Intercostal muscle flap reconstruction and primary sternal closure for mediastinal abscess

Poststernotomy mediastinal abscess is a life-threatening complication after cardiac operations. A 21-year-old woman had a late presentation of mediastinal abscess 9 years after ascending aortic graft replacement. Three days after the initial débridement and vacuum-assisted closure treatment, successful reconstruction was performed using an intercostal muscle flap and primary sternal closure, without recurrent infection.     

The rectus abdominis free flap for lower extremity reconstruction

The authors present their successful experience with an attractive alternative to the latissimus dorsi and gracilis muscle flaps for lower extremity reconstruction--the free rectus abdominis muscle flap. The muscle flap has a dual blood supply, but the longer pedicle length and larger vessel diameter of the inferior epigastric vascular pedicle favor its use for free-tissue transfer. Surgical anatomy, technique, indications, and potential complications are outlined.     

Scrotal reconstruction with a rectus abdominis muscle flap

The rectus abdominis muscle flap provides excellent coverage of major scrotal defects. It is a simple, reliable, one-stage procedure which covers the exposed testes and gives a satisfactory aesthetic result and is an ideal choice for covering the contaminated wound.     

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.     

Vaginal reconstruction with a rectus abdominis musculoperitoneal flap

In more than 300 clinical cases, the authors have observed and documented the presence of a branch of the deep inferior epigastric artery that penetrates the posterior rectus sheath near the umbilicus. Their cadaveric anatomic and animal injection studies confirm the vascularity of the peritoneum via the deep inferior epigastric artery. They report 2 patients treated with a new technique of vaginal reconstruction using a thin, pliable flap with a peritoneal-lined rectus abdominis muscle based on the deep inferior epigastric vessels.     

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.     

Breast reconstruction using a deepithelialized rectus abdominis musculocutaneous flap

There are many methods for breast reconstruction. Using implants can achieve good results without conspicuous scarring, but this method has disadvantages, such as infection, exposure, and capsular contracture. The rectus abdominis musculocutaneous (RAM) flap has become a standard technique because of its safety and abundant volume, but its main problem is the lack of a color and texture match between the skin paddle and the skin around the flap. To overcome such shortcomings, the authors perform breast reconstruction using tissue expansion and a RAM flap. First a tissue expander is inserted superficially to the pectoralis major muscle at the time of or after mastectomy, and is expanded to a size larger than the contralateral breast. The expander is replaced with the deepithelialized RAM flap. Scar revision is performed if the expander is inflated satisfactorily. The authors used this technique in 11 patients and obtained good results without severe complications.     

Our experience using the vertical rectus abdominis muscle flap for reconstruction in 12 patients with dehiscence of a median sternotomy wound and mediastinitis

The vertical rectus abdominis (VRAM) flap has been used for reconstruction of sternal defects, particularly in the inferior third, since it was first described 20 years ago. We describe 12 patients with mediastinitis or chronic sternal osteomyelitis after sternotomy treated between 1994 and 1997, nine performed at the Royal Hospitals Trust, London. Sternal osteomyelitis and mediastinitis after median sternotomy is an uncommon (0.4%–8.4%) but often fatal condition. Vascularised pedicles are the treatment of choice, and VRAM flaps were used in all cases. We report good long-term outcome with a follow up of 2–5 years, and no long-term morbidity relating to the VRAM reconstruction. We had only one partial failure of a flap. The operations were largely done in hospitals away from the plastic surgical unit in extremely sick patients, which illustrates the importance of multidisciplinary management to reduce hospital stay, mortality, and morbidity. We argue that early involvement of plastic surgical specialists in the treatment of sternal dehiscence is essential to ensure a successful outcome.     

Transpelvic rectus abdominis flap reconstruction of defects following abdominal-perineal resection

Abdominal-perineal resection for advanced rectal carcinoma may leave a large defect for which complete secondary healing can be slow. In such cases, the inferiorly based rectus abdominis myocutaneous flap, passed through the pelvis into the perineum, can provide a large amount of well-vascularized tissue that may be placed in the defect to facilitate primary healing and allow a quicker recovery. Additional advantages include displacement of the bowel out of the pelvis to facilitate postoperative radiotherapy, and the ability to reconstruct vaginal wall defects. We report a series of seven patients for whom the transpelvic rectus abdominis myocutaneous flap was used to cover perineal defects following abdominal-perineal resection. Although one flap failed, all patients healed rapidly and the only lasting complication was a possibly related small upper-abdominal hernia found one year after surgery.     

三叶状下腹部腹直肌肌皮瓣乳房重建

目的用改善血供的下腹部横行腹直肌肌皮瓣（ＴＲＡＭＦ）重建乳房。方法在通常以上部腹直肌为蒂的ＴＲＡＭＦ的肌蒂表面附加一块脐旁三角形皮瓣,使共同组成三叶状,藉以增加肌皮穿支动脉的血供及肌皮瓣提供的组织量,便于乳房塑形和腋部瘢痕挛缩的充分松解修复,以及胸壁的放射性烧伤创面的修复。结果乳癌术后单侧乳房缺失伴胸壁放射性溃疡及腋部瘢痕挛缩６例,肌皮瓣完全成活者４例,皮瓣最远端少量坏死及脂肪液化者２例。重建乳房外形良好,胸壁放射性烧伤创面修复及腋部瘢痕挛缩修复。结论本术式最适用于单侧乳房缺失伴放疗后有胸壁烧伤溃疡及腋窝瘢痕挛缩的病例。     

三叶状下腹部腹直肌肌皮瓣乳房重建

目的用改善血供的下腹部横行腹直肌肌皮瓣(TRAMF)重建乳房。方法在通常以上部腹直肌为蒂的 TRAMF 的肌蒂表面附加一块脐旁三角形皮瓣,使共同组成三叶状,藉以增加肌皮穿支动脉的血供及肌皮瓣提供的组织量,便于乳房塑形和腋部瘢痕挛缩的充分松解修复,以及胸壁的放射性烧伤创面的修复。结果乳癌术后单侧乳房缺失伴胸壁放射性溃疡及腋部瘢痕挛缩6例,肌皮瓣完全成活者4倒,皮瓣最远端少量坏死及脂肪液化者2例。重建乳房外形良好,胸壁放射性烧伤创面修复及腋部瘢痕挛缩修复。结论本术式最适用于单侧乳房缺失伴放疗后有胸壁烧伤溃疡及腋窝瘢痕挛缩的病例。     

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.