Aesth Plast Surg DOI 10.1007/s00266-014-0273-y
ORIGINAL ARTICLE
GENERAL RECONSTRUCTION
Optimizing the Pedicled Rectus Abdominis Flap: Revised Designs and Vascular Classification for Safer Procedures Bouraoui Kotti
Received: 12 April 2013 / Accepted: 30 December 2013 Ó Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2014
Abstract Background The rectus abdominis myocutaneous (RAM) flap is one of the most commonly used flaps in reconstructive surgery, and many designs have been published. The transverse rectus abdominis myocutaneous (TRAM), vertical rectus abdominis myocutaneous (VRAM), and oblique designs (ORAM) are the most common. The most frequent complication with these flaps is partial flap necrosis. We describe a new vascular zoning method and a revised classification of abdominal wall perfusion that is applicable when harvesting pedicled TRAM flaps to make them more secure. Methods From February 2009 to February 2013, we performed 70 pedicled RAM flaps in 68 patients for breast reconstruction (79 %) as well as pelvic and inguinal reconstruction after bowel and gynecologic tumor resection. Clinical data about cutaneous vascularization of the flaps along with before and after photos were prospectively collected and analyzed, and results were evaluated retrospectively. We collected observations on partial flap necrosis, reviewed the literature, and made design modifications to exclude doubtful vascular territories. Results Of the total number of flaps, 59 were TRAMs, 7 were VRAMs, and 1 was an ORAM flap. Three combined
B. Kotti Medical School of Tunis, Tunis Elmanar University, Tunis, Tunisia B. Kotti Medical School of Nice, Sophia Antipolis University, Nice, France B. Kotti (&) Institut Salah Azaiz, Bvd 9 Avril, 1006 Tunis, Tunisia e-mail: [email protected]; [email protected]
horizontal and vertical flaps, or what we call TV RAM flaps, were performed. No flap-related complications were observed with VRAM, TV RAM, or ORAM flaps. Three instances of partial necrosis (in the same vascular territory) occurred with TRAM flaps; as a result, we changed our approach to these flaps and examined alternatives to the classical vascular zoning. Conclusion We discussed abdominal skin perfusion in accordance with the literature and based on our experience with harvesting pedicled RAM flaps. We proposed safer skin paddles made possible by adopting a revised vascular classification. Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266. Keywords Rectus abdominis Pedicled flap TRAM VRAM Breast reconstruction Pelvic reconstruction Abdominal vascularization
Introduction The rectus abdominis myocutaneous (RAM) flap is one of the most commonly used flaps in reconstructive surgery. Many designs have been published since its first description by Holmstro¨m [1] and its popularization by Hartrampf et al. [2], but three designs were usually performed in their pedicled version: the horizontal paddle or transverse rectus abdominis myocutaneous flap (TRAM), the vertical paddle or vertical rectus abdominis myocutaneous flap (VRAM), or the oblique paddle (ORAM) as first described by Taylor et al. [3].
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Fig. 2 Right breast reconstruction using a unipedicled TRAM flap. The NAC was created after 6 months using a skin graft and local flaps. Result after 18 months
Fig. 1 Classical classification as described by Hartrampf [15]. The arrow indicates the pedicle Fig. 3 Left breast reconstruction using a unipedicled TRAM flap. The NAC was created after 7 months using a skin graft and local flaps. Result after 1 year
We commonly use the rectus abdominis flap for breast reconstruction as well as pelviperineal and inguinal reconstruction, particularly after gynecologic and bowel/ colorectal tumor resection. Partial flap necrosis is the most common major complication in our practice and reported in the literature. According to clinical observations of the involved vascular territories and review of postsurgical results, we reevaluated the abdominal wall vascular territories of TRAM flaps and changed the design of our flaps to create safer skin paddles. This article summarizes our experience and presents the rationale for the proposed new flap designs.
on and followed up by the same surgeon. The standard technique was performed as described by Hartrampf et al. [2] according to the standard classification (Fig. 1). Clinical data about cutaneous vascularization of the flap along with before and after photos were prospectively collected and analyzed, and results were evaluated retrospectively. We collected observations on partial flap necrosis, assessed the literature, and made revisions to our flap designs to exclude doubtful vascular territories.
Material and Methods
Results
From February 2009 to February 2013, a total of 70 procedures that used pedicled RAM flaps were performed in 68 patients (66 females and 2 males). There were no formal exclusion criteria except epigastric scars with no medical reports that alluded to prospective damage of the deep superior epigastric pedicle. Delayed reconstruction was performed an average of 12 months after radiotherapy. Two immediate breast reconstructions with RAM flaps were performed, followed by radiotherapy 4 weeks later. All patients were operated
A total of 70 procedures with flaps were performed in 68 patients aged 18–62 years (mean age 41 years). The patient population had only two males. The horizontal design (TRAM flap) was performed in 55 cases (79 %) for breast reconstruction and two cases (3%) for trunk and axilla reconstruction; two patients had bilateral reconstruction. The vertical design (VRAM flap) was used in seven cases (10 %) for vaginal and perineal reconstruction. A combined design, which we call the Transverse Vertical flap or TV RAM flap, was used in three cases (4 %) for inguinal,
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Aesth Plast Surg Fig. 4 a posterior exenteration for a rectal adenocarcinoma in a 39-year-old female scarifying the posterior vaginal wall. b VRAM flap, X is the deepithelialized paddle used to fulfill the dead space; Y is the skin paddle used for vaginal reconstruction; Z is the scarified skin paddle. c Final result after a year and after regaining the ability to have sexual intercourse
Fig. 5 a, b neglected and painful breast cancer in a woman from a foreign country. c After Adriamycin/ TAXOTEREÒ preoperative treatment, a large excision of a 29 9 22 9 15-cm specimen, exceeding 50 cm (arrow) and scarifying the pectoralis major muscle, was made and 26 positive axillary lymph nodes were collected. d–f A ‘‘Mercedes symbol’’-shaped TV RAM bipedicled flap. The umbilicus site is placed in the future NAC position. G Result after 1 month. h, i Good tolerance of radiation by the flap after 6 months
perineal, and breast reconstruction, while the oblique design (ORAM flap) was used in one case for inguinal reconstruction.
There were no total flap losses among the 70 flaps. The 57 TRAM flaps used for breast reconstruction yielded good breast shape and volume with minimal or no donor site or
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Fig. 6 a inguinal synovial sarcoma in a 29-year-old man which was invading the femoral pedicle. Intraoperative view after excision and vascular prosthesis replacement. b Design of the TV RAM unipedicled flap in a ‘‘lobster claw’’ shape. c After 3 days, the flap viability is good, despite the inner pressure from the lymph edema, because of the large lymphadenectomy. d After 3 weeks, the viability remained good but seroma seriously affected the sutures and the borders of the flap. The fat is the first tissue to suffer from the seroma. A twice-daily dressing was indicated after surgical debridement of the cytosteatonecrosis. The skin paddle was respected. e Final result after 3 months
recipient site complications (Fig. 2) and (Fig. 3). The concomitant improvement in abdominal contour was popular for some patients. No vascular complications were noted with the VRAM (Fig. 4), TV RAM (Fig. 5) and (Fig. 6), or ORAM flap (Fig. 7). Three cases of partial necrosis (less than 35 % of the skin paddle) occurred in TRAM flaps harvested using the classical technique (Fig. 8) among the first ten patients. Two more occurred after our first design alteration but before adopting the final proposed design. No partial flap necrosis occurred after adopting the final new classification and design. Four patients developed compromise of the abdominal wall incisions, particularly after the placement of hightension sutures. The compromise resolved with dressings or debridement and antibiotics. Six patients had local infection with partial dehiscence, four of which were successfully treated with antibiotics and dressings and two required surgical debridement.
Discussion The subject of cutaneous vascular territories has generated much discussion over the years, from the important work of Salmon [4], through the pioneering work of Taylor et al.
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[5] on the angiosome concept, to the more recent perforasome theory enunciated by Saint-Cyr et al. [6]. Clearly, knowledge of the abdominal wall’s vascular anatomy significantly contributes to the ability to harvest different combinations of tissue, which explains the development of a new generation of procedures such as perforator flaps; these latter procedures, though more time-consuming, have fewer complications when performed by experienced surgeons. Free flaps are not the subject of the present review, but suffice it to say that, for logistical reasons, we use them only if they are the only feasible solution to a particular problem case in our hospital (The Tunisian Anti-Cancer Center). The lack of the ability to perform a radiological investigation and the shortage of specifically trained nursing staff are important considerations for us, as well as the procedure’s operating time in an institution that is working above capacity with a single plastic surgeon, which can be different in other circumstances [7]. Pedicled flaps remain very common in our practice and are sometimes superior to perforator flaps because of the volume-filling options they offer. For instance, muscle and the relatively deepithelialized skin paddle can be used to fill dead space left after extended pelviperineal resections (Fig. 4)] [8, 9. In this situation, pedicled flaps are also more robust in terms of transposition into the pelviperineal region [10].
Aesth Plast Surg
The RAM flap is vascularized by two dominant pedicles (Mathes and Nahai Type III [11]): the deep inferior epigastric artery (DIEA) and the deep superior epigastric artery (DSEA). The DSEA supplies blood to the upper portion of the abdominal wall. The DIEA and its paired veins ascend within the rectus sheath on the deep surface of the muscle, and the artery usually divides into two primary branches below the umbilicus. Most authors agree that these primary branches ascend within the muscle to connect with the superior epigastric system above the umbilicus [12–15]. The goal has been to harvest the TRAM flap with care at this periumbilical region, to the point that some authors have advocated a secondary suture to avoid venous congestion [16]. However, this does not eliminate problems, and TRAM cartography has been widely criticized
because of complications involving a partial skin paddle and fat necrosis and the randomized zone distribution of the resulting vascular compromise. The zoning classification was first described in 1983 by Scheflan and Dinner [17, 18]. Based on their experience with 16 patients, they divided the flap into four equal parts: Zone 1 was considered the safest and Zone 4 the least reliable (Fig. 1). One year later, Dinner et al. [19] proposed to switch Zones 2 and 3 for a safer skin paddle and persuaded us to change our minds about the arrangement of the zones. Despite this, the original zones as described by Hartrampf, in accordance with Scheflan’s design, remain well known and taught from one generation of plastic surgeons to the next. It is thus still found in some core plastic surgery courses [20]. We do not completely agree
Fig. 7 a inguinal synovial sarcoma in a 56-year-old foreign man admitted in serious condition with severe anemia. b MRI showing the tumor invading the femoral pedicle. c Large excision with vascular prosthesis replacement and large lymphadenectomy. d, e contralateral ORAM flap designed and harvested after local muscular flap rotations
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Fig. 8 a, b Partial necrosis occurring in the same place, spontaneously delimiting an area that always respects the ipsilateral periumbilical side
Fig. 10 a obese candidate for breast reconstruction. The design is made according to our classification. b Breast reconstruction with unipedicled TRAM flap. c, d Final result after NAC reconstruction and right breast lift
Fig. 9 Our classification. IIIa starts from the anterior axillary line. It is advised to stop the skin paddle design at this line. Only sectors I, IIa, and IIb are involved with the deepithelialized skin paddle in our flap
with this classification and have proposed a modification. Based on our experience, after late 2009 we changed our drawing to simply follow the delimited necrosis zones (Fig. 8) for a safer skin paddle. After two cases of partial necrosis despite this change, we finalized the design by including the periumbilical region in the flap (Fig. 9). We have not observed any necrosis—even for important paddles in obese patients—since making this change (Fig. 10).
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The learning curve of the technique is closely linked to the changes we made. This may explain the shortening of the procedure time by half; however, we believe that it does not account for the absence of partial flap necrosis. We can explain the lack of partial necrosis in our revised flaps by examining the angiosome and perforasome concepts in more detail. Focusing on the work by Taylor and Saint-Cyr on this topic [5, 6, 21], we learned that adjacent territories or angiosomes are connected in each tissue layer by reduced-caliber choke arteries. The clinical implication of this concept in regard to myocutaneous flaps is that the skin paddle is fed by indirect perforators. The perforasomes are linked by both direct and indirect linking vessels, which themselves are linked by communicating branches. All of these vascular connections protect from ischemia. When a flap is raised on a significant vascular pedicle, one adjacent anatomical vascular territory can be captured with safety. Rickard [22] described this theory well and proposed a more logical classification. Most complications associated with TRAM flaps occur as a result of venous outflow problems. This can happen regardless of whether the flap is pedicled on the DSEA or transferred free on the DIEA stem (and therefore has better viability) [7, 22]. In a unipedicled DSEA-based TRAM flap, the skin paddle above the muscle typically does not suffer any vascular compromise; it remains Zone 1 supplied by DIEA perforators [20, 22]. The adjacent zones are supplied by the superficial inferior epigastric artery (SIEA) [6, 21, 22] and viability can be variable, creating randomized patterns of vascular compromise.
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Fig. 11 Photos of the SIEA territory 30 s a and 60 s b after indocyanine green injection (from [23] with permission)
Among our complications, we noticed that the delimited necrosis always occurred in the upper and lower portions of the classical Hartrampf’s Zone 2, which suggests a lack of perfusion in this area defined as SIEA territory (Fig. 8a, b). We observed that the ipsilateral
periumbilical region was always safe and that the necrosis stopped within the lower limit of the umbilicus on the contralateral side. This led us to finalize our revised design by including this periumbilical region in the flap and tilting the design to its final shape (Fig. 9). In 2010, 6 months after our design revision, Quilichini et al. [23] described the SIEA skin distribution using fluorescent angiography with indocyanine green; the similarity with our design is remarkable (Fig. 11). We determined that a new vascular classification is not really needed. Instead, in our practice, we focus more on captured vascular territories via the shock vessels between DSEA and DIEA as a first intramuscular relay and between DIEA and SIEA as a second fascial relay, allowing retrograde vascularization of the skin paddle (Fig. 12). The observance of the periumbilical region can be explained by the venous drainage of this territory and its confluence with the DIEA venous system near the umbilicus to ultimately drain into the DSEA venous system. This concept can then be applied to the entire abdominal region. This enables the harvest of safer skin paddles, not only above the muscle but also based on the superficial arterial distribution in relation to the main flap pedicle via one or more vascular relays. For example, the DIEA angiosome was shown to supply the caudal two-thirds of the rectus abdominis muscle. Because of choke connections with the terminal DSEA branches, which predominantly supply the proximal rectus abdominis muscle, a transversal skin paddle can be harvested (via two principal relays) from the epigastric to the hypochondrium region, along with a skin paddle based on the ipsilateral thoracic artery or on one or more lateral intercostal perforators at the umbilical region to the lumbar area (harvested via one relay) (Fig. 6). This revised design produces safe combined TV RAM flaps.
Conclusion Fig. 12 The useful skin paddle is vacularised by the terminal branches of the SIEA with retrograde flow from the DSEA through the DIEA, serving as the conduit for the retrograde flow established after flap harvest
This preliminary new clinical approach to pedicled RAM flaps aims to optimize the common flaps used from the
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abdominal region in reconstructive surgery. Reverse vascularization from the muscle to the skin can change direction and utilize different vessels to follow the superficial arterial distribution and vascularize the skin in delimited and interconnected angiosomes. Further exploration of this theory while harvesting flaps may yield a better understanding of cutaneous vascularization to facilitate even safer flaps. Acknowledgments I thank Dr. Jaidane for her diligent assistance. Thanks to Dr. Bechouche and many thanks to the Salah Azaiz Surgery team for their hard work and excellent performance every day, sometimes under difficult conditions. Conflict of interest interest to disclose.
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The author declares that he has no conflicts of 14.
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References 1. Holmstro¨m H (1979) The free abdominoplasty flap and its use in breast reconstruction. An experimental study and clinical case report. Scand J Plast Reconstr Surg 13(3):423–427 2. Hartrampf CR, Scheflan N, Black PM (1982) Breast reconstruction with transverse abdominal island flap. Plast Reconstruct Surg 69:216–225 3. Taylor GI, Corlett R, Boyd JB (1983) The extended deep inferior epigastric flap: a clinical technique. Plast Reconstr Surg 72:165–751 4. Salmon M (1936) Arte`res de la peau. Masson, Paris 5. Taylor GI, Palmer JH (1987) The vascular territories (angiosomes) of the body: experimental study and clinical applications. Br J Plast Surg 40:113–141 6. Saint-Cyr M, Wong C, Schaverien M, Mojallal A, Rohrich RJ (2009) The perforasome theory: vascular anatomy and clinical implications. Plast Reconstr Surg 124(5):1529–1544 7. Hamza F, Yousif J, Kotti B (2010) Breast reconstruction using the free TRAM flap in a private practice setting. A review of 20 cases. Ann Chir Plast Esthet 55(6):524–530 8. Staiano JJ, Wong L, Butler J, Searle AE, Barton DP, Harris PA (2009) Flap reconstruction following gynaecological tumour resection for advanced and recurrent disease–a 12 year experience. J Plast Reconstr Aesthet Surg 62(3):346–351 9. Soper JT, Secord AA, Havrilesky LJ, Berchuck A, Clarke-Pearson DL (2005) Rectus abdominis myocutaneous and
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16. 17.
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myoperitoneal flaps for neovaginal reconstruction after radical pelvic surgery: comparison of flap-related morbidity. Gynecol Oncol 97(2):596–601 John HE, Jessop ZM, Di Candia M, Simcock J, Durrani AJ, Malata CM (2013) An algorithmic approach to perineal reconstruction after cancer resection–experience from two international centers. Ann Plast Surg 71(1):96–102 Mathes SJ, Nahai F (1981) Classification of the vascular anatomy of muscles: experimental and clinical correlation. Plast Reconstr Surg 67(2):177–187 Boyd JB, Taylor GI, Corlett R (1984) The vascular territories of the superior epigastric and the deep inferior epigastric systems. Plast Reconstr Surg 73:1–4 Buck DW 2nd, Fine NA (2009) The pedicled transverse rectus abdominis myocutaneous flap: indications, techniques, and outcomes. Plast Reconstr Surg 124(4):1047–1054 Moon HK, Taylor GI (1988) The vascular anatomy of rectus abdominis musculocutaneous flaps based on the deep superior epigastric system. Plast Reconstr Surg 82:815–832 Hartrampf CR (1984) Transverse abdominal island flap technique. University Park Press, Baltimore Alvi R, Falder S, McGeorge DD (2002) A simple modification of TRAM flap breast reconstruction. Br J Plast Surg 55(2):173 Scheflan M, Dinner MI (1983) The transverse abdominal island flap: part I. Indications, contraindications, results, and complications. Ann Plast Surg 10:24–35 Scheflan M, Dinner MI (1983) The transverse abdominal island flap: part II. Surgical technique. Ann Plast Surg 10:120–129 Dinner MI, Dowden RV, Scheflan M (1983) Refinements in the use of the transverse abdominal island flap for postmastectomy reconstruction. Ann Plast Surg 11:362–372 Masson J, Staub G, Binder JP, Martinaud C, Couturaud B, Revol M, Servant JM (2007) Reconstruction mammaire. Techniques et indications. Elsevier Masson, Paris, pp 45–665. doi:10.1016/ S1286-9325(07)47005-4 Taylor GI, Corlett RJ, Dhar SC, Ashton MW (2011) The anatomical (angiosome) and clinical territories of cutaneous perforating arteries: development of the concept and designing safe flaps. Plast Reconstr Surg 127(4):1447–1459 Rickard R (2001) TRAM and DIEP flap zones. Br J Plast Surg 54(3):272–273 Quilichini J, Le Masurier P, Guihard T (2010) Increasing the reliability of SIEA flap using peroperative fluorescent angiography with indocyanine green in breast reconstruction. Ann Chir Plast Esthet 55(6):531–538
ORIGINAL ARTICLE
GENERAL RECONSTRUCTION
Optimizing the Pedicled Rectus Abdominis Flap: Revised Designs and Vascular Classification for Safer Procedures Bouraoui Kotti
Received: 12 April 2013 / Accepted: 30 December 2013 Ó Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2014
Abstract Background The rectus abdominis myocutaneous (RAM) flap is one of the most commonly used flaps in reconstructive surgery, and many designs have been published. The transverse rectus abdominis myocutaneous (TRAM), vertical rectus abdominis myocutaneous (VRAM), and oblique designs (ORAM) are the most common. The most frequent complication with these flaps is partial flap necrosis. We describe a new vascular zoning method and a revised classification of abdominal wall perfusion that is applicable when harvesting pedicled TRAM flaps to make them more secure. Methods From February 2009 to February 2013, we performed 70 pedicled RAM flaps in 68 patients for breast reconstruction (79 %) as well as pelvic and inguinal reconstruction after bowel and gynecologic tumor resection. Clinical data about cutaneous vascularization of the flaps along with before and after photos were prospectively collected and analyzed, and results were evaluated retrospectively. We collected observations on partial flap necrosis, reviewed the literature, and made design modifications to exclude doubtful vascular territories. Results Of the total number of flaps, 59 were TRAMs, 7 were VRAMs, and 1 was an ORAM flap. Three combined
B. Kotti Medical School of Tunis, Tunis Elmanar University, Tunis, Tunisia B. Kotti Medical School of Nice, Sophia Antipolis University, Nice, France B. Kotti (&) Institut Salah Azaiz, Bvd 9 Avril, 1006 Tunis, Tunisia e-mail: [email protected]; [email protected]
horizontal and vertical flaps, or what we call TV RAM flaps, were performed. No flap-related complications were observed with VRAM, TV RAM, or ORAM flaps. Three instances of partial necrosis (in the same vascular territory) occurred with TRAM flaps; as a result, we changed our approach to these flaps and examined alternatives to the classical vascular zoning. Conclusion We discussed abdominal skin perfusion in accordance with the literature and based on our experience with harvesting pedicled RAM flaps. We proposed safer skin paddles made possible by adopting a revised vascular classification. Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266. Keywords Rectus abdominis Pedicled flap TRAM VRAM Breast reconstruction Pelvic reconstruction Abdominal vascularization
Introduction The rectus abdominis myocutaneous (RAM) flap is one of the most commonly used flaps in reconstructive surgery. Many designs have been published since its first description by Holmstro¨m [1] and its popularization by Hartrampf et al. [2], but three designs were usually performed in their pedicled version: the horizontal paddle or transverse rectus abdominis myocutaneous flap (TRAM), the vertical paddle or vertical rectus abdominis myocutaneous flap (VRAM), or the oblique paddle (ORAM) as first described by Taylor et al. [3].
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Fig. 2 Right breast reconstruction using a unipedicled TRAM flap. The NAC was created after 6 months using a skin graft and local flaps. Result after 18 months
Fig. 1 Classical classification as described by Hartrampf [15]. The arrow indicates the pedicle Fig. 3 Left breast reconstruction using a unipedicled TRAM flap. The NAC was created after 7 months using a skin graft and local flaps. Result after 1 year
We commonly use the rectus abdominis flap for breast reconstruction as well as pelviperineal and inguinal reconstruction, particularly after gynecologic and bowel/ colorectal tumor resection. Partial flap necrosis is the most common major complication in our practice and reported in the literature. According to clinical observations of the involved vascular territories and review of postsurgical results, we reevaluated the abdominal wall vascular territories of TRAM flaps and changed the design of our flaps to create safer skin paddles. This article summarizes our experience and presents the rationale for the proposed new flap designs.
on and followed up by the same surgeon. The standard technique was performed as described by Hartrampf et al. [2] according to the standard classification (Fig. 1). Clinical data about cutaneous vascularization of the flap along with before and after photos were prospectively collected and analyzed, and results were evaluated retrospectively. We collected observations on partial flap necrosis, assessed the literature, and made revisions to our flap designs to exclude doubtful vascular territories.
Material and Methods
Results
From February 2009 to February 2013, a total of 70 procedures that used pedicled RAM flaps were performed in 68 patients (66 females and 2 males). There were no formal exclusion criteria except epigastric scars with no medical reports that alluded to prospective damage of the deep superior epigastric pedicle. Delayed reconstruction was performed an average of 12 months after radiotherapy. Two immediate breast reconstructions with RAM flaps were performed, followed by radiotherapy 4 weeks later. All patients were operated
A total of 70 procedures with flaps were performed in 68 patients aged 18–62 years (mean age 41 years). The patient population had only two males. The horizontal design (TRAM flap) was performed in 55 cases (79 %) for breast reconstruction and two cases (3%) for trunk and axilla reconstruction; two patients had bilateral reconstruction. The vertical design (VRAM flap) was used in seven cases (10 %) for vaginal and perineal reconstruction. A combined design, which we call the Transverse Vertical flap or TV RAM flap, was used in three cases (4 %) for inguinal,
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Aesth Plast Surg Fig. 4 a posterior exenteration for a rectal adenocarcinoma in a 39-year-old female scarifying the posterior vaginal wall. b VRAM flap, X is the deepithelialized paddle used to fulfill the dead space; Y is the skin paddle used for vaginal reconstruction; Z is the scarified skin paddle. c Final result after a year and after regaining the ability to have sexual intercourse
Fig. 5 a, b neglected and painful breast cancer in a woman from a foreign country. c After Adriamycin/ TAXOTEREÒ preoperative treatment, a large excision of a 29 9 22 9 15-cm specimen, exceeding 50 cm (arrow) and scarifying the pectoralis major muscle, was made and 26 positive axillary lymph nodes were collected. d–f A ‘‘Mercedes symbol’’-shaped TV RAM bipedicled flap. The umbilicus site is placed in the future NAC position. G Result after 1 month. h, i Good tolerance of radiation by the flap after 6 months
perineal, and breast reconstruction, while the oblique design (ORAM flap) was used in one case for inguinal reconstruction.
There were no total flap losses among the 70 flaps. The 57 TRAM flaps used for breast reconstruction yielded good breast shape and volume with minimal or no donor site or
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Fig. 6 a inguinal synovial sarcoma in a 29-year-old man which was invading the femoral pedicle. Intraoperative view after excision and vascular prosthesis replacement. b Design of the TV RAM unipedicled flap in a ‘‘lobster claw’’ shape. c After 3 days, the flap viability is good, despite the inner pressure from the lymph edema, because of the large lymphadenectomy. d After 3 weeks, the viability remained good but seroma seriously affected the sutures and the borders of the flap. The fat is the first tissue to suffer from the seroma. A twice-daily dressing was indicated after surgical debridement of the cytosteatonecrosis. The skin paddle was respected. e Final result after 3 months
recipient site complications (Fig. 2) and (Fig. 3). The concomitant improvement in abdominal contour was popular for some patients. No vascular complications were noted with the VRAM (Fig. 4), TV RAM (Fig. 5) and (Fig. 6), or ORAM flap (Fig. 7). Three cases of partial necrosis (less than 35 % of the skin paddle) occurred in TRAM flaps harvested using the classical technique (Fig. 8) among the first ten patients. Two more occurred after our first design alteration but before adopting the final proposed design. No partial flap necrosis occurred after adopting the final new classification and design. Four patients developed compromise of the abdominal wall incisions, particularly after the placement of hightension sutures. The compromise resolved with dressings or debridement and antibiotics. Six patients had local infection with partial dehiscence, four of which were successfully treated with antibiotics and dressings and two required surgical debridement.
Discussion The subject of cutaneous vascular territories has generated much discussion over the years, from the important work of Salmon [4], through the pioneering work of Taylor et al.
123
[5] on the angiosome concept, to the more recent perforasome theory enunciated by Saint-Cyr et al. [6]. Clearly, knowledge of the abdominal wall’s vascular anatomy significantly contributes to the ability to harvest different combinations of tissue, which explains the development of a new generation of procedures such as perforator flaps; these latter procedures, though more time-consuming, have fewer complications when performed by experienced surgeons. Free flaps are not the subject of the present review, but suffice it to say that, for logistical reasons, we use them only if they are the only feasible solution to a particular problem case in our hospital (The Tunisian Anti-Cancer Center). The lack of the ability to perform a radiological investigation and the shortage of specifically trained nursing staff are important considerations for us, as well as the procedure’s operating time in an institution that is working above capacity with a single plastic surgeon, which can be different in other circumstances [7]. Pedicled flaps remain very common in our practice and are sometimes superior to perforator flaps because of the volume-filling options they offer. For instance, muscle and the relatively deepithelialized skin paddle can be used to fill dead space left after extended pelviperineal resections (Fig. 4)] [8, 9. In this situation, pedicled flaps are also more robust in terms of transposition into the pelviperineal region [10].
Aesth Plast Surg
The RAM flap is vascularized by two dominant pedicles (Mathes and Nahai Type III [11]): the deep inferior epigastric artery (DIEA) and the deep superior epigastric artery (DSEA). The DSEA supplies blood to the upper portion of the abdominal wall. The DIEA and its paired veins ascend within the rectus sheath on the deep surface of the muscle, and the artery usually divides into two primary branches below the umbilicus. Most authors agree that these primary branches ascend within the muscle to connect with the superior epigastric system above the umbilicus [12–15]. The goal has been to harvest the TRAM flap with care at this periumbilical region, to the point that some authors have advocated a secondary suture to avoid venous congestion [16]. However, this does not eliminate problems, and TRAM cartography has been widely criticized
because of complications involving a partial skin paddle and fat necrosis and the randomized zone distribution of the resulting vascular compromise. The zoning classification was first described in 1983 by Scheflan and Dinner [17, 18]. Based on their experience with 16 patients, they divided the flap into four equal parts: Zone 1 was considered the safest and Zone 4 the least reliable (Fig. 1). One year later, Dinner et al. [19] proposed to switch Zones 2 and 3 for a safer skin paddle and persuaded us to change our minds about the arrangement of the zones. Despite this, the original zones as described by Hartrampf, in accordance with Scheflan’s design, remain well known and taught from one generation of plastic surgeons to the next. It is thus still found in some core plastic surgery courses [20]. We do not completely agree
Fig. 7 a inguinal synovial sarcoma in a 56-year-old foreign man admitted in serious condition with severe anemia. b MRI showing the tumor invading the femoral pedicle. c Large excision with vascular prosthesis replacement and large lymphadenectomy. d, e contralateral ORAM flap designed and harvested after local muscular flap rotations
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Fig. 8 a, b Partial necrosis occurring in the same place, spontaneously delimiting an area that always respects the ipsilateral periumbilical side
Fig. 10 a obese candidate for breast reconstruction. The design is made according to our classification. b Breast reconstruction with unipedicled TRAM flap. c, d Final result after NAC reconstruction and right breast lift
Fig. 9 Our classification. IIIa starts from the anterior axillary line. It is advised to stop the skin paddle design at this line. Only sectors I, IIa, and IIb are involved with the deepithelialized skin paddle in our flap
with this classification and have proposed a modification. Based on our experience, after late 2009 we changed our drawing to simply follow the delimited necrosis zones (Fig. 8) for a safer skin paddle. After two cases of partial necrosis despite this change, we finalized the design by including the periumbilical region in the flap (Fig. 9). We have not observed any necrosis—even for important paddles in obese patients—since making this change (Fig. 10).
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The learning curve of the technique is closely linked to the changes we made. This may explain the shortening of the procedure time by half; however, we believe that it does not account for the absence of partial flap necrosis. We can explain the lack of partial necrosis in our revised flaps by examining the angiosome and perforasome concepts in more detail. Focusing on the work by Taylor and Saint-Cyr on this topic [5, 6, 21], we learned that adjacent territories or angiosomes are connected in each tissue layer by reduced-caliber choke arteries. The clinical implication of this concept in regard to myocutaneous flaps is that the skin paddle is fed by indirect perforators. The perforasomes are linked by both direct and indirect linking vessels, which themselves are linked by communicating branches. All of these vascular connections protect from ischemia. When a flap is raised on a significant vascular pedicle, one adjacent anatomical vascular territory can be captured with safety. Rickard [22] described this theory well and proposed a more logical classification. Most complications associated with TRAM flaps occur as a result of venous outflow problems. This can happen regardless of whether the flap is pedicled on the DSEA or transferred free on the DIEA stem (and therefore has better viability) [7, 22]. In a unipedicled DSEA-based TRAM flap, the skin paddle above the muscle typically does not suffer any vascular compromise; it remains Zone 1 supplied by DIEA perforators [20, 22]. The adjacent zones are supplied by the superficial inferior epigastric artery (SIEA) [6, 21, 22] and viability can be variable, creating randomized patterns of vascular compromise.
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Fig. 11 Photos of the SIEA territory 30 s a and 60 s b after indocyanine green injection (from [23] with permission)
Among our complications, we noticed that the delimited necrosis always occurred in the upper and lower portions of the classical Hartrampf’s Zone 2, which suggests a lack of perfusion in this area defined as SIEA territory (Fig. 8a, b). We observed that the ipsilateral
periumbilical region was always safe and that the necrosis stopped within the lower limit of the umbilicus on the contralateral side. This led us to finalize our revised design by including this periumbilical region in the flap and tilting the design to its final shape (Fig. 9). In 2010, 6 months after our design revision, Quilichini et al. [23] described the SIEA skin distribution using fluorescent angiography with indocyanine green; the similarity with our design is remarkable (Fig. 11). We determined that a new vascular classification is not really needed. Instead, in our practice, we focus more on captured vascular territories via the shock vessels between DSEA and DIEA as a first intramuscular relay and between DIEA and SIEA as a second fascial relay, allowing retrograde vascularization of the skin paddle (Fig. 12). The observance of the periumbilical region can be explained by the venous drainage of this territory and its confluence with the DIEA venous system near the umbilicus to ultimately drain into the DSEA venous system. This concept can then be applied to the entire abdominal region. This enables the harvest of safer skin paddles, not only above the muscle but also based on the superficial arterial distribution in relation to the main flap pedicle via one or more vascular relays. For example, the DIEA angiosome was shown to supply the caudal two-thirds of the rectus abdominis muscle. Because of choke connections with the terminal DSEA branches, which predominantly supply the proximal rectus abdominis muscle, a transversal skin paddle can be harvested (via two principal relays) from the epigastric to the hypochondrium region, along with a skin paddle based on the ipsilateral thoracic artery or on one or more lateral intercostal perforators at the umbilical region to the lumbar area (harvested via one relay) (Fig. 6). This revised design produces safe combined TV RAM flaps.
Conclusion Fig. 12 The useful skin paddle is vacularised by the terminal branches of the SIEA with retrograde flow from the DSEA through the DIEA, serving as the conduit for the retrograde flow established after flap harvest
This preliminary new clinical approach to pedicled RAM flaps aims to optimize the common flaps used from the
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abdominal region in reconstructive surgery. Reverse vascularization from the muscle to the skin can change direction and utilize different vessels to follow the superficial arterial distribution and vascularize the skin in delimited and interconnected angiosomes. Further exploration of this theory while harvesting flaps may yield a better understanding of cutaneous vascularization to facilitate even safer flaps. Acknowledgments I thank Dr. Jaidane for her diligent assistance. Thanks to Dr. Bechouche and many thanks to the Salah Azaiz Surgery team for their hard work and excellent performance every day, sometimes under difficult conditions. Conflict of interest interest to disclose.
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The author declares that he has no conflicts of 14.
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