Vertical Rectus Abdominis Musculocutaneous Flap Research Articles

Radical sternectomy and primary musculocutaneous flap reconstruction to control sternal osteitis.

Sternal osteitis after median sternotomy is associated with considerable morbidity and mortality. The use of muscle and omentum flaps has been proved as valid adjunct to combat these severe infections. In this study we present our experience with a more radical approach. Sternectomy consisted of the resection of the entire sternum, including the costochondral arches and the sternoclavicular joints, and was followed by the repair of the defect with musculocutaneous flaps without any restabilization of the thoracic wall. Thirteen patients received a vertical rectus abdominis musculocutaneous flap, 14 patients received a pedicled latissimus dorsi musculocutaneous flap, and 12 patients received a free latissimus dorsi musculocutaneous flap (total of 40 flaps in 39 patients of 66 patients who required surgical revision for sternal osteitis of 6078 total patients with sternotomies). Two patients died within 30 days after the operation (early mortality of 5.1%); however, they did not die of sternal infection, which was cured without any recurrence in all cases. Seventeen patients (44%) required secondary, mostly minor operations for local complications. Despite some paradoxic chest movements, the patient satisfaction rating was unanimously high at the long-term follow-up (0.4 to 8.5 years, median 2.3 years). The short- and long-term complication rates were similar in the three groups. We conclude that radical sternectomy and immediate musculocutaneous flap repair provided definitive control of sternal infection in even the most severe cases, thus reducing infection-related mortality. The trade-off was a substantial rate of local complications; however, these did not cause any relevant morbidity.

An experimental study of skin flap associated with muscle: is muscle nourishment possible through the musculocutaneous perforators?

An experimental study was planned to examine whether the blood supply of muscle would be maintained by reverse flow from the cutaneous arteriolar microcirculatory system via the musculocutaneous perforators. A flap model containing both muscle and skin based on the inferior superficial epigastric vessels was designed with the blood supplied directly from the cutaneous arteriolar microcirculatory system. A total of 154 male Wistar Albino rats were divided into three groups. Group I included the standard vertical rectus abdominis musculocutaneous flap based on the superior deep epigastric vessels (N = 48). Group II included the acute cutaneous muscle flap (N = 53). Group III contained the delayed cutaneous muscle flap (N = 53). Skin flap survival area, muscle scintigraphy with technetium-99m-methoxy-isobutyl-isonitrile, microangiography, and histopathological examination of the flaps were conducted. The mean percentage of surviving skin paddle area was 96.4 +/- 5.2%, 84.9 +/- 21.6%, and 91.0 +/- 16.8% in groups I, II, and III respectively. There was no significant difference between groups. Microangiography revealed the blood flow from skin to muscle through the musculocutaneous perforators. The radioisotope uptake of the muscle flap was expressed as A percentage of the intact contralateral muscle. Mean uptake in group I was 90.1 +/- 4.9% immediately after flap elevation, 62.5 +/- 13.5% on day 2, and 88.3 +/- 12.0% on day 7. These values were 53.7 +/- 7.1%, 63.6 +/- 14.1%, and 89.2 +/- 18.1% in group II, and 64 +/- 7.8%, 75.5 +/- 9.8%, and 92.8 +/- 40.1% in group III. Radioisotope uptake in group I was significantly higher than groups II and III immediately after flap elevation (p < 0.05, analysis of variance), whereas there was no significant difference on days 2 and 7. Histopathological examination revealed surviving muscle tissue without marked atrophy. There was no marked difference between groups histopathologically. These results indicate that muscle tissue may survive by reverse flow through the musculocutaneous perforators when elevated with an axial skin flap.

Viability of the vertical rectus abdominis musculocutaneous flap in the rat following prior internal mammary artery ligation

A large abdominal skin flap nourished superiorly by a single rectus abdominis muscle has well known advantages for providing vascularized tissue coverage of thoracic defects. Unfortunately, if both internal mammary arteries have previously been violated, as is increasingly common today following coronary artery revascularization, initial consideration of this flap would seem to be contraindicated. Nevertheless, anecdotal examples of clinical survival of the rectus abdominis muscle flap in this situation exist. This laboratory study was initiated to ascertain whether a musculocutaneous flap could also be expected to survive. Using a Sprague-Dawley rat model, identical bilateral vertical rectus abdominis musculocutaneous (VRAM) flaps were designed. The internal thoracic [sic. mammary] vessels supplying one muscle had been divided two weeks previously just above the costal margin, as frequently encountered in the clinical situation. Mean survival of control flaps (intact internal thoracic) was 85.5±5.9% versus 67.9±35.3% for the delayed flap that relied on collateral circulation for any viability. Although no statistical difference per se existed between these groups (p=0.32), the great variability in surviving portions of those flaps dependent only on available collaterals suggests extreme caution before assuming that any abdominal skin flap based on a rectus abdominis muscle without an intact internal mammary source vessel would be reliable.

Closure of mediastinal wounds with deepithelialized rectus abdominis musculocutaneous flaps.

Deep and narrow mediastinal defect after sternal debridement can be effectively obliterated by deepithelialized vertical rectus abdominis musculocutaneous flaps, based on the superior epigastric vessels. This composite flap has sufficient mass to obviate the need for additional vascularized tissue and is, therefore, offered as an alternative to multiple flap procedures. It offers a superior cosmetic appearance and better chest stability than a traditional island myocutaneous flap. Eleven patients had their mediastinal wounds repaired by this method with a low complication rate and good final results.

Total scrotal reconstruction with vertical rectus abdominis musculocutaneous (VRAM) flap in the treatment of penoscrotal lymphedema

A 37-year-old man with scrotal and penile lymphedema was treated by total excision of the scrotal and penile skin and subcutaneous tissue. Split thickness skin grafts were used to cover the penis and the pubic area. An inferiorly based left rectus abdominis muscle with a 12 x 16 cm skin island from the epigastric region was used to reconstruct the scrotum. The VRAM flap is a simple, reliable flap and it provides sufficient coverage of the exposed testicles after total excision of diseased scrotal skin. It also gives a satisfactory esthetic result. The VRAM flap may be another source for reconstruction of the total scrotum.

Reconstruction of a large full thickness chest wall defect by a double-folded vertical rectus abdominis musculocutaneous flap

A case is reported in which a double-folded vertical rectus abdominis musculocutaneous flap was successfully transferred to cover a large full thickness chest wall defect after resection of recurrent breast cancer. A brief discussion on chest wall reconstruction is included.

Vertical rectus abdominis musculocutaneous flap for chest wall reconstruction after irradiation.

We have used a contralateral vertical rectus abdominis musculocutaneous flap based upon the superior epigastric vessels in six patients to provide coverage after resection of locally recurrent breast carcinoma in irradiated tissues. Primary healing of defects as large as 16 cm X 35 cm has been obtained using this technique. Although there is no evidence to suggest that such a procedure significantly lengthens survival, it was clearly beneficial to the quality of life in these patients. Our results suggest that older patients with relatively indolent disease receive the greatest benefit from this procedure.