The rectus abdominis myocutaneous free flap

The successful transfer of a free rectus abdominis myocutaneous flap based on the inferior epigastric vessels is reported. The preliminary experimental investigations leading to the design of this flap are described.     

The rectus abdominis myocutaneous island flap in breast cancer

The use of 30 rectus abdominis flaps in patients with breast cancer is described. In 7 patients the flap has been used to repair the defect following ablation of recurrent disease or radionecrotic ulcers. In the remaining 23 the flap has been used as part of a primary reconstruction at the time of mastectomy. The technique is described together with the results in these patients. The cosmetic results have been satisfactory. The technique as described has proved completely reliable. Follow-up to 18 months has shown that fears of incisional hernias developing are unfounded.     

Use of the vertical rectus abdominis myocutaneous flap after abdominoplasty.

A vertical rectus abdominis myocutaneous flap was used to provide cover for a recurrent angiosarcoma in the abdominal skin. Of note, the patient had 9 years previously undergone formal abdominoplasty to allow closure following excision of the primary tumour. This flap is normally reliant on myocutaneous perforators originating from the deep epigastric system, which are divided during abdominoplasty. Despite this, the flap survived well, implying that a new blood supply had formed during the intervening years. This flap can, therefore, be considered a possible option in reconstructive cases where other options are limited, despite a preceding abdominoplasty. In the future because of the increasingly common occurrence of abdominoplasty in young females, this procedure may need to be considered.     

Late necrosis of a pedicled rectus abdominis myocutaneous flap

Flap neovascularization is an important plastic surgery phenomenon, which allows the pedicle to achieve an alternative blood supply basis for pedicled flap autonomization. Numerous historical flaps have been described which provided the clinical evidence of its occurrence Neovascularization is assumed to happen between flap and recipient bed and numerous experimental and clinical studies have documented this phenomenon. There are, however, some literature reports of late flap failure due to lack of neovascularization. We present a case report that reinforces such findings, with a late rectus abdominis myocutaneous flap failure due to documented axial venous obstruction 4 months after inset.     

Reconstruction with rectus abdominis myocutaneous flap for total glossectomy with laryngectomy

From October 1999 to July 2005, defects after total glossectomy with laryngectomy (TGL) for cancer of the tongue or middle pharynx were reconstructed with rectus abdominis myocutaneous (RAMC) flaps in nine patients. The skin flaps were designed larger in width than the original defect to create a funnel-shaped oropharynx and prevent stricture. Six patients had uneventful postoperative courses and began to eat perorally 8 to 15 days postoperatively. One patient suffered flap necrosis due to arterial thrombosis and two patients had leakage. Eventually, eight patients could eat soft foods or gruel, except one patient who had ingested food through a gastrostomy preoperatively. When TGL was performed without mandibulectomy, the blood supply for the remnant mucosa of the backside of the mandible is generally not good, for which the reconstruction with the overlapping deepithelialized flap and muscle is useful for prevention of the fistula formation. We considered that the RAMC flap is a good option for reconstruction after TGL.     

Transfer of an inferior rectus abdominis myocutaneous flap following enterostomy.

A rectus abdominis myocutaneous flap was successfully transferred in a patient in whom a mucous fistula had previously been brought through the midportion of the muscle. The flap was used to close a large defect in a paraplegic. Previous enterostomy is not a contraindication to the use of this flap. Preoperative arteriography to confirm the presence of a patent deep inferior epigastric artery is recommended prior to flap transfer.     

Problems with the transverse rectus abdominis myocutaneous island flap in breast reconstruction

The transverse rectus abdominis myocutaneous (TRAM) island flap would appear to be ideal for breast reconstruction where a significant skin and muscle deficiency exists after mastectomy. The flap is bulky enough to allow reconstruction without a prosthesis and leaves an excellent donor scar. However, in contrast to the impression gained from most reports, we have found the TRAM flap to have a high failure rate. Careful patient selection is essential to avoid flap necrosis.     

The free transverse rectus abdominis myocutaneous flap in breast reconstruction after mastectomy.

Breast reconstruction after mastectomy by the transverse rectus abdominis myocutaneous (TRAM) flap technique is a widely accepted method which allows reconstruction without the need for an implanted silicone prosthesis. Even in suitable patients, deficiencies of the traditional technique, where the blood supply is based on anastomotic vessels in the superior part of the rectus abdominis muscle, may lead to complications. These include flap failure, fat necrosis which may mimic recurrence of breast carcinoma or sub-optimal cosmetic results. By transferring the same abdominal tissue as a free flap based on the inferior epigastric vessels, a more reliable blood supply and better cosmetic results can be obtained. This article reports a series of 14 flaps in 13 patients in whom an entirely free flap technique was used. No flap losses were recorded and the results are judged to be superior to the traditional technique.     

Rotation flap of the anterior rectus abdominis sheath for hernia prevention in TRAM breast reconstruction

Prevention of hernia or bulge of the abdominal wall after TRAM breast reconstruction has been a challenge for the reconstruction surgeon. Different techniques have been described to avoid this complication. The use of anterior rectus abdominis sheath (ARAS) for the repair of various abdominal wall hernias has been well described in the literature and is the basis of the authors' technique. The authors present the use of ARAS flap in TRAM breast reconstruction. It is a simple and safe technique using autologous tissues for hernia or bulge prevention.     

Use of a vertical rectus abdominis myocutaneous flap in bilateral groin dissection for recurrent carcinoma of the penis.

We present a 42-year-old man requiring bilateral groin dissection for recurrent squamous cell carcinoma of the penis. Tissue cover was obtained using a pedicled vertical rectus abdominis myocutaneous flap. This case is made interesting by the use of a unilateral flap to cover a large bilateral lower abdominal tissue defect, enabling minimal weakening of the abdominal wall, primary skin closure, and allowing early mobilization and hospital discharge.     

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

Purpose  

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.     

Abdominal repair after harvesting a rectus abdominis myocutaneous flap]

After reviewing the anatomy and physiology of the abdominal wall, the author discusses the variants of skin paddles and pedicles used in the various types of rectus abdominis flaps for mammary reconstruction. In the light of the literature and his personal experience, he analyses the various abdominal wall repair procedures and the abdominal wall and aesthetic sequelae.     

Liposuctioned rectus abdominis myocutaneous flap to cover a vulval skin defect.

A woman with genital Paget disease had a reconstruction with a rectus abdominis myocutaneous flap after primary liposuction during operation. The patient recovered satisfactorily.     

Chylous ascites after pedicled transverse rectus abdominis myocutaneous flap harvest

Chylous ascites is a rare clinical condition that occurs as a consequence of disruption of the abdominal lymphatics. Here, we present the case of a 58-year-old woman with sustained chylous ascites after pedicled transverse rectus abdominis myocutaneous (TRAM) flap harvest. The chylous ascites did not decrease despite conservative therapy. For the diagnosis and localization of the chyle leakage, lymphangiography with lipiodol delivery was performed. Chylous drainage continued in a decreasing manner for the next 4 d because lipiodol accumulated to the point of leakage outside the lymphatic vessel causing a regional inflammatory reaction and obstructing the lymphatic vessels. To our knowledge, there is no case of chylous ascites related to pedicled TRAM flap harvest that has been reported in the English literature, in which the chyle leakage spontaneously resolved after lymphangiography.     

Female urethral reconstruction using a tubed rectus abdominis myocutaneous flap

We describe the novel use of a rectus abdominis myocutaneous flap for reconstruction of the female urethra following an oncological pelvic resection. Reconstruction of the female urethra from the bladder neck to external urethral orifice was successfully performed, avoiding the need for a urostomy. To our knowledge, the myocutaneous flap has never been described for complete urethral reconstruction.     

Correction of high pelvic defects with the inferiorly based rectus abdominis myocutaneous flap

The two inferiorly based rectus abdominis myocutaneous flaps are the most versatile and accessible flaps for high pelvic defects. Their primary contribution is in the obliteration of the pelvic "deadspace." At the present time, these useful flaps are generally considered only for massive defects of the perineum, groin, and pelvis, but improved flap designs will enhance their usefulness for smaller defects.