|Year : 2019 | Volume
| Issue : 4 | Page : 172-175
Free muscle sparing vertical rectus abdominis myocutaneous flap
Said Algan1, Onder Tan2, Kerem Yilmaz3, Harun Karaduman3
1 Plastic and Reconstructive and Aesthetic Surgery Clinic, Basari Hospital, Gaziosmanpasa, Turkey
2 Plastic and Reconstructive and Aesthetic Surgery Clinic, Medical Park Hospital, Gaziosmanpasa, Istanbul, Turkey
3 Department of Plastic Reconstructive and Aesthetic Surgery, Faculty of Medicine, Ataturk University, Erzurum, Turkey
|Date of Submission||06-Dec-2018|
|Date of Acceptance||21-Jan-2019|
|Date of Web Publication||26-Sep-2019|
Dr. Said Algan
Yeni Mahalle, Hekimsuyu Caddesi, No: 53, Küçükköy - Gaziosmanpasa, Istanbul
Source of Support: None, Conflict of Interest: None
Introduction: Abdominal region is a unique donor area in the reconstructive surgery to provide numerous flaps. The aim of this study is to show effectivity of the free vertical rectus abdominis muscle (VRAM) flap in the complex wounds reconstruction without damaging integrity of the rectus abdominis muscle and sacrificing the opposite deep inferior epigastric artery. Materials and Methods: The study population was composed of all patients who applied to our department for evaluation and management of the complex wounds reconstruction with the free muscle sparing (MS) vertical rectus abdominis flap, between September 2011 and October 2015. Results: We utilized the free MS vertical rectus abdominis flap to closure complex wounds in seven patients (6 males and 1 female) in our department. Etiologies were malign skin tumors, amputation stump, unstable scar, and crush injury in three, two, one, and one patients, respectively. All MS vertical rectus abdominis flaps survived completely. A hematoma developed in the recipient site in one case, and it was immediately evacuated without any problem. Conclusions: Free MS vertical rectus abdominis flap is a quite easy and reliable flap to harvest from abdominal wall, reducing the possibility of bulging or hernia formation with less morbidity of the donor site.
Keywords: Abdominal, flap, reconstruction, vertical, vertical rectus abdominis muscle
|How to cite this article:|
Algan S, Tan O, Yilmaz K, Karaduman H. Free muscle sparing vertical rectus abdominis myocutaneous flap. Turk J Plast Surg 2019;27:172-5
| Introduction|| |
Abdominal region is a unique donor area in the reconstructive surgery to provide numerous flaps. The best-known ones of these flaps are rectus abdominis muscle (RAM) flap, transverse RAM (TRAM) flap, deep inferior epigastric artery (DIEA), deep inferior epigastric perforator (DIEP) flap, and superficial inferior epigastric artery flap. These flaps usually are performed for filling dead cavity, closure huge, and complex wounds.
Holmström first described the RAM flap in 1979. Then, Hartrampf et al. popularized it in the breast reconstruction in 1982. Taylor et al. raised the RAM flap in three different designs involving horizontal or TRAM flap, vertical RAM (VRAM) flap, and oblique RAM flap in 1983.
Reconstructive surgeons have often used the RAM flaps as free or pedicled transfers in the breast reconstruction, vaginal, pelviperineal, and inguinal defects.,,,, However, some authors reported the donor site morbidities such as abdominal hernia due to the RAM and fascia damaging in the literature. The mentioned rectus muscle flaps have been recently harvested with the muscle sparing (MS) technique to prevent abdominal hernia complication.
The aim of this study is to show effectivity of the free VRAM flap in the complex wounds reconstruction without damaging the integrity of the RAM and sacrificing the opposite DIEA.
| Materials and Methods|| |
This study was granted an exemption from our Local Institutional Review Board. To state the research goal, the investigators designed and performed a retrospective case series. All patients in this manuscript have given written informed consent to publish these case details. The study population was composed of all patients who applied to our department for evaluation and management of the complex wounds reconstruction with the free MS-VRAM flap, between September 2011 and October 2015. Patients with complex wounds and patients who could not be repaired with a skin graft were included in the study. Patients operated with skin graft were excluded. Postoperative complications such as survival of the flap, hematoma, seroma, abdominal hernia, and patient satisfaction were outcome variables. We collected all patients' data from their photographs and hospital records and evaluated clinically.
We determined bilateral paraumbilical perforators arising from the lateral branch of the DIEA carefully by handled Doppler ultrasonography at supine position, preoperatively. These perforators are often located in a distance of 8–10 cm from the umbilicus where it is over the lateral part of the rectus muscle topographically. After measuring the defect size, we designed the vertical skin island flap by centering the perforators.
The dissection was begun with the skin incision of the lateral margin, and after passing the skin and subcutaneous fat, the external oblique fascia was reached. The whole dissection was achieved only through the lateral incision of the skin island under loupe magnification (×2.5). We encountered the lateral row of the perforators over the anterior rectus abdominis sheath as dissection continued medially. Then, we incised the anterior rectus sheath at laterally and elevated the RAM to see main vascular DIEA pedicle. After confirming the perforator inputting point to the RAM, we identified and suspended DIEA perforators with a silicone vascular loop. At this point, the medial margin skin incision and the dissection were completed carefully. We incised the anterior rectus sheath at medially. At the end of this step, a small muscle cuff of 3 cm × 4 cm was included into the flap by leaving intact two muscle strips of 1.5 cm in width bilaterally. Thus, the flap was become a full island. From that point, the dissection was relatively easier. We traced the vascular pedicle inferiorly under the RAM up to the external iliac vessels. We allowed the flap perfusion increasing about 15 min under a warm towel compress. The pedicle was divided, and the flap was transferred to the defected site for anastomoses.
| Results|| |
We utilized the free MS-VRAM flap to closure complex wounds in seven patients (6 males and 1 female) in our department. Etiologies were malign skin tumors, amputation stump, unstable scar, and crush injury in three, two, one, and one patients, respectively [Table 1]. The wounds localizations were in the head in four patients, in the leg in two patients, and in the forearm in one patient. The median age was 65 years (quartiles 32–69), 85.7% male and median duration of follow-up was 13 months (ranged from 7 to 20 months). The flap dimensions ranged from 8 cm × 5 cm to 16 cm × 10 cm. The average dissection time was 56 min. We raised all free MS-VRAM flap a small muscle cuff without intramuscular perforator dissection. We used only side DIEA perforators without damaging the integrity of the RAM and sacrificing the other side branch in all cases. We closed all donor sites primarily. [Table 1] shows patients' data.
All MS-VRAM flaps survived completely. A hematoma developed in recipient site in one case, and it was immediately evacuated without any problem. No other early complications such as infection, vascular thrombosis, and fat necrosis were seen in any patient. Adaptations of the recipient sites were quite good in late postoperative period. Cosmetic outcomes and patient satisfaction were acceptable in our series. We did not encounter secondary abdominal hernia in donor site due to surgery in any patient. All donor site scars were also acceptable with minimal contour irregularities. Subsequent liposuction for debulking of the flap as a late revision was only performed in one patient.
The case samples are demonstrated in [Figure 1], [Figure 2], [Figure 3].
|Figure 1: Case 7: 53-year-old female had the left ankle stump with recurrent ulcer. We excised the ulcer and scar tissue and planned free muscle sparing-vertical rectus abdominis muscle flap, which was 12 cm × 7 cm in size. (a) Preoperative the left ankle stump with recurrent ulcer. (b) Removing of the ulcer and scar tissue. (c) Intraoperative view of the flap raising. (d)Intraoperative view of the flap in the recipient site. (e) After 30 months postoperative late view of the flap. (f) Postoperative late appearance of the donor site|
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|Figure 2: Case 3: 69-year-old male had the diagnosis of metatypical carcinoma located on the right side of the nose and maxilla. Free muscle sparing-vertical rectus abdominis muscle flap, which was 9 cm × 6 cm in size, was planned for reconstruction. (a) Appearance of the defect. A serious dead space appeared after resection of the tumor. (b) Design and marking of the muscle sparing-vertical rectus abdominis muscle flap. (c) Elevation of the flap. (d) Postoperative oblique appearance of 1 year. (e) Postoperative lateral appearance. (f) Postoperative donor site appearance|
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|Figure 3: Case 6: 32-year-old patient suffered from a crush injury on his left leg. Free muscle sparing-vertical rectus abdominis muscle flap of 16 cm × 10 cm was planned for soft tissue coverage after the repair of open tibia fracture with external fixator. (a) Preoperative view of the defect after surgical debridement of the wound. (b)Harvest of the flap on its pedicle. (c)Inset of the flap into the recipient site. (d)Postoperative view|
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| Discussion|| |
The purpose of this study is to show effectivity of the free VRAM flap in the complex wounds reconstruction without damaging the integrity of the RAM and sacrificing the contralateral DIEA.
Abdominal wall-originated flaps are still the first option for autologous breast reconstruction. Moreover, these flaps have been preferred in the reconstructions of head and neck, lower extremity and pelvic areas defects, particularly to fill dead spaces or cover the complex and large-sized defects. Using abdominal wall, flaps have some advantages such as a well-defined vascular anatomy, rich and optional blood supply, concealed donor site, and two-team working simultaneously., However, performing of these flaps may cause in some donor site complications such as abdominal wall weakness, prolonged pain, functional disturbance, and the formation of bulges or hernias.
This study is the first study in the literature by using the MS-VRAM flap as a free flap. The main advantage of this flap is the preservation of opposite vascular pedicle as a backup. Thus, we can prevent an extra loss of the donor area and increase achievement of the reconstruction. Because we can harvest on the contralateral side immediately or afterward.
There were low donor site morbidities related to abdominal wall integrity in our cases. MS-VRAM flap is reliable in patients in whom the TRAM and classical DIEP flaps are contraindicated owing to midline abdominal scars and insufficiency in one-half of the abdomen. MS-VRAM flap has some superiorities over the vertical designed DIEP flap such as easier, more rapid, and more reliable dissection, and short operative time because of perforator-free dissection. On the other hand, an obvious scar and contour depression may be a major handicap, when the larger MS-VRAM flap would be harvested. Mennie et al. stated donor-site hernia repair in abdominal flap breast reconstruction in a population-based cohort study of 7929 patients. In their comparison, the 3-year rates for abdominal hernia repair following DIEP, free TRAM, and pedicled TRAM flap procedures were 1.65, 3.18, and 4.91%, respectively. According to their report, the TRAM flaps had a higher relative risk of donor-site hernia compared to the DIEP flap.
Nahabedian et al. reported a series of 177 cases undergone MS-TRAM and DIEP flaps for breast reconstruction. They found no significant difference in the comparison of MS-2-free TRAM to the DIEP flaps unilaterally or bilaterally, with regard to fat necrosis, venous congestion, flap loss, abdominal bulge, and ability to perform sit-ups.
Chang et al. compared the three different abdominal-based free flaps, TRAM, MS-TRAM, and DIEP, in the view of donor site morbidity in 1507 breast reconstruction cases. They found that TRAM flap was significantly more likely to develop an abdominal bulge/hernia than was an MS-TRAM flap or the DIEP flap (9.9% vs. 3.7% vs. 5.9%; P= 0.004). However, there was no difference in the risk of developing an abdominal bulge/hernia between the MS-TRAM and the DIEP flap (P = 0.36). Houdek et al. performed pedicled VRAM flap surgery to reconstruct a posterior wound following high sacral tumor resection in 87 patients. Their abdominal wall hernia rate was 7%. Based on these data, we can theoretically introduce that free MS-VRAM flap has low-donor site complication rates as in the vertical designed DIEP flap we previously described.
Weiwei et al.first utilized the pedicled MS-VRAM flap for vaginal reconstruction in five patients with congenital absence of the vagina. No hernia or abdominal bulging occurred, and there was no necrosis of flap. The donor site was closed primarily in all patients without using skin grafts. Then, Iyengar et al. used the same pedicled flap for filling the anorectal defect owing to the squamous cell carcinoma in a case.
| Conclusions|| |
Free MS-VRAM flap is a quite easy and reliable flap raising from abdominal wall, reducing the possibility of bulging or hernia formation without sacrificing the RAM and the contralateral vascular pedicle. We believe that this flap can be performed for the reconstruction of various defects by means of free microvascular style.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]