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Optimizing the Pedicled Rectus Abdominis Flap: Revised Designs and Vascular Classification for Safer Procedures

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Abstract

Background

The rectus abdominis myocutaneous (RAM) flap is one of the most commonly used flaps in reconstructive surgery, and many designs have been published. The transverse rectus abdominis myocutaneous (TRAM), vertical rectus abdominis myocutaneous (VRAM), and oblique designs (ORAM) are the most common. The most frequent complication with these flaps is partial flap necrosis. We describe a new vascular zoning method and a revised classification of abdominal wall perfusion that is applicable when harvesting pedicled TRAM flaps to make them more secure.

Methods

From February 2009 to February 2013, we performed 70 pedicled RAM flaps in 68 patients for breast reconstruction (79 %) as well as pelvic and inguinal reconstruction after bowel and gynecologic tumor resection. Clinical data about cutaneous vascularization of the flaps along with before and after photos were prospectively collected and analyzed, and results were evaluated retrospectively. We collected observations on partial flap necrosis, reviewed the literature, and made design modifications to exclude doubtful vascular territories.

Results

Of the total number of flaps, 59 were TRAMs, 7 were VRAMs, and 1 was an ORAM flap. Three combined horizontal and vertical flaps, or what we call TV RAM flaps, were performed. No flap-related complications were observed with VRAM, TV RAM, or ORAM flaps. Three instances of partial necrosis (in the same vascular territory) occurred with TRAM flaps; as a result, we changed our approach to these flaps and examined alternatives to the classical vascular zoning.

Conclusion

We discussed abdominal skin perfusion in accordance with the literature and based on our experience with harvesting pedicled RAM flaps. We proposed safer skin paddles made possible by adopting a revised vascular classification.

Level of Evidence V

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References

  1. Holmström H (1979) The free abdominoplasty flap and its use in breast reconstruction. An experimental study and clinical case report. Scand J Plast Reconstr Surg 13(3):423–427

    Article  PubMed  Google Scholar 

  2. Hartrampf CR, Scheflan N, Black PM (1982) Breast reconstruction with transverse abdominal island flap. Plast Reconstruct Surg 69:216–225

    Article  CAS  Google Scholar 

  3. Taylor GI, Corlett R, Boyd JB (1983) The extended deep inferior epigastric flap: a clinical technique. Plast Reconstr Surg 72:165–751

    Article  Google Scholar 

  4. Salmon M (1936) Artères de la peau. Masson, Paris

    Google Scholar 

  5. Taylor GI, Palmer JH (1987) The vascular territories (angiosomes) of the body: experimental study and clinical applications. Br J Plast Surg 40:113–141

    Article  CAS  PubMed  Google Scholar 

  6. Saint-Cyr M, Wong C, Schaverien M, Mojallal A, Rohrich RJ (2009) The perforasome theory: vascular anatomy and clinical implications. Plast Reconstr Surg 124(5):1529–1544

    Article  CAS  PubMed  Google Scholar 

  7. Hamza F, Yousif J, Kotti B (2010) Breast reconstruction using the free TRAM flap in a private practice setting. A review of 20 cases. Ann Chir Plast Esthet 55(6):524–530

    Article  CAS  PubMed  Google Scholar 

  8. Staiano JJ, Wong L, Butler J, Searle AE, Barton DP, Harris PA (2009) Flap reconstruction following gynaecological tumour resection for advanced and recurrent disease–a 12 year experience. J Plast Reconstr Aesthet Surg 62(3):346–351

    Article  PubMed  Google Scholar 

  9. Soper JT, Secord AA, Havrilesky LJ, Berchuck A, Clarke-Pearson DL (2005) Rectus abdominis myocutaneous and myoperitoneal flaps for neovaginal reconstruction after radical pelvic surgery: comparison of flap-related morbidity. Gynecol Oncol 97(2):596–601

    Article  PubMed  Google Scholar 

  10. John HE, Jessop ZM, Di Candia M, Simcock J, Durrani AJ, Malata CM (2013) An algorithmic approach to perineal reconstruction after cancer resection–experience from two international centers. Ann Plast Surg 71(1):96–102

    Article  CAS  PubMed  Google Scholar 

  11. Mathes SJ, Nahai F (1981) Classification of the vascular anatomy of muscles: experimental and clinical correlation. Plast Reconstr Surg 67(2):177–187

    Article  CAS  PubMed  Google Scholar 

  12. Boyd JB, Taylor GI, Corlett R (1984) The vascular territories of the superior epigastric and the deep inferior epigastric systems. Plast Reconstr Surg 73:1–4

    Article  CAS  PubMed  Google Scholar 

  13. Buck DW 2nd, Fine NA (2009) The pedicled transverse rectus abdominis myocutaneous flap: indications, techniques, and outcomes. Plast Reconstr Surg 124(4):1047–1054

    Article  CAS  PubMed  Google Scholar 

  14. Moon HK, Taylor GI (1988) The vascular anatomy of rectus abdominis musculocutaneous flaps based on the deep superior epigastric system. Plast Reconstr Surg 82:815–832

    Article  CAS  PubMed  Google Scholar 

  15. Hartrampf CR (1984) Transverse abdominal island flap technique. University Park Press, Baltimore

    Google Scholar 

  16. Alvi R, Falder S, McGeorge DD (2002) A simple modification of TRAM flap breast reconstruction. Br J Plast Surg 55(2):173

    Article  CAS  PubMed  Google Scholar 

  17. Scheflan M, Dinner MI (1983) The transverse abdominal island flap: part I. Indications, contraindications, results, and complications. Ann Plast Surg 10:24–35

    Article  CAS  PubMed  Google Scholar 

  18. Scheflan M, Dinner MI (1983) The transverse abdominal island flap: part II. Surgical technique. Ann Plast Surg 10:120–129

    Article  CAS  PubMed  Google Scholar 

  19. Dinner MI, Dowden RV, Scheflan M (1983) Refinements in the use of the transverse abdominal island flap for postmastectomy reconstruction. Ann Plast Surg 11:362–372

    Article  CAS  PubMed  Google Scholar 

  20. Masson J, Staub G, Binder JP, Martinaud C, Couturaud B, Revol M, Servant JM (2007) Reconstruction mammaire. Techniques et indications. Elsevier Masson, Paris, pp 45–665. doi:10.1016/S1286-9325(07)47005-4

    Google Scholar 

  21. Taylor GI, Corlett RJ, Dhar SC, Ashton MW (2011) The anatomical (angiosome) and clinical territories of cutaneous perforating arteries: development of the concept and designing safe flaps. Plast Reconstr Surg 127(4):1447–1459

    Article  CAS  PubMed  Google Scholar 

  22. Rickard R (2001) TRAM and DIEP flap zones. Br J Plast Surg 54(3):272–273

    Article  CAS  PubMed  Google Scholar 

  23. Quilichini J, Le Masurier P, Guihard T (2010) Increasing the reliability of SIEA flap using peroperative fluorescent angiography with indocyanine green in breast reconstruction. Ann Chir Plast Esthet 55(6):531–538

    Article  CAS  PubMed  Google Scholar 

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Acknowledgments

I thank Dr. Jaidane for her diligent assistance. Thanks to Dr. Bechouche and many thanks to the Salah Azaiz Surgery team for their hard work and excellent performance every day, sometimes under difficult conditions.

Conflict of interest

The author declares that he has no conflicts of interest to disclose.

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Correspondence to Bouraoui Kotti.

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Kotti, B. Optimizing the Pedicled Rectus Abdominis Flap: Revised Designs and Vascular Classification for Safer Procedures. Aesth Plast Surg 38, 387–394 (2014). https://doi.org/10.1007/s00266-014-0273-y

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  • DOI: https://doi.org/10.1007/s00266-014-0273-y

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