe. Among the remaining 18 flaps, 3 (17%) reported a remarkable decrease in PtO2 values, with the mean PtO2 registered in the second postoperative day being significantly lower than in the other flaps (7.3 ± 0.7 vs. 17.0 ± 0.9; P-value <.05). These three flaps have been promptly re-explored, with a final flap failure rate of 5.5% (1 flap). The continuous oxygen tension evaluation represents a promising method for the postoperative monitoring of breast reconstructive surgery flaps when used in combination with the traditional periodic clinical evaluations.

Reconstruction par lambeau de Taylor après amputation abdomino-périnéale : à propos de 68 cas

Healing after abdomino-perineal resection is often difficult, especially in patients who have undergone radiation therapy. Vaginal reconstruction is also an important issue for the women who undergo this surgery. We describe and analyze here our series of perineal reconstructions with modified Taylor flaps. Between 2010 and 2016, 68 patients (52 women, 16 men) with cancer of the anal canal (53), adenocarcinoma of the lower rectum (9), or other malignant neoplasms of the perineum underwent reconstruction with a rectus abdominis myocutaneous (RAM) flap with an inferior pedicle and an oblique skin paddle. This review of records showed that all patients healed, with a median of 30 days. The reoperation rate was 11.7% including 1 for eventration. The principal causes for delayed healing were scar dehiscence, abscess, and partial necrosis. No flap required removal, however. The mean duration of hospitalization was 23.7 days. Modified Taylor flaps substantially improved the reconstruction of defects resulting from abdomino-perineal resection. They enabled complete and rapid healing with low comorbidity.

Effects of flap or myocutaneous flap combined with fascia lata or composite mesh on repairing severe high-voltage electrical burn wounds in abdomen of patients

Objective: To investigate the effects of flap or myocutaneous flap combined with fascia lata or composite mesh on repairing wounds in abdomen of patients with severe high-voltage electrical burn. Methods: From January 2010 to May 2017, 11 patients with severe high-voltage electrical burn in abdomen were hospitalized in our burn wards. In 3 hours to 7 days after burn, operation was performed when patients were in stable condition. After debridement, intestines with necrosis or perforation in 4 patients with peritoneal defects were resected and intestinal anastomosis was performed. The size of abdominal wounds after debridement ranged from 13 cm×9 cm to 41 cm×32 cm. Five patients were treated with rectus abdominis myocutaneous flap and size of which ranged from 14 cm×10 cm to 30 cm×17 cm. Among the above 5 patients, 4 patients with peritoneal defects used composite mesh of 25 cm×20 cm to enhance abdominal wall. Three patients were treated with tensor fascia lata myocutaneous flap, and size of the flap ranged from 24 cm×10 cm to 27 cm×13 cm. Three patients were treated with anterolateral thigh flap with fascia lata, and one of them was treated with the lobulated flap; size of the flap ranged from 18 cm×13 cm to 25 cm×15 cm. The later 6 patients used fascia lata of flap to enhance abdominal wall. The donor sites were sutured directly or repaired with intermediate split-thickness skin graft of thigh. Results: After operation, flaps or myocutaneous flaps of patients were survived, and strength of abdominal wall recovered. During follow-up of 6 month to 1 year, flaps or myocutaneous flaps were in good appearance, with no ankylenteron or abdominal wall hernia. Conclusions: Flap or myocutaneous flap combined with fascia lata or composite mesh can achieve good effects on repairing severe high-voltage electrical burn wounds in abdomen.

Comparison of breast reconstruction using ipsilateral and contralateral pedicle transverse rectus abdominis musculocutaneous flaps

Aim: Breast reconstruction has several beneficial effects on psychosocial well-being and quality of life. The ultimate goal has always been to create the most natural breast mound. Thus in many centers, the unilateral pedicled transverse rectus abdominis myocutaneous (TRAM) flap remains the most common technique for breast reconstruction. Our objective was to retrospectively compare the outcomes of ipsilateral and contralateral pedicle TRAM flaps.

Classification of chronic radiation-induced ulcers in the chest wall after surgery in breast cancers

Background and purposeTo explore the methods of clinical classification in chronic radiation-induced ulcers in the chest wall (CRUCWs).Materials and methodsA total of 64 patients with CRUCWs were treated. We divided the cases into 3 types (mild, moderate, or severe) according to their clinical manifestations. Conservative treatments, axial-pattern myocutaneous or local flaps, or filleted flaps were applied correspondingly.ResultsThe cases were divided as follows: mild (n = 11), moderate (n = 45), and severe (n = 8). Eight cases were cured by conservative surgical therapy. One case had a recurrence 6 months after conservative therapy and was cured by a latissimus dorsi myocutaneous flap. The transferred flaps all survived, including 26 transverse rectus abdominis myocutaneous flaps, 8 longitudinal rectus abdominis myocutaneous flaps, 6 latissimus dorsi myocutaneous flaps, 3 contralateral breast flaps, 5 lateral thoracic rotation flaps, and 7 filleted flaps. In 2 transverse rectus abdominis myocutaneous flaps and 2 latissimus dorsi myocutaneous flaps, distal necrosis appeared in small areas. The resulting wounds were salvaged with skin graft and full healing was achieved.ConclusionCRUCWs can be divided into three types. Surgical methods should vary with distinguished classifications. The effective classification of CRUCWs has definite instructive significance on the selection of surgical approaches.

The Pararectus approach provides secure access to the deep circumflex iliac vessel for harvest of a large sized and vascularized segment of the iliac crest

BackgroundThe feasibility of harvesting a vascularized iliac crest utilizing the Pararectus approach was assessed in cadavers and then this new technique was implemented in a clinical case. MethodsBilaterally in five cadavers the branches of both external iliac arteries were injected with colored silicone to assess their position to each other and to harvest a bone graft vascularized by the deep circumflex iliac artery (DCIA) through the Pararectus approach. This technique was implemented in a 68-years-old female patient, initially admitted to a level-I-trauma center after sustaining multiple injuries by falling from great height. For definitive treatment of a severely contaminated medially open (Gustilo-Anderson Type 3A) calcaneal luxation fracture (Sanders type IIIBC) in this patient a vascularized iliac crest autograft harvest by the Pararectus approach was used for reconstructive surgery. ResultsThe DCIA and the deep inferior epigastric vessels (DIEV: vascularizing the rectus abdominis muscle and main pedicle of the inferiorly based rectus abdominis myocutaneous flap) are very close on the lateral and medial border of the external iliac artery, respectively. As a consequence, the retrograde dissection of the DIEV towards the DCIA through the Pararectus approach made the dissection of the vascularized iliac crest more amenable, preserving both the lateral femoral cutaneous and the genitofemoral nerves. Four months after the surgery the patient was able to fully weight-bear in orthopedic shoes. Radiographs and CT scans showed correct hind foot alignment and bony integration of the vascularized iliac crest graft into the residual calcaneal body. ConclusionThe Pararectus approach allowed for secure collection of large vascularized iliac grafts. The presented technique was successful as a salvage procedure in a clinical case with substantial bone loss after an open calcaneal fracture.

USE of arterialized saphenous vein venous flow-through flaps as a temporizing measure for hand salvage in contaminated wounds presenting with limb ischemia: A case series.

Vascular injuries resulting in limb ischemia are traditionally treated acutely with autologous or prosthetic bypass grafts. Traumatic contaminated injuries with soft tissue and vascular segmental loss are challenging as prosthetic bypasses are at risk of erosion, infection, and occlusion; and autologous bypasses are at risk of desiccation, blow-out, infection, and clotting. We propose a novel approach to these injuries by using arterialized saphenous vein venous flow-through free flaps (S-VFTF) as an autologous bypass, and present the results of its application in a series of cases. Spanning 2008 to 2015, four patients presenting with large contaminated crush/avulsion wounds with vascular injury underwent hand revascularization with S-VFTF, allowing the contaminated wounds to be serially debrided. Definitive soft tissue reconstruction was performed once the wound was considered clean. The S-VFTF skin paddle was de-epithelialized and the soft tissue defect covered with a free latissimus dorsi flap or a rectus abdominis myocutaneous flap. All ischemic limbs were successfully reperfused and there were no take backs for perfusion issues. All S-VFTF remained patent at discharge and final follow-up. No partial or complete finger/hand amputations were required. All definitive coverage free flap survived with no complications. The two-stage reconstruction presented may help reconstructive and vascular surgeons consider alternatives to traditional vascular reconstruction methods. This technique avoids an exposed vascular graft in an extensively contaminated open wound. It allows the surgeon to perform thorough and sufficient debridement of the wound, preventing definitive reconstruction in a not yet declared zone of injury.

Effectiveness of “Indocyanine Green Dye Clamp Test” in Selecting Perforators for Muscle-Sparing-2 Transverse Rectus Abdominis Myocutaneous Flaps in Breast Reconstruction

Introduction In breast reconstruction for cases in which tissue from zones 1 to 4 is required or a lower midline scar exists, it is possible to predict the need for vascular anastomosis with a vascular pedicle on the contralateral side if the dominant territory of each perforator can be identified in advance. In addition, it is possible to determine whether a single- or multiple-perforator-based flap is needed. We, therefore, developed the “indocyanine green dye (ICG) clamp test” to select perforators for breast reconstruction. Methods The blood flow of a perforator was blocked using a microvascular clamp when determining its inclusion in a flap. The clamps were released after the enlargement of the ICG fluorescence imaging range. The enlarged imaging range was then observed to determine whether an additional pedicle was required. Subjects One hundred thirty-two breast reconstruction procedures had been performed using the free muscle-sparing-2 transverse rectus abdominis myocutaneous (MS2 TRAM) flap method from May 2012 to December 2015. The population of the present study included 29 of these cases in which the selection of perforators was deemed necessary. Results We investigated the cases in which anastomosis of the contralateral vascular pedicle was unnecessary. It was possible to preserve the medial muscle in 79.3% of the cases using our procedure. Conclusion Our newly developed ICG clamp test was useful in selecting perforators for MS2 TRAM flaps and facilitated the performance of minimally invasive surgery.

Lengthening the pedicle of the rectus abdominis myocutaneous flap for repair of upper chest and neck defects.

INTRODUCTION The aim of this study was to investigate whether the pedicle of the rectus abdominis flap can be lengthened by resecting the inferior costal cartilage segments or associated muscle when repairing upper body defects. A formula was generated that calculates the expected increase in pedicle length. METHODS Thirty patients underwent computed tomography. The width and thickness of the third to seventh inferior costal cartilage segments as well as the width of the respective intercostal spaces were recorded. Four patients underwent reconstruction of an upper body defect with the relevant flap. RESULTS The expected mean increases in pedicle length were 4.07cm (standard deviation [SD]: 0.31cm) and 4.63cm (SD: 0.54cm) following resection of the left and right sides respectively of the seventh inferior costal cartilage segment, 7.99cm (SD: 0.49cm) and 10.82cm (SD: 0.23cm) following resection of the left and right sides respectively of the sixth and seventh inferior costal cartilage segments while resection of the fourth to seventh inferior costal cartilage segments would equate to increases of 17.48cm (SD: 0.62cm) and 22.05cm (SD: 0.21cm) for the left and right sides respectively. In four patients who required reconstruction, three flaps survived without problems but one flap developed partial necrosis. CONCLUSIONS Resecting inferior costal cartilage segments or associated muscle can lengthen the pedicle of the rectus abdominis flap for reconstruction of defects on the upper chest and neck.

A rare case of umbilical metastasis after delayed transverse rectus abdominis myocutaneous flap reconstruction for invasive breast cancer

A 46-year-old female presented with an inflamed and painful umbilicus. Past medical history included breast cancer, followed by metastatic sternal cancer two years after the initial breast cancer diagnosis.The painful umbilicus was confirmed metastasis from a primary breast cancer she had treated eleven years previously.Metastases to the umbilicus are rare, and are usually gastrointestinal in origin. To our knowledge this is the first report of a metastasis from any primary cancer to the umbilicus after transverse rectus abdominis myocutaneous flap (TRAM). Any lesion at any stage after treatment for breast cancer should be viewed with suspicion of recurrence and investigated and treated appropriately.

深下腹壁静脈の還流不全を認めた遊離腹直筋皮弁の 1 例

深下腹壁静脈の還流不全を認めた遊離腹直筋皮弁の 1 例

Donor-Site Complications and Remnant of Rectus Abdominis Muscle Status after Transverse Rectus Abdominis Myocutaneous Flap Reconstruction.

Background:Transverse rectus abdominis myocutaneous (TRAM) flap reconstruction after mastectomy in breast cancer patients has become one of the milestones in breast reconstruction. There are several techniques that have been used in an attempt to minimize untoward complications. We present the whole muscle with partial sheath-sparing technique that focuses on the anatomy of arcuate line and the closure of the anterior abdominal wall techniques with mesh and determine factors associated with its complications and outcomes.Methods:We retrospectively and prospectively review the results of 30 pedicled TRAM flaps that were performed between November 2013 and March 2016, focusing on outcomes and complications.Results:Among the 30 pedicled TRAM flap procedures in 30 patients, there were complications in 5 patients (17%). Most common complications were surgical-site infection (7%). After a median follow-up time of 15 months, no patient developed abdominal wall hernia or bulging in daily activities in our study, but 6 patients (20%) had asymptomatic abdominal wall bulging when exercised. Significant factors related to asymptomatic exercised abdominal wall bulging included having a body mass index of more than 23 kg/m2.Conclusion:Pedicled TRAM flap by using the technique of the whole muscle with partial sheath-sparing technique combined with reinforcement above the arcuate line with mesh can reduce the occurrence of abdominal bulging and hernia.

Reconstruction of a large defect of the female chest following keloid excision with use of the rectus abdominis myocutaneous flap

Aim: This study aimed to investigate the efficacy of the myocutaneous flap of the rectus abdominis in the surgical treatment of a large defect on the female chest following keloid excision.