The vascular anatomy of rectus abdominis musculocutaneous flaps based on the deep superior epigastric system

Radiographic studies of the deep superior epigastric artery (DSEA) and its connections within the soft tissues of the abdominal wall were performed in 64 fresh cadavers. The patterns of anastomosis between the deep superior epigastric artery and the deep inferior epigastric artery (DIEA) were noted. Type I (29 percent) revealed a single deep superior epigastric artery and deep inferior epigastric artery, type II (57 percent) revealed a double-branched system of each vessel, and type III (14 percent) revealed a system of three or more major branches. In each case, the two systems were united by choke vessels in the segment of muscle above the umbilicus. The supply to the various transverse and vertical skin flaps from the deep superior epigastric artery was defined as a series of captured anatomic territories bounded by choke vessels. The upper transverse and vertical flaps had the best supply, and the TRAM flap had the most tenuous supply. Midline crossover occurs predominantly in the subdermal plexus and on the surface of the rectus sheath. Modifications of the design of the TRAM flap, the case for a delay procedure, the wisdom of including a strip of anterior rectus sheath, and the risks of splitting the muscle with respect to its nerve supply and vascular patterns are discussed on an anatomic basis.     

Ex vivo intraoperative angiography for rectus abdominis musculocutaneous free flaps

In this study, the vascular architecture of rectus abdominis free flaps nourished by deep inferior epigastric vessels was investigated using an ex vivo intraoperative angiogram. Oblique rectus abdominis free flaps were elevated and isolated from the donor site. In 11 patients, the vascular architecture of these flaps was analyzed before the flap was thinned. Radiographic study identified an average of 2.1 large deep inferior epigastric arterial perforators in each flap. In nine of the 11 flaps, the axial artery was visible. In four flaps, the axial artery originated from the perforator of the lateral branch of the deep inferior epigastric artery; in five others, it originated from the medial branch. In each flap, the angle of the axial perforator from its anterior rectus sheath in the vertical plane was measured; its mean was 50.6 degrees. All flaps survived, although three showed partial necrosis in the distal portions. In two of these three flaps, the axial artery was not visible in the angiograms, and the third revealed a one-sided distribution of axial flap arteries. Using ex vivo intraoperative angiography, the architecture of the individual flap, its axial perforator, and its connecting axial flap vessel could be investigated. This information can help the surgeon safely thin and separate the flap.     

Surgical augmentation of skin blood flow and viability in a pig musculocutaneous flap model

A porcine rectus abdominis musculocutaneous (TRAM) flap model was designed and validated in nine pigs. This TRAM flap was based on the deep inferior epigastric (DIE) vessels with an 8 x 18 cm transverse skin paddle at the superior end of the rectus abdominis muscle. The model was subsequently used to test our hypothesis of surgical augmentation of flap viability by vascular territory expansion. Specifically, we observed that ligation of the superior epigastric (SE) vessels at 4, 7, 14, and 28 days (N = 6 to 8) prior to raising the TRAM flaps significantly increased (p less than 0.05) the length and area of the viable skin in the transverse skin paddles of the treatment flaps compared with the contralateral shammanipulated control flaps. This significant increase in skin viability was seen to be accompanied by a significant increase (p less than 0.05) in skin and muscle capillary blood flow in the treatment TRAM flaps compared with the controls (N = 9). The mechanism of vascular territory expansion is unclear. We postulate that hypoxia resulting from the ligation of the superior epigastric vessels prior to the flap surgery may play a role in the triggering of the deep inferior epigastric artery to take over some of the territory previously perfused by the superior epigastric artery. This would then increase the skin and muscle capillary blood flow in the transverse paddle when the TRAM flap was raised on the deep inferior epigastric vascular pedicle.     

Breast reconstruction with superficial inferior epigastric artery flaps: a prospective comparison with TRAM and DIEP flaps

Breast reconstruction using the lower abdominal free superficial inferior epigastric artery (SIEA) flap has the potential to virtually eliminate abdominal donor-site morbidity because the rectus abdominis fascia and muscle are not incised or excised. However, despite its advantages, the free SIEA flap for breast reconstruction is rarely used. A prospective study was conducted of the reliability and outcomes of the use of SIEA flaps for breast reconstruction compared with transverse rectus abdominis musculocutaneous (TRAM) and deep inferior epigastric perforator (DIEP) flaps. Breast reconstruction with an SIEA flap was attempted in 47 consecutive free autologous tissue breast reconstructions between August of 2001 and November of 2002. The average patient age was 49 years, and the average body mass index was 27 kg/m. The SIEA flap was used in 14 (30 percent) of these breast reconstructions in 12 patients. An SIEA flap was not used in the remaining 33 cases because the SIEA was absent or was deemed too small. The mean superficial inferior epigastric vessel pedicle length was approximately 7 cm. The internal mammary vessels were used as recipients in all SIEA flap cases so that the flap could be positioned sufficiently medially on the chest wall. The average hospital stay was significantly shorter for patients who underwent unilateral breast reconstruction with SIEA flaps than it was for those who underwent reconstruction with TRAM or DIEP flaps. Of the 47 free flaps, one SIEA flap was lost because of arterial thrombosis. Medium-size and large breasts were reconstructed with hemi-lower abdominal SIEA flaps, with aesthetic results similar to those obtained with TRAM and DIEP flaps. The free SIEA flap is an attractive option for autologous tissue breast reconstruction. Harvest of this flap does not injure the anterior rectus fascia or underlying rectus abdominis muscle. This can potentially eliminate abdominal donor-site complications such as bulge and hernia formation, and decrease weakness, discomfort, and hospital stay compared with TRAM and DIEP flaps. The disadvantages of an SIEA flap are a smaller pedicle diameter and shorter pedicle length than TRAM and DIEP flaps and the absence or inadequacy of an arterial pedicle in most patients. Nevertheless, in selected patients, the SIEA flap offers advantages over the TRAM and DIEP flaps for breast reconstruction.     

Deep inferior epigastric perforator dermal-fat or adiposal flap for correction of craniofacial contour deformities

Craniofacial contour deformities are difficult to reconstruct. This article summarizes the authors' use of deep inferior epigastric perforator dermal-fat or adiposal flaps in eight patients with such deformities. Of these patients, three had traumatic craniofacial or facial deformities, one had congenital craniofacial deformity, two had hemifacial atrophy (one because of radiation), one had hemifacial microsomia, and one had localized frontonasal lipodystrophy. Stable restoration of the facial contour was achieved in all eight patients. The advantages of this flap are numerous. It has minimal donor-site morbidity, because the rectus abdominis muscle is preserved as a whole, and it accommodates pregnancy in female patients. Simultaneous elevation of this flap during preparation of the recipient site makes it possible to complete surgery in a shorter time than with the scapular flap. Furthermore, a considerable amount of the superficial or deep fatty layer can be removed primarily, making a bulky flap into a thinner one. This flap also allows the use of a large transverse abdominal ellipse of skin, fat, and Scarpa's fascia with abdominoplasty closure. Conversely, it requires a technically difficult dissection of the muscle perforator and skin grafting of donor defects in patients with a large dermal-fat flap. Also, additional minor operations may be necessary to reduce fat volume around the perforator. Ultimately, the deep inferior epigastric perforator adiposal flap seems to be suitable for craniofacial contouring surgery. It is especially indicated for use in children and female patients who are expecting to have children.     

Contour abnormalities of the abdomen after breast reconstruction with abdominal flaps: the role of muscle preservation.

The purpose of the present study was to determine whether contour abnormalities of the abdomen after breast reconstruction with abdominal flaps are related to the harvest of the rectus abdominis muscle. Abdominal contour was analyzed in 155 women who had breast reconstruction with abdominal flaps; 108 women had free transverse rectus abdominis muscle (TRAM) flaps, 37 had pedicled TRAM flaps, and 10 had deep inferior epigastric perforator (DIEP) flaps. The reconstruction was unilateral in 110 women and bilateral in 45 women. Three methods of muscle-sparing were used; they are classified as preservation of the lateral muscle, preservation of the medial and lateral muscle, or preservation of the entire muscle. One of these three methods of muscle-sparing was used in 91 women (59 percent) and no muscle-sparing was used in 64 women (41 percent). Postoperative contour abnormalities occurred in 15 woman and included epigastric fullness in five, upper bulge in three, and lower bulge in 10. One woman experienced two abnormalities, one woman experienced three, and no woman developed a hernia. Of these abnormalities, 11 occurred after the free TRAM flap, seven after the pedicled TRAM flap, and none after the DIEP flap. Bilateral reconstruction resulted in 11 abnormalities in nine women, and unilateral reconstruction resulted in seven abnormalities in six women. chi2 analysis of the free and pedicled TRAM flaps demonstrates that muscle-sparing explains the observed differences in upper bulge and upper fullness (p = 0.02), with a trend toward significance for lower bulge (p = 0.06). chi2 analysis of the free TRAM and DIEP flaps does not explain the observed difference in abnormal abdominal contour. Analysis of muscle-sparing and non-muscle-sparing methods demonstrates that the observed difference between the techniques is only explained for a lower bulge after the bilateral free TRAM flap (p = 0.04).     

The vascular territories of the superior epigastric and the deep inferior epigastric systems

The vascular territories of the superior and the deep inferior epigastric arteries were investigated by dye injection, dissection, and barium radiographic studies. By these means it was established that the deep inferior epigastric artery was more significant than the superior epigastric artery in supplying the skin of the anterior abdominal wall. Segmental branches of the deep epigastric system pass upward and outward into the neurovascular plane of the lateral abdominal wall, where they anastomose with the terminal branches of the lower six intercostal arteries and the ascending branch of the deep circumflex iliac artery. The anastomoses consist of multiple narrow "choke" vessels. Similar connections are seen between the superior and the deep inferior epigastric arteries within the rectus abdominis muscle well above the level of the umbilicus. Many perforating arteries emerge through the anterior rectus sheath, but the highest concentration of major perforators is in the paraumbilical area. These vessels are terminal branches of the deep inferior epigastric artery. They feed into a subcutaneous vascular network that radiates from the umbilicus like the spokes of a wheel. Once again, choke connections exist with adjacent territories: inferiorly with the superficial inferior epigastric artery, inferolaterally with the superficial circumflex iliac artery, and superiorly with the superficial superior epigastric artery. The dominant connections, however, are superolaterally with the lateral cutaneous branches of the intercostal arteries. For breast reconstruction, it would appear that prior ligation of the deep inferior epigastric artery would be of advantage when elevating the lower abdominal skin on a superiorly based rectus abdominis musculocutaneous flap. The vascularity of this flap would be further increased by positioning some part of the skin paddle over the dense pack of large paraumbilical perforators. Based on these anatomic studies, the relative merits of the superior and deep inferior epigastric arteries with respect to local and distant tissue transfer using various elements of the abdominal wall are discussed in detail.     

A new extended external oblique musculocutaneous flap for reconstruction of large chest-wall defects

A new extended external oblique musculocutaneous flap utilized in the reconstruction of chest-wall defects is described. The flap is drawn as a V-Y rotation flap on the ipsilateral abdominal wall. It is laterally based, and its pedicle coincides with the five lowest costal insertions of the external oblique. The flap extends above the transiliac line, from the posterior axillary line to the linea alba, and includes the dynamic territory of the external oblique muscle. Vascular supply is provided by the musculocutaneous perforating arteries of the intercostal vessels and their subcutaneous branches. The flap is raised medially and includes the anterior sheath of the rectus. Undermining continues between the external and the internal oblique muscles as far as the posterior axillary line. The donor site on the abdominal wall is reinforced by the plication of the internal oblique sheath. This flap was used in 13 patients with major anterior chest-wall excisional defects. The mean chest-wall defect was about 390 cm2. Marginal necrosis with distal skin loss was observed in one patient. All other flaps healed without complications. The extended external oblique musculocutaneous flap differs from other external oblique flaps already described in several aspects that allow it to obtain better functional and aesthetic results.     

Venous congestion and blood flow in free transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flaps

A series of 240 deep inferior epigastric perforator (DIEP) flaps and 271 free transverse rectus abdominis myocutaneous (TRAM) flaps from two institutions was reviewed to determine the incidence of diffuse venous insufficiency that threatened flap survival and required a microvascular anastomosis to drain the superficial inferior epigastric vein. This problem occurred in five DIEP flaps and did not occur in any of the free TRAM flaps. In each of these cases, the presence of a superficial inferior epigastric vein that was larger than usual was noted. It is therefore suggested that if an unusually large superficial inferior epigastric vein is noted when a DIEP flap is elevated, the vein should be preserved for possible use in flap salvage. Anatomical studies with Microfil injections of the superficial venous system of the DIEP or TRAM flap were also performed in 15 cadaver and 3 abdominoplasty specimens to help determine why venous circulation (and flap survival) in zone IV of the flaps is so variable. Large lateral branches crossing the midline were found in only 18 percent of cases, whereas 45 percent had indirect connections through a deeper network of smaller veins and 36 percent had no demonstrable crossing branches at all. This absence of crossing branches in many patients may explain why survival of the zone IV portion of such flaps is so variable and unpredictable.     

Intraoperative physiologic blood flow studies in the TRAM flap.

An intraoperative study was done to establish the functional and quantitative properties of the blood supply to the TRAM flap through the assessment and manipulation of blood flow through the deep epigastric arterial system. Seventeen patients undergoing unilateral postmastectomy breast reconstruction with lower transverse rectus abdominis myocutaneous (TRAM) flaps were studied. The study is divided into two parts: (1) ultrasonic measurement of blood flow in the deep inferior epigastric artery (DIEA), and (2) direct measurement of blood pressure in the deep epigastric arterial system, after division of the deep inferior epigastric artery. With occlusion of the superior epigastric artery at the level of the upper edge of the skin flap, 71 percent of the patients had a decrease in the blood flow through the deep inferior epigastric artery, with an average decrease of 23 percent. This implies that the area of watershed perfusion in the lower TRAM flap is superior to the umbilicus, and therefore, survival of all lower TRAM flap tissues requires reversal in the normal direction of arterial flow to the flap. The blood pressure in the proximal stump of the deep inferior epigastric arterial system averaged 46 percent of the mean systemic blood pressure. Occlusion of the medial and lateral thirds of the isolated rectus muscle decreased the mean arterial blood pressure in the flap an average of 19 percent in 80 percent of the individuals studied. These data support the technique of harvesting the entire rectus muscle, avoiding muscle-splitting maneuvers that may compromise axial blood flow.     

The external oblique flap for reconstruction of the rectus sheath.

Despite the availability of synthetic materials and distant fascial flaps, primary closure of ventral abdominal defects with contiguous tissues remains the preferred solution. Increased experience with such defects in the lower abdomen, particularly at the time of bilateral rectus muscle transposition, led in 1985 to the investigation of an external oblique abdominis flap for closure of the anterior rectus sheath. From October of 1985 to October of 1990, 33 patients underwent repair of bilateral lower rectus abdominis defects with the help of bilateral external oblique flaps. Each of the patients had undergone synchronous chest or breast reconstruction using a transverse rectus abdominis musculocutaneous flap including bilateral rectus muscle pedicles. Although all patients in this study had undergone double-pedicle rectus muscle procedures, not all patients having had double-pedicle rectus muscle procedures required this maneuver. External oblique flaps were performed at the time of rectus sheath repair only if fascia could not be approximated without tearing. After closure of the bilateral paramedian defect, synthetic mesh overlay was added only if the direct closure still appeared excessively tight. At the time of advancement of the external oblique muscle and fascia, the internal oblique abdominis muscle and lateral cutaneous nerve of the thigh were preserved. Of the 33 patients who underwent this procedure, 7 required the addition of mesh overlay. Thirty-two patients healed uneventfully with a remarkably solid ventral abdominal wall. One patient developed an early postoperative hernia subsequent to a major and prolonged abdominal-wall infection and abscess. Patient follow-up ranged from 1 to 36 months, with a mean of 12 months.(ABSTRACT TRUNCATED AT 250 WORDS)     

The free thoracoumbilical flap for resurfacing large soft-tissue defects of the lower extremity

Both cadavers and living patients were studied regarding a method to resolve large skin defects with bone exposure in the leg, with long-distance thrombosis of the anterior tibial vessels or posterior tibial vessels resulting from traumatic lesions. Forty-six casting mold specimens of cadaveric legs were investigated. There were rich communication branches among the anterior tibial artery, posterior tibial artery, and fibular artery in the foot and ankle, which complemented each other well. Twenty-six patients with large skin defects with bone exposure in the proximal or middle segment of the leg were admitted to the authors' hospital. Among those patients, 19 demonstrated long-distance thrombosis of the anterior tibial vessels or posterior tibial vessels resulting from traumatic lesions. During treatment, a thoracoumbilical flap based on the inferior epigastric vessels was anastomosed to the distal stump of the anterior tibial vessels or the posterior tibial vessels, with reversed flow. All defects were successfully repaired, with good color and texture matches of the flaps. This method can be used for patients with normal anterior tibial vessels or posterior tibial vessels, normal distal stumps of the injured blood vessels, and good reversed flow. The method has the advantages of dissecting blood vessels in the recipient area during the débridement, not affecting the blood circulation of the injured leg, not sacrificing blood vessels of the opposite leg, and not fixing the patient in a forced posture. The muscles are less bulky in the distal one-third of the leg, and the blood vessels are shallow and can be dissected and anastomosed easily. When the flap is used for reconstruction in the proximal two-thirds of the leg, the blood vessel pedicle of the free flap is at a straight angle, without kinking.     

Prefabricated sensate myocutaneous and osteomyocutaneous free flaps: an experimental model. Preliminary report

Principles of neovascularization have been reported for the successful creation of a variety of muscle and bone free flaps. This study demonstrates a simple and effective technique for construction of prefabricated sensate myocutaneous and osteomyocutaneous free flaps in a rat model. These experiments were carried out in 20 Sprague-Dawley male rats. In half the animals, a sensate myocutaneous flap was constructed by sandwiching the superficial inferior epigastric vessels between a laterally based external abdominal oblique muscle flap and a laterally based skin flap served by an identified cutaneous nerve. A similar preparation included a piece of iliac crest bone. Two to three weeks later, now neovascularized by the sandwiched vessels, the flaps were harvested and transferred as free flaps with high reliability. An increased number of potential donor sites, the versatility of design, and the ability to customize flaps to the specific recipient-site needs are proffered.     

Comparison of strategies for preventing abdominal-wall weakness after TRAM flap breast reconstruction.

To determine the best method for preserving abdominal-wall integrity after TRAM flap breast reconstruction, the records of 130 patients followed for at least 6 months (mean 18 months) were examined. Three strategies for management of the abdominal-wall repair were compared. In the first group (72 patients), the entire width of the rectus abdominis muscle was harvested with the flap, and the anterior rectus sheath was closed in one layer. In the second group (20 patients), only the medial two-thirds of the rectus abdominis muscle was removed from the abdomen. The muscle and fascial donor defects were closed in separate layers. In the third group (38 patients), only one-fifth of the muscle was preserved, and a two-layered fascial closure of the anterior rectus sheath was performed, emphasizing repair of the internal oblique fascia to the midline fascia deep to the linea alba. Reinforcing synthetic mesh was used (in 10 patients) if closure was difficult or sutures tended to pull through the fascia. The incidence of abdominal weakness and/or bulging was similar in the first two groups (33 and 40 percent, respectively), but significantly lower (8 percent) in the third group (p = 0.006).     

Pfannenstiel incision as an alternative approach for harvesting the rectus abdominis muscle for free-tissue transfer

The rectus abdominis muscle has been one of the most commonly used donor tissues for free-flap reconstruction of defects in the extremities and in selected head and neck patients. The rectus abdominis has provided adequate soft-tissue mass with predictable anatomy and results for the majority of its applications in free-flap reconstruction. Harvesting of this muscle has typically been done through a paramedian or midline incision, which has left a lengthy notable scar on a patient's abdomen. To avoid the late aesthetic deformity associated with this typical approach for the rectus abdominis, we began harvesting the muscle through a Pfannenstiel incision. Patients were initially selected based on young age and limited soft-tissue requirements. With additional experience, this technique was extended to include all healthy patients regardless of age. Also, soft-tissue limitations no longer became an issue, as we learned the entire rectus abdominis muscle could be harvested from this approach. An extended Pfannenstiel incision was made from the ipsilateral anterior superior iliac spine to the lateral border of the contralateral rectus abdominis. A superiorly based flap was raised to expose the full length of the anterior rectus sheath from pubis to costal margin. In our earlier patients, a periumbilical incision was made for presumed easier access, but we discovered this was an unnecessary maneuver. With the anterior sheath fully exposed, the muscle was harvested and the sheath repaired in a routine manner. The elevated abdominal flap was returned to its anatomic position and closed over a suction drain. Since 1993, 10 patients have undergone a Pfannenstiel approach for harvesting of the rectus abdominis muscle. The mean age was 16. The areas requiring coverage included a traumatic elbow defect, seven traumatic lower extremity defects, one lower extremity sarcoma defect, and one lower extremity septic joint defect. Mean follow-up for these patients was 12 months. There were no flap failures. One patient developed an arterial thrombosis on postoperative day 5 and was treated with successful revision. There were no abdominal wall complications. Cosmesis was judged as good in all patients. We would recommend avoiding this approach in heavy or moderate smokers, diabetic patients, and patients with significant obesity. The Pfannenstiel approach to the rectus abdominis muscle has allowed for complete harvest of the muscle, improved aesthetic results compared with alternative techniques, and avoidance of donor-site morbidityin healthy patients.     

A clinical experience with perforator flaps in the coverage of extensive defects of the upper extremity

Traditional skin free flaps, such as radial arm, lateral arm, and scapular flaps, are rarely sufficient to cover large skin defects of the upper extremity because of the limitation of primary closure at the donor site. Muscle or musculocutaneous flaps have been used more for these defects. However, they preclude a sacrifice of a large amount of muscle tissue with the subsequent donor-site morbidity. Perforator or combined flaps are better alternatives to cover large defects. The use of a muscle as part of a combined flap is limited to very specific indications, and the amount of muscle required is restricted to the minimum to decrease the donor-site morbidity. The authors present a series of 12 patients with extensive defects of the upper extremity who were treated between December of 1999 and March of 2002. The mean defect was 21 x 11 cm in size. Perforator flaps (five thoracodorsal artery perforator flaps and four deep inferior epigastric perforator flaps) were used in seven patients. Combined flaps, which were a combination of two different types of tissue based on a single pedicle, were needed in five patients (scapular skin flap with a thoracodorsal artery perforator flap in one patient and a thoracodorsal artery perforator flap with a split latissimus dorsi muscle in four patients). In one case, immediate surgical defatting of a deep inferior epigastric perforator flap on a wrist was performed to immediately achieve thin coverage. The average operative time was 5 hours 20 minutes (range, 3 to 7 hours). All but one flap, in which the cutaneous part of a combined flap necrosed because of a postoperative hematoma, survived completely. Adequate coverage and complete wound healing were obtained in all cases. Perforator flaps can be used successfully to cover a large defect in an extremity with minimal donor-site morbidity. Combined flaps provide a large amount of tissue, a wide range of mobility, and easy shaping, modeling, and defatting.     

The segmental rectus abdominis free flap for ankle and foot reconstruction.

The reconstruction of soft-tissue defects of the ankle and foot usually requires free-tissue transfer. Although certain local flaps have been described for the reconstruction of these injuries, their utility may be compromised by significant crush injury or the size and location of the defect. Part of the rectus abdominis muscle, the segmental rectus abdominis free flap, is ideally suited for this use because of the muscle's versatility, reliability, and negligible donor deformity when harvested through a low transverse abdominal incision. Seven patients reconstructed with this flap are presented, and the technique is discussed. All patients have been successfully reconstructed with preservation of the ankle and foot. At present, all patients are fully or partially weight-bearing. The segmental rectus abdominis free flap is recommended for the reconstruction of such wounds.     

The rectus abdominis free flap as an emergency procedure in extensive upper extremity soft-tissue defects

Stable wound coverage after extensive soft-tissue loss of the upper extremity remains a difficult problem in the management of large defects of the upper limb. To prevent further tissue loss owing to infection or inadequate cover when important structures such as vessels, tendons, nerves, joints, and bones are exposed, various free flaps have been introduced into the therapeutic armamentarium of acute plastic surgical management options. Emergency or delayed early reconstruction has been proposed to prevent chronic infection and further tissue loss. We report a series of 12 emergency and delayed early reconstructions of the forearm, wrist, carpus, metacarpus, and hand using the free rectus abdominis muscle flap with split-skin coverage, demonstrating the versatility of this flap within this special context. Emergency free rectus muscle flap transfer is safe, technically easy, and expandable.     

Breast Reconstruction with the free TRAM or DIEP flap: patient selection,choice of flap,and outcome

Recent reports of breast reconstruction with the deep inferior epigastric perforator (DIEP) flap indicate increased fat necrosis and venous congestion as compared with the free transverse rectus abdominis muscle (TRAM) flap. Although the benefits of the DIEP flap regarding the abdominal wall are well documented, its reconstructive advantage remains uncertain. The main objective of this study was to address selection criteria for the free TRAM and DIEP flaps on the basis of patient characteristics and vascular anatomy of the flap that might minimize flap morbidity. A total of 163 free TRAM or DIEP flap breast reconstructions were performed on 135 women between 1997 and 2000. Four levels of muscle sparing related to the rectus abdominis muscle were used. The free TRAM flap was performed on 118 women, of whom 93 were unilateral and 25 were bilateral, totaling 143 flaps. The DIEP flap procedure was performed on 17 women, of whom 14 were unilateral and three were bilateral, totaling 20 flaps. Morbidities related to the 143 free TRAM flaps included return to the operating room for 11 flaps (7.7 percent), total necrosis in five flaps (3.5 percent), mild fat necrosis in 14 flaps (9.8 percent), mild venous congestion in two flaps (1.4 percent), and lower abdominal bulge in eight women (6.8 percent). Partial flap necrosis did not occur. Morbidities related to the 20 DIEP flaps included return to the operating room for three flaps (15 percent), total necrosis in one flap (5 percent), and mild fat necrosis in two flaps (10 percent). Partial flap necrosis, venous congestion, and a lower abdominal bulge were not observed. Selection of the free TRAM or DIEP flap should be made on the basis of patient weight, quantity of abdominal fat, and breast volume requirement, and on the number, caliber, and location of the perforating vessels. Occurrence of venous congestion and total flap loss in the free TRAM and DIEP flaps appears to be independent of the patient age, weight, degree of muscle sparing, and tobacco use. The occurrence of fat necrosis is related to patient weight (p < 0.001) but not related to patient age or preservation of the rectus abdominis muscle. The ability to perform a sit-up is related to patient weight (p < 0.001) and patient age (p < 0.001) but not related to preservation of the muscle or intercostal nerves. The incidence of lower abdominal bulge is reduced after DIEP flap reconstruction (p < 0.001). The DIEP flap can be an excellent option for properly selected women.     

TRAM flap safety optimized with intraoperative Doppler

Anatomic studies have clearly documented the variable position of the deep superior epigastric vessels in the rectus abdominis muscle. In our opinion, only that part of the rectus abdominis muscle containing the vascular pedicle should be transposed with the TRAM flap. The Doppler probe provides a simple method of identifying the dominant intramuscular vascular axis. It consistently alerts the surgeon to any unusual position of a vessel at the costal margin or within the rectus abdominis muscle. This knowledge enables a conservative yet safe dissection of the vascular pedicle, rectus abdominis muscle, and its sheath. This in turn will enable a competent abdominal closure. The Doppler technique is safe, simple, quick, noninvasive, familiar to most surgeons, and applicable to all patients.