Rectus Abdominis Muscle Flap With Microvascular Anastomoses for Repair of Recurrent Sarcoma T. Waris, MD, 0. Kaarela, MD, H. Teerikangas, MD, and J. Nissinen, MD Division of Plastic Surgery and Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Oulu University Central Hospital, Oulu, Finland
After radical resection of a recurrent leiomyosarcoma, the thoracic wall was stabilized with a Gore-Tex graft. The skin and soft tissue defect was repaired with a large rectus abdominis flap in which the circulation was secured by end-to-end microvascular anastomosis of the inferior epigastric artery to the internal mammary artery, which had to be cut during tumor removal. (Ann Thorac Surg 1991;51:133-5)
R
adical resection and repair of large tumors penetrating through the wall of the thorax is always demanding, and musculocutaneous flaps are now generally used for this purpose [l].As latissimus dorsi and pectoralis major flaps will not usually reach the lower part of the anterior thoracic wall, a transverse rectus abdominis musculocutaneous (TRAM)flap is most suitable in this area [2, 31. This flap commonly involves complications, however, owing to the poor and variable circulation in the contralateral random portion of the flap [4]. It is also possible to transfer the TRAM flap to the thorax area as a free flap [5]. In the present case report, we describe the use of a large TRAM flap and a Gore-Tex graft (W.L. Gore & Co, Salzburg, Germany) for the correction of a large thoracic wall defect. The circulation in the flap was further improved by microvascular anastomosis of the inferior epigastric artery to the internal mammary artery and of the inferior epigastric veins to the cephalic vein. Our patient was a 59-year-old man who had been operated on eight times for a recurrent soft tissue tumor on the right side of the thorax diagnosed as a leiomyosarcoma in 1980. A new recurrence was noticed in October 1988. Preoperative computed tomography and ultrasonic examination showed a parasternal tumor infiltrating the thoracic wall in the region of the third and fourth ribs. It was poorly distinguishable from the surrounding tissues and measured 3 X 4 cm in diameter. No signs of metastases were observed. A radical tumor excision was carried out. The area of skin removed measured 17 x 20 cm. The transthoracic excision was 10 x 10 cm and included the mid-portion of the sternum and the cartilages of the third and fourth ribs Accepted for publication July 13, 1990. Address reprint requests to Dr Waris, Gunillankuja 2816 00870, Helsinki, Finland.
0 1991 by The Society of Thoracic Surgeons
with the underlying pleura. The right internal mammary artery had to be sacrificed during the operation. The transthoracic defect was stabilized by suturing a 10 x 10-cm Gore-Tex (1 mm thick) graft to its margins, and reconstruction was achieved with a 17 x 20-cm musculocutaneous rectus abdominis flap that included both rectus muscles. The inferior epigastric vessels were severed and ligated bilaterally near their origin in the iliac vessels for inclusion in the flap. The flap was mobilized using the rectus muscles and was turned toward the area under repair. As the internal mammary artery supplying the right rectus muscle had been severed in connection with the radical excision of the tumor, the stump of the internal mammary artery was sutured end-to-end to the right epigastric artery. To ensure venous return, the inferior epigastric veins on both sides were sutured to the cephalic vein, which was turned from the right upper arm to the operative field. The anastomoses to the veins were made end to end and end to side. The abdominal wall was reconstructed below by suturing the lower portion of the rectus muscle to the arcuate line. To secure the posterior wall of the rectus muscle during the initial phase of healing, a Dexon net (Davis & Geck, Gosport Hampshire, England) was applied to the top of the muscle, and the skin was directly closed after subcutaneous mobilization (Figs 1-3). Postoperative recovery was uneventful, and healing of the flap was excellent owing to the good circulation. The thorax drain was removed on the third postoperative day. A small skin portion at the margin of the abdominal closure was lost and was replaced with a free skin graft. The patient was discharged from the hospital on the 30th postoperative day. He was symptom-free at check-ups, and stabilization of the thorax was good. In terms of the histological reports, the operation was a radical one. No recurrences have been observed during a follow-up time of 1 year postoperatively (Fig 4).
Comment The use of excisions of maximum extent together with a local plastic operation was not considered in this case because the patient had already been treated in this way eight times before and tumor residues had proved unavoidable. Instead, a more radical resection was now deemed necessary. A musculocutaneous latissimus dorsi reconstruction was not considered possible for this central defect, and thus a pedicled TRAM flap with additional microvascular anastomoses was preferred. The arterial 0003-4975/91/$3.50
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Ann Thorac Surg 1991;51:133-5
CASE REPORT WARIS ET AL RECTUS ABDOMINIS MUSCLE FLAP
Fig 1 . The recurrent tumor on the right side of the thoracic wall.
supply to this flap was through the left superior epigastric artery, the blood supply to the right epigastric artery being lost because it was necessary to sacrifice the right internal mammary artery during tumor removal. This was the reason for the additional microvascular anastomoses. A conventional musculocutaneous TRAM flap is extensively used in reconstructions of the female breast after cancer operations, for instance [l,31, but the contralateral random portion of the flap may occasionally be compromised and lead to skin or fat necrosis. Even a small, partial flap loss would be disastrous after a major, full-
Fig 2. The excised area at the top, with the Gore-Tex graft in the middle of it. The internal mammary artery stump can be seen in clamps on the graft.
Fig 3. Anatomy of the flap and location of the microvascular anastomoses. The rectus abdominis muscle flap used for reconstruction has an intact blood supply through the left superior epigastric artery. The blood flow to the pap was further secured by end-to-end anastomosis of the internal mammary artery to the right inferior epigastric artery. Venous return was ensured by end-to-end and end-to-side anastomoses of the inferior epigastric veins to the cephalic vein. (a = artery.)
thickness thoracic wall excision. A microvascular TRAM flap also carries a high risk for complications [5],but the combination of a conventional TRAM flap with microvas-
Fig 4. The result 2 year after the operation.
Ann Thorac Surg 1991;51:13>5
cular anastomoses has been found advantageous in reconstructions of the female breast [6]. In our case the combination of a conventional flap with microvascular anastomoses gives additional security to the reconstruction. This is especially important when treating a widespread tissue defect extending through the thorax. We believe that because the mammary artery supplying the flap had to be sacrificed in connection with resection of the tumor, the microvascular anastomoses securing the blood supply to the flap were extremely important for the good recovery of our patient.
References 1. Mathes SJ, Nahai F. Clinical applications for muscle and musculocutaneous flaps. St. Louis: C.V. Mosby, 1982.
CASE REPORT WARIS ET AL RECTUS ABDOMINIS MUSCLE FLAP
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2. Slavin SA, Goldwyn RM. The midabdominal rectus abdominis myocutaneous flap: a review of 236 flaps. Plast Reconstr Surg 1988;81:189-99. 3. Hartrampf CR, Bennett GK. Autogenous tissue reconstruction in the mastectomy patient. A critical review of 300 patients. Ann Surg 1987;205:50%19. 4. Moon HK, Taylor GI. The vascular anatomy of rectus abdominis musculocutaneous flaps based on the deep superior epigastric system. Plast Reconstr Surg 1987;82:815-32. 5. HolmstrOm H. The free abdominoplasty flap and its use in breast reconstruction. Scand J Plast Reconstr Surg 1979;13: 423-7. 6. Harashina T, Sone K, lnoue T, Fukuzumi S, Enomoto K. Augmentation of circulation of pedicled transverse rectus abdominis musculocutaneous flaps by microvascular surgery. Br J Plast Surg 1987;40:367-70.
After radical resection of a recurrent leiomyosarcoma, the thoracic wall was stabilized with a Gore-Tex graft. The skin and soft tissue defect was repaired with a large rectus abdominis flap in which the circulation was secured by end-to-end microvascular anastomosis of the inferior epigastric artery to the internal mammary artery, which had to be cut during tumor removal. (Ann Thorac Surg 1991;51:133-5)
R
adical resection and repair of large tumors penetrating through the wall of the thorax is always demanding, and musculocutaneous flaps are now generally used for this purpose [l].As latissimus dorsi and pectoralis major flaps will not usually reach the lower part of the anterior thoracic wall, a transverse rectus abdominis musculocutaneous (TRAM)flap is most suitable in this area [2, 31. This flap commonly involves complications, however, owing to the poor and variable circulation in the contralateral random portion of the flap [4]. It is also possible to transfer the TRAM flap to the thorax area as a free flap [5]. In the present case report, we describe the use of a large TRAM flap and a Gore-Tex graft (W.L. Gore & Co, Salzburg, Germany) for the correction of a large thoracic wall defect. The circulation in the flap was further improved by microvascular anastomosis of the inferior epigastric artery to the internal mammary artery and of the inferior epigastric veins to the cephalic vein. Our patient was a 59-year-old man who had been operated on eight times for a recurrent soft tissue tumor on the right side of the thorax diagnosed as a leiomyosarcoma in 1980. A new recurrence was noticed in October 1988. Preoperative computed tomography and ultrasonic examination showed a parasternal tumor infiltrating the thoracic wall in the region of the third and fourth ribs. It was poorly distinguishable from the surrounding tissues and measured 3 X 4 cm in diameter. No signs of metastases were observed. A radical tumor excision was carried out. The area of skin removed measured 17 x 20 cm. The transthoracic excision was 10 x 10 cm and included the mid-portion of the sternum and the cartilages of the third and fourth ribs Accepted for publication July 13, 1990. Address reprint requests to Dr Waris, Gunillankuja 2816 00870, Helsinki, Finland.
0 1991 by The Society of Thoracic Surgeons
with the underlying pleura. The right internal mammary artery had to be sacrificed during the operation. The transthoracic defect was stabilized by suturing a 10 x 10-cm Gore-Tex (1 mm thick) graft to its margins, and reconstruction was achieved with a 17 x 20-cm musculocutaneous rectus abdominis flap that included both rectus muscles. The inferior epigastric vessels were severed and ligated bilaterally near their origin in the iliac vessels for inclusion in the flap. The flap was mobilized using the rectus muscles and was turned toward the area under repair. As the internal mammary artery supplying the right rectus muscle had been severed in connection with the radical excision of the tumor, the stump of the internal mammary artery was sutured end-to-end to the right epigastric artery. To ensure venous return, the inferior epigastric veins on both sides were sutured to the cephalic vein, which was turned from the right upper arm to the operative field. The anastomoses to the veins were made end to end and end to side. The abdominal wall was reconstructed below by suturing the lower portion of the rectus muscle to the arcuate line. To secure the posterior wall of the rectus muscle during the initial phase of healing, a Dexon net (Davis & Geck, Gosport Hampshire, England) was applied to the top of the muscle, and the skin was directly closed after subcutaneous mobilization (Figs 1-3). Postoperative recovery was uneventful, and healing of the flap was excellent owing to the good circulation. The thorax drain was removed on the third postoperative day. A small skin portion at the margin of the abdominal closure was lost and was replaced with a free skin graft. The patient was discharged from the hospital on the 30th postoperative day. He was symptom-free at check-ups, and stabilization of the thorax was good. In terms of the histological reports, the operation was a radical one. No recurrences have been observed during a follow-up time of 1 year postoperatively (Fig 4).
Comment The use of excisions of maximum extent together with a local plastic operation was not considered in this case because the patient had already been treated in this way eight times before and tumor residues had proved unavoidable. Instead, a more radical resection was now deemed necessary. A musculocutaneous latissimus dorsi reconstruction was not considered possible for this central defect, and thus a pedicled TRAM flap with additional microvascular anastomoses was preferred. The arterial 0003-4975/91/$3.50
134
Ann Thorac Surg 1991;51:133-5
CASE REPORT WARIS ET AL RECTUS ABDOMINIS MUSCLE FLAP
Fig 1 . The recurrent tumor on the right side of the thoracic wall.
supply to this flap was through the left superior epigastric artery, the blood supply to the right epigastric artery being lost because it was necessary to sacrifice the right internal mammary artery during tumor removal. This was the reason for the additional microvascular anastomoses. A conventional musculocutaneous TRAM flap is extensively used in reconstructions of the female breast after cancer operations, for instance [l,31, but the contralateral random portion of the flap may occasionally be compromised and lead to skin or fat necrosis. Even a small, partial flap loss would be disastrous after a major, full-
Fig 2. The excised area at the top, with the Gore-Tex graft in the middle of it. The internal mammary artery stump can be seen in clamps on the graft.
Fig 3. Anatomy of the flap and location of the microvascular anastomoses. The rectus abdominis muscle flap used for reconstruction has an intact blood supply through the left superior epigastric artery. The blood flow to the pap was further secured by end-to-end anastomosis of the internal mammary artery to the right inferior epigastric artery. Venous return was ensured by end-to-end and end-to-side anastomoses of the inferior epigastric veins to the cephalic vein. (a = artery.)
thickness thoracic wall excision. A microvascular TRAM flap also carries a high risk for complications [5],but the combination of a conventional TRAM flap with microvas-
Fig 4. The result 2 year after the operation.
Ann Thorac Surg 1991;51:13>5
cular anastomoses has been found advantageous in reconstructions of the female breast [6]. In our case the combination of a conventional flap with microvascular anastomoses gives additional security to the reconstruction. This is especially important when treating a widespread tissue defect extending through the thorax. We believe that because the mammary artery supplying the flap had to be sacrificed in connection with resection of the tumor, the microvascular anastomoses securing the blood supply to the flap were extremely important for the good recovery of our patient.
References 1. Mathes SJ, Nahai F. Clinical applications for muscle and musculocutaneous flaps. St. Louis: C.V. Mosby, 1982.
CASE REPORT WARIS ET AL RECTUS ABDOMINIS MUSCLE FLAP
135
2. Slavin SA, Goldwyn RM. The midabdominal rectus abdominis myocutaneous flap: a review of 236 flaps. Plast Reconstr Surg 1988;81:189-99. 3. Hartrampf CR, Bennett GK. Autogenous tissue reconstruction in the mastectomy patient. A critical review of 300 patients. Ann Surg 1987;205:50%19. 4. Moon HK, Taylor GI. The vascular anatomy of rectus abdominis musculocutaneous flaps based on the deep superior epigastric system. Plast Reconstr Surg 1987;82:815-32. 5. HolmstrOm H. The free abdominoplasty flap and its use in breast reconstruction. Scand J Plast Reconstr Surg 1979;13: 423-7. 6. Harashina T, Sone K, lnoue T, Fukuzumi S, Enomoto K. Augmentation of circulation of pedicled transverse rectus abdominis musculocutaneous flaps by microvascular surgery. Br J Plast Surg 1987;40:367-70.
