Burned breast: treatment with a transverse rectus abdominis island musculocutaneous flap

A contralateral transverse rectus abdominis island musculocutaneous flap was employed in the treatment of a unilateral burned breast. The vascularization of the flap was based on the superior epigastric pedicle. The advantages of this method are that a transverse island musculocutaneous flap of the rectus muscle can be used with good results in the reconstruction of the burned breast; and that in patients with hypertrophic contralateral breasts, the inferior pole of the opposite breast can be added to obtain a larger area of the flap. The cutaneous color and the texture offered by this method assure a more symmetrical appearance in the area.     

Perineal reconstruction after radical pelvic surgery: A cost-effectiveness analysis

BackgroundRadical resection of pelvic and low rectal malignancies leads to complex reconstructive challenges. Many pelvic reconstruction options have been described including primary closure, omental flaps, and various fasciocutaneous and myocutaneous flaps. Little consensus exists in the literature on which of the various options in the reconstructive armamentarium provides a superior outcome. The authors of this study set out to determine the costs and quality-of-life outcomes of primary closure, vertical rectus abdominus muscle flap, gluteal thigh flap, and gracilis flap to aid surgeons in identifying an optimal reconstructive algorithm.MethodsA decision tree analysis was performed to analyze the cost, complications, and quality-of-life associated with reconstruction by primary closure, gluteal thigh flap, vertical rectus abdominus muscle flap, and gracilis flap. Costs were derived from Medicare reimbursement rates (FY2021), while quality-adjusted life-years were obtained from the literature.ResultsGluteal thigh flap was the most cost-effective treatment strategy with an overall cost of $62,078.28 with 6.54 quality-adjusted life-years and an incremental cost-effectiveness ratio of $5,649.43. Gluteal thigh flap was always favored as the most cost-effective treatment strategy in our 1-way sensitivity analysis. Gracilis flap became more cost-effective than gluteal thigh flap, in the scenario where gluteal thigh flap complication rates increased by roughly 4% higher than gracilis flap complication rates.ConclusionOur data suggest that, when available, gluteal thigh flap be the first-line option for reconstruction of pelvic defects as it provides the best quality-of-life at the most cost-effective price point. However, future studies directly comparing outcomes of gluteal thigh flap to vertical rectus abdominus muscle and gracilis flap are needed to further delineate superiority.     

Secondary epispadias repair with rectus abdominis musculocutaneous flap

Genital defects in patients with epispadias cause functional, aesthetic, and psychological problems. Successful reconstruction of epispadias should improve the body image and enable the patient to perform sexually. Although various operative techniques have been defined for reconstruction of epispadias--predominantly using local tissue flaps--classic reconstructive methods are sometimes not sufficient in severe cases. Secondary reconstruction is inevitable after failed reconstructive attempts with classic techniques. The authors used the rectus abdominis musculocutaneous flap for severe secondary epispadias repair. The urethra, dorsal chordee, osteo-escutcheon contour defect, and the tissue defect created after dissection of the dorsal surface of the penis were reconstructed successfully using the rectus abdominis musculocutaneous flap. The neourethra was constructed using the skin island of the flap, and the muscle segment was used to reconstruct the dorsal defects. A straightened and lengthened penis and a new urethra without stricture were created during one operative procedure using this method.     

The superior gluteal artery perforator flap: an additional tool in the treatment of sacral pressure sores.

We describe the use of a large skin-subcutaneous tissue flap based on one perforator of the superior gluteal artery (SGA) to reconstruct large midline posterior defects in one stage. The integrity of the gluteus muscles is preserved and we feel this is particularly important in non-paralysed patients. Donor sites were always closed primarily. Use of the superior gluteal artery perforator (SGAP) flap preserves the entire contralateral side as a future donor site. On the ipsilateral side, the gluteal muscle itself is preserved and all flaps based on the inferior gluteal artery are still possible. We recommend this flap in an area where reconstructive possibilities are limited, as it preserves other reconstructive flap options, both on the ipsilateral and contralateral sides.     

Rectus abdominis muscle flaps used successfully for median sternotomy wounds after ipsilateral internal mammary artery ligation

Use of the rectus abdominis muscle for reconstruction based on its superior blood supply has been said by some to be contraindicated if the ipsilateral internal mammary artery (IMA) has been divided for reasons such as coronary artery bypass grafting. The authors describe 5 patients in whom either both IMAs were used for coronary revascularization or in whom there was a contralateral subcostal incision, and they were thus compelled to perform sternal reconstruction using at least one rectus abdominis muscle ipsilateral to prior IMA ligation. In all patients the muscle flap was used to reconstruct an open median sternotomy wound successfully. An injection study as well as a fresh cadaveric dissection revealed rich collateral circulation to the superior epigastric vascular pedicle through the musculophrenic artery as well as through the lower intercostal arteries. This case report and the series of 5 patients indicate that if elevation of the rectus muscle and division of the lateral segmental vessels is done only up to the costal margin, one can reliably maintain a viable rectus muscle flap, even in the face of prior ipsilateral IMA ligation. This enables useful reconstruction to the lower half of a sternal wound using the rectus abdominis muscle, requiring a pectoralis major muscle flap for the superior part of the wound.     

Use of the rectus abdominis muscle flap in urological reconstructive procedures

The rectus abdominis muscle flap has been used successfully in 4 reconstructive procedures complicated by tissue loss or urinary fistula. This simple procedure is advocated as an alternative to the use of omentum when prior abdominal surgery precludes omental mobilization. No adverse functional nor cosmetic result to the abdominal wall resulted.     

The anatomic basis of the transversus and rectus abdominis musculoperitoneal (TRAMP) composite flap

Summary The aim of this study was to provide an anatomic basis for the transversus and rectus abdominis musculoperitoneal (TRAMP) flap, recently successfully introduced for vulvovaginal reconstruction. In 25 cadavers the width and length of the portions of rectus and transversus abdominis muscles suitable for the TRAMP flap as well as the length and diameter of the inferior epigastric artery were assessed. The mean length of the rectus abdominis muscle was 32.42±0.48 cm and its width 6.15±0.12 cm. The suitable part of the transversus abdominis muscle measured 19.08±0.3 cm mean length with a mean width of 18.62±0.19 cm. No significant left-right differences were observed. The resulting area of the rectus abdominis muscle was 197.78±5.09 cm² and that of the transversus abdominis muscle 356.20±7.87 cm². The mean extramuscular course of the deep inferior epigastric artery (DIEA) was 4.97±0.09 cm with a mean diameter of 0.29±0.01 cm. This offers numerous possibilities for an anastomosis of the DIEA when the TRAMP flap is desired as a free flap. Because of its dimensions and flexibility the TRAMP offers several possibilities in reconstructive surgery.     

Three-dimensional reconstruction of types iv and v midfacial defects by free rectus abdominis myocutaneous (RAM) flap

Extensive midfacial defects after ablative surgery constitutes a challenging problem for reconstructive surgeons. Particularly for types IV and V midfacial defects, provision of missing bony support and obliteration of the maxillary cavity defects require microsurgical free tissue transfers. In the last three years, four patients have undergone total maxillectomy for midfacial tumours and the postmaxillectomy defects were three-dimensionally repaired with free rectus abdominis muscle flap and skin graft or myocutaneous flaps. Obliteration of maxillary cavity defects and orbital support were achieved with this type of free flap. The least follow-up period of the patients is one year and slight ectropion, later corrected, was seen in two patients. In this study, the free rectus abdominis myocutaneous (RAM) flap, with its long vascular pedicle and availability of various skin paddle designs and muscle bulk, is presented in treatment of extensive midfacial defects. In spite of initial overcorrection of contour, the denervated rectus abdominis muscle gradually atrophies, resulting in loss of contour. The muscle bulk fills the cavity defect, but, in order to achieve good facial contour, it is necessary to support the bony skeleton with some material. © 1998 Wiley-Liss, Inc. MICROSURGERY 18:148–151 1998     

Anatomic and clinical study of rectus abdominis musculocutaneous flaps based on the superior epigastric system: ipsilateral pedicled TRAM flap as a safe alternative

This anatomic and clinical study supports the use of the ipsilateral transverse rectus abdominis musculocutaneous (TRAM) flap over the contralateral TRAM flap for breast reconstruction. The costomarginal artery was constant in these dissections and supplied a vascular pedicle to the rectus abdominis muscle. Radiologic studies confirmed the communications between the costomarginal artery and the deep epigastric system, the same as between the costomarginal artery and the musculophrenic and intercostal arteries. The results of the clinical series confirmed the costomarginal artery as an alternative or adjuvant vascular pedicle of the deep superior epigastric artery in cases of potential lesion of the latter. The lack of pedicle tension because of the shorter distance to be transposed allowed a greater versatility in flap shaping and positively affected its aesthetic result. This fact made the authors change from the contralateral to the ipsilateral pedicled TRAM flap as the first option for autologous breast reconstruction because of vascular security.     

The augmented TRAM flap: a technique for the large-breasted patients

The transverse rectus abdominis myocutaneous (TRAM) flap is the most common method of autogenous breast reconstruction. In high-risk patients, a reliable and bulky flap is needed to achieve breast symmetry and a mound together with durable satisfactory projection. The purpose of this study is to look into the use of contralateral zones of the pedicled TRAM flap to improve flap survival and to reduce the incidence of fat necrosis in order to achieve good cosmetic results. Seven obese large-breasted patients of cup size C and above who underwent primary breast reconstruction by the same surgeon are presented. In each case, all the four zones of the TRAM flap were used to achieve symmetry of the reconstruction. Patients had mastectomy with or without axillary clearance. The pedicled TRAM flap was elevated and the other side was raised as a perforator flap for microvascular augmentation. The perforator vascular pedicle was anastomosed to the thoracodorsal vessels in all cases. The anterior rectus sheath was repaired with a mesh in all cases. All the flaps were coned to achieve a good projection. All flaps survived with no complications or loss. All patients were satisfied with the outcome. One of our patients developed an abdominal bulge that was treated conservatively. Microvascular augmentation improved survival of zones III and IV of the TRAM flap, exemplified by flap survival and no incidence of fat necrosis. It is a good reconstructive tool to achieve breast volume, symmetry, and projection. In addition, it reduces the need of secondary breast surgery for the contralateral breast in the future.     

Augmentation of circulation of pedicled transverse rectus abdominis musculocutaneous flaps by microvascular surgery

The biggest problem of the TRAM flap for breast reconstruction is distal necrosis or fat lysis due to poor circulation. In order to utilise the entire TRAM flap tissue in extensive tissue defects, the contralateral rectus muscle is used as a pedicled carrier and the ipsilateral superficial or inferior epigastric vessels are anastomosed with appropriate recipient vessels in the axilla. This procedure has been performed in three cases with no necrosis, fat lysis or hardening of the flap tissue, proving adequate circulation in the flap.     

SPLIT rectus abdominis myocutaneous double free flap for extremity reconstruction

A Mathes and Nahai type III muscle, such as the rectus abdominis muscle, can be utilized to cover two separate wounds simultaneously utilizing its dual blood supply thereby minimizing donor site morbidity and operative time. We report a case for treatment of bilateral Gustillo type IIIB lower extremity injuries treated with a single rectus abdominis muscle split into two free flaps, with one based on the deep inferior epigastric vessels and one on the superior epigastric vessels to cover the contralateral wound. In our patient, both lower extremity wounds were covered with muscle flaps from the same donor site in a single operation, salvaging both limbs with progression to unassisted ambulatory status. We show in this case report that the utilization of the vascular anatomy of the rectus muscle allows for division of the flap into two flaps, permitting preservation of the contralateral abdominal wall integrity and coverage of two wounds with a single muscle. © 2013 Wiley Periodicals, Inc. Microsurgery 34:54–57, 2014.     

下腹部横行腹直肌肌皮瓣联合腹壁下动脉穿支皮瓣乳房再造术

目的 探讨应用下腹部腹直肌肌皮瓣联合腹壁下动脉穿支皮瓣行乳房再造的手术方法，并分析其适应证。方法 以健侧腹直肌为肌蒂、患侧腹壁下动、静脉穿支为吻合血管蒂形成下腹部横行腹直肌肌皮瓣与腹壁下动脉穿支联合皮瓣，将腹壁下动、静脉与患侧胸背血管或胸廓内血管相吻合，进行乳房再造。结果 自2003年以来，于临床应用17例，所有皮瓣皆成活，随访3～12个月，再造乳房外形满意。结论 下腹部腹直肌肌皮瓣联合腹壁下动脉穿支皮瓣，具有血运可靠、提供组织量丰富、塑形自由度大、供区损伤较小等优点，尤适宜需要移植体积多以及胸廓内血管受损的乳房再造患者。     

四维CT血管显影在腹壁下动脉穿支血管构造基础研究中的应用

目的 应用四维CT血管显影研究腹壁下动脉穿支的血管构造.方法 2008年10月至2009年5月,取10具新鲜尸体腹壁标本,在腹壁下动脉的不同水平段将造影剂欧乃派克灌注入皮瓣,包括腹壁下动脉主干、内排分支、外排分支、外排单根穿支、内排单根穿支,在灌注过程中应用四维CT进行扫描(三维CT加上时间轴称之为四维),将所获得的数据在CT工作站上进行图像重建与分析.结果 腹壁下动脉穿支在Scarpa筋膜(腹壁浅筋膜深层)浅面以及真皮下两个层次产生分支,最终走向真皮下血管网.腹壁中线两侧穿支吻合发生在真皮下血管网,较稀疏.皮瓣内血流的分布包括真皮下血管网以及已存在的血管结构2种途径.皮瓣灌注最好的区域是血管蒂同侧腹直肌的表面,其次是血管蒂同侧腹直肌的外侧,再其次是对侧腹直肌表面,灌注最差的是对侧腹直肌外侧.结论 四维CT血管显影是一种有效地研究腹壁下动脉穿支在浅筋膜内结构的方法.     

Two for one: salvage of bilateral lower extremities with a single free flap

It is thought that free muscle flaps may remain dependent on their original pedicle for more than 1-year postoperation, particularly in the lower extremity of patients with peripheral vascular disease. We present the first case report of bilateral lower extremity salvage with a single rectus abdominis myocutaneous free flap by transecting the main pedicle. The pedicle of the free flap, going to the contralateral extremity, was safely divided at 6-weeks postoperation. A tourniquet was used to compress the pedicle at the division point to assess viability of the flap distal to the point of occlusion prior to transection of the flap.     

The "parasite" TRAM flap for autogenous tissue breast reconstruction in patients with vertical midabdominal scars.

Abdominal scars play an important role in risk factors in transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction. In particular, vertical midline scars are a difficult problem to solve. Traditional techniques include the use of a single hemiflap (which may be insufficient to achieve an adequate volume), the transfer of a double-pedicle flap (which causes major trauma to the abdominal wall), or more complicated procedures such as two free hemiflaps. Since 1991 the authors have used an innovative technique to improve vascularity in the contralateral side of a standard unipedicled TRAM flap. They call this flap the recharged TRAM flap. By means of their technique, the retrograde flow coming from the deep inferior epigastric vessels raised in continuity with a superiorly pedicled flap is used to "recharge" the contralateral rectus muscle harvested as a free flap. On the basis of hemodynamic studies, this procedure was carried out in patients with vertical midabdominal scars. This flap was named the parasite flap because the free unit survives on the vascular source of the pedicled unit-the superior epigastric artery supplying both flaps in a retrograde fashion. Sixteen patients with vertical midabdominal scars underwent this procedure. Total flap survival was observed in 15 patients. One patient developed a partial flap necrosis and 1 patient developed abdominal bulging on the pedicled side. According to the surgeons' evaluation, aesthetic outcome was considered to be good to excellent in all patients.     

腺苷促进猪横行腹直肌骨皮瓣成活的实验研究

目的人研究腺苷对猪横行腹直肌肌皮瓣成活率的影响。方法 横行腹直肌肌皮瓣以左侧腹壁下去共血血管,肌蒂宽６ｃｍ,皮瓣面积８ｃｍ×３０ｃｍ。２０头猪分为生理盐水对照组和１ｍｇ、２ｍｇ、５ｍｇ腺苷注射实验组,掀起此瓣前从腹壁上动脉注射不同剂量的腺苷和生理盐水。术后７天注射荧光素,以模片法记录腹直肌同侧皮瓣、对侧皮瓣和整个皮瓣的成活率。结果 ２ｍｇ和５ｍｇ腺苷注射级,肌皮瓣成活率明显高于生理盐水对照组（Ｐ〈     

Reconstruction of exposed sternum following electrical burns using a superior transverse rectus abdominis musculocutaneous flap

An unusual case of a patient with electrical burns with exposed sternum was reconstructed using a superior transverse rectus abdominis flap (also known as ‘epigastric rectus flap’). The clinical rarity of the condition and the innovation of the reconstructive method is discussed.     

Limb salvage of infected diabetic foot ulcers with free deep inferior epigastric perforator flaps

Soft-tissue reconstruction of the feet in diabetic patients with angiopathy, sensorial neuropathy, and immunopathy is a complicated problem. Until the mid-1980s, chronic foot ulcers in diabetic patients were treated conservatively, because flap surgery was regarded as too risky. However, in recent years, early debridement and flap coverage have become popular reconstructive methods for diabetic foot wounds. Several flap donor sites are available, depending on the nature of the defect. The deep inferior epigastric artery perforator (DIEP) flap is a relatively new flap that developed as a modification of the transverse rectus abdominis muscle (TRAM) flap. It provides a large amount of skin and subcutaneous tissue, without the donor-site morbidity of the ordinary TRAM flap. Furthermore, using the DIEP flap avoids the loss of major vessels. In this study, we report on the successful use of the DIEP flap in four cases of diabetic foot ulceration.     

The Use of the Ipsilateral Versus Contralateral Pedicle and Vertical Versus Horizontal Flap Inset Models in TRAM Flap Breast Reconstruction: The Aesthetic Outcome

The use of an ipsilateral or a contralateral rectus abdominis muscle as a pedicle and comparison of their advantages and disadvantages in TRAM flap breast reconstruction have been reported in the literature. In our clinical experience with 22 pedicled TRAM flap breast reconstructions, the use of either an ipsilateral or contralateral pedicle was found to be equivocal regarding the flap viability and the aesthetic outcome. Thus, it seems better to decide their use according to the needs of an individual patient. In our series, the contralateral pedicled TRAM flap with a vertical flap inset was preferred in patients with a small opposite breast or in patients with infraclavicular tissue losses (four patients). The ipsilateral pedicled TRAM flap reconstruction with a horizontal flap inset was preferred in patients with a full and attractive opposite breast, unless they received adjuvant radiotherapy (six patients). In patients who received adjuvant radiotherapy the contralateral pedicle was used regardless of the inset model preferred (10 patients). Bilateral TRAM flap breast reconstruction was applied in one of our cases, which is not included in the three categories above mentioned. The aesthetic outcome was determined by analyzing a patient satisfaction questionnaire. Overall satisfaction was achieved in 17 patients. Four patients were dissatisfied. We think that choosing the correct flap inset model is one of the most important factors in achieving a satisfactory aesthetic outcome. Choosing the correct pedicle regarding the type of the flap inset model is equally important to facilitate technical ease during flap transposition and to improve flap survival.