Advertisement

Rectus Abdominis Flap

  • Klaus-Dietrich Wolff
  • Frank Hölzle

Abstract

In 1974, an upper transverse abdominal flap for breast reconstruction was described by Tai and coworkers, who gave the first description of this myocutaneous flap based on the deep superior epigastric vessels and their perforating vessels through the rectus muscle [515]. Another early report of flap raising procedures at the anterior abdominal wall including parts of the rectus muscle was given by Brown et al., who described the myocutaneous rectus abdominis flap used as a pedicled flap for covering an extensive ipsilateral defect of the arm after a shotgun injury [61]. Two years later, Drever described a superiorly based rectus abdominis flap with a vertical skin island which he used as a pedicled flap to treat a scar contracture at the chest. In this publication, he also proposed using this flap for many reconstructive purposes, especially in the head and neck region, as a free flap. Like Brown and Tai, he recognized the dependence of skin perfusion from perforators through the rectus muscle, and they pointed out that long transverse skin island of the abdominal skin could be based on these perforators. In the years to follow, the superiorly based rectus abdominis flap, nourished via the internal mammary vessels, was primarily taken with a horizontal skin paddle and used for breast reconstruction [360, 372]. These reports were followed by the first microvascular transfer with anastomoses to the deep inferior epigastric vessels performed by Pennington and Pelly [406]. In their report, they present two free flaps based on the deep inferior epigastric artery and highlight the long, wide lumen pedicle and the ease of flap raising. Nevertheless, the authors also mentioned the need to reconstruct the anterior rectus sheath and the possible bulk of the flap as disadvantages. Before that, free flaps from the lower abdominal wall have already been raised, but using the superficial epigastric vascular system. Antia and Buch [15] are credited to be the first having successfully performed a microsurgical free-flap transfer by transferring a dermis-fat flap from the lower abdomen for facial contour augmentation, thereby using the superficial inferior epigastric vessels and including a cuff of the femoral artery for safe anastomosis [15]. A few years later, Taylor and Daniel [529] gave an anatomic description on this superficial epigastric vascular system, which, compared to the deep epigastric vessel, was highly variable and consisted of small caliber vessels. Both, the deep and the superficial system, have partially overlapping vascular territories and are connected by choke arteries. Of these, the paraumbilical perforators originating from the deep system are the strongest and therefore contribute most to skin perfusion of the anterior abdominal wall [50, 59, 160]. Very soon after the first reports, a number of different flap designs and orientations of the skin paddle were described, all confirming the unique usefulness of myocutaneous flaps from the deep inferior vascular system. Intraoperatively, Harris and coworkers studied the blood flow of the deep and superficial epigastric vessels and showed that most vascular connections between both systems are concentrated centrally. Nevertheless, they emphasized elevating the entire muscle to preserve all vascular connections to the skin [201]. The main use of this conventional myocutaneous flap which includes significant parts of the rectus abdominis muscle is in breast reconstruction, but it is also used for other regions of the body like the skull base, face, head and neck, trunk, and extremities [63, 125, 129, 203, 364, 528, 549, 551, 607]. Due to the dense anastomotic network between the deep inferior and superior epigastric vessels, which was extensively investigated using cadaver dissections and angiograms [360, 372], the perfusion of the flap is also reliable via the internal mammary vessels, making the pedicled transfer to defects of the breast or thorax possible. Undoubtedly, the most common design when using the rectus abdominis flap is the TRAM flap with a horizontal orientation, using the deep inferior epigastric vessels as the pedicle and incorporating the skin from the entire lower abdomen, but many other variations of the skin paddle have been described, such as the standard longitudinal skin paddle positioned over the entire length of the rectus muscle, the oblique design, or the raising of the muscle without any skin. It has been estimated that the deep inferior epigastric artery may provide the largest territory of vascularized skin available in the human body [59]. The skin territory can be extended even more using the “supercharging” technique, if the most distal flap zone is additionally anastomosed to an artery or vein from the superficial system, thereby enhancing the blood supply to the flap provided by the deep inferior epigastric vessels [517].

Supplementary material

Video 7.1

Rectus abdominis flap (MP4 362679 kb)

References

  1. 13.
    Anita M, Haque M, Gupta A, Nasar A (2015) Variation in tendinous intersections of rectus abdominis muscle in North Indian population with clinical implications. J Clin Diagn Res 9(6):AC10–AC12. doi:10.7860/JCDR/2015/14027.6028PubMedPubMedCentralGoogle Scholar
  2. 15.
    Antia NH, Buch VI (1971) Transfer of an abdominal dermo-fat graft by direct anastomosis of blood vessels. Br J Plast Surg 24(1):15–19Google Scholar
  3. 20.
    Atisha D, Alderman AK (2009) A systematic review of abdominal wall function following abdominal flaps for postmastectomy breast reconstruction. Ann Plast Surg 63(2):222–230. doi:10.1097/SAP.0b013e31818c4a9ePubMedGoogle Scholar
  4. 38.
    Baumann DP, Lin HY, Chevray PM (2010) Perforator number predicts fat necrosis in a prospective analysis of breast reconstruction with free TRAM, DIEP, and SIEA flaps. Plast Reconstr Surg 125(5):1335–1341. doi:10.1097/PRS.0b013e3181d4fb4aPubMedGoogle Scholar
  5. 49.
    Blondeel PN, Hallock GG, Morris SF, Neligan PC (2005) Perforator flaps: anatomy, technique & clinical applications, vol 1. Quality Medical Publishing, Inc, St. LouisGoogle Scholar
  6. 51.
    Blondeel PN, Morrison CM (2005) Deep inferior epigastric artery perforator flap. In: Blondeel PN, Hallock GG, Morris SF, Neligan PC (eds) Perforator flaps: anatomy, technique & clinical applications, vol 1. Quality Medical Publishing, St. Louis, pp 385–404Google Scholar
  7. 60.
    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):1–16PubMedPubMedCentralGoogle Scholar
  8. 62.
    Brown RG, Vasconez LO, Jurkiewicz MJ (1975) Transverse abdominal flaps and the deep epigastric arcade. Plast Reconstr Surg 55(4):416–421PubMedGoogle Scholar
  9. 63.
    Bucky LP, May JW Jr (1994) Synthetic mesh. Its use in abdominal wall reconstruction after the TRAM. Clin Plast Surg 21(2):273–277PubMedGoogle Scholar
  10. 64.
    Bunkis J, Walton RL, Mathes SJ (1983) The rectus abdominis free flap for lower extremity reconstruction. Ann Plast Surg 11(5):373–380PubMedGoogle Scholar
  11. 68.
    Carramenha e Costa MA, Carriquiry C, Vasconez LO, Grotting JC, Herrera RH, Windle BH (1987) An anatomic study of the venous drainage of the transverse rectus abdominis musculocutaneous flap. Plast Reconstr Surg 79(2):208–217Google Scholar
  12. 110.
    Cyriac C, Sharma RK, Singh G (2010) Assessment of the abdominal wall function after pedicled TRAM flap surgery for breast reconstruction: use of modified mesh repair for the donor defect. Indian J Plast Surg 43(2):166–172. doi:10.4103/0970-0358.73430PubMedPubMedCentralGoogle Scholar
  13. 125.
    Drever JM (1983) The lower abdominal transverse rectus abdominis myocutaneous flap for breast reconstruction. Ann Plast Surg 10(3):179–185PubMedGoogle Scholar
  14. 126.
    Drever JM, Hodson-Walker N (1985) Closure of the donor defect for breast reconstruction with rectus abdominis myocutaneous flaps. Plast Reconstr Surg 76(4):558–565PubMedPubMedCentralGoogle Scholar
  15. 128.
    Duchateau J, Declety A, Lejour M (1988) Innervation of the rectus abdominis muscle: implications for rectus flaps. Plast Reconstr Surg 82(2):223–228PubMedGoogle Scholar
  16. 130.
    Ebihara H, Maruyama Y (1989) Free abdominal flaps: variations in design and application to soft tissue defects of the head. J Reconstr Microsurg 5(3):193–201PubMedGoogle Scholar
  17. 134.
    Elliott LF, Hartrampf CR Jr (1983) Tailoring of the new breast using the transverse abdominal island flap. Plast Reconstr Surg 72(6):887–893PubMedGoogle Scholar
  18. 144.
    Feller AM (1994) Free TRAM. Results and abdominal wall function. Clin Plast Surg 21(2):223–232PubMedGoogle Scholar
  19. 161.
    Geddes CR, Tang M, Yang D, Morris SF (2005) Anatomy of the integumnet of the trunk. In: Blondeel PN, Hallock GG, Morris SF, Neligan PC (eds) Perforator flaps: anatomy, technique & clinical applications, vol 1. Quality Medical Publishing, St. Louis, pp 359–384Google Scholar
  20. 170.
    Godfrey PM, Godfrey NV, Romita MC (1994) The “circummuscular” free TRAM pedicle: a trap. Plast Reconstr Surg 93(1):178–180PubMedGoogle Scholar
  21. 185.
    Hallock GG (1989) Aesthetic approach to the rectus abdominis free tissue transfer. J Reconstr Microsurg 5(1):69–73. doi:10.1055/s-2007-1006853PubMedGoogle Scholar
  22. 192.
    Hallock GG (2005) The superior epigastric(RECTUS ABDOMINIS) muscle perforator flap. Ann Plast Surg 55(4):430–432. doi:00000637-200510000-00021 [pii]Google Scholar
  23. 202.
    Harris NR, 2nd, Webb MS, May JW Jr (1992) Intraoperative physiologic blood flow studies in the TRAM flap. Plast Reconstr Surg 90(4):553–558; discussion 559–561Google Scholar
  24. 204.
    Hartrampf CR Jr (1984) Abdominal wall competence in transverse abdominal island flap operations. Ann Plast Surg 12(2):139–146PubMedPubMedCentralGoogle Scholar
  25. 205.
    Hartrampf CR Jr, Black PW, Beegle PH Jr (1987) Breast reconstruction following mastectomy. J Med Assoc Ga 76(5):328–334PubMedGoogle Scholar
  26. 206.
    Hata Y, Yano K, Matsuka K, Ito O, Matsuda H, Hosokawa K (1990) Treatment of chronic facial palsy by transplantation of the neurovascularized free rectus abdominis muscle. Plast Reconstr Surg 86(6):1178–1187; discussion 1188–1179Google Scholar
  27. 212.
    Heitmann C, Felmerer G, Durmus C, Matejic B, Ingianni G (2000) Anatomical features of perforator blood vessels in the deep inferior epigastric perforator flap. Br J Plast Surg 53(3):205–208. doi:10.1054/bjps.1999.3257 S0007-1226(99)93257-5 [pii]
  28. 223.
    Holm C, Mayr M, Hofter E, Ninkovic M (2006) Perfusion zones of the DIEP flap revisited: a clinical study. Plast Reconstr Surg 117(1):37–43PubMedPubMedCentralGoogle Scholar
  29. 256.
    Jones NF, Sekhar LN, Schramm VL (1986) Free rectus abdominis muscle flap reconstruction of the middle and posterior cranial base. Plast Reconstr Surg 78(4):471–479PubMedGoogle Scholar
  30. 263.
    Kaufman T, Hurwitz DJ, Boehnke M, Futrell JW (1985) The microcirculatory pattern of the transverse-abdominal flap: a cross-sectional xerographic and CAT scanning study. Ann Plast Surg 14(4):340–345PubMedGoogle Scholar
  31. 304.
    Kroll SS, Marchi M (1992) Comparison of strategies for preventing abdominal-wall weakness after TRAM flap breast reconstruction. Plast Reconstr Surg 89(6):1045–1051; discussion 1052–1043Google Scholar
  32. 305.
    Kropf N, Macadam SA, McCarthy C, Disa JJ, Pusic AL, Da Lio A, Crisera C, Mehrara BJ (2010) Influence of the recipient vessel on fat necrosis after breast reconstruction with a free transverse rectus abdominis myocutaneous flap. Scand J Plast Reconstr Surg Hand Surg 44(2):96–101. doi:10.3109/02844311003675354PubMedGoogle Scholar
  33. 315.
    Lejour M, Dome M (1991) Abdominal wall function after rectus abdominis transfer. Plast Reconstr Surg 87(6):1054–1068Google Scholar
  34. 368.
    Miller LB, Bostwick J 3rd, Hartrampf CR Jr, Hester TR Jr, Nahai F (1988) The superiorly based rectus abdominis flap: predicting and enhancing its blood supply based on an anatomic and clinical study. Plast Reconstr Surg 81(5):713–724PubMedGoogle Scholar
  35. 369.
    Milloy FJ, Anson BJ, McAfee DK (1960) The rectus abdominis muscle and the epigastric arteries. Surg Gynecol Obstet 110:293–302PubMedGoogle Scholar
  36. 372.
    Miyamoto Y, Harada K, Kodama Y, Takahashi H, Okano S (1986) Cranial coverage involving scalp, bone and dura using free inferior epigastric flap. Br J Plast Surg 39(4):483–490PubMedGoogle Scholar
  37. 373.
    Mizgala CL, Hartrampf CR Jr, Bennett GK (1994) Abdominal function after pedicled TRAM flap surgery. Clin Plast Surg 21(2):255–272PubMedGoogle Scholar
  38. 381.
    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):815–832PubMedGoogle Scholar
  39. 387.
    Muhlbauer W, Olbrisch RR (1977) The latissimus dorsi myocutaneous flap for breast reconstruction. Chir Plast 4(1):27–34Google Scholar
  40. 390.
    Mulvey CL, Cooney CM, Daily FF, Colantuoni E, Ogbuago OU, Cooney DS, Rad AN, Manahan MA, Rosson GD, Sacks JM (2013) Increased flap weight and decreased perforator number predict fat necrosis in DIEP breast reconstruction. Plast Reconstr Surg Glob Open 1(2):1–7. doi:10.1097/GOX.0b013e318294e41dPubMedPubMedCentralGoogle Scholar
  41. 401.
    Nincovic M (2005) Superficial inferior epigastric artery perforator. In: Blondeel PN, Hallock GG, Morris SF, Neligan PC (eds) Perforator flaps: anatomy, technique & clinical applications, vol 1. Quality Medical Publishing, St. Louis, pp 405–420Google Scholar
  42. 414.
    Pennington DG, Nettle WJ, Lam P (1993) Microvascular augmentation of the blood supply of the contralateral side of the free transverse rectus abdominis musculocutaneous flap. Ann Plast Surg 31(2):123–126; discussion 126–127Google Scholar
  43. 415.
    Pennington DG, Pelly AD (1980) The rectus abdominis myocutaneous free flap. Br J Plast Surg 33(2):277–282PubMedGoogle Scholar
  44. 434.
    Ridha H, Thompson MK, Cameron MG, Durrani AJ (2011) Anatomical variation in deep inferior epigastric pedicles and implications for harvest of lower abdominal flaps. Br J Oral Maxillofac Surg 49(3):233–234. doi:10.1016/j.bjoms.2010.04.008PubMedGoogle Scholar
  45. 455.
    Sadove R, Merrell JC (1987) The split rectus abdominis free muscle transfer. Ann Plast Surg 18(2):179–181PubMedPubMedCentralGoogle Scholar
  46. 480.
    Schusterman MA, Kroll SS, Miller MJ, Reece GP, Baldwin BJ, Robb GL, Altmyer CS, Ames FC, Singletary SE, Ross MI et al (1994) The free transverse rectus abdominis musculocutaneous flap for breast reconstruction: one center’s experience with 211 consecutive cases. Ann Plast Surg 32(3):234–241; discussion 241–232Google Scholar
  47. 481.
    Schusterman MA, Kroll SS, Weldon ME (1992) Immediate breast reconstruction: why the free TRAM over the conventional TRAM flap? Plast Reconstr Surg 90(2):255–261; discussion 262Google Scholar
  48. 485.
    Seidenstuecker K, Legler U, Munder B, Andree C, Mahajan A, Witzel C (2016) Myosonographic study of abdominal wall dynamics to assess donor site morbidity after microsurgical breast reconstruction with a DIEP or an ms-2 TRAM flap. J Plast Reconstr Aesthet Surg 69(5):598–603. doi:10.1016/j.bjps.2015.11.007PubMedGoogle Scholar
  49. 489.
    Selber JC, Fosnot J, Nelson J, Goldstein J, Bergey M, Sonnad S, Serletti JM (2010) A prospective study comparing the functional impact of SIEA, DIEP, and muscle-sparing free TRAM flaps on the abdominal wall: part II. Bilateral reconstruction. Plast Reconstr Surg 126(5):1438–1453. doi:10.1097/PRS.0b013e3181ea42edPubMedGoogle Scholar
  50. 501.
    Slavin SA, Goldwyn RM (1988) The midabdominal rectus abdominis myocutaneous flap: review of 236 flaps. Plast Reconstr Surg 81(2):189–199PubMedGoogle Scholar
  51. 514.
    Souto LR, Cardoso LA, Claro BM, de Oliveira Peres MA (2011) Double-mesh technique for correction of abdominal hernia following mammary reconstruction carried out with bipedicled TRAM flap and the primary closing of the donor area by using a single polypropylene mesh. Aesthet Plast Surg 35(2):184–191. doi:10.1007/s00266-010-9581-zGoogle Scholar
  52. 524.
    Tai Y, Hasegawa H (1974) A transverse abdominal flap for reconstruction after radical operations for recurrent breast cancer. Plast Reconstr Surg 53(1):52–54PubMedPubMedCentralGoogle Scholar
  53. 526.
    Takayanagi S, Ohtsuka M (1989) Extended transverse rectus abdominis musculocutaneous flap. Plast Reconstr Surg 83(6):1057–1060PubMedGoogle Scholar
  54. 537.
    Taylor GI, Corlett RJ, Boyd JB (1984) The versatile deep inferior epigastric (inferior rectus abdominis) flap. Br J Plast Surg 37(3):330–350PubMedGoogle Scholar
  55. 538.
    Taylor GI, Daniel RK (1975) The anatomy of several free flap donor sites. Plast Reconstr Surg 56(3):243–253Google Scholar
  56. 558.
    Urken ML, Catalano PJ, Sen C, Post K, Futran N, Biller HF (1993) Free tissue transfer for skull base reconstruction analysis of complications and a classification scheme for defining skull base defects. Arch Otolaryngol Head Neck Surg 119(12):1318–1325PubMedGoogle Scholar
  57. 559.
    Urken ML, Cheney ML, Sullivan MJ, Biller HF (1990) Atlas of regional and free flaps for head and neck reconstruction. Raven Press, New YorkGoogle Scholar
  58. 560.
    Urken ML, Turk JB, Weinberg H, Vickery C, Biller HF (1991) The rectus abdominis free flap in head and neck reconstruction. Arch Otolaryngol Head Neck Surg 117(9):1031PubMedPubMedCentralGoogle Scholar
  59. 561.
    Urken ML, Turk JB, Weinberg H, Vickery C, Biller HF (1991) The rectus abdominis free flap in head and neck reconstruction. Arch Otolaryngol Head Neck Surg 117(8):857–866PubMedGoogle Scholar
  60. 579.
    Watterson PA, Bostwick J 3rd, Hester TR Jr, Bried JT, Taylor GI (1995) TRAM flap anatomy correlated with a 10-year clinical experience with 556 patients. Plast Reconstr Surg 95(7):1185–1194PubMedGoogle Scholar
  61. 618.
    Yamada A, Harii K, Ueda K, Asato H (1992) Free rectus abdominis muscle reconstruction of the anterior skull base. Br J Plast Surg 45(4):302–306PubMedGoogle Scholar

Copyright information

© Springer International Publishing AG 2018

Authors and Affiliations

  • Klaus-Dietrich Wolff
    • 1
  • Frank Hölzle
    • 2
  1. 1.Department of Oral and Maxillofacial SurgeryKlinikum rechts der Isar, Technische Universität MunichMunichGermany
  2. 2.Department of Oral and Maxillofacial SurgeryUniversity Hospital of RWTH Aachen UniversityAachenGermany

Personalised recommendations