Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) 67, e118ee119
CORRESPONDENCE AND COMMUNICATION Intercostal arterybased rectus abdominis muscle flap for groin reconstruction Dear Sir, Management of non-healing groin wounds after vascular surgery is a common and challenging problem for reconstructive surgeons. This is particularly difficult in the presence of prosthetic material. When prosthetic material becomes exposed, most authors advocate for graft removal and extra-anatomic reconstruction. This may not always be a viable option; therefore muscle flap coverage of exposed vessels or to salvage prosthetic material may be needed. The goals of mobilizing a muscle flap are to achieve adequate coverage and control infection in a single procedure that includes definitive closure of the muscle donor-site.1 The transposed muscle provides a well-vascularized organ that increases oxygen tension in the area and enhances the ability of macrophages to combat infection. In addition, this increased blood flow supports the delivery of antibiotic agents.2 Gracilis3 and rectus abdominis4,5 muscle flaps have been the traditional workhorses in reconstructing defects of the groin and perineum, with excellent results. The rectus abdominis flap offers several advantages, including a large diameter pedicle, a rapid technique, a large arc of rotation, voluminous, well-vascularized tissue that can be transferred to cover large defects or fill dead space, and acceptable donor-site morbidity. According to the classification by Mathes and Nahai, the rectus abdominis is a class III muscle with a dual blood supply of the deep superior epigastric artery (DSEA) and the deep inferior epigastric artery (DIEA). Usually, one of the vascular pedicles is sufficient for perfusion of the entire musculocutaneous flap. Additionally there is significant inflow to the rectus abdominis muscle through the intercostal perforators. The DIEA is the dominant artery of the abdominal wall (average size, 2.5e3.8 mm), which is double the size of the DSEA.
When used for groin reconstruction, the rectus abdominis flap is traditionally perfused only by the DIEA, as the DSEA and intercostal arteries are ligated in order to afford arc of rotation. Here we report on a viable alternative: an intercostal artery-based rectus abdominis muscle flap after ligation of DSEA and loss of the DIEA due to vascular bypass surgery. We report a 58-year-old male patient with history of multiple lower extremity bypass procedures, including an end-to-end bypass from the common iliac artery to the distal femoral artery (see Figure, Supplemental Digital Content 1). The inferior epigastric artery was ligated as a result of this bypass. Wound complications required debridement of the left groin, which resulted in exposed vascular conduit. A sartorius muscle flap was utilized as the initial soft tissue coverage; however this failed, exposing the vascular graft. These vascular procedures eliminated the primary vascular pedicles of the sartorius, gracilis, rectus, or rectus flap. Instead, a rectus abdominis muscle flap based on the twelfth intercostal artery was performed. Debridement of the left groin wound bed was performed. The rectus abdominis was harvested by performing a left paramedian incision, from its maximum superior extent off of the underlying chest wall. After the deep superior epigastric artery was divided, flap elevation continued from superior to inferior. We dissected down to but did not divide the T11 and T12 intercostal perforators (see Figure, Supplemental Digital Content 2). We confirmed that we had sufficient length of the muscle flap for it to reach into the wound. We confirmed a strong Doppler signal into the distal-most extent of the flap with respect to its remaining pedicle. Retrograde flow into the DIEA was observed, as well as Doppler signal up to the ligated DSEA. The flap was then transposed into the left groin wound through a subcutaneous tunnel and reached without any tension. The rectus sheath was then closed; a 3 cm fascia opening was maintained above the turned-over rectus abdominis muscle to ensure no vascular compromise. After inset there was a strong Doppler signal in the distal-most limit of the flap. Standard split-thickness skin was harvested to cover the muscle. The wounds healed without incident until 6 months postoperative, when he developed an abdominal wall hernia at the donor-site. This was repaired without complications,
1748-6815/$ - see front matter ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.11.015
Correspondence and communication and the patient had no further issues in the one year since that surgery. He has returned to full employment. With limited local muscle flap options remaining in our patient, we safely performed a successful groin reconstruction utilizing an intercostal artery-based rectus abdominis flap. This effectively salvaged the patient’s leg by providing coverage to the vascular graft. A postoperative abdominal hernia complicated the operation; this occurred at the location below the arcuate line where incomplete fascial closure was performed in order to avoid compression of the flap pedicle. A bioprosthetic mesh inlay over the muscle might be useful to prevent such a complication in the future. Although not the primary choice for groin reconstruction, the intercostal artery-based rectus abdominis muscle flap is a viable option for groin wound coverage.
Ethical approval Not required.
Funding None.
Conflict of interest None declared.
Support No support to disclose.
Supplementary data
e119
Supplementary data Supplementary data related to this article can be found online at http://dx.doi.org/10.1016/j.bjps.2013.11.015.
References 1. Qi F, Zhang Y, Gu J. Repairs of complex groin wounds with contralateral rectus abdominis myocutaneous flaps. Microsurgery 2009;29(3):199e204. 2. Graham RG, Omotoso PO, Hudson DA. The effectiveness of muscle flaps for the treatment of prosthetic graft sepsis. Plast Reconstr Surg 2002;109(1):108e13 [discussion 114e5]. 3. Heckler FR. Gracilis myocutaneous and muscle flaps. Clin Plast Surg 1980;7(1):27e44. 4. Logan SE, Mathes SJ. The use of a rectus abdominis myocutaneous flap to reconstruct a groin defect. Br J Plast Surg 1984;37(3): 351e3. 5. Brandner MD, Bunkis J. Shotgun blast injuries to the groin: reconstruction using the rectus abdominis flap. Ann Plast Surg 1987;18(6):541e6.
Eric G. Wimmers Department of Plastic and Reconstructive Surgery, Johns Hopkins University, Baltimore, MD, USA Scott D. Lifchez Department of Plastic and Reconstructive Surgery, Johns Hopkins University, Baltimore, MD, USA Johns Hopkins/University of Maryland Plastic Surgery Residency, USA Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, Room A518, Baltimore, MD 21224, USA E-mail addresses: [email protected], [email protected]
The following are the Supplementary data related to this article:
5 August 2013
CORRESPONDENCE AND COMMUNICATION Intercostal arterybased rectus abdominis muscle flap for groin reconstruction Dear Sir, Management of non-healing groin wounds after vascular surgery is a common and challenging problem for reconstructive surgeons. This is particularly difficult in the presence of prosthetic material. When prosthetic material becomes exposed, most authors advocate for graft removal and extra-anatomic reconstruction. This may not always be a viable option; therefore muscle flap coverage of exposed vessels or to salvage prosthetic material may be needed. The goals of mobilizing a muscle flap are to achieve adequate coverage and control infection in a single procedure that includes definitive closure of the muscle donor-site.1 The transposed muscle provides a well-vascularized organ that increases oxygen tension in the area and enhances the ability of macrophages to combat infection. In addition, this increased blood flow supports the delivery of antibiotic agents.2 Gracilis3 and rectus abdominis4,5 muscle flaps have been the traditional workhorses in reconstructing defects of the groin and perineum, with excellent results. The rectus abdominis flap offers several advantages, including a large diameter pedicle, a rapid technique, a large arc of rotation, voluminous, well-vascularized tissue that can be transferred to cover large defects or fill dead space, and acceptable donor-site morbidity. According to the classification by Mathes and Nahai, the rectus abdominis is a class III muscle with a dual blood supply of the deep superior epigastric artery (DSEA) and the deep inferior epigastric artery (DIEA). Usually, one of the vascular pedicles is sufficient for perfusion of the entire musculocutaneous flap. Additionally there is significant inflow to the rectus abdominis muscle through the intercostal perforators. The DIEA is the dominant artery of the abdominal wall (average size, 2.5e3.8 mm), which is double the size of the DSEA.
When used for groin reconstruction, the rectus abdominis flap is traditionally perfused only by the DIEA, as the DSEA and intercostal arteries are ligated in order to afford arc of rotation. Here we report on a viable alternative: an intercostal artery-based rectus abdominis muscle flap after ligation of DSEA and loss of the DIEA due to vascular bypass surgery. We report a 58-year-old male patient with history of multiple lower extremity bypass procedures, including an end-to-end bypass from the common iliac artery to the distal femoral artery (see Figure, Supplemental Digital Content 1). The inferior epigastric artery was ligated as a result of this bypass. Wound complications required debridement of the left groin, which resulted in exposed vascular conduit. A sartorius muscle flap was utilized as the initial soft tissue coverage; however this failed, exposing the vascular graft. These vascular procedures eliminated the primary vascular pedicles of the sartorius, gracilis, rectus, or rectus flap. Instead, a rectus abdominis muscle flap based on the twelfth intercostal artery was performed. Debridement of the left groin wound bed was performed. The rectus abdominis was harvested by performing a left paramedian incision, from its maximum superior extent off of the underlying chest wall. After the deep superior epigastric artery was divided, flap elevation continued from superior to inferior. We dissected down to but did not divide the T11 and T12 intercostal perforators (see Figure, Supplemental Digital Content 2). We confirmed that we had sufficient length of the muscle flap for it to reach into the wound. We confirmed a strong Doppler signal into the distal-most extent of the flap with respect to its remaining pedicle. Retrograde flow into the DIEA was observed, as well as Doppler signal up to the ligated DSEA. The flap was then transposed into the left groin wound through a subcutaneous tunnel and reached without any tension. The rectus sheath was then closed; a 3 cm fascia opening was maintained above the turned-over rectus abdominis muscle to ensure no vascular compromise. After inset there was a strong Doppler signal in the distal-most limit of the flap. Standard split-thickness skin was harvested to cover the muscle. The wounds healed without incident until 6 months postoperative, when he developed an abdominal wall hernia at the donor-site. This was repaired without complications,
1748-6815/$ - see front matter ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.11.015
Correspondence and communication and the patient had no further issues in the one year since that surgery. He has returned to full employment. With limited local muscle flap options remaining in our patient, we safely performed a successful groin reconstruction utilizing an intercostal artery-based rectus abdominis flap. This effectively salvaged the patient’s leg by providing coverage to the vascular graft. A postoperative abdominal hernia complicated the operation; this occurred at the location below the arcuate line where incomplete fascial closure was performed in order to avoid compression of the flap pedicle. A bioprosthetic mesh inlay over the muscle might be useful to prevent such a complication in the future. Although not the primary choice for groin reconstruction, the intercostal artery-based rectus abdominis muscle flap is a viable option for groin wound coverage.
Ethical approval Not required.
Funding None.
Conflict of interest None declared.
Support No support to disclose.
Supplementary data
e119
Supplementary data Supplementary data related to this article can be found online at http://dx.doi.org/10.1016/j.bjps.2013.11.015.
References 1. Qi F, Zhang Y, Gu J. Repairs of complex groin wounds with contralateral rectus abdominis myocutaneous flaps. Microsurgery 2009;29(3):199e204. 2. Graham RG, Omotoso PO, Hudson DA. The effectiveness of muscle flaps for the treatment of prosthetic graft sepsis. Plast Reconstr Surg 2002;109(1):108e13 [discussion 114e5]. 3. Heckler FR. Gracilis myocutaneous and muscle flaps. Clin Plast Surg 1980;7(1):27e44. 4. Logan SE, Mathes SJ. The use of a rectus abdominis myocutaneous flap to reconstruct a groin defect. Br J Plast Surg 1984;37(3): 351e3. 5. Brandner MD, Bunkis J. Shotgun blast injuries to the groin: reconstruction using the rectus abdominis flap. Ann Plast Surg 1987;18(6):541e6.
Eric G. Wimmers Department of Plastic and Reconstructive Surgery, Johns Hopkins University, Baltimore, MD, USA Scott D. Lifchez Department of Plastic and Reconstructive Surgery, Johns Hopkins University, Baltimore, MD, USA Johns Hopkins/University of Maryland Plastic Surgery Residency, USA Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, Room A518, Baltimore, MD 21224, USA E-mail addresses: [email protected], [email protected]
The following are the Supplementary data related to this article:
5 August 2013
