Anatomo-clinical study of rectus abdominis myocutaneous flap

At the Plastic and Reconstructive Surgery Department of Perugia, 52 patients were examined by color flow duplex scanning, in order to study rectus abdominis myocutaneous flap vascular supply before surgical procedures. This ultrasound technique permits a precise and accurate measurement of blood flow volume and velocity within the epigastric arteries (which represent the superior and inferior vascular pedicles of the flap) and makes it possible to detect the exact location of the perforating branches with their cutaneous distribution. This preoperative evaluation, pointing out vascular pathologies which contra-indicate the use of rectus abdominis flap, can be considered a great help for the reconstructive surgeon in the choice of the operative procedure and can surely lead to a significant decrease in postoperative complication rate.     

Successful twin pregnancy and delivery following free rectus abdominis muscle flap at 15 weeks gestational age

Although a vertical rectus abdominis flap would not have been selected for reconstruction of the patient's defect had her pregnancy been detected preoperatively, the present case does demonstrate the remarkable resiliency and integrity of the anterior abdominal wall after rectus abdominis muscle flap surgery. Meticulous closure of the abdominal wall is of utmost importance in maintaining abdominal wall competence. Although the merits of muscle splitting techniques and the use of mesh are beyond the scope of this report, there is no evidence that modification of technique should be performed in the patient considering future pregnancy. Our case supports other reports that rectus abdominis flap surgery is not a contraindication to future pregnancy. Intuitively waiting at least 1 year, as recommended by Chen et al., seems reasonable, although the present case demonstrated a successful pregnancy and delivery of twins after a vertical rectus abdominis flap was harvested during pregnancy.     

Tongue reconstruction: outcomes with the rectus abdominis flap

Advanced carcinoma of the oral cavity is a devastating disease, with the potential for severe speech and swallowing dysfunction. This is a retrospective review documenting the outcome of 14 patients who underwent resection of at least 75 percent of their tongue with preservation of the larynx and an intact mandible. Reconstruction was accomplished with rectus abdominis free tissue transfer. There were seven male and seven female patients between the ages of 25 and 77 years (mean, 55 years) who underwent total (eight patients) or subtotal (six patients) glossectomy and reconstruction. Decannulation of the tracheostomy tube was performed in 12 patients (86 percent) at an average of 3.5 months postoperatively. One patient required interval laryngectomy for intractable aspiration 1 month postoperatively. Independent evaluation of speech, articulation, and deglutition was performed. Fifty percent of patients achieved oral intake of pureed foods or better. Sixty-four percent had acceptable speech. Reconstruction with rectus abdominis free tissue transfer is a viable method for rehabilitation, improving quality of life after total or subtotal glossectomy with laryngeal preservation.     

Treatment of linea alba hernia and diastasis of rectus abdominis

The asynchronous development of structural and metabolic disorders of aponeurosis, leading to the development of defects in sheath of the rectus abdominis is the major factor of hernia of linea alba formation. Development of diastasis of m. rectus abdominis is caused by primary structural and metabolic changes of myocytes caused by the extreme overload. The important factor of the operation is restoration of anatomic and physiologic parameters of the abdominal wall by bringing mm. rectus abdominis together, shortening and enforsing of aponeurosis makes it possible to distribute regularly the load on the aponeurotic sheath of musculi recti.     

Breast reconstruction by means of innervated rectus abdominis myocutaneous flap

We performed immediate breast reconstruction in 22 patients using rectus abdominis myocutaneous flap accompanied by neurorrhaphy in the past 2 years. In the neurorrhaphy, the 11th intercostal nerve, which controls the sensation of the myocutaneous flap, was anastomosed to the lateral cutaneous branch of the 4th intercostal nerve, which controls the sensation of the breast. Our study included 15 patients, and the postoperative follow-up period was 4 to 24 months, with an average of 14.0 months. For control subjects, there were 16 cases of rectus abdominis myocutaneous flap, whose sensory nerve had not been reconstructed (postoperative follow-up period 11 to 41 months, average 24.1 months). The sensory examination included tests of touch, pain, and temperature. The innervated myocutaneous flap sensation showed gradual recovery at about 6 months after surgery and reached the value of the normal side after about 1 year. In the control subjects, recovery of sensation was not observed at all in the first 10 postoperative months. Then, after more than 1 year, the recovery was gradual and reached the value of the normal side in only some control subjects. Therefore, we consider the present technique useful for recovery of sensation in immediate breast reconstruction.     

The transversus and rectus abdominis musculoperitoneal (TRAMP) composite flap for vulvovaginal reconstruction

The transversus and rectus abdominis musculoperitoneal (TRAMP) flap, a novel composite flap supplied by the deep inferior epigastric vessels, was used successfully for partial vulvovaginal reconstruction following anterior and posterior exenteration. The full potential of the TRAMP flap in vulvovaginal reconstruction is being investigated further.     

Breast reconstruction in a male with a transverse rectus abdominis flap

The TRAM flap may be the best choice in male breast reconstruction not just because it can replace the missing skin and fat but also because it may be a source of hair-bearing skin similar to the native breast skin.     

Laparoscopic incisional hernia repair after transverse rectus abdominis myocutaneous flap reconstruction

Abdominal wall herniation is a relatively rare but well recognized complication that is known to occur following TRAM flap mobilization. Herein is presented a novel means to approach such a hernia, using the minimally invasive surgical approach to repair the defect with a piece of prosthetic material.     

An ipsilateral superdrainaged transverse rectus abdominis myocutaneous flap for breast reconstruction

A conventional single pedicled TRAM (transverse rectus abdominis myocutaneous) flap is a musculocutaneous flap widely used for breast reconstruction. However, complications such as partial flap necrosis, fat necrosis, and fatty induration may occur as a result of unstable blood flow circulation to the flap. One major factor is venous congestion in the flap. In an effort to obtain more stable TRAM flap blood circulation, we anastomosed the ipsilateral deep inferior epigastric vein of a pedicled TRAM flap to the thoracodorsal vein. This procedure provides superdrainage by means of enhanced venous perfusion. This flap with superdrainage augmentation is referred to as a superdrainaged TRAM flap (12 patients). Changes in cutaneous blood flow were also assessed by measurement of cutaneous blood flow in zone IV using a laser blood flow meter (8 patients). The patients who underwent breast reconstructive surgery using this technique showed no evidence of postoperative complications such as flap necrosis, fat necrosis, or fatty induration. Satisfactory results were obtained during breast reconstruction in patients who had previously undergone a radical mastectomy with resultant large areas of tissue defects. In addition, the two patient groups, 12 patients with superdrainaged TRAM flap and 20 patients with single pedicled TRAM flap, were compared to assess differences in complications. The incidence of partial flap necrosis, fat necrosis, and fatty induration was lower among patients with superdrainaged flap than those with single pedicled flap.     

Overview of the rectus abdominis myocutaneous flap in head and neck reconstruction

OBJECTIVES: To examine the current in-patient respite service in terms of the type of patient served, whether their care could be provided satisfactorily outwith hospital and whether hospital resources could be used more efficiently. DESIGN: Multi-disciplinary assessment of subjects and completion of recording form. SETTING: Inverclyde and Renfrew, Scotland (population 288,000). SUBJECTS: All elective respite admissions to Merchiston Hospital during the period 1.1.93 to 31.12.93. RESULTS: Twenty-six patients received respite care in the period studied. Seventy-three per cent had severe/profound handicap, and all had at least one additional problem to their learning disability. We found the majority (73%) would require extra nursing care in hospital. Current social work respite placements do not cater for this level of disability. Respite bed occupancy rates are lower during the week than at the weekend. CONCLUSIONS: Most patients receiving respite care in our hospital are a highly dependent group whose needs cannot be met by local social work services. There is a need for more accurate planning of respite provision to maximise the efficient use of beds.     

Transosseous transposition of a pedicled rectus abdominis flap to cover hip wounds

Bone-marrow transplantation may be complicated by aseptic necrosis of the femoral head. Prolonged immunosuppression places the patient at increased risk of infection and is of particular concern if replacement arthroplasty is contemplated. Infection of a prosthesis usually requires thorough debridement and removal of the device. However, attention must also be paid to the resultant cavity and soft-tissue cover. Several flaps have been reported for this problem, though limitations of flap size may make it difficult to achieve both objectives. This report describes the use a pedicled rectus abdominis flap that was tunnelled through the acetabulum in order to gain direct access to the hip and allow adequate length both to fill the dead-space and to provide cover.     

Reconstruction of pelvic exenterative wounds with transpelvic rectus abdominis flaps: a case series

Exenterative pelvic surgery is commonly performed for advanced carcinoma of the cervix and selected cases of locally advanced colorectal cancers. Low-lying lesions that are locally invasive in contiguous organs require resection of the perineal body en bloc with the resected specimen. The resulting defect, both in the pelvis and the perineum, creates a difficult management problem. Dead space in the pelvis, especially with adjunctive irradiation, leads to delayed wound healing and prolapse of small bowel into the pelvis. Small bowel obstruction and/or fistula formation are the greatest sources of morbidity in the operative group. Fifteen patients underwent exenterative pelvic procedures (total exenteration, 1 patient; posterior exenteration, 8 patients; abdominoperineal resection, 6 patients). All patients were reconstructed by transpelvic placement of the rectus abdominis muscle (muscle only, 4 patients; muscle with skin grafting, 8 patients; musculocutaneous, 3 patients). Eighty-seven percent received radiation therapy. One patient had Crohn's disease and all others had carcinoma. Healing was complete in 12 of 15 patients at discharge. There were no complications related to pelvic dead space (i.e., bowel obstruction, perineal fistula), with a mean follow-up time of 24.3 months. Small bowel was effectively excluded from the pelvis to the level of the acetabular roof by computerized axial tomography scan. The transpelvic rectus abdominis muscle flap is effective in preventing major morbidity after exenterative pelvic surgery.     

Reconstruction of posterior mandibular defects with soft tissue using the rectus abdominis free flap

Nitric oxide (NO) plays an important regulatory role in airway function and seems to be implicated in the pathophysiology of several airway diseases. We studied the presence of NO synthase activity in human nasal mucosa and nasal polyp tissues obtained from patients undergoing septoplasty or polypectomy, respectively. NO synthase activity was quantified in tissue homogenates using citrulline release assay and was located in tissue sections using NADPH-diaphorase histochemistry. The results indicated that nasal polyps contain higher levels of total NO synthase activity than nasal mucosa tissue. In addition, nasal polyps contained mainly inducible NO synthase activity whereas all NO synthase activity detected in the nasal mucosa was in constitutive form. In both cases, NO synthase activity was localized in epithelial cells. In view of these results, we conclude that NO may be an important inflammatory mediator in the respiratory system and that the epithelium may be a source of NO production.     

The use of free rectus abdominis myocutaneous flap to close the empyema space with alveolar fistula--a case report

A 59-year-old man, who had had right middle and lower lobectomy for pulmonary tuberculosis, admitted for the treatment of empyema with fistula. Closure of empyema space with free rectus abdominis myocutaneous flap was performed following open window thoracotomy and thoracoplasty. As he previously underwent two major operation, lobectomy by posterolateral approach and gastrectomy for gastric ulcer, free rectus abdominis flap was chosen instead of omental flap or latissimus dorsi myocutaneous flap. Postoperative CT film showed that this flap was filled up in all interstices of the empyema cavity. The pedicle vessels to this flap are large enough to provide long stalks, so microsurgical anastomosis can be accomplished safely. The use of free rectus abdominis myocutaneous flap is one of a useful maneuver for chronic empyema with fistula.     

Immediate, bilateral transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction after mastectomy

Although breast reconstruction has been shown to provide psychological benefits in mastectomy patients, there is reluctance to perform immediate, bilateral TRAM flap reconstruction because of concerns regarding magnitude of the procedure, length of hospitalization, potential complications, and long-term recovery. Between June, 1990 and March 1992, 15 patients underwent immediate, bilateral TRAM flap reconstruction following bilateral mastectomy at the University of Michigan Hospitals. Diagnoses included lobular carcinoma in situ (nine patients), strong family history of breast cancer (five), or bilateral breast cancer (one). Invasive breast cancer was present in three patients. Three modified radical mastectomies and 27 simple mastectomies were performed. Bilateral pedicle TRAM flap reconstruction was carried out at the same time in all patients (30 flaps total). Marginal loss occurred in one flap (3%). Additional complications included marginal necrosis of the abdominal donor site wound (one), wound infection (two), and abdominal donor site hernia (one). Median hospital stay was 7 days. Median follow-up was 13 months (range 4-25 months). All patients have resumed their accustomed pre-operative activity patterns. These findings demonstrate that immediate, bilateral TRAM flap reconstruction is a safe and effective option for breast reconstruction after mastectomy.     

Intercostal thorascopic harvesting of the internal mammary artery for supercharging a pedicled rectus abdominis flap

This review on non-heartbeating donation focusses on three issues: the number of kidneys procured from a non-heartbeating donor programme, the transplant results and the influence of a non-heartbeating programme on public opinion regarding transplantation.     

Experience with the rectus abdominis myocutaneous flap with vascularized hard tissue for immediate orbitofacial reconstruction

We have previously reported (Badolato, R., J.M. Wang, W.J. Murphy, A. R. Lloyd, D.F. Michiel, L.L. Bausserman, D.J. Kelvin, and J.J. Oppenheim. 1994. J. Exp. Med. 180:203; Xu, L., R. Badolato, W.J. Murphy, D.L. Longo, M. Anver, S. Hale, J.J. Oppenheim, and J.M. Wang. 1995. J. Immunol. 155:1184.) that the acute phase protein serum amyloid A (SAA) is a potent chemoattractant for human leukocytes in vitro and mouse phagocytes in vivo. To identify the signaling mechanisms, we evaluated patterns of cross-desensitization between SAA and other leukocyte chemoattractants. We found that the chemotactic bacterial peptide, N-formyl- methionyl-leucyl-phenylalanine (fMLP), was able to specifically attenuate Ca2+ mobilization in human phagocytes induced by SAA, but only at very high concentrations, suggesting that SAA uses a low affinity fMLP receptor. Here we demonstrate that SAA selectively induced Ca2+ mobilization and migration of HEK cells expressing FPRL1, a human seven-transmembrane domain phagocyte receptor with low affinity for fMLP, and high affinity for lipoxin A4. Furthermore, radiolabeled SAA specifically bound to human phagocytes and FPRL1-transfected 293 cells. In contrast, SAA was not a ligand or agonist for FPR, the high affinity fMLP receptor. Thus, SAA is the first chemotactic ligand identified for FPRL1. Our results suggest that FPRL1 mediates phagocyte migration in response to SAA.