Advertisement

Surgical and Radiologic Anatomy

, Volume 40, Issue 8, pp 865–872 | Cite as

Rectus abdominis muscle innervation: an anatomical study with surgical implications in diep flap harvesting

  • Carla SteccoEmail author
  • Gian Paolo Azzena
  • Veronica Macchi
  • Andrea Porzionato
  • Astrid Behr
  • Anna Rambaldo
  • Cesare Tiengo
  • Raffaele De Caro
Original Article

Abstract

Purpose

To improve the current knowledge of rectus abdominis innervation, so as to identify a safe area where the vascular pedicle should be dissected to reduce the risk of nerve damage during deep inferior epigastric perforator (DIEP) flap harvesting.

Methods

Ten abdominal wall dissections were performed. Perforating arteries were identified and classified into nerve-related perforators and non-nerve-related perforators depending on the presence of nerve branches crossing vessels. The width of rectus abdominis and the distance between perforators and lateral edge of rectus abdominis muscle were measured. In contralateral hemi-abdomen, full-thickness specimens were sampled for microscopical analysis.

Results

Nerves enter the rectus sheath piercing the lateral edge (60% of cases) or the posterolateral surface of the sheath (40% of cases). They enter the rectus abdominis muscle at a mean distance of 4.3 cm from the lateral margin of the sheath. Within rectus abdominis, nerves have a mean thickness of 200.3 µm and split into 2–4 sensitive and 2–4 muscular branches. Close relationship between muscular branches and deep inferior epigastric artery perforators were shown. The mean distance between nerve-related perforators and the lateral edge of the rectus abdominis was of 3.26 ± 0.88 cm. The mean distance between non-nerve-related perforators and the lateral edge of the rectus abdominis was of 6.26 ± 0.90 cm.

Conclusions

To spare nerves and reduce donor-site complications, a perforator located beyond an imaginary line of 3.26 ± 0.88 cm far from the lateral edge of rectus abdominis muscle should be included in the DIEP flap.

Keywords

Rectus abdominis innervation Thoracolumbar nerves DIEP flap Abdominal wall morbidity 

Notes

Compliance with ethical standards

Financial support

This study was permitted thanks to the funding from University Research (ex 60%).

Conflict of interest

The authors declare no potential conflicts of interest.

References

  1. 1.
    Allen RJ, Treece P (1994) Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg 32(1):32–38CrossRefPubMedGoogle Scholar
  2. 2.
    Aubry S, Pauchot J, Kastler A, Laurent O, Tropet Y, Runge M (2013) Preoperative imaging in the planning of deep inferior epigastric artery perforator flap surgery. Skelet Radiol 42(3):319–327CrossRefGoogle Scholar
  3. 3.
    Bajaj AK, Chevray PM, Chang DW (2006) Comparison of donor-site complications and functional outcomes in free muscle-sparing TRAM flap and free DIEP flap breast reconstruction. Plast Reconstr Surg 117(3):737–746CrossRefGoogle Scholar
  4. 4.
    Davies F, Gladstone RJ, Stibbe EP (1931) The anatomy of the intercostal nerves. J Anat 66(Pt 3):323–333Google Scholar
  5. 5.
    Holmstrom H (1979) The free abdominoplasty flap and its use in breast reconstruction. An experimental study and clinical case report. Scand J Plast Reconstr Surg 13:423–427CrossRefPubMedGoogle Scholar
  6. 6.
    Korenkov M, Paul A, Sauerland S, Neugebauer E, Arndt M, Chevrel JP, Corcione F et al (2001) Classification and surgical treatment of incisional hernia. Langenbeck’s Arch Surg 386(1):65–73CrossRefGoogle Scholar
  7. 7.
    Koshima I, Saeda S (1989) Inferior epigastric artery skin flaps without rectus abdominis muscle. Br J Plast Surg Nov 42(6):645–648CrossRefGoogle Scholar
  8. 8.
    Moon HK, Taylor GI (1988) The vascular anatomy of rectus abdominis musculocutaneous flaps based on the deep superior epigastric system. Plast Reconstr Surg 82(5):815–832CrossRefPubMedGoogle Scholar
  9. 9.
    Mori H, Akita K, Hata Y (2007) Anatomical study of innervated transverse rectus abdominis musculocutaneous and deep inferior epigastric perforator flaps. Surg Radiol Anat 29(2):149–154CrossRefPubMedGoogle Scholar
  10. 10.
    Nahabedian MY, Patel K (2016) Autologous flap breast reconstruction: surgical algorithm and patient selection. J Surg Oncol 113(8):865–874CrossRefPubMedGoogle Scholar
  11. 11.
    Porzionato A, Macchi V, Stecco C, Mazzi A, Rambaldo A, Sarasin G et al (2012) Quality management of body donation program at the University of Padova. Anat Sci Educ 5(5):264–272CrossRefPubMedGoogle Scholar
  12. 12.
    Robbins TH (1979) Rectus abdominis myocutaneous flap for breast reconstruction. Aust N Z J Surg 49:527–530CrossRefPubMedGoogle Scholar
  13. 13.
    Rozen WM, Ashton MW, Kiil BJ, Grinsell D, Seneviratne S, Corlett RJ, Taylor GI (2008) Avoiding denervation of rectus abdominis in DIEP flap harvest: the importance of medial row perforators. Plast Reconstr Surg 122:710–716CrossRefPubMedGoogle Scholar
  14. 14.
    Rozen WM, Tran TMN, Ashton MW, Barrington MJ, Ivanusic JJ, Taylor GI (2008) Refining the course of the thoracolumbar nerves: a new understanding of the innervation of the anterior abdominal wall. Clin Anat 21(4):325–333CrossRefPubMedGoogle Scholar
  15. 15.
    Rozen WM, Ashton MW, Kiil BJ, Grinsell D, Seneviratne S, Corlett RJ, Taylor GI (2008) Avoiding denervation of rectus abdominis in DIEP flap harvest II: an intraoperative assessment of the nerves to rectus. Plast Reconstr Surg 122:1321–1325CrossRefPubMedGoogle Scholar
  16. 16.
    Sailon AM, Schachar JS, Levine JP (2009) Free transverse rectus abdominis myocutaneous and deep inferior epigastric perforator flaps for breast reconstruction. A systematic review of flap complication rates and donor-site morbidity. Ann Plast Surg 62(5):560–563CrossRefPubMedGoogle Scholar
  17. 17.
    Sakamoto H, Akita K, Sato T (1996) An anatomical analysis of the relationships between the intercostal nerves and the thoracic and abdominal muscles in man: I. Ramifications of the intercostal nerves. Acta Anat 156(2):132–142CrossRefPubMedGoogle Scholar
  18. 18.
    Sakamoto H, Akita K, Sato T (1996) An anatomical analysis of the relationships between the intercostal nerves and the thoracic and abdominal muscles in man: II. Detailed analysis of innervation of the three lateral abdominal muscles. Acta Anat 156(2):143–150CrossRefPubMedGoogle Scholar
  19. 19.
    Stecco C, Gagey O, Belloni A, Pozzuoli A, Porzionato A, Macchi V et al (2007) Anatomy of the deep fascia of the upper limb. Second part: study of innervation. Morphologie 91(292):38–43CrossRefPubMedGoogle Scholar
  20. 20.
    Thiel W (2002) Supplement to the conservation of an entire cadaver according to W. Thiel. Ann Anat 184(3):267–269 (in German) CrossRefPubMedGoogle Scholar
  21. 21.
    Uda H, Tomioka YK, Sarukawa S, Sunaga A, Sugawara Y (2015) Comparison of abdominal wall morbidity between medial and lateral row-based deep inferior epigastric perforator flap. J Plast Reconstr Aesthet Surg 68(11):1550–1555CrossRefPubMedGoogle Scholar
  22. 22.
    Walmsley T (1916) The costal musculature. J Anat Physiol 50(Pt 2):165–171PubMedPubMedCentralGoogle Scholar
  23. 23.
    Yap LH, Whiten SC, Forster A, Stevenson JH (2002) The anatomical and neurophysiological basis of the sensate free TRAM and DIEP flaps. Br J Plast Surg 55(1):35–45CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag France SAS, part of Springer Nature 2017

Authors and Affiliations

  1. 1.Department of Molecular Medicine, Institute of AnatomyUniversity of PadovaPadovaItaly
  2. 2.Plastic Surgery ClinicUniversity of PadovaPadovaItaly
  3. 3.Orthopaedic ClinicUniversity of PadovaPadovaItaly

Personalised recommendations