Delayed Vertical Rectus Abdominis Myocutaneous Flap for Anterior Chest WallReconstruction

Masao Fujiwara, M.D.,1 Yoko Nakamura, M.D.,1 Akira Sano, M.D.,2 Ei Nakayama, M.D.,3

Miyuki Nagasawa, M.D.,3 and Toru Shindo, M.D.3

1Department of Plastic and Reconstructive Surgery, Tenri Hospital, 200, Mishima, Tenri, Nara, 632-8552, Japan2Department of Radiology, Tenri Hospital, 200, Mishima, Tenri, Nara, 632-8552, Japan3Department of Respiratory Surgery, Tenri Hospital, 200, Mishima, Tenri, Nara, 632-8552, Japan

Abstract.

Background: Not only is a radiation ulcer nonviable itself,

but the surrounding irradiated tissue also shows poorhealing. Therefore, healing in an irradiated eld cannot beexpected if a ap used for reconstruction fails even par-tially. For repair of radiation ulcers, a ap with a stable

blood supply is required. A superiorly based vertical rectusabdominis myocutaneous (VRAM) ap is commonly usedfor chest wall reconstruction. Because the VRAM ap is

nourished only by the superior epigastric vessels, the bloodsupply to the distal part of the ap often is precarious.Case Report: A case is reported in which a delayed VRAM

ap was used successfully to treat a radiation ulcer on theanterior chest wall.Results: Consecutive angiograms showed that the delay

procedure augmented the blood supply to the VRAM ap.The ap showed complete take without any postoperativecomplications.Conclusion: A delay procedure may make the VRAM ap

more reliable for anterior chest wall reconstruction. Thisap may be a valuable option for reconstruction ofintractable ulcers such as radiation ulcers, and may be

applicable for breast reconstruction after radiation therapy.

Key words: DelayRectus abdominis myocutaneousapRadiationUlcer

A rectus abdominis myocutaneous (RAM) ap maybe either horizontal or vertical, and the vertical ap

may be based inferiorly or superiorly. Use of asuperiorly based RAM ap has become the standardmethod for reconstruction of the anterior chest wall,including breast reconstruction [3].The superiorly based vertical RAM (VRAM) ap

would appear to have a better blood supply than thesuperiorly based transverse RAM (TRAM) ap,because the ap is designed over the rectus muscle[8]. However, the blood supply to the distal part ofthe ap often is precarious because the VRAM apis nourished only by the superior epigastric vascularsystem [1,9,10,13]. Therefore, the standard proce-dure for mobilizing a VRAM ap sometimes leadsto ischemia or venous congestion in the distal por-tion of the ap, which can result in graft failure[9,11]. Shrotria et al. [11] reported that the incidenceof partial necrosis was 12.5% (11/88 cases) whenconventional VRAM aps were used in cosmeticbreast reconstruction, whereas it was 43.8% (7/16cases) when they were used to cover chest walldefects.To our knowledge, there have been only two re-

ports about augmentation of the blood supply tosuperiorly based VRAM aps [9,13]. In both re-ports, microvascular anastomosis was performedbetween the inferior epigastric system and theavailable vessels from the axillary, brachial, or cer-vical vascular system [9,13]. Use of a delay proce-dure to improve survival has been reported forTRAM aps [2,4], but there have been no reportsabout the use of a delay procedure for superiorlybased VRAM aps. Accordingly, this is the rstreport about a delayed superiorly based VRAMap. We describe the operative details and discussthe features of this ap.

Correspondence to M. Fujiwara M.D.; email: masaofuj@mth.biglobe.ne.jp

Aesth. Plast. Surg. 30:120124, 2006DOI: 10.1007/s00266-005-0145-6

Operative Procedure

The skin markings are drawn while the patient isawake preoperatively. The ap may extend from thexiphoid process to the mons pubis. The level with thegreatest width is determined by skin tension becausethe ap should be harvested so that the defect can beclosed directly. The lateral abdominal skin is pushedmedially from both sides to conrm the tension on it.The delay procedure consists of making the incisionfor the inferior one-third of the ap (surgical delay)and ligation of the deep inferior epigastric artery andvein (vascular delay), which are accessed via the apincision down to the fascia about 2 weeks before theactual ap transfer (Fig. 1).After a 2-week delay, the VRAM ap is elevated.

At the graft site, aggressive debridement of thenecrotic soft tissue, bone, and cartilage is performed.When possible, it is better to remove the entire eld ofradiation-aected tissue before reconstruction [5].Reconstruction of bony defects is not always neces-sary. Even very large defects can be covered suc-cessfully by using a bulky myocutaneous ap withoutskeletal stabilization [6,7] because the thickness of theap, subsequent ap brosis, and radiation brosisall tend to minimize the occurrence of paradoxicalwall motion and to maintain chest wall stability [5].After the same skin ap incision from the delay

procedure is refreshed, the anterior sheath of therectus abdominis is incised, and the rectus muscle iscut after ligation of the muscle belly. The muscle isalways divided cephalad to the arcuate line to pre-vent lower abdominal wall herniation [10]. Theblood supply to the skin passes through the anteriorrectus sheath from the rectus abdominis muscle, sothe skin must remain attached to the muscle. Afterthe incision is also made for the superior two-thirdsof the ap, the abdominal skin is undermined lat-

erally beyond the margins of the rectus abdominismuscle in the fascial plane. The medial and lateralborders of the anterior rectus sheath are incisedlongitudinally, with care taken to preserve a 1-cmstrip of the sheath along both borders for closure.Then the ap is elevated as far as the costal margin,leaving the posterior rectus sheath in situ. The pointat which the superior epigastric vessels enter therectus abdominis muscle is the pivot of this ap.The donor site is closed by approximating themedial and lateral fascial borders, and a suctiondrain is placed in the undermined lateral abdominalarea.

Case Report

A 61-year-old woman presented with an infectedradiation ulcer on the anterior chest. She hadundergone mastectomy 16 years previously, followedby chemotherapy and radiation therapy. A deep ulcer(8 11 cm) that exposed necrotic ribs, the sternum,and the surface of the pericardium had developedwithin the radiation eld on the anterior chest wall.Reconstruction using an ipsilateral latissimus dorsimyocutaneous ap had been performed, but wasfollowed by partial necrosis of the distal portion ofthe ap. A delayed VRAM ap was planned. Thedelay procedure involved both vascular and surgicaldelay (Fig. 1). Consecutive selective angiograms viathe right internal thoracic artery showed that thedelay procedure led to augmentation of the bloodsupply to the VRAM ap (Fig. 2).Two weeks after the delay procedure, aggressive

debridement and transfer of a large VRAM ap (13 26 cm) were performed (Fig. 3A). Graft site resectionincluded portions of three ribs (2nd to 4th) and par-tial sternectomy, but skeletal repair was not per-

Fig. 1. The deep inferior epigastric vessels (ar-row) have been dissected. In addition to vasculardelay with ligation of the deep inferior epigastricvessels, partial surgical delay with an incision forthe distal third of the ap was performed.

M. Fujiwara et al. 121

formed. The distal portion of the ap was used tocover the cephalad part of the ulcer, which exposedthe ribs and sternum. The ap showed complete take,and neither ail chest nor respiratory insuciencyoccurred. Four months after surgery, the patientswounds were healed completely (Fig. 3B).

Discussion

Infection, scarring, and devascularization from irra-diation represent some of the most dicult problemsfor reconstructive surgery. Irradiation alters the sur-rounding tissues and structures in a permanent and

Fig. 2. Selective angiograms obtained via the right internal thoracic artery before delay (A) and 10 days after delay (B). Theangiogram obtained after delay shows dilation of vessels (arrowhead) in the caudal part of the superior epigastric vascularsystem, as compared with that obtained before delay.

Fig. 3. (A) Design of a delayed vertical rectus abdominis myocutaneous ap. A dotted line shows the skin incision. (B)Appearance 4 months after surgery. Improvement in the waistline is notable, although a longitudinal abdominal scar ispresent.

122 Delayed VRAM Flap

progressive manner. Among the changes to normaltissues are loss of healing capacity, skin atrophy,brosis, alterations of the microcirculation, and thepotential for necrosis to occur [5]. Therefore, whensurgery is performed in an irradiated eld, a nonhe-aling wound with progressive necrosis may be theresult [5]. For reconstruction of radiation ulcers, aap with a stable blood supply is required.The perforators that supply the skin overlying the

rectus abdominis muscle are located predominantlyabove the level of the arcuate line, and detection ofmore than one perforator below this line is rare [3].On the basis of dissection and radiographic studies,Moon and Taylor [8] concluded that the blood supplyto a superiorly based VRAM ap is from the myo-cutaneous perforators that originate in the deepsuperior epigastric artery, as well as from retrogradelling of perforators from the deep inferior epigastricartery. The distal 3 to 4 cm of a VRAM ap designedfrom the xiphoid process to the mons pubis showedlittle contrast enhancement. This area corresponds tothe territory of the supercial external pudendalartery.When TRAM aps are used, good ap survival is

obtained by a delay procedure. Erdmann et al. [4]used a unipedicled TRAM ap for reconstruction ofthe breast, nding that combined vascular and partialsurgical delay for 2 weeks before ap transfer resultedin 6.6% partial necrosis (fat necrosis) and no com-plete ap necrosis in a series of 76 consecutive cases.Their delay procedure consisted of partial surgicaldelay with a three-fourths inferior ap incision, aswell as vascular delay with bilateral ligation of thedeep inferior epigastric artery and vein [4].For the reported patient, when angiograms were

obtained 10 days after the delay procedure, the cau-dal part of the superior epigastric vascular systemwas shown to be dilated, as compared with itsappearance before the procedure. Contrast mediumwas selectively injected into the superior epigastricartery by use of a microcatheter, so the angiogramdirectly demonstrated blood ow in the superiorepigastric vascular system (Fig. 2).Anatomically, there are obstructions to ow in

both the muscle and skin of the ap. In the muscle, asystem of small-caliber choke arteries connects thedeep superior and inferior epigastric arteries. In theskin, many of the veins contain valves directed awayfrom the muscle pedicle. The choke arteries withinthe muscle undergo dilation, and the veins in the skinand muscle become regurgitant to allow free owtoward to the superior epigastric pedicle after ligationof the deep inferior epigastric vessels. The ipsilateralsuperior epigastric vessels and deep inferior epigastricvessels virtually coalesce into one system after thedelay procedure [2,12]. In the reported patient, dila-tion of caudal vessels after the delay procedure mayindicate improvement in the arterial supply andvenous drainage of the distal part of the VRAM ap(Fig. 2).

When microvascular anastomosis is used for aug-mentation of the blood supply to a VRAM ap,additional dissection of the neck or axilla is requiredto prepare recipient vessels such as external carotidartery branches, the internal or external jugular vein,the thoracodorsal artery, and the thoracodorsal vein[9,13]. Such additional dissection of the neck or axillaincreases postoperative scarring. The delayed VRAMap has the following advantages over the modiedVRAM aps using microvascular anastomosis de-scribed earlier. First, the skin incision is the same asfor a conventional VRAM ap because dissection ofrecipient vessels is unnecessary. Second, because thereis no microvascular anastomosis, ap failure attrib-utable to thrombosis is unlikely, and positioning ofthe ap is not limited by anastomosis, and thus canbe optimized.On consecutive angiograms, the delayed VRAM

ap showed enlargement of the superior epigastricvascular system, as compared with the conventionalVRAM ap. In addition, a larger ap that includesmore of the lower abdomen may be harvested by thedelay procedure, as compared with the conventionalVRAM method, because the territory of the super-cial external pudendal artery and that of the deepinferior epigastric artery can be included. Therefore,there is a simultaneous benecial eect ofabdominoplasty, which improves the waistline.For both cosmetic reasons and a better blood

supply, a delayed VRAM ap should be regarded asa valuable option for reconstruction of intractableulcers such as radiation ulcers. It also should beapplicable to breast reconstruction after radiationtherapy.

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