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.     

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.     

Umbilical transposition in TRAM flap: a simple horizontal translocation

A simple method of umbilical repositioning by incising the anterior rectus sheath and rectus abdominis muscle is reported for cases of unilateral abdominal wall plication during the TRAM flap operation. This method keeps the umbilicus stable and nonstenotic, and it avoids hypertrophic scars, which result from other techniques such as direct suturing of the stalk to the skin. Although this method might weaken contralateral muscle activity, the patients we operated on maintained their ability to perform sit-ups, and no periumbilical weakening was noticed.     

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.     

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.     

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.     

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 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.     

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.     

New microsurgical breast reconstruction using free paraumbilical perforator adiposal flaps

Pedicled transverse rectus abdominis musculocutaneous (TRAM) flaps have generally been used for bilateral breast losses. The major disadvantages of this method are the total or partial loss of the rectus abdominis muscles and various resulting postoperative complications, such as abdominal bulging and lumbar pain. With the recent development of perforator flaps and supermicrosurgery with anastomosis of 0.5-mm caliber vessels, these serious complications can be overcome with a paraumbilical perforator adiposal flap, without sacrificing the rectus abdominis muscle. The breasts of a 57-year-old woman who had undergone a bilateral subcutaneous mastectomy, including silicone prostheses, were repaired simultaneously with this new method using free paraumbilical perforator adiposal flaps. This new method of breast augmentation with a vascularized adiposal flap and without any muscle component is minimally invasive; its advantages are the preservation of the rectus abdominis muscles and the short time elevation for the adiposal flap.     

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.     

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)     

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.     

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).     

Periumbilical rectus abdominis perforator preservation significantly reduces superficial wound complications in "separation of parts" hernia repairs

Midline ventral hernia repair with bilateral sliding myofascial rectus abdominis flaps, or the "separation of parts" technique, has low hernia recurrence rates. However, this technique, as originally described, creates massively undermined skin and subcutaneous tissue flaps. These undermined skin flaps can suffer marginal skin loss, fat necrosis, and delayed wound healing. The authors propose that preserving the periumbilical rectus abdominis perforators to the abdominal skin flaps will decrease the prevalence of postoperative superficial wound complications. A retrospective review of 66 consecutive, large, midline hernia repairs using a separation of parts technique was undertaken to identify any correlation between the preservation of periumbilical rectus abdominis perforators to the skin flaps and the prevalence of postoperative wound complications. In 25 cases, the standard separation of parts technique was performed with wide undermining of the skin and subcutaneous tissues. In 41 cases, the modified separation of parts technique was performed with maintenance of the periumbilical rectus abdominis perforators to the abdominal skin flaps.Comparison of these two groups revealed no difference in age; sex; body mass index; initial hernia size on physical examination; prevalence of smoking, diabetes, or steroid use; or prevalence of a simultaneous intraabdominal procedure. A statistically significant difference was noted in postoperative wound complications between the two groups (p < 0.05). Of patients who underwent the standard separation of parts technique, five of 25 patients (20 percent) had wound complications as compared with one of 41 patients (2 percent) who underwent the modified separation of parts technique with perforator preservation. The postoperative hernia recurrence (7 percent and 8 percent, respectively) and hematoma (4 percent and 2 percent, respectively) rates were similar in both groups. A trend of increased wound complications was noted when separation of parts was combined with an intraabdominal procedure (18 percent versus 3 percent, p = 0.08). Interestingly, within this group, the modified separation of parts technique with preservation of the periumbilical rectus abdominis perforators demonstrated a trend of fewer wound complications as compared with the standard separation of parts technique (7 percent versus 31 percent, p = 0.15). The authors conclude that preservation of the periumbilical rectus abdominis perforators significantly reduces the prevalence of major postoperative superficial wound complications in separation of parts hernia repairs. Simultaneous intraabdominal procedures with separation of parts hernia repairs seem to increase the prevalence of wound complications. This increased prevalence of wound complications seems to be minimized when the modified separation of parts technique is performed.     

Vaginal and pelvic reconstruction with distally based rectus abdominis myocutaneous flaps

This report introduces a new method of vaginal reconstruction using a single rectus abdominis myocutaneous flap based distally. Applications of this flap in reconstruction of major abdominal wall and pelvic defects, such as hemipelvectomies, are also described. The flap is designed to carry a paddle of upper abdominal skin on a distally based muscle and vascular pedicle. Advantages of this flap design are (1) the technique is straightforward and rapid, (2) flap viability is reliable, (3) the epigastric skin-fascial donor defect preserves the anterior rectus fascia distal to the linea semicircularis, which prevents hernia, (4) a large arc of rotation is provided, and (5) the epigastric donor site does not interfere with colostomy and urinary conduit stomas in the pelvic exenteration patient. We have done 11 vaginal reconstructions and 9 major pelvic defect reconstructions with this flap during the last 3 1/2 years. In these 20 patients, the only complications were two partial flap losses. No major flap losses or ventral hernias occurred.     

The long-term durability of plication of the anterior rectus sheath assessed by ultrasonography

The purpose of this study was to assess the long-term durability of a standard vertical plication of the anterior rectus sheath. For this purpose, 70 women who had undergone this procedure as part of an abdominoplasty were sent a questionnaire, their records were studied, and they were invited back to the clinic for an examination using ultrasound. A total of 63 patients returned the questionnaire, and 40 were willing to attend a follow-up consultation and ultrasound investigation. The presence of rectus diastasis was assessed by ultrasound (a real time scanner with a 7.5-MHz linear probe).The study showed that after a follow-up of 32 to 109 months (mean, 64 months), standard plication of the abdominal wall with absorbable material led to residual or recurrent diastasis in 40 percent of the patients. It also confirmed that vertical plication only is not enough to improve the waistline and may eventually lead to epigastric bulging.     

Marriage abdominoplasty expands the mini-abdominoplasty concept

The marriage of aggressive superwet liposculpture of the abdomen and adjacent anatomic regions with a modification of well-established open surgical techniques to address skin excess and perform muscle plication was used to treat 29 patients presenting for aesthetic abdominal contouring over the past 3 1/2 years. The charts of 57 patients who had aesthetic contouring procedures on the abdomen performed from December of 1994 to July of 1998 were retrospectively reviewed. Fifteen patients underwent suction lipectomy alone, 13 patients were treated with conventional abdominoplasty, and 29 underwent "marriage abdominoplasty." The 29 patients who underwent marriage abdominoplasty presented with deformities marked by excess lower abdominal skin and adipose tissue, with or without muscle laxity (Psillakis types II, III, and IV). Seventeen procedures were performed under local anesthesia with deep conscious sedation on an outpatient surgical basis. In 12 patients, the operation accompanied a hysterectomy, urologic procedure, or additional aesthetic surgical procedure(s) and was done under general anesthesia. Suction aspirates ranged between 540 and 2600 cc (mean, 1160 cc) and were accompanied by lower abdominal skin excision in every case, which was performed predominantly through short and medium-length incisions (mean, 15 cm). Rectus abdominis muscle plication was performed where necessary, using vertical plication of the infraumbilical rectus muscles in 27 patients (93 percent) and full-length plication in two patients (7 percent). All patients demonstrated significantly improved contours and have seemed to manifest less pain when compared with patients treated by full traditional abdominoplasty. Postoperative complications have included upper abdominal skin waviness (2), annoying paresthesias and discomfort persisting for 6 months (1), seroma (1), and marginal skin necrosis with an open wound (1). The latter problem occurred in the only patient who was treated with a revision procedure. Thus, the complication rate was 17 percent (5 of 29 patients). The marriage of aggressive superwet liposculpture of the entire abdomen with standard open surgical techniques used to treat skin excesses and allow abdominal muscle plication where necessary offers the advantage of reduced surgery when compared with full abdominoplasty, while consistently achieving significant contour improvement. This concept is applicable to the majority of patients presenting for the treatment of abdominal deformities and has markedly expanded the application of the mini-abdominoplasty concept.     

Breast reconstruction with an external oblique abdominis muscle turnover flap and a bipedicled abdominal skin flap

A new technique of breast reconstruction is demonstrated using a turnover flap of the external oblique abdominis muscle together with a sheath of the rectus muscle to enlarge the submuscular pectoralis major pocket for the implant. To overcome a tight skin, a bipedicled abdominal skin flap is transposed for breast reconstruction. In so doing, a natural-looking breast is formed by a simple operative technique with rare complications. The technique has been applied in 11 patients with good results.     

Acute repair of a full-thickness right ventricular defect with a composite myofascial pedicle flap.

A full-thickness defect of the right ventricle presented acutely after mediastinitis and sternal dehiscence. This developed 29 days after bilateral internal mammary artery harvest for coronary artery bypass grafting. The defect was managed successfully with a pedicled left rectus abdominis muscle flap using an attached island of the anterior rectus sheath for endocardial lining. The vascular anatomic basis for viability of the rectus abdominis muscle flap after internal mammary artery harvest is derived primarily from musculophrenic, lumbar, lower sixth intercostal, and subcostal artery communications. In addition, the advantages of a myofascial pedicle flap for reconstruction of full-thickness cardiac defects are its ready availability and a strong anterior fascial sheath that can be used as a neoendocardial lining. The patient did well and remains asymptomatic after 3 years.