Transverse dual-perforator fascia-sparing free TRAM flap: technique description

As techniques for breast reconstruction with autologous abdominal tissue have evolved, free transverse rectus abdominis myocutaneous flaps have persevered because of their superior reliability and minimal donor-site morbidity compared with muscle-sparing techniques. Further refinements are described in this article to maximize abdominal flap perfusion and ensure primary closure of the rectus fascia. It has been well documented that incorporating both the lateral and medial perforators provides maximal perfusion to all zones of the lower abdominal transverse skin flap. However, dissection and harvest of both sets of perforators requires disruption and/or sacrifice of abdominal wall tissues. The technique presented here was designed to use both the lateral and medial row perforators, and to minimize abdominal wall disruption. Deep inferior epigastric artery medial and lateral row perforators are selected for their diameter, proximity, and transverse orientation to each other. A transverse ellipse of fascia is incised to incorporate both perforators. The fascial incision is then extended inferiorly in a T configuration to allow for adequate exposure and harvest of the vascular pedicle and/or rectus abdominis, and primary closure. Limiting perforator selection to one row of inferior epigastric arteries diminishes perfusion to the abdominal flap. Furthermore, perforator and inferior epigastric artery dissection often results in fascial defects that are not amenable to primary closure. However, maximal abdominal flap perfusion and minimal donor-site morbidity can be achieved with the transverse dual-perforator fascia-sparing free transverse rectus abdominis myocutaneous flap technique and can be performed in most patients.     

Refinements in transverse rectus abdominis myocutaneous flap breast reconstruction: projection and contour improvements

A surgical procedure with the transverse rectus abdominis myocutaneous (TRAM) flap for breast reconstruction is presented using parameters from the opposite normal breast to achieve a better cone shape in the new breast to project the nipple-areola complex. This cone projection is obtained through a vertical plication of both skin/fat halves of the TRAM flap and with two supraumbilical fat flaps to avoid cone collapse. The infraclavicular and axillary regions are filled with a de-epithelialized "fish-fin" cutaneous-fat or fat-only flap, which is placed as a lateral TRAM extension. The de-epithelialized lateral extremity of the TRAM flap folded over itself gives a mound shape to the lateral aspect of the new breast, and the inverted umbilical stalk attached to the TRAM flap imitates a nipple. This procedure is based on six breast reconstructions with a 2-year follow-up. The procedure is a simple, safe, and versatile way to mimic the opposite breast. It is mostly indicated for thin patients who have small to moderate breasts without ptosis or hypertrophy who refuse breast implants or request a mastopexy or reduction mammaplasty on the opposite normal breast during the same procedure.     

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.     

The midabdominal rectus abdominis myocutaneous flap: review of 236 flaps

The midabdominal rectus abdominis myocutaneous flap is described in this review of 236 flaps in 223 patients. This flap is safe, reliable, and extremely well vascularized. It has been our flap of choice for purposes of reconstructing the moderate- or large-sized breast. In particular, the midabdominal flap permits restoration of fascial continuity over the entirety of the abdominal wall without the necessity for synthetic materials. A 2.2 percent incidence of hernias has been observed over a 4-year period. The flap is well suited to immediate reconstruction of the breast, particularly among the growing number of patients with antecedent radiation therapy.     

Immediate reconstruction of the penis using an inferiorly based rectus abdominis myocutaneous flap

A new method for reconstruction of the penis using an inferiorly based rectus abdominis myocutaneous flap is described that seems to be particularly suitable for immediate one-stage reconstruction. Function of the residual portion of rectus muscle is preserved, and the abdominal wall is not significantly weakened.     

Reconstruction of large composite oromandibulomaxillary defects with free vertical rectus abdominis myocutaneous flaps

Large composite oromandibulomaxillary defects resulting from oncologic resection can be challenging to reconstruct with a single flap, and functional outcomes remain anecdotal. The purpose of this study was to evaluate the authors' surgical experience and scientifically analyze and describe the functional outcomes associated with the use of the vertical rectus abdominis myocutaneous flap for reconstruction of these defects. The records of seven patients (mean age, 62 years) who underwent composite resection including hemimandibulectomy, partial maxillectomy, partial pharyngectomy, and floor-of-mouth resection followed by immediate free vertical rectus abdominis myocutaneous flap reconstruction at The University of Texas M. D. Anderson Cancer Center (1998 to 2002) were retrospectively reviewed. The tumor type was squamous cell carcinoma in all seven cases; four patients had T4 primary lesions and three had local recurrences. Radiotherapy was used preoperatively in each of the three recurrent cases (mean dose, 70.6 Gy) and postoperatively in three of the four patients with primary tumors (mean dose, 63.0 Gy). The mean length of hospitalization was 8.7 days. There were no major flap complications, fistulas, or donor-site complications. Partial flap necrosis (4 percent of flap area) occurred in one patient and dehiscence of the neck incision occurred in another. Both cases were managed with surgical débridement and closure. A third patient developed a 0.75-cm superficial suture line abscess that healed with dressing changes. The mean postoperative follow-up was 15 months. Six of the seven patients remained tube dependent for their nutrition despite some swallowing improvement; one patient returned to full oral intake. The most common swallowing deficit was impaired laryngeal excursion, which occurred in all six patients evaluated with videofluoroscopic examination and resulted in risk for aspiration in patients and frank aspiration in 83 percent. Speech was intelligible on routine follow-up visits in all patients except one. Four patients died as a result of their cancer, one was alive with metastatic disease, and two were alive with no evidence of disease at last follow-up. The goal for patients undergoing extensive composite oromandibulomaxillary resection for advanced cancer is to restore structure, minimize postoperative morbidity, and optimize the quality of remaining life. Reconstruction with the free vertical rectus abdominis myocutaneous flap achieves early wound healing, allows timely delivery of adjuvant therapy, and can be accomplished with predictable success and minimal morbidity. To our knowledge, this study represents the first to scientifically analyze and quantify swallowing function following free vertical rectus abdominis myocutaneous flap reconstruction for large oromandibulomaxillary defects. Understanding of the specific physiologic swallowing deficits that typically occur after such reconstructions will provide clinicians with important surgical and reconstructive information to enable future improvements in functional success in a population for whom the prognosis is poor and treatment options are limited.     

Breast reconstruction with contralateral rectus abdominis myocutaneous flap

A transverse myocutaneous rectus abdominis flap from the contralateral side has been employed for breast reconstruction in 52 patients. This flap has the advantage of balancing the patient by utilizing skin from an area of relative excess. The blood supply to the flap is based on the superior epigastric vessel and its perforators. The scar of the donor area is acceptable because it falls in the submammary sulcus. The use of a silicone implant can be avoided in some patients because of the adequate bulk of skin, muscle, and fat that is available. Abdominoplasty of the superior abdomen can be obtained during the same operation and can enhance the overall aesthetic results. Breast reconstruction is now possible with either ipsilateral or contralateral upper-abdominal transfer flaps, and further refinement of operative technique using the contralateral upper-rectus abdominis myocutaneous island flap must await further experience.     

Immediate breast reconstruction with deepithelialized TRAM flaps: techniques for improving breast reconstruction

In selected patients with lower quadrant breast masses, large breasts, and sufficient abdominal tissue, standard techniques for breast reconstruction can be modified to improve overall results. The transverse abdominal island flap can be deepithelialized and mobilized to reconstruct unilateral or bilateral defects. Furthermore, skin markings prior to mastectomy that conform to a modified Wise pattern will allow for more aesthetic positioning of eventual scars. We present a case report of a patient who underwent immediate breast reconstruction with bilateral deepithelialized lower rectus abdominis myodermal flaps.     

Small intestinal submucosa in abdominal wall repair after TRAM flap harvesting in a rat model

The strength of porcine small intestinal submucosa in abdominal wall repair after transverse rectus abdominis myocutaneous flap harvesting was examined in a rat model. Changes in the levels of selected molecular markers of inflammation after small intestinal submucosa implantation were also studied. Eighty-three rats were divided into three groups. In experimental group I, an abdominal wall defect created by removal of the rectus abdominis muscle was repaired with placement of a 1.5 x 5-cm2 patch of small intestinal submucosa. In experimental group II, the muscle defect was repaired with a combination of small intestinal submucosa patch placement and fascial closure. In the control group, the defect was repaired with direct fascial closure. At postoperative times of 3 days, 2 weeks, 1 month, and 2 months, the muscle tissues adjacent to the abdominal wall repair site were subjected to biopsies for assessment of inflammation markers. Full-thickness sections of the abdominal wall from the repair site in each animal were removed for tensile strength testing and histological examinations. The results demonstrated that interleukin-6 and interferon-gamma levels were increased in the two experimental, small intestinal submucosa-treated groups at 3 days and 2 weeks postoperatively. The results of mechanical testing demonstrated that the average tensile strength of the repaired abdominal wall in the repair model with combined small intestinal submucosa placement and fascial repair was significantly greater than the values for repairs with fascial closure or small intestinal submucosa placement alone. The use of small intestinal submucosa placement in combination with fascial repair can significantly improve the strength of the repaired abdominal wall after transverse rectus abdominis myocutaneous flap harvesting.     

"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 deep inferior epigastric perforator flap for breast reconstruction in overweight and obese patients

The authors retrospectively reviewed the computerized records of 71 women undergoing 80 deep inferior epigastric perforator (DIEP) flap reconstructions after mastectomy over a 1-year period. There were 33 normal, 26 overweight, and 12 obese patients. No statistically significant difference in flap complications was found between groups. Overall fat necrosis rates were 11.4 percent for the normal-weight patients, 6.7 percent for the overweight patients, and 6.7 percent for the obese patients. Postoperative hospital time was similar for all groups. The occurrence of abdominal wall fascial laxity was uncommon and similar for all groups. Large (>900 g) reconstructions were completed without prohibitive complications in the reconstruction flap. The DIEP flap represents a significant advance in autologous breast tissue reconstruction. Although concerns regarding fat necrosis rates in DIEP flaps have been voiced, the authors did not see an increasing rate of fat necrosis in their overweight and obese patients, and their overall rate of fat necrosis is comparable to rates reported for free transverse rectus abdominis myocutaneous (TRAM) flaps. Also, increasing body mass index did not seem to affect the rate of delayed complications of the abdominal wall, such as abdominal wall hernia or bulging. Although it was not statistically significant, the authors did observe a trend toward increased wound-healing complications with increasing body mass index. Their data also support the claim that the complete sparing of the rectus abdominis muscles afforded by the DIEP flap avoids abdominal wall fascial bulging or defects often seen in obese TRAM reconstruction patients. Because flap and wound complication rates are similar or superior to those of other autologous tissue reconstruction techniques and the occurrence of abdominal wall defects is all but eliminated, the DIEP flap likely represents the preferred autologous breast reconstruction technique for overweight and obese patients.     

Breast reconstruction with a transverse abdominal island flap

A rectus abdominis musculocutaneous island flap for breast reconstruction following mastectomy is presented. The vascular anatomy of the abdominal wall has been clinically studied in patients undergoing abdominal lipectomy. Cadaver dissections are shown, demonstrating the anatomy, arc of rotation, and design alternatives of the rectus abdominis flap. The surgical technique is demonstrated and representative patients are shown.     

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.     

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 lateral transverse thigh free flap: an alternative for autogenous-tissue breast reconstruction

The lateral transverse thigh free flap is a horizontal variant of the more commonly known vertical tensor fasciae latae myocutaneous free flap. Fresh cadaver injections of the lateral circumflex femoral artery indicated simultaneous perfusion of the upper lateral thigh tissues and the standard tensor fasciae latae territory extending down the lateral thigh. These experimental data strongly indicated that the clinical application would be successful. The flap is composed mostly of fat from the prominence of the upper lateral thigh ("saddlebags") based on a small plug of underlying tensor fasciae latae muscle. The amount of skin that can be included with this flap is limited in a vertical dimension to about 6 to 8 cm but is determined by the ability to close the defect. We have performed 17 flaps in 11 patients with up to 18 months of follow-up. Ten were delayed and 7 were immediate reconstructions. The chest and hip dissections are performed simultaneously by two microsurgeons. There has been one flap loss due to arterial disruption on day 3. An early problem was seroma formation in the donor site, which has been improved in the later patients by closing the dead space with sutures. The lateral transverse thigh free flap has the following advantages over other methods of autogenous-tissue breast reconstruction: (1) longer, more peripherally placed vessels, (2) easier flap dissection and no need to turn the patient during the procedure, (3) decreased postoperative morbidity and more rapid recovery, (4) reduction of an area of excess fat in those patients in whom the hips are more prominent than the abdomen, (5) greater intrinsic internal projection of the flap, and (6) excellent vascularity. The disadvantages of the flap are (1) microsurgery is required, (2) the amount of skin available is not as great as that with the gluteal or transverse rectus abdominis musculocutaneous (TRAM) flap, (3) the scar on the upper lateral thigh is probably more visible than on the buttock or the abdomen, and (4) a balancing procedure on the opposite hip is usually necessary in unilateral cases. Our current indications for the lateral transverse thigh free flap are (1) the transverse rectus abdominis musculocutaneous flap is unavailable, (2) for a particular breast size, the thigh fat proportions are greater than the abdominal proportions, or (3) the patient prefers this option to the transverse rectus abdominis musculocutaneous or gluteus flap. Results and complications with the lateral transverse thigh free flap will be presented along with pertinent comparisons with the other choices for autogenous-tissue breast reconstruction.     

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.     

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

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

Treatment of difficult TRAM flap hernias using intraperitoneal synthetic mesh application

The authors report the successful repair of large lower abdominal hernia defects after transverse rectus abdominis muscle (TRAM) flap breast reconstruction in 11 patients using a technique of intraperitoneal application of synthetic polypropylene (Prolene) mesh anchored to the peritoneal surface of the abdominal wall tissues. Five of these patients had previously failed hernia repairs after a unipedicle TRAM flap breast reconstruction employing the onlay mesh technique, with two of the patients having undergone three previous hernia repairs. The other six patients had developed large hernias after bipedicle TRAM flap reconstruction without previous mesh supplementation of the abdominal wall repair. After their successful hernia repairs, all of the patients healed without difficulty and demonstrated no sign of recurrence in an 8 to 36-month follow-up. Each patient returned to her activity level before breast reconstruction.     

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.     

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.