VERSATILITY OF RECTUS ABDOMINIS FREE FLAP FORRECONSTRUCTION OF SOFT-TISSUE DEFECTS IN EXTREMITIES

ZHANG XING-QUAN, M.D., Ph.D.,* WANG SHAO-DONG, M.D., Ph.D., FAN QING-YU, Ph.D., and MA BAO-AN, Ph.D.

Rectus abdominis flaps, whose blood supply is mainly provided by superior and deep inferior epigastric vessels, are suitable not only for localtransfer but also as free flaps. Based on abundant anastomoses of deep inferior epigastric vessels with other vessels such as superiorepigastric vessels, lower intercostal vessels, subcostal vessels, lumbar vessels, superficial epigastric vessels, and superficial and deep iliaccircumflex vessels, the rectus abdominis flap may be designed as a vertical flap, transverse flap, or oblique flap. From September1995�October 2002, 42 free rectus abdominis flaps were transferred to reconstruct a variety of soft-tissue defects. The size of rectusabdominis flaps ranged from 6�25 cm in length and 5�12 cm in width. The overall success rate was 100% (42 of 42). The donor area wasclosed directly in 8�10-cm-wide flaps, leaving an inconspicuous scar. Larger flaps required skin grafting. After a mean 7-month (range, 3weeks�18 months) follow-up, all flaps have healed uneventfully, and donor abdominal morbidity is minimal. ª 2004 Wiley-Liss, Inc.

In 1977, Mathes and Bostwick1 described the skin,fasciocutaneous, and muscle circulation of the superiorand deep inferior epigastric vessels. Since then, variousabdominal flaps such as musculocutaneous, fasciocuta-neous, and extended flaps in the abdominal region havebeen clinically applied. The free rectus abdominis flap,based on the deep inferior epigastric artery and vein,was first described by Pennington2 in 1980, and hasgained increasing popularity in recent years, primarilybecause of its large and consistent vascular pedicle aswell as ease of dissection.

The rectus abdominis flap, using the deep inferiorepigastric vessels as nutrient vessels, can be used notonly for local transfer but also as a free flap. Based onabundant anastomoses of deep inferior epigastric vesselswith other vessels such as superior epigastric vessels,lower intercostal vessels, subcostal vessels, lumbar ves-sels, superficial epigastric vessels, and superficial anddeep iliac circumflex vessels, there is a different-directionvascular axis. Therefore, the rectus abdominis flap maybe designed as variously shaped flaps, i.e., a vertical-shaped type, a transverse-shaped type, and an oblique-shaped type. These flaps can be used for reconstructionof a variety of soft-tissue defects caused by trauma in theextremities. We present our experience with 42 consec-utive rectus abdominis flaps used for a variety of soft-tissue deficits, and discuss their wide versatility.

MATERIALS AND METHODS

From September 1995�October 2002, 42 free rectusabdominis flaps were transferred to reconstruct a varietyof soft-tissue defects in the extremities. There were 36male patients and 6 female patients. Patient ages rangedfrom 15�72 years (mean, 31 years). In total, 31 of theserectus abdominis flaps were used in the legs, 9 were usedin the feet, and 2 were used in the upper limbs.

The size of rectus abdominis flaps ranged from 6�25cm in length and 5�12 cm in width. In our patients,there were 23 immediate and 19 delayed reconstructionsfor soft-tissue defects in the extremities to cover boneexposure resulting from trauma.

The deep inferior epigastric artery originates fromthe external iliac artery. It is 3�4 mm in diameter at itsorigin, and has two venae comitantes. Arising just deepto the inguinal canal, the deep inferior epigastric arteryperforates the transversalis1 fascia, and enters the rectussheath lateral and inferior to the arcuate line. Then thedeep inferior epigastric artery enters the rectus abdo-minis muscle along its deep surface, courses superiorlyfrom the rectus abdominis muscle to the umbilicus, anddivides into 4�5 branches during its course, communi-cating with branches from the superior epigastric arteryas well as anastomosing with the lower intercostal,subcostal, and lumbar arteries. Also, communicationsexist between the lower intercostal arteries, subcostalartery, lumbar artery, superficial inferior epigastric ar-tery, and superficial and deep iliac circumflex artery, justlike the anastomoses of these superior and deep inferiorepigastric arterial branches. The deep inferior epigastricartery has many laterooblique ascending branches, de-veloping and coursing toward the anterior axillary lineof the costal arch. Among them, the largest perforator islocated approximately 2 cm from the umbilicus, headsfor the inferior angle of the scapula, anastomoses withthe lower intercostal artery, and angulates 45� withthe midline.

Department of Bone and Joint Surgery, Tang Du Hospital, Fourth MilitaryMedical University, Xi’an, P.R. China

*Correspondence to: Zhang Xing-Quan, M.D., Ph.D., Department of Boneand Joint Surgery, Tang Du Hospital, Fourth Military Medical University, Xi’an710038, P.R. China. E-mail: zhxqsd@fmmu.edu.cn

Received 6 June 2003; Accepted 18 October 2003

Published online 11 March 2004 in Wiley InterScience (www.interscience.wiley.com). DOI. 10.1002/micr.20007

ª 2004 Wiley-Liss, Inc.

The rectus abdominis flap, using the deep inferiorepigastric artery and vein as nutrient vessels, may bedesigned in three directions: vertically, horizontally, andobliquely, whichever type has sufficient blood supply,and it can be varied in other ways as to extension andthickness because of the developing radiating vascularnetwork and thick perforating branches centeringaround the umbilicus (Fig. 1).

The patient is placed supine, with both arms ab-ducted. The rectus abdominis flap is designed, depend-ing on the shape of soft-tissue defects in the recipientsite. In our clinical experience, the ultrasonic Dopplerflowmeter is useful in determining the location of thedeep inferior epigastric artery and its perforators pre-operatively. Prepare and drape the entire abdomen fromthe costal margins above to the pubic tubercle below.Flap harvesting starts under tourniquet control. Thefirst step of the procedure is to expose, identify, anddivide the deep inferior epigastric vessels arising fromthe external iliac vessels immediately above the inguinalligament. The fibers of the rectus muscle are thenproperly divided along the deep inferior epigastric ves-sels, in order to get a long vascular pedicle. Next, theincisions of the flap are made on the basis of designa-tion. The skin-fat island is then elevated off the externaloblique fascia on the side of the vascular pedicle, untilthe lateral row of perforators is encountered. Then theopposite side is elevated to expose the medial row ofperforators. Depending on the size of these perforators,one or more in the medial or lateral row are chosen asthe vascular basis of the entire flap. The anterior rectusfascia is opened vertically between these perforators,and the rectus abdominis muscle is split longitudinallyuntil the flap is completely harvested. It is necessary tocarry a part of the anterior sheath of the rectus abdo-minis2 muscle just near the chosen perforators as little aspossible before lifting the flap, to avoid injuring theperforators in the dissection and to avoid repair diffi-culties at the donor site at the same time, especially whentaking large skin paddles. Observe that the muscle isbeing adequately perfused throughout its length by thedeep inferior epigastric vessels only. Once the recipientsite is ready, divide and ligate the vascular pediclecarefully near its origin. Transferred to the recipient bed,the flap is inset with absorbable sutures before the an-astomosis. This prevents bleeding and edema followingrevascularization. Restore the posterior rectus sheathwith a strong nonabsorbable suture to prevent hernia ifit has been violated. The rectus muscle is approximatedwhere it was split longitudinally with absorbable su-tures. The anterior rectus sheath is closed primarily byusing 1-0 Vicryl mattress sutures. Complete the subcu-taneous and skin closure in layers or by skin grafting.Generally speaking, the donor site is closed directly

when the width of the flap is smaller than 8 cm in obesepatients, or less than 10 cm wide in elderly or thinnerpatients.

RESULTS

The overall success rate was 100% (42 of 42). Thedonor area was closed directly in an 8�10-cm-wide flap,leaving an inconspicuous scar. Larger flaps requiredskin grafting. In 33 of 42 patients who had undergoneprimary skin closure, postoperative recovery of the do-nor abdominal wound was uneventful and withouthematoma, skin necrosis, or infection. Nine patientsreceived skin grafts. After a mean 7-month (range, 3weeks�18 months) follow-up, all flaps have healed un-eventfully, and donor abdominal morbidity is minimal.

PATIENT REPORTS

Restorations of soft-tissue defects in the extremitieswere successfully undertaken, using rectus abdominisfree flaps in which the deep inferior epigastric vesselsserved as vascular pedicles. Representative cases arepresented below.

Patient 1

A 17-year-old boy had a scar contracture on theposterior region of the right ankle due to trauma. Wideexcision of the scar and Achilles tendon-lengtheningwere performed. A 12 · 7 cm rectus abdominis free flapwas harvested to reconstruct the soft-tissue defect. Avascular pedicle 13 cm in length was anastomosed inend-to-side fashion, with the right posterior tibial artery

Figure 1. A: Schematic drawing of anastomosis of deep inferior

epigastric artery with branches of other vessels. Branches of deep

inferior epigastric artery, which perforate anterior sheath running up

and away from muscle, anastomose with superior epigastric artery,

lower intercostal artery, subcostal artery, and lumbar artery. They

have their own oblique, vertical, and transverse axes. 1, lower in-

tercostal artery; 2, largest perforator of deep inferior epigastric artery;

3, subcostal artery; 4, lumbar artery; 5, deep inferior epigastric ar-

tery; 6, superior epigastric artery. B: Designation of rectus abdominis

flap. Three dierent-shaped flaps can be made, based on perforators

having their own axes.

Rectus Abdominis Free Flap Reconstruction 129

and vein under the operating microscope. The flaphealed uneventfully. The patient had nothing negative toreport regarding the recipient and donor sites postop-eratively (Fig. 2).

Patient 2

A 23-year-old man sustained the middle third of hisleft leg with scarring and infection after skin contusioncaused by trauma in a traffic accident. A right freerectus abdominis flap was used to reconstruct the soft-tissue defect after debridement of the wound and re-section of the scar. The size of the flap was 20 · 8 cm.The design of the flap was transverse. This allowed agood fit with the round shape of the soft-tissue defect inhis leg. The vascular pedicle was about 10 cm in length,and an end-to-side anastomosis with the left anteriortibial artery and vein was performed under the operatingmicroscope. Complete flap survival was achieved with-out daily ambulating difficulty postoperatively (Fig. 3).

Patient 3

A 37-year-old man sustained a left tibial fractureafter being involved in a traffic accident. A plate andscrews for fixation were done primarily at anotherhospital. The patient came to our department 4 weekspostoperatively because the wound was deep, with ex-posed plate and bone at the site of the injury. A rightfree rectus abdominis flap measuring 20 · 8 cm washarvested from the right thoraco-abdominal site for re-construction, following debridement of the wound. The

design of the flap was an oblique shape, and the anteriorsheath of the rectus abdominis muscle remained adher-ent to the flap at the umbilical level during harvesting.The vascular pedicle was anastomosed to the anteriortibial vessels, and the wound had healed satisfactorily at1-year follow-up (Fig. 4).

Patient 4

A 33-year-old man complained of a serious soft-tissuedefect in the medial region of the left elbow joint fol-lowing skin contusion due to a traffic accident. An 18 · 7cm rectus abdominis free flap was transferred to restorethe soft-tissue defect after debridement of the wound.The vascular pedicle was about 10 cm in length and un-derwent end-to-side anastomosis, with the brachial arteryand vein under the operating microscope. The prognosiswas favorable, with an excellent aesthetic result. Fur-thermore, no complications were observed. The patient isnow enjoying a satisfactory everyday life (Fig. 5).

DISCUSSION

The free rectus abdominis flap is probably the mostversatile and useful free flap in all of plastic surgery. In1889, Manchot detailed variable anastomoses betweenindividual arteries and veins in the abdomen. Taylor andDaniel3 elucidated the anatomy of the abdominal flap in1975. Next, Mathes and Bostwick1 described the circu-latory morphology and hemodynamics of the abdominalregion. Thereafter, variable flaps in the abdominalregion were developed and became clinically applicable.

Figure 2. A 17-year-old boy had a scar contracture on posterior region of right ankle due to trauma. A: Scar contracture. B: Wide excision of

scar. C: Flap design. D: Three weeks postoperatively. [Color figure can be viewed in the online issue, which is available at www.inter-

science.wiley.com.]

130 Xing-Quan et al.

Pennington2 first described a free abdominal musculo-cutaneous flap based on the deep inferior epigastricvessels in 1980 which is now evaluated with keen inter-est, primarily because it is technically easy to elevate,and so failure of the flap is distinctly uncommon.

The rectus abdominis flap using the deep inferiorepigastric vessels as nutrient vessels, which have abundantanastomoses with other vessels such as the superior epi-gastric vessels, lower intercostal vessels, subcostal vessels,

lumbar vessels, superficial epigastric vessels, and super-ficial and deep iliac circumflex vessels, may be designed asa vertical-shaped type, transverse-shaped type, or ob-lique-shaped type that have their own different-directionaxes in the abdomen. These flaps can be used to restorevarious soft-tissue defects caused by trauma in the ex-tremities. Moreover, the oblique-shaped flap, based onthe largest cutaneous perforator of the periumbilicalperforators of the deep inferior epigastric vessels, pro-

Figure 4. A 37-year-old man sustained a left tibial fracture after being involved in a traffic accident. A: Skin defect and exposed plate and

bone. B: Flap design. C: Freed flap. D: Eighteen months later. [Color figure can be viewed in the online issue, which is available at

www.interscience.wiley.com.]

Figure 3. A 23-year-old man sustained middle third of left leg with scarring and infection after skin contusion caused by trauma in a traffic

accident. A: Preoperative medial and lateral view. B: Flap design. C: Elevation of flap. D: Final result, 4 weeks later. [Color figure can be

viewed in the online issue, which is available at www.interscience.wiley.com.]

Rectus Abdominis Free Flap Reconstruction 131

vides a good and reliable blood supply to the skin of thelateral thoraco-umbilical and abdominal area, allowingelevation of a sufficiently large flap to cover substantialsoft-tissue defects of the extremities. In our clinical ex-perience, the oblique-shaped flap can be harvested atapproximately 40 · 20 cm (unpublished results). Inpractice, leaving a greater part of the rectus abdominismuscle and anterior sheath behind could preserve ab-dominal strength and avoid such complications as hernia.

Compared with other free flaps,4�12 the rectus abdo-minis flap has numerous advantages: 1) The flap mayshorten operative time. Two-team surgery can proceedsimultaneously.While the first team is raising the flap, thesecond team prepares the recipient site in the same posi-tion. But other free flaps, such as free latissimus dorsimusculocutaneous flaps, require a positional changeduring the procedure, and this undoubtedly prolongsoperative time. 2) The flap can carry a skin paddle forlarge defects and enough tissue volume for breast recon-struction. 3) A long vascular pedicle can be obtained. Theinfectious wound at the recipient site often requires a longvascular pedicle. 4) The donor site may be closed directlyin most cases. 5) The donor site is easily hidden byclothing. 6) The deep inferior epigastric vessels have aconstant course. 7) Since the vascular pedicle as nutrientvessel has abundant anastomoses with other vessels, therectus abdominis flap can be designed in different-shapedtypes. 8) Finally, it is technically easy to elevate, and sofailure of the flap is distinctly uncommon. In addition, themuscle carried by the rectus abdominis flap can be used tofill dead spaces in bony3 defects of the extremities, to avoidinfection after surgery.

In our clinical experience, a part of the rectus ab-dominis muscle can be used for added bulk. A goodcontour of the receipt site and a satisfactory resultpostoperatively were achieved. There are some disad-vantages to this flap. The donor site scars associatedwith use of skin grafts in a large defect or resection ofthe rectus abdominis muscle may weaken the strength ofthe abdominal wall and increase the occurrence of her-nia, especially in male physical laborers. Another dis-advantage is that sensory4 flaps using a famouscutaneous nerve cannot be obtained.

In summary, although a wide variety of options areavailable for restoration of soft-tissue defects in the ex-tremities, the free rectus abdominis flap is usually thebest choice when variable shapes of defects are encoun-tered. The rectus abdominis flap may be elevated with avariety of designs, making for a good fit with the variableshapes of soft-tissue defects in the extremities. Also, doesthe muscle carried by the rectus abdominis flap still ob-literate5 dead space. In addition, donor-site morbidity isacceptable. The large caliber and long pedicle of the deepinferior epigastric vessels, and the ease of flap harvesting,ensure a high survival rate and make possible theachievement of one-stage reconstructive goals.

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Figure 5. A 33-year-old man complained of serious soft-tissue defect in medial region of left elbow joint, following skin contusion due to a

traffic accident. A: Serious soft-tissue defect after debridement of wound. B: Rectus abdominis free-flap design. C: Elevation of flap. D: Three

months postoperatively. [Color figure can be viewed in the online issue, which is available at www.interscience.wiley.com.]

132 Xing-Quan et al.

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Rectus Abdominis Free Flap Reconstruction 133