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Scapulothoracic dissociation, particularly in combination with open fractures of the shoulder girdle, can be associated with significant soft tissue injury and present challenges with coverage and fixation. A single case of an open scapulothoracic dissociation was reviewed. Case presentation, clinical course and initial outcomes are discussed. A 22-year-old patient presented with an open left segmental clavicle fracture, sternoclavicular dislocation and scapulothoracic dissociation after being ejected in a motor vehicle collision. The shoulder girdle was initially stabilized with trans-clavicular trans-manubrial plating followed by staged pedicled rotational rectus abdominis flap. Follow-up at 1 month revealed well healed wounds and 90 degrees of forward flexion. Patients with open fractures and scapulothoracic dissociation can present multiple challenges when considering fixation and soft tissue coverage. A viable option in these patients is a pedicled rotational rectus abdominis flap when more typical coverage options are precluded from associated injuries.

Highlights • The travails in the management of complex duodenal injuries is well known among the surgical fraternity. • We here present a salvage technique of primary reinforcement with pedicled rectus abdominis muscle flap (RAMF) for a tenuous post traumatic duodenal perforation (PTDP) of the second part. • The majority of the studies in the literature are on the use RAMF for the repair of duodenal fistulas following failed primary repair of peptic perforations of first part of duodenum. • Reinforcement with RAMF is a useful rescue technique when the omentum is not available and other simpler techniques are not feasible in the primary repair setting., Introduction The conventional techniques for management of complex duodenal injuries are duodenal diverticularisation, pyloric exclusion or triple tube decompression. We here present a salvage technique of primary reinforcement with pedicled rectus abdominis muscle flap (RAMF) for a tenuous post traumatic duodenal perforation (PTDP). The majority of the studies in the literature are on the use RAMF for the secondary repair of peptic duodenal perforations. Presentation of case A 38 year old male presented with an acute abdomen, three days after sustaining a blunt abdominal trauma. The clinical and radiological findings in the abdomen were subtle and not contributory. An emergency laparotomy with a high index of suspicion revealed a large perforation in the anterolateral wall of the second portion of the duodenum with a friable unhealthy wall and shearing of the serosa around the perforation site. The entire omentum was unhealthy, contused with areas of gangrene and omentectomy done. The perforation site was closed using 3.0 vicryl and reinforced with a pedicled right RAMF based on the superior epigastric artery. The patient recovered uneventfully and was discharged. Discussion The addition of conventional diversion techniques to primary duodenorrhaphy is sophisticated, time consuming and adds morbidity. Conclusion RAMF is a good tissue substitute to buttress tenuous duodenal injuries presenting late with inflamed, friable perforation sites and associated tissue loss, where duodenorrhaphy alone may not be successful. RAMF is a valuable salvage technique when the omentum is not available and the local tissue condition negates the effectiveness of other simpler techniques.

Summary:. Some techniques to reconstruct the abdominal wall have been published, including the component separation procedure. The contribution of the rectus abdominis flap in the reconstruction of a giant incisional hernia is reported. The authors report three clinical cases in which the component separation technique was insufficient to reconstruct a giant midline incisional hernia. As a salvage technique, the rectus abdominis flap was dissected in the form of a hinge. The postoperative period was successful in all patients, combining both techniques. The rectus abdominis hinge flap could be used as a complementary technique to component separation to reconstruct a giant midline incisional hernia. There are several options to reconstruct the abdominal wall, such as anterior transposition of the posterior rectus sheath,1 or rotation of the anterior sheath toward the midline. This strategy is known as open book.2 The rectus turnover flap is also used.3 The anterior component separation technique closes defects less than 20 cm width.4 If it is wider, the reconstruction is more difficult. When the operative plan fails in the operating room, an additional technique should be considered. We report on the cases in which we use the rectus abdominis hinge flap.

The deep inferior epigastric perforator (DIEP) flap is widely recognized as safe for use as a first-choice option in autologous tissue breast reconstruction; however, DIEP is often not performed for breast reconstruction in the elderly. We report a case of an 85-year-old woman who underwent DIEP flap reconstruction. Immediate reconstruction was performed after mastectomy. The patient successfully underwent DIEP flap reconstruction with no complications. Other options for reconstruction include a latissimus dorsi flap, a transverse rectus abdominis flap and implant-based reconstruction. DIEP flap reconstruction was performed, which does not cause muscle damage and provides sufficient volume. To our knowledge, this study is the first to report DIEP breast reconstruction in a patient over 85 years of age. This case demonstrates the usefulness of DIEP flap reconstruction for elderly patients.

Introduction: Treatment of soft tissue lumbosacral defects is based on dead space management and defect coverage. The aim of this study is to describe the surgical technique, results and complications of patients who underwent rectus abdominis flap for lumbosacral defects coverage.Methods: A six-year retrospective review was performed. Demographic characteristics are analyzed. Surgical technique and intra-operative complications are described. Postoperative variables, such as donor site complications, recipient site complications, and flap survival were also reported. Results: Five patients met the inclusion criteria (average age, 50 years). Four patients presented sacral tumor diagnosis and one patient had lumbosacral osteomyelitis. Mean follow-up was 20 months. Flap average size was 8 x 13 cm. Intraoperative complications were one pedicle injury (microsurgical repair) and the death of a patient. Regarding postoperative complications, one wound dehiscence was reported. None of the flaps suffered vascular complications and all remained vital throughout follow-up.Conclusion: Rectus abdominis flap should be considered a valid option in the management of large soft tissue lumbosacral defects. This flap provides sufficient skin volume and muscular tissue. Surgical technique is relatively simple with no need for microsurgical procedure.

Penile cancer accounts for 1-10% of men neoplastic diseases and 30-60% of patients have inguinal metastases at the time of diagnosis. Inguinal metastases of penile cancer with femoral vessel involvement could lead to vascular fistula and hemorrhagic shock. We present 3 consecutive patients with inguinal metastases of penile cancer complicated by infection and hemorrhage from femoral vessels invaded by the tumor. Simultaneous extra-anatomical axillo-femoral bypass graft, wide excision of tumor and groin defect reconstruction was used to achieve “tumor-free” oncologic aim and to save the lower limb. We consider the extra-anatomic axillo-femoral bypass associated with wide inguinal tumor excision and defect covering a feasible surgical solution for improving the life quality and extend life expectancy in patients with lymph node metastasis of penile cancer complicated by necrosis, infection and femoral vessel involvement.

Summary:. Carbon ion radiotherapy (CIRT) has been used for malignant tumors that are difficult to excise surgically, such as sacral chordoma, and the success of its outcomes is attributable to the high dose concentration and biological effects. CIRT has produced successful clinical outcomes, and it is considered to have fewer adverse effects on surrounding normal tissues; moreover, complications have been rarely reported. We describe a 75-year-old woman with a full-thickness sacral defect, who had received CIRT for sacral chordoma 3 years earlier. Computed tomography showed sacral bone destruction, and a colonoscopy revealed rectal necrosis. Rectectomy in addition to sacral bone resection was necessary, which resulted in a huge sacral defect of slightly anxious viability. We performed reconstruction of the sacral defect by using pedicled vertical rectus abdominis myocutaneous (VRAM) flap, obliterating sacral defects and intrapelvic dead space that occurred after rectectomy. Six months after surgery, the wound had healed well, and no complication was observed. Sacral complications after CIRT may affect surrounding normal tissues such as the rectum, and it would be difficult to reconstruct the resulting complications. The vertical rectus abdominis myocutaneous flap is considered useful for the simultaneous obliteration of sacral defects and intrapelvic dead space after CIRT.

Choke vessels dilate and contract to regulate blood flow between adjacent arterial angiosomes. In skin flap surgery, when arterial inflow to an angiosome is ligated, choke vessels allow blood supply from an adjacent angiosome. In muscle flap surgery, the vascular anatomy is analogous to skin flaps; however, while it is established that the choke vessels will fully dilate irreversibly after two to three days, no study has yet analyzed the acute changes in each vascular region immediately following ligation of one pedicle.To establish whether the choke vessels open or close immediately following ligation of a pedicle, and how this change affects blood flow in the adjacent proximal and distal vascular regions.Radioactive and fluorescent microspheres in a pig model were used to study the regional intramuscular blood flow in each anatomical zone of a rectus abdominis flap. Blood flow measurements for each zone were calculated relative to the entire muscle at preligation, ligation and various times (15 min to 90 min) postligation.There was no statistically significant difference in blood flow across choke zones as a result of ligation. This signifies that the choke vessels do not significantly dilate to produce a statistically significant measureable change in blood flow.Given these results and previous literature findings, the anatomical presence of choke vessels in a muscle is the strongest determining factor for acute flap viability in surgery.Les vaisseaux anastomotiques se dilatent et se contractent pour réguler le débit sanguin entre les angiosomes artériels adjacents. Dans le cadre d’une chirurgie par lambeau cutané, lors de la ligature du débit artériel vers un angiosome, les vaisseaux anastomotiques assurent un débit sanguin en provenance d’un angiosome adjacent. L’anatomie vasculaire est alors analogue aux lambeaux cutanés. Cependant, bien qu’il soit établi que les vaisseaux anastomotiques se dilatent pleinement et de manière irréversible au bout de deux ou trois jours, aucune étude n’a encore analysé les changements aigus de chaque région vasculaire immédiatement après la ligature d’un pédicule.Établir si les vaisseaux anastomotiques s’ouvrent ou se ferment immédiatement après la ligature d’un pédicule et examiner l’effet de ce changement sur le débit sanguin des régions proximales et distales adjacentes.Les chercheurs ont utilisé les microsphères radioactives et fluorescentes d’un porc pour étudier le débit sanguin intramusculaire régional de chaque zone anatomique d’un lambeau du grand droit. Ils ont mesuré le débit sanguin de chaque zone par rapport au muscle entier avant la ligature, au moment de la ligature et à divers moments (de 15 à 90 minutes) après la ligature.Il n’y avait pas de différence statistiquement significative du débit sanguin dans les diverses zones anastomotiques après une ligature. Ainsi, les vaisseaux anastomotiques ne se dilatent pas au point de produire un changement du débit sanguin pouvant être mesuré de manière statistiquement significative.Compte tenu de ces résultats et des conclusions de publications scientifiques, la présence anatomique de vaisseaux anastomotiques dans un muscle est le principal déterminant de viabilité aiguë d’un lambeau lors d’une chirurgie.

Extensive electric burn around the chest in children is rare and this type of injury always poses a great challenge for its management. A 12-year-old male child with extensive electric burn of the chest wall was admitted to hospital. It was a neglected case of 9 days old burn; the young boy was in critical condition having systemic features of toxemia with widespread necrosis of the skin, subcutaneous tissues, and muscles along with exposed bones (ribs and sternum) with the risk of impending rupture of pleura through the exposed intercostal spaces. After initial resuscitation, a thorough debridement of all necrotic tissues was done. Thereafter, a superiorly based vertical rectus abdominis myocutaneous flap was harvested to cover the exposed bones and intercostal spaces. The remaining raw areas were skin grafted. The child made an excellent recovery with good outcome.

INTRODUCTION The aim of this study was to investigate whether the pedicle of the rectus abdominis flap can be lengthened by resecting the inferior costal cartilage segments or associated muscle when repairing upper body defects. A formula was generated that calculates the expected increase in pedicle length. METHODS Thirty patients underwent computed tomography. The width and thickness of the third to seventh inferior costal cartilage segments as well as the width of the respective intercostal spaces were recorded. Four patients underwent reconstruction of an upper body defect with the relevant flap. RESULTS The expected mean increases in pedicle length were 4.07cm (standard deviation [SD]: 0.31cm) and 4.63cm (SD: 0.54cm) following resection of the left and right sides respectively of the seventh inferior costal cartilage segment, 7.99cm (SD: 0.49cm) and 10.82cm (SD: 0.23cm) following resection of the left and right sides respectively of the sixth and seventh inferior costal cartilage segments while resection of the fourth to seventh inferior costal cartilage segments would equate to increases of 17.48cm (SD: 0.62cm) and 22.05cm (SD: 0.21cm) for the left and right sides respectively. In four patients who required reconstruction, three flaps survived without problems but one flap developed partial necrosis. CONCLUSIONS Resecting inferior costal cartilage segments or associated muscle can lengthen the pedicle of the rectus abdominis flap for reconstruction of defects on the upper chest and neck.

The rectus abdominis flap offers a number of advantages over other flaps used in head and neck reconstruction. The flap can be harvested by a separate team and can be tailored to include skin, muscle, and fat. In addition, the available vascular pedicle is long and its large caliber provides an appropriate size match with recipient neck vessels. Central to reconstructive success is defining an arterial and venous pedicle that provides balanced perfusion to all components of the flap. Anomalous vascular anatomy presents principal challenges in reestablishing free flap perfusion. We present a case of double, right deep inferior epigastric arteries encountered during vertical rectus abdominis myocutaneous flap reconstruction of the tongue and floor of the mouth and discuss the clinical outcomes of this reconstruction.

Although being a safe and standardised procedure, free-flap reconstruction can be harmful if unpredictable situations occur intraoperatively. The case presented reveals a situation in which an unscheduled interdisciplinary approach allowed to complete our reconstructive aim. An extensive defect at the thigh was planned for reconstruction by means of a free rectus abdominis flap. As the distant part of the flap showed a compromised perfusion during operation and had to be partially discarded, our colleagues from the vascular surgery department created an arterio-venous loop for anastomosis. This allowed a more distant positioning of the flap and ensured a complete defect reconstruction.

The rectus abdominis muscle is well known to be segmented by tendinous intersections into a certain number of serially arranged compartments. The tendinous intersections are present only on the anterior aspect and fused with anterior sheat of the muscle. Since the rectus abdominis is used as a graft, there are lots of studies in the literature about the rectus abdo- minis muscle and its intersections. In the dissection of a 64-year-old man at the Department of Anatomy of Ege University Medicine Faculty, an anatomical form of the rectus abdominis muscle not described in the available literature was encoun- tered. Both rectus muscles, right and left, were symmetrical but there were not any tendinous intersections on them. The total length of the muscle was 30 cm for both sides. The width at the umbilical level was 5.7 cm on the right side and 5.4 cm on the left side. The thickness of the muscle at the umbilical level was 0.5 cm for both sides. This previously unreported variation is very interesting for clinical approaches since the transverse rectus abdominis flap is an important reconstructive tool, particularly in reconstruction of the breast following mastectomy.

口腔悪性腫瘍症例の即時再建術に伴う腹直筋採取術において腹部の術後疼痛管理を目的として硬膜外麻酔を使用した。持続硬膜外カテーテルの挿入は術前日に施行し, 術後7日間留置した。局所麻酔薬としては, 1%あるいは1.5%リドカインを持続硬膜外カテーテルより2.1ml/hの速度で投与した。硬膜外麻酔施行により腹部の疼痛の訴えはほとんどなく, 術後の良好な疼痛管理を行うことができた。また硬膜外麻酔手技による合併症は認められなかった。全身麻酔に硬膜外麻酔を併用することは, 術野からの上行性痛覚伝導路の遮断により, 外科的侵襲に対する生体反応が軽減されることで麻酔薬の使用量も少なくてすむとともに, 硬膜外持続注入は, 術後の痔痛管理の点でも有用であった。以上より, 口腔外科領域においても手術内容に応じて硬膜外麻酔の適応について考慮する必要があると思われた。, Continous epidural anesthesia was administered to relieve postoperative abdominal pain in patients undergoing immediate reconstructive surgery with a rectus abdominis flap. An epidural catheter was inserted on the first preoperative day and remained in place until the seventh postoperative day. The patients were given 1.0% or 1.5% lidocaine into the epidural space at a rate of 2.1 ml/hr to relieve postoperative pain. There were mininal complaints of abdominal pain and no complications due to epidural anesthesia. The depth of general anesthesia can be decreased by the concurrent use of epidural analgesia because this treatment reduces sympathetic and sensory responses to surgical stimulation by blocking the sympathetic and sensory tracts. Epidural anesthesia prevented side effects such as respiratory and cardiovascular inhibition associated with inhalational anesthetics.Epidural anesthesia may therefore be useful in the management of perioperative pain in oral and maxillofacial surgery.

The authors report 8 cases of coverage of the inguinal and perineal areas with the inferiorly based rectus abdominis myocutaneous flap. This flap seems to be the technique of choice for coverage of such defects. The design of the flap can be explained by the low venous pressure zone concept.

Deep inferior epigastric (DIE) vessels, important to vascular apastomosis of an inferior rectus abdominis free flap, were studied clinicoanatomically. This study included morphologic and morphometric examinations of the DIE artery and vein. Bifurcations of the DIE vessels, venous valves, the inner diameters of the DIE vessels, and their lengths were recorded. The following results were obtained:1. Morphologic examination: 1) In the artery, single type (no bifurcation of the DIE artery observed) accounted for 72%. 2) In the vein, single type (no bifurcation of the DIE vein observed) accounted for 2%, distal type (two companion veins of the DIE vein come together to form one trunk before joining the external iliac vein) 33%, medial type (two companion veins of the DIE vein come together just at the point of joining the external iliac vein) 14%, and direct type (two companion veins of the DIE vein join the external iliac vein independently) 2%. 3) The DIE artery anastomosed with the superior epigastric artery in the upper abdomen. 4) Numerous surface branches of DIE arteries were evident in the paraumbilicas region. 5) Most venous valves were bicuspid. 6) Most venous valves were at the bifurcation in the distal type.2. Morphometric examination: 1) The mean inner diameter of the DIE artery 5 mm distal from the DIE artery junction was 1.9±0.5 mm. 2) The mean inner diameters of the DIE veins 5 mm distal from the external iliac veins were 1.7±1.1 mm in the medial type, 2.5±1.5 mm in the distal type, 2.1±1.1 mm in the direct type, and 2.6 mm in the single type. 3) The maximum mean length of artery that could be used as a vascular pedicle was 12.3±2.5 cm.

The rectus abdominis flap has been widely utilised but a disadvantage is that the flap is rather thick. We have succeeded in preparing a stable thin flap in obese patients. This has been achieved through prefabrication by the subcutaneous insertion of a silicone sheet adjacent to a conventional deep inferior epigastric flap.

Treatment of empyema after pneumonectomy is challenging. We treated 4 patients with postpneumonectomy empyema using a free rectus abdominis myocutaneous flap together with a pedicled pectoralis major muscle flap. The pectoralis major flap was used to fill the apical portion of the cavity, while the rectus abdominis flap was used to fill the caudal portion and occlude any bronchial fistula present. All empyemas were treated successfully without recurrence. This method has the advantage of filling apical and caudal parts of the space at once, making effective use of the combined volume of the two flaps.

We described our experience with a recurrent case of buccal cancer in which reconstruction was performed with a skin-grafted rectus abdominis flap. The patient was a 61-year-old woman. She had been undergone tumor excision and reconstruction with a D-P flap at 54 years of age (histopathological diagnosis, acinic cell carcinoma). Recurrence occurred 7 years later. We planned to excise the tumor and perform reconstruction with a rectus abdominis flap. A rectus abdominis flap was prepared before tumor excision, at the same time, free skin was grafted to the raw surface of the flap. Three weeks later, the tumor was excised, and reconstruction was performed. The rectus abdominis flap covered with skin was positioned so that the skin side of the flap formed the cheek and the graft side formed the oral wall. Fat reduction of the flap was performed 18 days later. The flap was successfully transplanted without any necrosis. The outcome was excellent because the flap resembled the natural curve of the cheek. This method is useful for secondary reconstruction and for reconstruction after excision of benign tumors or slowly progressing cancers, such as salivary grand carcinomas.

Recently, microvascular tissue transplantation has come to be generally used for oral and maxillofacial reconstruction. The present status of clinical use of microvascular tissue transplantation for maxillofacial lesions was investigated at 335 oral and maxillofacial surgery centers in Japan. The number of reported was cases 687. Among these, 497 (72.4%) received forearm flap transplantation. A rectus abdominis flap was employed in 104 cases (15.2%). The total survival rate of all transplants was 89.1%

We present a case with vertical rectus abdominis myocutaneous free flap in which deep inferior epigastric perforators does not nourish skin paddle of the flap. The skin paddle of musclocutaneous flaps is nourished by musculocutaneous perforators originating from the main vascular system of the muscle. The skin paddle of rectus abdominis flap is also supplied by musculocutaneous perforators of deep inferior epigastric artery (1). Cutaneous perforators end directly within the skin. Their origin may be either from the source artery or from the subcutaneous or fascial brances (2).

Various myocutaneous flaps (upper sartorius, upper gracilis and lower rectus abdominis) have been used in a series of 17 block dissections of the groin with gross skin involvement. Only one of these flaps developed appreciable necrosis. The sartorius flap is restricted in its application for anatomical reasons. The rectus abdominis flap can only be used from the opposite side in unilateral cases, though it does appear to be the most dependable flap. The gracilis flap appears to be the most suitable for the majority of the patients who usually present with bilateral involvement of the lymph nodes and skin.

The deep inferior epigastric vascular system nourishes a vast area of the anterior abdominal wall and offers a versatile variety of tissue combinations to the reconstructive surgeon for local or free flap transfer. Its supply to and beyond the rectus abdominis muscle provides the basis for flap design. Eighteen cases are presented to illustrate various muscle, myocutaneous and myosubcutaneous flaps that have been used to date to repair defects in the extremities and in the head and neck. The ease of dissection, coupled with the large calibre and length of the vascular stem, are key factors which combine to offer a speedy and a reliable technique. The donor site scar has been improved by the use of a suprapubic transverse incision to dissect the pedicle and this exposure provides access to the iliac crest for bone grafts where indicated. Time will evaluate this technique and further designs and modifications will undoubtedly be forthcoming. Meanwhile the initial results have been most promising.