An aesthetic classification of the abdomen based on the myoaponeurotic layer.

An objective classification for abdominoplasty based on myoaponeurotic deformities is described. Types A, B, C, and D correspond to different myoaponeurotic deformities. Patients with type A display rectus diastasis secondary to pregnancy, and plication of the anterior rectus sheath is indicated. Patients with type B present with laxity of the lateral and inferior areas of the abdominal wall after approximation of the anterior rectus sheaths. An L-shaped plication of the external oblique aponeurosis is performed in addition to the correction of rectus diastasis. Patients with type C are those whose rectus muscles are laterally inserted on the costal margins. Release and undermining of the rectus muscles from their posterior sheath and advancement of these muscles, attached to the anterior sheath, is the procedure of choice in these cases. Patients with type D display a poor waistline definition; external oblique muscle rotation associated with plication of the anterior rectus sheath is the procedure used to correct this deformity. Eighty-eight patients who underwent abdominoplasty were reviewed, and the incidence of each deformity was determined on this population. This study presents a practical classification that permits the plastic surgeon to critically evaluate which is the best option to correct abdominal deformities considering specific areas of myoaponeurotic weakness.     

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.     

Transverse rectus sheath plication in abdominoplasty

The standard abdominoplasty technique uses a wide, vertically oriented plication of the rectus sheath to narrow the waistline. This reduces the contribution of the rectus sheath to the anterior abdominal wall from more than 50 percent to 25 percent or less and creates an unnaturally flat appearance. No amount of exercise can restore the native form of the rectus sheath. For the past 3 years, the authors have performed a transverse plication of the rectus sheath, to address vertical laxity, complemented by a bilateral crescent-shaped plication of the external oblique fascia, to address waistline contour. Six consecutive patients who underwent the transverse rectus plication technique were compared with a similar group of patients who underwent vertical rectus plication. Comparison was made via preoperative and postoperative photographic analysis by two impartial judges. Although the overall result was excellent in both groups, the global score was significantly higher in the transverse plication group (4.5 versus 3.9, p = 0.044). Scores for anterior abdominal contour (4.7 versus 4.2, p = 0.029) and definition of the linea semilunaris (4.6 versus 3.7, p = 0.008) were also significantly higher for the transverse plication group. The difference for waistline contour (4.5 versus 3.8, p = 0.067), definition of the linea alba (4.4 versus 3.9, p = 0.067), and hip-waist transition (4.4 versus 3.7, p = 0.067) did not reach statistical significance. The outline of the rectus sheath is a significant portion of what is perceived as an aesthetic abdomen. Transverse plication of the rectus sheath with bilateral crescent-shaped plications of the external oblique fascia retains this native form. The result is improved anterior abdominal contour and definition of the rectus sheath with a comparable or better improvement in waistline contour and transition from the hips to the waist when compared with wide, vertical rectus plication.     

"Components separation" method for closure of abdominal-wall defects: an anatomic and clinical study

Closure of large abdominal-wall defects usually requires the transposition of remote myocutaneous flaps or free-tissue transfers. The purpose of this study was to determine if separation of the muscle components of the abdominal wall would allow mobilization of each unit over a greater distance than possible by mobilization of the entire abdominal wall as a block. The abdominal walls of 10 fresh cadavers were dissected. This demonstrated that the external oblique muscle can be separated from the internal oblique in a relatively avascular plane. The rectus muscle with its overlying rectus fascia can be elevated from the posterior rectus sheath. The compound flap of the rectus muscle, with its attached internal oblique-transversus abdominis muscle, can be advanced 10 cm around the waistline. The external oblique has limited advancement. These findings were utilized clinically in the reconstruction of abdominal-wall defects in 11 patients, ranging in size from 4 x 4 to 18 x 35 cm. This study suggests that large abdominal-wall defects can be reconstructed with functional transfer of abdominal-wall components without the need for resorting to distant transposition of free-muscle flaps.     

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)     

Abdominoplasty and abdominal wall rehabilitation: a comprehensive approach

Standard abdominoplasty techniques involve a low horizontal or W skin excision, muscle plication, and umbilical transposition. Newer techniques include suction-assisted lipectomy, the use of high lateral tension with fascial suspension, and external oblique muscle advancement. The author has modified these traditional procedures and added new techniques to improve the aesthetic and functional results of the abdominoplasty procedure. This modification provides a comprehensive approach to abdominal wall aesthetic improvement and rehabilitation. The comprehensive approach described includes four components: the "U-M dermolipectomy," "V umbilicoplasty," the rectus abdominis "myofascial release," and suction-assisted lipectomy. The patient is marked while standing for areas of suction lipectomy and undermining. The lower incision is designed as an open U with the lateral limbs placed inside the bikini line. The upper incision is a lazy M with the higher peaks located at the level of the flanks. Subcutaneous hydration is achieved to perform suction along the flanks, waistline, and iliac areas. Gentle suction of the flaps is also performed. The umbilicus is cored out in a heart shape. The flaps within the U-M marks are excised, and the undermining is performed to the xiphoid and costal margins. The rectus diastasis is marked, and the anterior rectus fascia is incised at the junction of the medial third with the central third of the width of the rectus sheath. Horizontal figure-eight plication sutures by using the lateral fascial edge enable easier infolding of the central tissue. The new recipient of the umbilicus is made by an incision in a V shape on the abdominal flap. The umbilicus is telescoped, and the triangular flap of the abdomen is sutured to the triangular defect of the umbilicus. Skin flap fixation to the umbilicus relieves tension in the lower portion of the flap. The upper skin flap, which is cut in an M manner, provides lateral tension and matches the length of the lower flap. A standard fascial suspension is used and closure is performed in layers. The techniques described here are intertwined procedures. Each facilitates the accomplishment of the other procedure, and they complement each other. They all attain the 12 objectives of the abdominoplasty described. These combined techniques have been used in 104 patients in a period of 11 years. Complications were minimal and easily manageable, except for one patient who required excision of a pseudobursa and retightening of the lower quadrants of the abdominal wall musculature to correct extreme lordosis. A comprehensive approach for the treatment of complex abdominal wall aesthetic and functional defects is presented. These require thoughtful integration of the four components mentioned. This approach has allowed predictable, reproducible, and aesthetically pleasing results.     

Abdominal wall partitioning (the accordion effect) for reconstruction of major defects: a retrospective review of 10 patients

Ten patients underwent abdominal wall reconstruction using the technique of abdominal wall partitioning. All defects were closed in the midline by approximating fascia to fascia with the assistance of a general surgeon. One patient had skin grafted small bowel. Five patients had chronically infected mesh and previous failed attempts at repair. Four patients had large ventral hernias following gastric reduction operations and massive weight loss. No defect in any dimension was less than 20 cm. All patients had secure abdominal wall repair by reconstruction of a midline anchor for the abdominal wall musculature. One patient was lost to follow-up after 3 weeks. The average follow-up time for the remaining nine patients was 18.6 months (range, 6 months to 4.7 years). One patient required readmission to the hospital for management of a limited area of skin necrosis. Two patients had minor wound infections, and three patients had subcutaneous seromas, all of which were managed on an outpatient basis. One patient developed a 2 x 2-cm subxiphoid hernia recurrence. Technical details include subcutaneous undermining of the abdominal skin to the anterior axillary lines bilaterally, mobilization of the viscera to expose the white lines of Toldt bilaterally, and parallel, parasagittal, staggered releases of the transversalis fascia, transversalis muscle, external oblique fascia, external oblique muscle, and rectus fascia. These multiple releases allow expansion and translation of the abdominal wall by an accordion-like effect. This accordion-like effect allows closure of abdominal wall defects that are substantially larger than what can be closed with current techniques.     

Activity in torso muscles during relaxed standing

Electromyographic activity of erector spinae, external oblique, and rectus abdominis muscles was studied during relaxed standing compared to lying down. Activity in the forearm extensors and forearm flexors was also studied. Surface electrodes were used. Each of the torso muscles exhibited 0.2 microV of activity and the forearm muscles 0.1 microV while subjects were relaxed and lying down. During quiet standing the erector spinae, external oblique, and rectus abdominis muscles showed a median activity of 1.0 microV, 2.5 microV, and 0.7 microV respectively (for a minimum of ten 10-sec samples per subject). Examination of the integrated records during standing revealed no periods without increased muscle activity in the torso muscles. By contrast, activity in the forearm muscles did not increase during standing. The major superficial muscles of posture in the torso appear to act as guy wires, being continually active during standing. There is no support for hypotheses of passive support for the torso, nor do torso muscles act in either/or fashion; both anterior and posterior muscles are active at once. There is no sign of generally increased muscle tone in all muscles or in extensors; only the postural muscles are continuously active.     

The separation of anatomic components technique for the reconstruction of massive midline abdominal wall defects: anatomy, surgical technique, applications, and limitations revisited

Reconstruction of massive abdominal wall defects has long been a vexing clinical problem. A landmark development for the autogenous tissue reconstruction of these difficult wounds was the introduction of "components of anatomic separation" technique by Ramirez et al. This method uses bilateral, innervated, bipedicle, rectus abdominis-transversus abdominis-internal oblique muscle flap complexes transposed medially to reconstruct the central abdominal wall. Enamored with this concept, this institution sought to define the limitations and complications and to quantify functional outcome with the use of this technique. During a 4-year period (July of 1991 to 1995), 22 patients underwent reconstruction of massive midline abdominal wounds. The defects varied in size from 6 to 14 cm in width and from 10 to 24 cm in height. Causes included removal of infected synthetic mesh material (n = 7), recurrent hernia (n = 4), removal of split-thickness skin graft and dense abdominal wall cicatrix (n = 4), parastomal hernia (n = 2), primary incisional hernia (n = 2), trauma/enteric sepsis (n = 2), and tumor resection (abdominal wall desmoid tumor involving the right rectus abdominis muscle) (n = 1). Twenty patients were treated with mobilization of both rectus abdominis muscles, and in two patients one muscle complex was used. The plane of "separation" was the interface between the external and internal oblique muscles. A quantitative dynamic assessment of the abdominal wall was performed in two patients by using a Cybex TEF machine, with analysis of truncal flexion strength being undertaken preoperatively and at 6 months after surgery. Patients achieved wound healing in all cases with one operation. Minor complications included superficial infection in two patients and a wound seroma in one. One patient developed a recurrent incisional hernia 8 months postoperatively. There was one postoperative death caused by multisystem organ failure. One patient required the addition of synthetic mesh to achieve abdominal closure. This case involved a thin patient whose defect exceeded 16 cm in width. There has been no clinically apparent muscle weakness in the abdomen over that present preoperatively. Analysis of preoperative and postoperative truncal force generation revealed a 40 percent increase in strength in the two patients tested on a Cybex machine. Reoperation was possible through the reconstructed abdominal wall in two patients without untoward sequela. This operation is an effective method for autogenous reconstruction of massive midline abdominal wall defects. It can be used either as a primary mode of defect closure or to treat the complications of trauma, surgery, or various diseases.     

Effect of hypercapnia and PEEP on expiratory muscle EMG and shortening

The present study examined the effects of hypercapnia and positive end-expiratory pressure (PEEP) on the electromyographic (EMG) activity and tidal length changes of the expiratory muscles in 12 anesthetized, spontaneously breathing dogs. The integrated EMG activity of both abdominal (external oblique, internal oblique, rectus abdominis, and transverse abdominis) and thoracic (triangularis sterni, internal intercostal) expiratory muscles increased linearly with increasing PCO2 and PEEP. However, with both hypercapnia and PEEP, the percent increase in abdominal muscle electrical activity exceeded that of thoracic expiratory muscle activity. Both hypercapnia and PEEP increased the tidal shortening of the external oblique and rectus abdominis muscles. Changes in tidal length correlated closely with simultaneous increases in muscle electrical activity. However, during both hypercapnia and PEEP, length changes of the external oblique were significantly greater than those of the rectus abdominis. We conclude that both progressive hypercapnia and PEEP increase the electrical activity of all expiratory muscles and augment their tidal shortening but produce quantitatively different responses in the several expiratory muscles.     

Responses of the anterolateral abdominal muscles during cough and expiratory threshold loading in the cat.

The present study was conducted to determine the pattern of activation of the anterolateral abdominal muscles during the cough reflex. Electromyograms (EMGs) of the rectus abdominis, external oblique, internal oblique, transversus abdominis, and parasternal muscles were recorded along with gastric pressure in anesthetized cats. Cough was produced by mechanical stimulation of the lumen of the intrathoracic trachea or larynx. The pattern of EMG activation of these muscles during cough was compared with that during graded expiratory threshold loading (ETL; 1-30 cmH(2)O). ETL elicited differential recruitment of abdominal muscle EMG activity (transversus abdominis > internal oblique > rectus abdominis congruent with external oblique). In contrast, both laryngeal and tracheobronchial cough resulted in simultaneous activation of all four anterolateral abdominal muscles with peak EMG amplitudes 3- to 10-fold greater than those observed during the largest ETL. Gastric pressures during laryngeal and tracheobronchial cough were at least eightfold greater than those produced by the largest ETL. These results suggest that, unlike their behavior during expiratory loading, the anterolateral abdominal muscles act as a unit during cough.     

The oblique rectus abdominis musculocutaneous flap: revisited clinical applications

The authors present their experience with a previously described but infrequently used variation of the rectus abdominis myocutaneous flap. Skin paddles angled obliquely from the line of the rectus abdominis and toward the rib cage were successfully carried on periumbilical perforators from the inferior epigastric system. Skin paddle dimensions ranged from 6.5 to 12 cm in width and from 10 to 27 cm in length in 14 consecutive patients. In six of the 14 patients, the flap was used intraabdominally to obliterate radiated pelvic defects and to close radiated vaginal defects. Five flaps were placed externally to repair radiated wounds of the perineum, thigh, and trunk, and the remaining three cases were performed as free tissue transfers. One cadaver injection study was performed to redemonstrate the preferential flow of fluid in a superior-oblique direction from periumbilical perforators. Termed the oblique rectus abdominis musculocutaneous ("ORAM") flap, this flap variation has significant advantages in terms of ease of dissection and versatility over its flap cousins the vertical rectus abdominis musculocutaneous flap and the transverse rectus abdominis musculocutaneous flap.     

Clinical applications of the posterior rectus sheath-peritoneal free flap

Soft-tissue injuries involving the dorsum of the hand and foot continue to pose complex reconstructive challenges in terms of function and contour. Requirements for coverage include thin, vascularized tissue that supports skin grafts and at the same time provides a gliding surface for tendon excursion. This article reports the authors' clinical experience with the free posterior rectus sheath-peritoneal flap foil dorsal coverage in three patients. Two patients required dorsal hand coverage; one following acute trauma and another for delayed reconstruction 1 year after near hand replantation. A third patient required dorsal foot coverage for exposed tendons resulting from skin loss secondary to vasculitis. In all three patients, the flap was harvested through a paramedian incision at the lateral border of the anterior rectus sheath. After opening the anterior rectus sheath, the rectus muscle was elevated off of the posterior rectus sheath and peritoneum. When elevating the muscle, the attachments of the inferior epigastric vessels to the posterior rectus sheath and peritoneum were preserved while ligating any branches of these vessels to the muscle. Segmental intercostal innervation to the muscle was preserved. The deep inferior epigastric vessels were then dissected to their origin to maximize pedicle length and diameter. The maximum dimension of the flaps harvested for the selected cases was 16 X 8 cm. The anterior rectus sheath was closed primarily with non-absorbable suture. Mean follow-up was 1 year, and all flaps survived with excellent contour and good function in all three patients. Complications included a postoperative ileus in one patient, which resolved after 5 days with nasogastric tube decompression.     

Perforator topography of the deep inferior epigastric perforator flap in 100 cases of breast reconstruction

The anatomic topography of the perforators within the rectus muscle and the anterior fascia largely determines the time needed to harvest the perforator free flap and the difficulty of the procedure. In 100 consecutive cases, the topographic patterns of the perforators were investigated. In 65 percent, a short intramuscular course was seen. In 16 percent, a perforator at the tendinous intersection was encountered. In 9 percent, the largest perforator was found to have a long intramuscular course. In 5 percent, a subfascial course was found, and in another 5 percent, a paramedian course was found. In 74 percent of flaps, just one perforator was used, whereas two perforators were dissected in 20 percent. Only in 6 percent of flaps were three perforators used. A long intramuscular course (>4 cm) lengthens the dissection substantially, especially when the intramuscular course is in a step-wise pattern. The subfascial course requires precarious attention at the early stage of the perforator dissection when splitting the fascia. The perforators at the tendinous intersections are the most accessible and require a short but intense dissection in the fibrotic tissue of intersection. A paramedian perforator, medial to the rectus muscle, is a septocutaneous rather than a musculocutaneous perforator. The straightforward dissection almost extends up to the midline. Therefore, dissection always is performed at one side and, if no good perforators are present, continued at the intact contralateral side. The size of these perforators and their location in the flap determine the choice. One perforator with significant flow can perfuse the whole flap. If in doubt, two perforators can be harvested, especially if they show a linear anatomy so that muscle fibers can be split. The only interference with the muscle exists in splitting the muscle fibers. A perforator that lies in the middle of the flap is preferable. For a large flap, a perforator of the medial row provides better perfusion to zone 4 than one of the lateral row because of the extra choke vessel for the lateral row perforators. The clinical appearance of the perforators is the key element in the dissection of the perforator flap. Perforator topography determines the overall length and difficulty of the procedure.     

Contribution of the skin,rectus abdominis and their sheaths to the structural response of the abdominal wall ex vivo

A better understanding of the abdominal wall biomechanics could help designing new treatments for incisional hernia. In the current study, an experimental protocol was developed to evaluate the contributions of the abdominal wall components to the structural response of the anterior part of the abdominal wall. The specimens underwent 3 dissections (removal of (1) skin and subcutaneous fat, (2) anterior rectus sheath, (3) rectus abdominis muscles). After each dissection, they were subjected to air pressure up to 3 kPa. Ultrasound images and associated elastographic maps were collected at 0, 2 and 3 kPa in the intact state and strains on the internal surface were calculated using stereo-correlation in all states. Strains on the rectus abdominis and linea alba were analyzed. After the dissection of the anterior sheath of the rectus abdominis, longitudinal strain was found significantly different on the linea alba (5% at 3 kPa) and on the rectus abdominis area (11% at 3 kPa). The current results highlight the importance of the rectus sheath in the structural response of the anterior part of the abdominal wall ex vivo. Geometrical characteristics such as thicknesses and radii of curvature and mechanical properties (shear modulus of the rectus abdominis, e.g. at 0 pressure the average value is 14 kPa) were provided in order to facilitate future modeling efforts.     

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).     

The L-shaped combined vertical and transverse abdominal island flap for breast reconstruction

The occasional patient will present for reconstruction after mastectomy who refuses a foreign-body implant or is desirous of reconstruction by autogenous tissue. An unfavorable midline abdominal scar that extends both below and above the umbilicus will preclude the use of the standard lower or upper transverse abdominal island flaps for such purposes. For these highly select circumstances, we present our experiences with two such patients where a combination of an L-shaped vertical and transverse rectus abdominis myocutaneous flap was employed. In this procedure, the vertical component is planned to provide the external skin cover, while the ipsilateral hemiellipse transverse component is deepithelialized and buried deep to the vertical component to provide the bulk and mound projection.     

The effect of posture on respiratory activity of the abdominal muscles

The purpose of this study was to determine the influence of posture on the expiratory activity of the abdominal muscles. Fifteen young adult men participated in the study. Activities of the external oblique abdominis, internal oblique abdominis, and rectus abdominis muscles were measured electromyographically in various postures. We used a pressure threshold in order to activate the abdominal muscles as these muscles are silent at rest. A spirometer was used to measure the lung volume in various postures. Subjects were placed in the supine, standing, sitting, and sitting-with-elbow-on-the-knee (SEK) positions. Electromyographic activity and mouth pressure were measured during spontaneous breathing and maximal voluntary ventilation under the respiratory load. We observed that the lung volume changed with posture; however, the breathing pattern under respiratory load did not change. During maximal voluntary ventilation, internal oblique abdominis muscle expiratory activity was lower in the SEK position than in any other position, external oblique abdominis muscle inspiratory activity was lower in the supine position than in any other position, and internal oblique abdominis muscle activity was higher in the standing position than in any other position. During spontaneous breathing, external oblique abdominis muscle activity was higher during expiration and inspiration in the SEK position than in any other position. The internal oblique abdominis muscle activity was higher during both inspiration and expiration in the standing position than in any other position. The rectus abdominis muscle activity did not change with changes in posture during both inspiration and expiration. Increase in the external oblique abdominis activity in the SEK position was due to anatomical muscle arrangement that was consistent with the direction of lower rib movement. On the other hand, increase in the internal oblique abdominis activity in the standing position was due to stretching of the abdominal wall by the viscera. We concluded that differences in activity were due to differences in the anatomy of the abdominal muscles and the influence of gravity.     

Difference in abdominal muscularity at the umbilicus level between young and middle-aged men

This study aimed to examine how the muscularity of the abdomen at the umbilicus level differs between sedentary middle-aged and young men. Magnetic resonance imaging was applied to determine the cross-sectional areas of skeletal muscle, subcutaneous fat, and interperitoneal tissue in 43 middle-aged (40 58yrs) and 38 young (21-29 yrs) men. The cross-sectional area of the skeletal muscle was analyzed as the sum of those of the rectus abdominis, abdominal oblique, lower back, and iliopsoas skeletal muscle groups. The middle-aged men showed greater waist circumference and whole abdominal cross-sectional area than the young men. In addition, the cross-sectional areas of subcutaneous fat and interperitoneal tissue were greater in the middle-aged men than in the young men. However, the total cross-sectional area of the skeletal muscle was similar between the two groups, although its percentage to the whole abdominal cross-sectional area was higher in the young men compared to the middle-aged men. Among the four skeletal muscle groups analyzed, the percentage of the cross-sectional areas in abdominal oblique muscles to that of total skeletal muscle was higher in the middle-aged men than in the young men and that of the lower back muscles was the reverse. These results were similar even when cross-sectional area data were analyzed using a subsample (33 middle-aged and 23 young men) matched for body height and mass. Thus, the present study indicated that the total muscularity of the abdomen at the umbilicus level was similar between the middle-aged and young men, but the relative distributions of lower back and abdominal oblique muscles varied between the two generations.     

Closure of the donor defect for breast reconstruction with rectus abdominis myocutaneous flaps

The abdominal muscles not only constitute a multidirectional cinch that holds the abdominal contents in place, but they also determine the flexion and rotational movements of the trunk. The rectus is mainly responsible for flexion and the obliques are responsible for rotating the trunk. It is therefore important to maintain the tone and direction of pull of the oblique muscles. The key to closure of the fascial defect is to replace the same area of anterior rectus fascia (tendon of both obliques and transversus muscles) as has been removed with the rectus abdominis flap pedicle. This replacement, done with a double Merselene mesh, should extend up to the costal margin and should be of the same width as the fascia taken with the muscle pedicle. This technique was drawn from experience with 186 patients. Of these, 31 were simply approximated, and 43 percent developed weakness, bulging, or hernias, of which 5 required secondary repair. A total of 155 patients were closed with Merselene mesh, and only 4 percent developed bulging that was later repaired and attributed to technical mistakes. There were two cases of infection and three cases of exposed mesh due to necrosis (mesh did not need removal). Seromas were common (14 percent), but the incidence was reduced to 5 percent after tacking stitches were done from the mesh to the subcutaneous fascia.