Bottero l, lefaucheur jp, fadhul s, raulo y, collins ed, lantieri l. The rectus sheath, also called the rectus fascia, is formed by the aponeuroses of the transverse abdominal and the internal and external oblique muscles. Here, we describe the use of bilateral gluteal fold flaps for pelvic and perineal reconstruction following. The rectus abdominis flap is based on the deep inferior epigastric artery. Three patients with chronic postoperative empyemas combined with bronchopleural fistulas underwent obliteration of the empyema tracts with free rectus abdominis. The flap may be advantageous for cases in which a large tongue. At this insertion the aponeurosis is fused with the aponeurosis of the transversus abdominis muscle to form the conjoint tendon. The rectus abdominis muscle advancement flap as a salvage option. Transverse rectus abdominis musculocutaneous flap tram. The rectus abdominis and rectus sheath the rectus muscle extends from the xiphoid process of the sternum and 5,6,7th costal cartilages to the pubic symphysis and pubic crest. Reconstruction of complex groin defects with inferior.
Rectus abdominis article about rectus abdominis by the. B, view of a large congenital left diaphragmatic defect. Find powerpoint presentations and slides using the power of, find free presentations research about free flaps ppt. Successful techniques include longterm antibiotic therapy, operative debridement, and muscle flap coverage. Breast reconstruction by the free lower transverse rectus. C, after division of the avascular plan between the ta and the io muscles, the. Technique during the past 4 years, 3 patients who presented with chronic ppes with bpfs 2 on the right side, 1 on the left side after pulmonary resections underwent free rectus abdominis musculocutaneous flap transposition as follows. The anterolateral thigh flap for groin and lower abdominal defects. Obliteration of empyema tract with deepithelialized. The rectus abdominis muscle has a type iii mathes and nahai vascular supply, meaning dominant perfusion from both the superior and the deep inferior epigastric vessels. Outline radial forearm flaps lateral arm flaps lateral thigh flap anterolateral thigh flap rectus abdominis flaps latissimus dorsi flap gracilis flap temperoparietal fascial flap fibular osteocutanous flap iliac crest flaps scapular flaps metatarsal flap rib flaps jejunum omentum gastroomentum. B the upper abdominal flap is elevated above the fascia to the level of the costal margin. The paired rectus muscles provide abdominal flexion and support for the intraabdominal contents. Subtotal glossectomy, rectus abdominis musculocutaneous flap, swallowing function, hyoid bone movement, width of the esophageal entrance 1.
The rectus abdominis musculocutaneous free flap, based on the deep inferior epigastric artery and vein, has been used widely in reconstruction of the breast and extremities. The rectus sheath is formed from decussating fibres from all three lateral abdominal muscles. When performing a rhinoplasty, the hump in the nose is removed. View and download powerpoint presentations on free flaps ppt.
Additionally, the rectus abdominis contains several transverse tendinous intersections which may provide additional strength. Rectus abdominis flap technique for head and neck reconstruction. Skin paddles angled obliquely from the line of the rectus abdominis and toward the rib cage were successfully carried on periumbilical perforators from the inferior epigastric system. Complications in breast reconstruction using a transverse.
Electromyographic assessment of rectus abdominis muscle function after deep. T1 pulmonary function after pedicled transverse rectus abdominis musculocutaneous flap breast reconstruction. It extends from the pubic symphysis, pubic crest and pubic tubercle inferiorly, to. Transversus abdominis release tar is the most recent technique to address limitations of traditional reconstructive options. It is a com posite flap and comprises muscle, over lying fascia and skin.
A rectus abdominis myocutaneous flap to reconstruct. Learn about the rectus abdominis musculocutaneous flap, an online 3dvideobased course, accredited by the royal college of surgeons of england. The rectus abdominis flap is favored for this application because of. Free rectus abdominis musculocutaneous flap for chronic. After the flap is removed, the abdominal skin and fat is undermined above the rectus sheath to the costal margin green arrows and line to allow closure of the donor defect. This elearning course provides a step by step approach, lessons on objectives, preoperative information and postoperative complications, procedural anatomy and. The first version of the vertical rectus abdominis vram flap for breast reconstruction was reported by drever4 in 1977. The muscle is enclosed within the rectus sheath formed by the aponeuroses of the lateral abdominal muscles. The rectus abdominis free flap, harvested as a myocutaneous flap or as a musclesparing variant i.
Along the length of this strap muscle there are three fibrous. As you can see in the two pictures, the rectus abdominis can send pain to the lower region of your belly as well as to your lower and mid back the deeper the red, the more common it is to experience pain if this muscle is too tight or afflicted with trigger points note. Transversus abdominis release for ventral hernia repair. What anatomy is relevant to a superior and inferior. Modifications to the standard surgical technique may reduce complications and improve the versatility of this flap. It contains the rectus abdominis and pyramidalis muscles it can be divided into anterior and posterior laminae. Superior pedicle is based on superior epigastric vessels. Rectus abdominis musculocutaneous flap incision academy.
Experience with 60 inferior rectus abdominis flaps journal of. Introduction it is important for reconstructive surgeons to evaluate swallowing function in patients with tongue cancer who have undergone glossectomy and flap reconstruction. Indications with the increased use of the forearm flap for intraoral and pharyngeal reconstruction, the rectus has been relegated to a secondline choice for reconstruction of these areas. Breast reconstruction with transverse rectus abdominis myocutaneous flap tram, single pedicle, including closure of donor site cpt code information is available to subscribers and includes the cpt code number, short description, long description, guidelines and more.
The deepithelialized skin island has provided sufficient bulk for tract obliteration. The rectus abdominis myocutaneous flap has been used as the first choice for pelvic and perineal reconstruction. The most common flap harvested from the abdominal wall is the vertical rectus abdominis myocutaneous vram flap. Rectus sheath the rectus sheath is a long fibrous sheath that encloses the rectus abdominis muscle and pyramidalis muscle if present.
The development of ever more sophisticated methods of postmastectomy breast reconstruction culminated in the early 1980s with the transverse rectus abdominis musculocutaneous tram flap. Inferior pedicle is based on inferior epigastric vessels. This dissection is carried laterally to 1 cm medial of the linea semilunaris. Here we present the case of primary placement of a pedicled rectus femoris flap to provide wellvascularized tissue interposed between an aortic dacron interposition graft and bowel. Risk factors and surgical refinements of postresective mandibular reconstruction. The rectus abdominis muscle flap retains the transversalis fascia dorsally, which provides additional strength that the cranial sartorius muscle, which has no fascial covering, lacks. This elearning course provides a step by step approach, lessons on objectives, preoperative information and postoperative complications, procedural anatomy and a test. Postmastectomy breast reconstruction have been the object of a series of studies by plastic surgeons and mastologists.
Radial forearm and rectus abdominis free flap reconstruction ravi pachigolla, md anna pou, md history of microvascular free flap reconstruction radial forearm. Rectus abdominis belongs to the anterior abdominal muscles together with pyramidalis muscle. Free musculocutaneous flap transplantation may provide a good alternative option in the treatment of these refractory complications after pulmonary resections. Chronic postoperative empyema remains a challenge for thoracic surgeons. The abdominal wall and hernias university of tennessee. There are two parallel muscles, separated by a midline band of connective tissue called the linea alba. However, due to previous abdominal surgery and multiple stoma placements in our patients, the rectus abdominis myocutaneous flap could not be used for such reconstruction. Four patients with chronic empyema after pneumonectomy have undergone successful obliteration of the empyema tract with a deepithelialized transverse rectus abdominis myocutaneous flap. The rectus abdominis muscle, also known as the abdominal muscle or abs, is a paired muscle running vertically on each side of the anterior wall of the human abdomen, as well as that of some other mammals. The lower abdominal skin flap is designed with the suprapubic skin crease, in line with. It extends from the rib cage all the way to the pubic bone. The inferior part of the aponeurosis inserts into the symphysis pubis.
Tight abdominal closures, as can be seen during transverse rectus abdominis musculocutaneous tram flap breast reconstruction, have been shown to increase intraabdominal pressure, thereby decreasing thoracopulmonary compliance and increasing the workload of breathing. Contour abnormalities of the abdomen after transverse. Gluteal fold flap for pelvic and perineal reconstruction. Undoubtedly, the most common design when using the rectus abdominis flap is the tram transverse rectus abdominis muscle 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. This has the great virtue of being a large mass of soft, autogenous tissue which does not require supplementary silicone prosthesis augmentation. Pdf a new technique of closing a gastroatmospheric. Rectus abdominis, informally known as the abs muscle, is a long muscle of the anterior abdominal wall. The oblique rectus abdominis musculocutaneous flap. The authors present their experience with a previously described but infrequently used variation of the rectus abdominis myocutaneous flap. The rectus abdominis myocutaneous flap to be described was successfully used in one such case. Historically, more complex muscle flap coverage, such as a rectus femoris muscle flap rff, has been performed by plastic and reconstructive surgeons. Case report a middleaged woman suffered a closerange shotgun blast. Contour abnormalities of the abdomen after transverse rectus abdominis muscle tram flap breast reconstruction occur with all methods of flap elevation and include lower and upper abdominal. The number of reports on its applications in the head and neck is limited.
Swallowing function before and after subtotal glossectomy. The lower abdominal skin is used in the tram, just as in the diep and siea flap. Among the several technichs proposed, the transverse rectus abdominis musculocutaneous flap tram flap have been the preferred choice in many services that work in the area of reconstructive surgery. Learn about the rectus abdominis muscle flap, an online 3dvideobased course, accredited by the royal college of surgeons of england. Distant flaps vi gastrocnemius muscle flap vii transverse rectus abdominis muscle flap tram flap. Below the arcuate line the aponeurosis passes anterior to the rectus muscle. The muscle is enclosed by the rectus sheath, but below the arcuate line, this sheath disappears posterior to the muscle. This article reports free rectus abdominis musculocutaneous flap transplantation for patients with chronic ppes. We describe a previously unreported technique of advancing the rectus abdominis muscle superiorly, based on the deep inferior epigastric. It extends from the rib cage all the way to the pubic bone rectus abdominis belongs to the anterior abdominal muscles together with pyramidalis muscle. During a pedicle flap mammoplasty reconstruction, a commonly used muscle is the. In contrast to creating large skin flaps to access and divide the eo muscle, tar begins by entering the posterior rectus sheath.
Rectus abdominis muscle pullin flap for closure of duodenal defect is a simple, technically easy and dependable procedure, which can be performed, quickly in critically ill patients. Vertical rectus abdominis musculocutaneous flap an. An important area of weakness that should be recognized when securing abdominal closure after flap harvest. The arrangement of the layers has important variations at different locations in the body. The rectus abdominis free flap is one of the most versatile softtissue flaps. The purpose of this article was to quantitate pulmonary function in patients who underwent pedicled tram flap breast. Rectus abdominis musculocutaneous flap can provide a large bulk of tissue for obliteration of a huge residual space. A prospective study of donorsite morbidity after anterolateral thigh fasciocutaneous and myocutaneous free flap harvest in 220 patients.
Primary selection of a pedicled rectus femoris flap for. While the pain onin your belly occurs on the side of the rectus abdominis that is affected, the back. Rotation of the skin island into the long axis of the rectus muscle has added considerable length to this flap, allowing it. Vertical rectus abdominis musculocutaneous flap an overview.
The tram flap is still among the most used free flaps for extensive soft. In those with low body fat, it is clearly visible beneath the skin forming the six pack. It is a composite flap and comprises muscle, overlying fascia and skin. Outcome of rectus femoris muscle flaps performed by. This study evaluated the effect of postoperative irradiation on transverse rectus abdominis muscle tram flap breast reconstruction. The vertical rectus abdominis musculocutaneous vram flap was the earliest. The muscle flap will be divided along the rectus abdominis dotted line. The rectus femoris pedicled muscle flap is a widely used option for coverage of infected vascular grafts in groin reconstruction as well as in reconstruction of abdominal wall defects. Reconstructive surgery for head and neck cancer patients. Radial forearm and rectus abdominis free flap reconstruction ppt presentation summary. Figure 1 the operative technique of the pedicled transverse rectus abdominis myocutaneous tram flap. Since then i have been able to gather practical experience by applying.
Anterolateral abdominal wall consists of 3 muscle layers. Radial forearm and rectus abdominis free flap reconstruction ravi pachigolla, md anna pou, md history of microvascular free flap reconstruction. A preoperative planning photographs showing the area of flap design and the ipsilateral muscle pedicle site. It presents a good alternative for reconstruction of this difficult problem. Reconstruction of complex groin defects with inferior epigastric arterybased rectus abdominis muscle flaps fig. Following successful management of her colon, small bowel and stomach injuries, the acute abdominal wall recon struction was accomplished with prolene mesh. The muscle can be up to 30 cm long and up to 10 centimeters wide.
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