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Introduction Infected abdominal defects are a challenge to surgeons. In this study, we describe 10 cases in which the latissimus dorsi myocutaneous flap was used for successful reconstruction of abdominal wall defects severely infected with methicillin-resistant Staphylococcus aureus (MRSA). Methods Retrospective review of 10 patients with abdominal wall defects that were reconstructed using the latissimus dorsi myocutaneous flap between 2002 and 2010. All patients had abdominal defects with hernias, combined with MRSA infections. The sizes of the flaps ranged from 120 to 364 cm2. The deep inferior epigastric artery was the recipient vessel in nine patients and the internal mammary vessels were used for one patient. Results There were no complications relating to the flaps, although there were other minor complications including wound dehiscence, haematoma and fluid correction. After reconstruction, there were no signs of infection during follow-up periods, and the patients were satisfied with the final results. Conclusion Reconstruction using the latissimus dorsi myocutaneous flap, including muscle fascia structures, is a potential treatment option for severely infected large abdominal wall defects.

BACKGROUND: Cadaveric research has widely influenced our understanding of clinical anatomy. However, while many soft-tissue structures remain quiescent after death, other tissues, such as viscera, undergo structural and functional changes that may influence their use in predicting living anatomy. In particular, our understanding of vascular anatomy has been based upon cadaveric studies, in which vascular tone and flow do not match the living situation. METHODS: An angiographic analysis of the abdominal wall vasculature was performed using plain film and computed tomography angiography in 60 cadaveric hemi-abdominal walls (from 31 cadavers) and 140 living hemi-abdominal walls (in 70 patients). The deep inferior epigastric artery (DIEA) and all of its perforating branches larger than 0.5 mm were analysed for number, calibre and location. RESULTS: Both large, named vessels and small calibre vessels show marked differences between living anatomy and cadaveric specimens. The DIEA was of larger diameter (4.2 mm versus 3.1 mm, P < 0.01) and had more detectable branches in the cadaveric specimens. Perforators were of greater calibre (diameter 1.5 mm versus 0.8 mm, P < 0.01) and were more plentiful (16 versus 6, P < 0.01) in cadaveric specimens. However, the location of individual vessels was similar. CONCLUSIONS: Cadaveric anatomy displays marked differences to in vivo anatomy, with the absence of living vascular dynamics affecting vessel diameters in cadaveric specimens. Blood vessels are of greater measurable calibre in cadaveric specimens than in the living. Consequently, cadaveric anatomy should be interpreted with consideration of post-mortem changes, while living anatomical studies, particularly with the use of imaging technologies, should be embraced in anatomical research.

New techniques in the harvest of deep inferior epigastric artery perforator (DIEP) flaps have become introduced as a result of modern imaging technologies that can allow virtual surgery to be achieved preoperatively. With computed tomographic angiography, individual anatomy can be appreciated in detail to a level not previously appreciated. These imaging techniques can be successfully used to guide DIEP flap surgery. 'Optimal' perforators can be selected based on size, location, intramuscular and subcutaneous course, and their association with motor nerves. Flap design can be safely achieved based on the cutaneous distribution of perforators. Abdominal wall closure can be improved based on the abdominal contour seen with imaging. Preoperative planning can aid patient selection, plan all aspects of the operative technique, reduce operating time and improve operative outcomes.

Purpose: The need for a secondary source of venous drainage in deep inferior epigastric artery perforator (DIEP) flaps is common, with the cephalic vein commonly utilized alternative venous recipient vessel. In using the cephalic vein, previous studies have described the deltopectoral groove or the infraclavicular fossa as the site for harvest. Methodology: We describe the use of a new technique in cephalic vein harvest, using an anterior axillary skin crease. The technique and outcomes in 100 patients undergoing DIEP flap breast reconstruction is described. Results: The technique is shown to improve aesthetic outcome, reduce the time needed for harvest, enable a greater length of vein to be transposed and minimize surgical insult to the upper breast / chest wall. Conclusion: An anterior axillary line skin fold can be used as the site for cephalic vein harvest, and using the methodology described, the technique can be fast, highly reliable and result in a final scar that is barely visible.

Perforator flaps such as the deep inferior epigastric artery (DIEA) perforator flap is used increasingly for breast reconstruction. This is often preferred to traditional transverse rectus abdominis musculocutaneous (TRAM) flaps where sparing of muscle significantly reduces the risk of abdominal wall weakness. Perforators however are often small (diameter of less than 1 mm) and travel substantial longitudinal and transverse distances within the rectus abdominus muscle. Some surgeons therefore, may find the DIEA perforator flap technically more difficult to dissect than the traditional TRAM flap. Pre-operative CT angiography (CTA) plays an integral part in mapping the size and location of these perforators. We describe a simple intra-operative technique, commonly used in plastic and ophthalmic surgery, which is invaluable in assisting the surgeon in the dissection of these perforators. This technique has been performed successfully on over 12 patients in the last 2 years.

Background: Autologous reconstruction with the deep inferior epigastric artery (DIEA) perforator (DIEP) flap is increasingly utilized for breast reconstruction. However, situations arise in which the DIEP flap is not an appropriate option, including the presence of a midline abdominal scar or an inadequate volume of abdominal tissue. While other donor sites may be considered, the stacked DIEP flap, in which the perforators of both hemi-abdominal walls are utilized in a single vascular pedicle, provides a safe technique to utilize the integument of both hemi-abdominal walls. Methods: Five consecutive patients underwent a stacked DIEP flap for breast reconstruction. Preoperative imaging with computed tomographic angiography (CTA) of the abdominal wall was undertaken, with each DIEA, its branching pattern, and all musculocutaneous perforating branches mapped using three-dimensional software reconstructions. The anatomical basis, operative technique and outcomes are discussed. Results: In all cases, CTA was able to demonstrate individual vascular anatomy, and guide planning for a stacked DIEP flap. Unique anatomy between individuals required a range of variations in flap anatomy, with the contralateral DIEA, SIEA, or perforators each used to perfuse the contralateral hemi-abdominal wall. There was a 100% flap survival, with no donor site morbidity reported. Conclusion: The stacked DIEP flap is a safe and reliable technique for augmenting the perfusion of the abdominal wall in cases where the single pedicle DIEP flap is limited. The anatomical basis of the flap can be planned preoperatively with CTA, facilitating faster operating times and good outcomes.

Introduction: Large defects of the lower trunk after cancer resections pose a challenge for a reconstructive surgeon. Pedicled flaps based on the deep inferior epigastric artery provide a very simple but an effective way to cover them. Methodology: 9 patients from 24–58 yrs of age were studied at 2 hospitals over a period of 2 yr (2007&2008). Soft tissue defects after resections of SCCs, melanomas etc ranged from 6 × 10 cm to 15 × 28 cm. All were reconstructed with an inferiorly based Rectus abdominus flap. Results: Almost all the patients had excellent results with no total flap loss. The average operative time was 2.5 hrs. Had a partial flap loss in one case and the average hospital stay being 7 days. Conclusion: The rectus flap with skin is quite reliable and a simple option for such complex defects. It provides enough bulk and skin pliability needed in these areas and are pretty fast to learn and do.

Background Abdominal donor site flaps, including the Transverse Rectus Abdominis Musculocutaneous (TRAM) and Deep Inferior Epigastric Artery (DIEA) perforator flaps, are the standard in autologous breast reconstruction. With variation in the vascular anatomy of the abdominal wall, preoperative imaging is essential for preoperative planning and reducing intraoperative error. Ultrasound has been used previously with varying results, and the quest continues for optimal preoperative assessment. Computerised Tomography Angiography (CTA) has been recently proposed as a non-invasive modality for this purpose. This is the first study to formally compare preoperative Doppler ultrasound with CTA for imaging the DIEA. Methodology Eight consecutive patients undergoing DIEA perforator flaps for breast reconstruction undertook both CTA and Doppler ultrasound preoperatively. All investigations and procedures were undertaken at the same institution with the same surgeon and radiology team. Results CTA was superior at identifying the course of the DIEA, its branching pattern and in visualizing its perforators than Doppler ultrasound. Preoperative CTA was highly specific (100%) and more sensitive in mapping and visualising perforators (p

Purpose Abdominal donor site flaps are the standard in autologous breast reconstruction. With significant variation in the vascular anatomy of the abdominal wall, preoperative imaging is essential. Computerised Tomography Angiography (CTA) has been recently described for this purpose. Uniquely, the branching pattern of the Deep Inferior Epigastric Artery (DIEA) is demonstrated clearly on CTA. We sought to correlate the branching pattern of the DIEA to the location and course of perforators, as a tool for preoperative planning. Methodology 45 hemi-abdominal walls from both fresh and embalmed cadavers were used for isolated injection of the DIEA with contrast and radiographic imaging, allowing analysis of the location and intramuscular course of the perforators. The branching pattern on radiography was thus correlated to individual perforators. Results DIEA branching pattern correlated closely with the intramuscular course of perforators. A bifurcating branching pattern demonstrated a reduced intramuscular transverse distance traversed by each perforator. A trifurcating (Type 3) branching pattern demonstrated perforators that traversed significantly greater transverse distances. The vessel type, however, displayed no correlation with the number of perforators. Conclusions Intramuscular courses of perforators are significantly greater with a trifurcating branching pattern of the DIEA, and reduced with a bifurcating pattern. This correlates with less rectus abdominis muscle sacrificed during a DIEA perforator flap. As CTA is the optimal modality for demonstrating this pattern preoperatively, we suggest the use of CTA for preoperative assessment in TRAM and DIEA perforator flaps.