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)     

"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.     

Restoration of abdominal wall integrity as a salvage procedure in difficult recurrent abdominal wall hernias using a method of wide myofascial release

The management of primary and recurrent giant incisional hernias remains a complex and frustrating challenge even with multiple alloplastic and autogenous closure options. The purpose of this study was to develop a reconstructive technique of restoring abdominal wall integrity to a subcategory of patients, who have failed initial hernia therapy, by performing superior and lateral myofascial release. Over a 1.5-year period, 10 patients with previously unsuccessful treatment of abdominal wall hernias, using either primary repair or placement of synthetic material, were studied. The patients had either recurrence of the hernia or complications such as infections requiring removal of synthetic material. The hernias were not able to be treated with standard primary closure techniques or synthetic material. The average defect size was 19 x 9 cm. Each patient underwent wide lysis of bowel adhesions releasing the posterior abdominal wall fascia to the posterior axillary line, subcutaneous release of the anterior abdominal wall fascia to a similar level, and complete removal of any synthetic material (if present). The abdominal domain was reestablished by releasing the laterally retracted abdominal wall. The amount of available abdominal wall tissue was increased by wide release of the cephalic abdominal wall fascia overlying the costal margin and the external oblique fascia and muscle laterally. If needed, partial thickness of the internal oblique muscle and its anterior fascia were also released laterally to perform a tension-free primary closure of the defect. All repairs were closed with satisfactory functional and aesthetic results. All alloplastic material was removed. Fascial release was limited so as to close only the hernia defect without tension. No significant release of the rectus sheath and muscle was needed. Good, dynamic muscle function was noted postoperatively. All repairs have remained intact, and no further abdominal wall hernias have been noted on follow-up.     

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.     

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.     

Anterolateral thigh flap for abdominal wall reconstruction

The free or pedicled anterolateral thigh flap was introduced for the reconstruction of large abdominal wall defects. This flap is superior to the tensor fasciae latae musculocutaneous flap in several respects. These include the wide, reliable skin territory (which can reach the level of the knee) and the long pedicle. Therefore, a pedicled anterolateral thigh flap with reliable blood circulation can easily be positioned above the umbilicus. In addition, the free anterolateral thigh flap has greater freedom of orientation and can be used to repair larger abdominal wall defects than can the tensor fasciae latae flap. Seven patients in whom abdominal wall defects had been reconstructed with pedicled or free anterolateral thigh flaps were reviewed. Their average age was 47.1 years (range, 21 to 74 years), and the average follow-up period was 10.7 months (range, 2 to 21 months). The size of the abdominal wall defects ranged from 12 x 12 cm to 18 x 24 cm, and the size of the transferred flap ranged from 10 x 20 cm to 20 x 20 cm. Three flaps were pedicled and four were free, of which three incorporated the tensor fasciae latae flap. All flaps survived completely, and no postoperative abdominal hernias developed. Despite some variations in vascular anatomy and technical difficulties in elevating the anterolateral thigh flap, the authors conclude that the pedicled or free anterolateral thigh flap is superior to the tensor fasciae latae flap for reconstruction of large abdominal wall defects.     

Abdominal wall reconstruction (the "mutton chop" flap).

Reconstruction of full-thickness abdominal wall defects can be a difficult surgical challenge. Reconstructing the epigastrium may be especially vexing. The use of prosthetic mesh has significant drawbacks, and the use of pedicled myofascial and myocutaneous flaps should be advantageous. We present 15 consecutive cases demonstrating highly successful reconstructions of massive abdominal wall defects using myofascial and myocutaneous flaps without prosthetic mesh. The extended rectus femoris flap, or "mutton chop" flap, which is capable of resurfacing the epigastrium, is described. Complications were minimal, and use of myofascial units, particularly the rectus femoris, should be considered as the technique of choice for reconstruction of major abdominal wall deficits.     

Extended V-Y latissimus dorsi musculocutaneous flap for anterior chest wall reconstruction

Patients presenting advanced breast tumors are usually subject to major resections of the anterior chest wall tissue. Flaps taken from the abdominal wall, such as the TRAM, the external oblique flap, and the thoracoabdominal flap are frequently used for closure of this type of lesion. In this study, a different shape was planned for the skin island from the latissimus dorsi musculocutaneous flap with primary closure in V-Y for the correction of major lesions in the anterior chest wall after mastectomies occasioned by advanced breast cancer. The technique was used on eight female patients, between November of 1998 and July of 1999, victims of advanced breast cancer, who had been submitted to radical mastectomies with major resections of the cutaneous tegument. It was possible to make primary closure of lesions in the anterior chest wall, the preoperative areas of which varied between 15 x 15 and 29 x 14 cm (vertical x horizontal). This technical variant permitted use of the flap without the need to create tunnels for its advancement and rotation. It also proved to be easy to perform and presented a low morbidity rate, with three patients presenting minor complications that did not require correction through any further surgical intervention. Closure was obtained in the donor and recipient sites without the use of skin grafts or other more major procedures. According to the authors, this procedure is a viable alternative in repairing large defects in the anterior chest wall.     

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.     

The internal oblique muscle flap: an anatomic and clinical study

A new muscle flap based on the ascending branch of the deep circumflex iliac artery is described. Twenty internal oblique muscle flaps have been dissected and studied in 10 fresh cadavers. This muscle flap has been used successfully as a free-tissue transfer in seven lower extremity defects. There was one loss of flap due to venous thrombosis. Other complications included a local wound abscess (one case), partial loss of skin graft (two cases), and arterial thrombosis (one case). There has been no donor-site morbidity. The donor scars are well concealed and no hernias have been observed, the longest follow-up being 9 months. The additional advantages of this flap include its thin, flat shape, excellent vascularity, and ease of application to areas about the ankle, with good aesthetic results. The disadvantages are (1) bloody and tedious dissection and (2) potential for abdominal weakness or hernia in the long run. This muscle flap appears to be excellent as a free flap for coverage of small- to moderate-sized defects of the distal lower extremity and as a pedicle flap for coverage of soft-tissue defects of the groin and anterior perineum.     

Advancement of the external oblique muscle flap to improve the waistline: a study in cadavers

Waist definition is an important goal of abdominoplasty. The purpose of this report is to study the effect of advancement and rotation of the external oblique muscles in the waistline. Twenty cadavers were dissected. Two parameters were analyzed: measurement of the waist circumference and the width of overlapped skin flaps of the abdomen in the midline. Three stages of dissection were compared: (1) initial stage, in which the myoaponeurotic structure of the anterior abdominal wall was intact; (2) stage 1, after advancement of the rectus muscles and its anterior aponeurosis toward the midline; and (3) stage 2, after advancement and rotation of the external oblique muscle. A significant statistical difference was found when waist circumference measured before dissection was compared with values obtained after the procedure. When the width of the overlapped skin flaps was compared during the different stages of dissection, a significant statistical difference was observed after each stage (paired t test). Therefore, the approximation of the rectus muscles alone improves the waistline, and when associated with external oblique muscle flap advancement and rotation, the cosmetic result in this area is even better. In conclusion, the procedure described decreases waist circumference and improves the frontal view of the waist.     

A classification system and reconstructive algorithm for acquired vaginal defects

Although multiple flaps have been used for vaginal reconstruction, a logical approach to reconstruction of these often complex defects has not been described. The objective of this study was to establish a classification system for acquired vaginal defects and to develop a reconstructive algorithm derived from this system. This study is a retrospective review of a 7-year experience with 51 flaps in 37 consecutive vaginal reconstructions. Twenty-two partial defects and 15 circumferential defects were reconstructed in 35 patients. Average patient age was 48 years (range, 19 to 69 years). Of the 22 patients with partial vaginal defects, six involved primarily the anterior and lateral wall and 16 the posterior vaginal wall. Among the 15 patients with circumferential defects, four included only the upper two-thirds of the vagina and 11 encompassed the entire vagina. On the basis of these defects, a classification system was developed. Partial defects involving the anterior or lateral vaginal wall were classified as type IA defects and were reconstructed primarily with pedicled Singapore fasciocutaneous flaps. Partial defects involving the posterior wall were classified as type IB and were reconstructed with pedicled rectus abdominis myocutaneous flaps. Circumferential defects involving the upper two-thirds of the vagina were classified as type IIA defects and were reconstructed with a rolled rectus flap or, less commonly, sigmoid colon (one patient). Total circumferential defects, type IIB, were reconstructed largely with bilateral gracilis flaps. Six patients had major complications, including one perioperative death, one complete flap loss, one partial flap loss, and three pelvic abscesses. Three patients had minor complications that included delayed wound healing and donor-site infection. Vaginal defects can be categorized into one of four types on the basis of the location and extent of resection. Flap selection is determined on the basis of the type of defect. Using this algorithm, immediate vaginal reconstruction with pedicled regional flaps can be performed with minimal patient morbidity and few surgical complications.     

Blood supply of the abdomen revisited, with emphasis on the superficial inferior epigastric artery

The key to understanding the blood supply of the anterior hemiabdomen is knowledge of the central superficial inferior epigastric artery system and the peripheral contribution of the epigastric, deep and superficial circumflex, and iliac arteries and external oblique perforators. These systems all feed into the subdermal plexus of the anterior abdominal wall. Angiographic confirmation of multiple communications between the superficial inferior epigastric artery and other major sources of abdominal wall blood supply has been obtained. Experience using the superficial inferior epigastric artery flap as a pedicled and microsurgical transfer has been described.     

Long-term survival after chest-wall reconstruction with musculocutaneous flaps

Reconstruction of chest-wall defects with musculocutaneous flaps permits resection of advanced chest-wall tumors and of tissues severely damaged by radiotherapy in patients who in a previous era were not surgically treatable. To determine the long-term outcome from this surgery, the records of 96 patients who had undergone chest-wall resection with musculocutaneous flap reconstruction were reviewed. Median survival for the entire group was 20.5 months, but a more accurate prediction of outcome could be obtained by dividing the patients into three groups. In group I, patients free of known malignancy and undergoing resection of radionecrotic tissues, median survival was 60.0 months. In group II, patients with resectable disease and free of tumor following surgery, median survival was 31.1 months. In group III, patients incompletely resected or known to have metastatic disease following surgery, median survival was only 12.5 months. Even in group III, however, some individuals achieved prolonged survival and lasting benefits from the surgery, so these data should not be used to exclude patients from undergoing necessary palliative procedures.     

The "reduced" latissimus dorsi musculocutaneous flap

This report introduces a new device among latissimus dorsi flaps: the "reduced" latissimus dorsi musculocutaneous flap. This flap consists of a proximal musculocutaneous unit and a distal, thin fasciocutaneous unit (the "reduced" portion). The former unit carries a reliable blood supply from the thoracodorsal artery and is able to cover deeper recipient defects, while the latter provides a well-contoured reconstruction of the defect. If needed, an extended portion and/or a thin cutaneous flap can be carried along with the flap according to the defect. In our clinic, we have so far used four pedicled and one free reduced latissimus dorsi musculocutaneous flap in the repair of a variety of defects. All flaps survived, and satisfactory contour of the recipient site was achieved in each case. These clinical experiences clarify that a reduced portion 10 cm in length can be safely carried, and it is suggested that survival of this flap does not depend on its width-to-length ratio.     

The extended pectoralis major myocutaneous flap: uses and indications

The vascular territory of the pectoralis major muscle and overlying skin was studied by selective intraarterial dye injections in fresh cadavers. The area of skin overlying the anterior chest and abdominal wall beyond the limits of the pectoralis major muscle that can be elevated as an extended myocutaneous flap was determined. The cadaver injections were evaluated to determine the size and shape of the skin island used to reconstruct defects of the head, neck, and upper trunk with an extended skin paddle off the pectoralis major muscle. Pectoralis muscle flaps with variously shaped skin paddles, some extending beyond the limits of the muscle, were used in 27 patients to cover large soft-tissue defects of the upper thorax, face, and floor of the mouth and as a skin tube to reconstruct the cervical esophagus. The size of the skin paddle ranged from 5 x 7 cm to 26 x 16 cm. All flaps survived completely, and there were no major donor-site complications.     

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.     

The adductor flap: a new method for transferring posterior and medial thigh skin

Skin flaps from the medial aspect of the thigh have traditionally been based on the gracilis musculocutaneous unit. This article presents anatomic studies and clinical experience with a new flap from the medial and posterior aspects of the thigh based on the proximal musculocutaneous perforator of the adductor magnus muscle and its venae comitantes. This cutaneous artery represents the termination of the first medial branch of the profunda femoris artery and is consistently large enough in caliber to support much larger skin flaps than the gracilis musculocutaneous flap. In all 20 cadaver dissections, the proximal cutaneous perforator of the adductor magnus muscle was present and measured between 0.8 and 1.1 mm in diameter, making it one of the largest skin perforators in the entire body. Based on this anatomic observation, skin flaps as large as 30 x 23 cm from the medial and posterior aspects of the thigh were successfully transferred. Adductor flaps were used in 25 patients. On one patient the flap was lost, in one the flap demonstrated partial survival, and in 23 patients the flaps survived completely. The flap was designed as a pedicle island flap in 14 patients and as a free flap in 11.When isolating the vascular pedicle for free tissue transfer, the cutaneous artery is dissected from the surrounding adductor magnus muscle and no muscle is included in the flap. Using this maneuver, a pedicle length of approximately 8 cm is isolated. In addition to ample length, the artery has a diameter of approximately 2 mm at its origin from the profunda femoris artery. The adductor flap provides an alternative method for flap design in the posteromedial thigh. Because of the large pedicle and the vast cutaneous territory that it reliably supplies, the authors believe that the adductor flap is the most versatile and dependable method for transferring flaps from the posteromedial thigh region.     

Musculocutaneous flap reconstruction of chest-wall defects: an experience with 50 patients

Precepts derived from a review of 50 patients included (1) prior radiation of the vessel supplying the flap does not appear to have any effect on viability; (2) in an open, infected wound, use of synthetic materials adds significantly to the risk of infection and, in fact, appears to be unnecessary; (3) in full-thickness chest-wall defects, reconstruction can be accomplished in almost all cases by inset of the flap only, without need of support of fascia, ribs, or prosthetic material; and (4) in locally recurrent breast cancer, chest-wall resection is an adjunct to chemotherapy. A schematic outlining potential defects and appropriate musculocutaneous reconstruction is also presented.     

Double-pedicle transverse rectus abdominis myocutaneous flap for unilateral breast and chest-wall reconstruction

Fifteen patients underwent unilateral breast and chest-wall reconstruction by a double-pedicle transverse rectus abdominis myocutaneous flap technique. Criteria for using both pedicles include (1) exceptionally large soft-tissue requirements, (2) prior abdominal operations compromising the vasculature to portions of the anterior abdominal wall, and (3) certain higher-risk patients with suspected microvascular pathology. Double pedicles allowed the transfer of the skin island as one unit or as two independent hemiellipses of tissue. Follow-up time ranges from 4 to 17 months. Complications included partial tissue loss in two patients, one abdominal flap seroma, and one patient with a hernia.