Grabb’s Encyclopedia of Flaps Upper Extremities, Torso, Pelvis, and Lower Extremities

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lamina is reinforced by the aponeurosis of the external oblique muscle, and the posterior lamina is reinforced by
the aponeurosis of the transversus abdominis muscle (Fig. 379.1). This fascial arrangement exists from the
costal margin above to a variable level below, usually midway between the umbilicus and the symphysis pubis.
At this level, the posterior sheath ends in a curved margin called the arcuate line (Fig. 379.1B). This is
particularly important in the restoration of abdominal wall integrity after raising the rectus abdominis muscle or
musculocutaneous flap.
FIGURE 379.2 A,B: Dual dominant blood supply, superior and inferior epigastric vessels.
This muscle has a dual dominant blood supply (Fig. 379.2). The upper vessel is the superior epigastric artery,
one of the two terminal branches of the internal mammary artery. This descends in the space between the costal
and xyphoid origins of the diaphragm and enters the rectus sheath at the upper medial extreme of the sheath and
continues along the posterior surface of the muscle.
The lower vessel is the inferior epigastric artery that arises from the external iliac artery above the level of the
inguinal ligament. It traverses upward and medially on the extraperitoneal tissues, where it perforates the
transversalis fascia to pass anterior to the arcuate line and continues between the posterior rectus sheath and
the rectus muscle. Within the muscle, these vessels divide into multiple terminal branches that communicate at
the level of the umbilicus (Fig. 379.2A). Both being dominant vessels, either may be ligated and the muscle will
survive.
The perforators to the skin overlying the rectus abdominis muscle are of the indirect type and traverse the rectus
abdominis muscle to supply the overlying skin (5). These tend to lie along the medial third of the rectus
abdominis muscle (see Fig. 379.1). They are predominantly above the level of the arcuate line, and more than
one perforator below the arcuate line is rare.
FLAP DESIGN AND DIMENSIONS
The rectus abdominis musculocutaneous (RAM) flap may be either horizontal or vertical. The vertical flap may be
inferiorly based or superiorly based.

FIGURE 379.3 Arc of rotation of the superior RAM flap.
Vertical Superiorly Based RAM Flap
The size will depend on the reconstructive requirements, but the skin may include the full length of the anterior
abdominal wall, about 30 cm long in the average adult. The width may vary from 10 to 15 cm, still allowing for
primary closure of the anterior abdominal wall. The axis of rotation point of the superior rectus abdominis
musculocutaneous flap will be the point of entry of the superior epigastric artery into the rectus abdominis muscle
at the subcostal margin. However, this point may be extended superiorly by dissection of the superior epigastric
vessel proximally to various levels of the internal mammary artery. The arc of rotation is 0 to 180 degrees in
either clockwise or counterclockwise direction. The reach of the flap includes the presternal and premanubrial
areas, the lateral chest wall, and the lateral abdominal wall (Fig. 379.3).
FIGURE 379.4 A: Design of the superior RAM flap. B: Dissection of flap to subcostal margin. C: Flap raised. D:
Flap rotated into position. E: Repair of fascial incision proximal to linea alba.

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Design begins by delineation of the rectus abdominis muscle by marking the midline and the lateral margin of the
muscle about four to five fingerbreadths lateral to the midline. Next, the ellipse of the skin flap required is
designed (Fig. 379.4A).
Inferior Vertical RAM Flap
The inferior axis will be the point of origin of the inferior epigastric vessel from the external iliac artery at the level
of the inguinal ligament. The arc of rotation will again be 0 to 180 degrees in either a clockwise or
counterclockwise direction. Sites of reach include the lower anterior abdominal wall, the inguinal areas, the iliac
areas, and the perineum (6, 7).
Extended Vertical and Horizontal RAM Flap
The RAM flap may be extended with an ipsilateral, contralateral, or combination extension in the form of random-
pattern flap extension (Fig. 379.6).
FIGURE 379.5 A: Preoperative view, modified radical mastectomy. B: Postoperative view, RAM flap for mound
reconstruction, abdominal scar. C: Postoperative view.
OPERATIVE TECHNIQUE
Vertical Superiorly Based RAM Flap
The skin is incised through subcutaneous tissue to expose the anterior rectus sheath (3). Sutures are inserted
between the dermis and the anterior rectus sheath to prevent a shearing strain on the indirect perforator system.
The anterior sheath is incised around the margins of the skin element, and superiorly, the anterior rectus sheath
may be incised in the midline, opening the sheath like the pages of a book (Fig. 379.4E).
The muscle is easily dissected from the subjacent posterior rectus sheath by sharp and blunt dissections. The
muscle is raised to the subcostal margin (Fig. 379.4B). It is not necessary to expose the superior epigastric
vessel that enters the muscle medially at the subcostal margin. The superior insertion of the rectus abdominis
muscle may be detached from the fifth, sixth, and seventh costal cartilages to facilitate rotation of the
musculocutaneous island element. The distal end of the muscle is raised from the subjacent transversalis fascia,
and the inferior epigastric vessels are located, transected, and ligated. The lower aspect of the rectus abdominis
muscle is transected with cutting cautery about two to three finger-breadths proximal to the pubic crest (Fig.
379.4B). The flap is then rotated into the required position (Fig. 379.4C and D).

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FIGURE 379.6 Variations of horizontal extensions of the RAM flap.
Above the level of the arcuate line, the anterior rectus sheath is repaired by direct approximation with
nonabsorbable sutures (Fig. 379.4E). Below the arcuate line, repair of the fascia is vital to prevent a
postoperative hernia and may be performed, in most cases, by advancement of the medial free edge of the
aponeurosis of the external oblique to the linea alba medially. This creates considerable tension that is released
by a relaxing incision in the fascia of the external oblique far laterally. If the defect is too large, a free fascial graft
of external oblique fascia harvested from the contralateral side is sutured
into position with nonabsorbable sutures under suitable tension. Marlex mesh may be used, but autogenous
material is preferable.

FIGURE 379.7 A: Type I extended horizontal RAM flap for mound reconstruction. B: Preoperative view, radical
mastectomy. C: Intraoperative flap. D: Intraoperative view. E: Postoperative view at 6 months.
Inferior Vertical RAM Flap
This flap is raised similarly to the superior counterpart. However, in this case, the superior aspect of the rectus
abdominis muscle is transected and the superior epigastric artery is ligated. The flap is maintained on the inferior
epigastric arteriovenous arcade and rotated into the required position.
Extended Vertical and Horizontal RAM Flap
Extending the RAM flap with ipsilateral, contralateral, or combination extension in the form of random-pattern flap
extension allows for safe, reliable transverse of the abdominal panniculus to the anterior chest wall for
reconstruction of the breast mound by vascularized autogenous abdominal skin and subcutaneous tissue (Fig.
379.7).
CLINICAL RESULTS
The rectus abdominis musculocutaneous flap is extremely reliable, and complications are invariably
technical in nature. Loss of the flap will be related to violation of the dominant vessels or shearing stresses
with injury to the indirect perforator system.
Donor-site functional deficit is minimal (Fig. 379.5). In the immediate postoperative period, difficulty in sitting
from a recumbent position is experienced. However, after a period of 6 weeks, the function is adequately
compensated for by action of the external oblique muscles.
Hernia is related to technically inadequate repair of the fascial integrity of the anterior abdominal wall below

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the arcuate line. Meticulous surgical repair will preclude this complication.
SUMMARY
The vertical or horizontal rectus abdominis musculocutaneous flap can be reliably used to reconstruct the
breast.
References
1. Drever JM. The epigastric island flap. Plast Reconstr Surg 1977;59:343.
2. Robbins TH. Rectus abdominis myocutaneous flap for breast reconstruction. Aust NZ J Surg 1979;49:527.
3. Dinner MI, Labandter HP, Dowden RV. Role of the rectus abdominis myocutaneous flap in breast
reconstruction. Plast Reconstr Surg 1982; 69:209.
4. Last RJ. The abdomen: the anterior abdominal wall. In: Anatomy, regional and applied, 4th ed. London:
J&A Churchill, 1966;382-385.
5. McCraw JB, Dibbell DG, Carraway JH. Clinical definition of independent myocutaneous vascular
territories. Plast Reconstr Surg 1977;60:341.
6. Mathes SJ, Bostwick J, III. A rectus abdominis myocutaneous flap to reconstruct abdominal wall defects. Br
J Plast Surg 1977;30:282.
7. Bostwick J, III, Hill HL, Nahai F. Repairs in the lower abdomen, groin, or perineum with myocutaneous or
omental flaps. Plast Reconstr Surg 1979;63:186.

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Chapter 380
Profunda Artery Perforator Flap (Pap) for Breast Reconstruction
ROBERT J. ALLEN
JOSHUA L. LEVINE
EDITORIAL COMMENT
The flap location makes this an outstanding choice for breast reconstruction, though the anatomy and
surgical approach are a difficult one and not for the casual surgeon.
INTRODUCTION
The abdomen is the first choice as a donor site for most women seeking autologous breast reconstruction. The
deep inferior epigastric (DIEP) flap has become the gold standard because it allows for the use of extra-
abdominal tissue without the sacrifice of underlying muscle (1). Some women, however, are not candidates for
abdominal tissue harvest. Absolute contraindications for the use of the abdomen in autologous breast
reconstruction include previous abdominoplasty, excessive abdominal surgery that has compromised essential
blood flow to the lower abdomen, and patients who are too thin and thus have inadequate abdominal fat volume
for breast reconstruction. Until the advent of the thigh flaps for breast reconstruction, the buttock flaps, namely,
the gluteal artery perforator (GAP) flaps, were the best and most common alternative donor sites for perforator
flap breast reconstruction (2, 3). The transverse upper gracilis (TUG) flap became an alternative to buttock flaps,
but the TUG requires muscle sacrifice. Therefore, the senior author developed a perforator flap option that
utilizes approximately the same territory as the TUG flap. The profunda artery perforator (PAP) flap (4) is based
on the area perfused by the profunda femoris artery perforators to the posterior thigh. These vessels perforate
through the adductor magnus just posterior to the gracilis muscle and perfuse the area just below the buttock
crease (commonly referred to as the “banana roll”). We have used the PAP flap in over 270 cases in the past 4
years.
INDICATIONS
Anyone who is a candidate for a GAP flap is most likely also a candidate for a PAP flap. Ideal candidates
are thin women with inadequate abdominal volume for breast reconstruction. Even very thin women tend to
have adequate posterior thigh volume for breast reconstruction, provided that their expectation of breast
reconstruction volume is reasonable. In other words, thin women with scant body fat should not expect to
have a large, disproportionate breast reconstruction. Some women will have a choice, having adequate
volume for reconstruction at both the abdomen and the posterior thigh. These women should be made
aware of the advantages and disadvantages of choosing the posterior thigh as the donor site for breast
reconstruction.
ANATOMY
The profunda femoral artery is a branch off of the common femoral artery. As it descends within the medial thigh,
it gives off the pedicle to the gracilis, followed by perforating branches

that travel through the adductor magnus muscle. These perforators terminate in the skin of the posterior and
medial thigh. One or more of these perforators can be used as the vascular pedicle to the PAP flap.
FIGURE 380.1 A: MRA of the thighs with the arrow pointing to a large perforator from the profunda artery going
through the adductor magnus muscle to perfuse the posterior and medial thigh skin. The thickness of the fatty
tissue is measured so that the flap weight is estimated preoperatively. B: Three-dimensional reconstruction
showing the positions of the vessels on the posterior thighs.
FLAP DESIGN AND DIMENSIONS
All patients undergo vascular imaging with magnetic resonance angiogram (MRA) (5) or computed tomography
angiogram (CTA). Imaging is essential for planning this procedure because it is extremely important to know
exactly where the primary perforator enters the flap. This point (or points) is designated by coordinates
calculated by the radiologist and confirmed by reviewing the imaging study. The coordinates of the perforators
are established with respect to specific landmarks. The main perforators are identified in their vertical orientation
by their distance from the most inferior point of the infragluteal crease. Their horizontal orientation is established
by the perforator's distance from the midline (Fig. 380.1). This gives the surgeon two points of reference. With
the patient prone, these points can be located with a tape measure and marked. The marked points of the
perforators are then confirmed with a Doppler signal.
We have found that most large perforators are between 2 and 7 cm below the infrabuttock crease. Once the
perforators have been marked, the flap is designed around these points (Fig. 380.2). In thin women, it is
advisable to harvest no more than 6 cm in the vertical orientation in order to limit tension on the closure of the
donor site. The horizontal orientation can be 20 cm or more. The flap design becomes a crescent of tissue just
below the infrabuttock crease; the anterior apex is in the inner thigh, posterior to the adductor tendon; and the
lateral apex terminates approximately at the lateral infrabuttock crease.
Since the vertical dimension of the flap is limited, it is essential that the marking is correct so that the key
perforator is not missed.
It is also very important to become familiar with the course of the perforator as it travels through the magnus
muscle. Details of its anatomy will be very useful during the dissection, and it is helpful to refer to the vascular
imaging study during the procedure.
OPERATIVE TECHNIQUE
The patient is placed in the supine position. Her arms and legs are prepped and draped into the surgical field.
Sequential compression devices are placed on the calves below the knees and then wrapped in sterile sheets so
that they can be prepped completely into the field. The legs are placed on sterile sheets. Two microsurgeons

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work simultaneously. One surgeon will
be preparing the reception site in the chest while the other is harvesting one of the flaps. The surgeon harvests
the PAP flap from the opposite side of the patient's body. The leg is abducted and externally rotated (frog
legged). It is also very helpful to position the patient in Trendelenburg with slight rotation away from the surgeon
in order to expose the inner thigh (Fig. 380.3). An incision is then made at the anterior apex of the flap. The
adductor longus tendon is identified, and the incision is taken down to its posterior edge. It is important to avoid
the saphenous vein and lymph nodes that may be located anterior to the adductor tendon. There will be a vein
branch from the saphenous vein that is ligated (Fig. 380.4). The dissection is then taken down to the gracilis
muscle, and the flap is elevated off of this muscle. It is important to bevel when approaching the area of the
perforator to be sure that the key perforator is contained within the harvested fat. Once the superior and inferior
incisions have been made down to the muscle and to a point beyond where the perforator is expected to enter
the flap, the flap is elevated off of the gracilis completely. The septum between the gracilis and the adductor
longus is identified. The gracilis is reflected anteriorly and the septum overlying the magnus is entered. This is a
key point in the procedure and begins the search for the perforator. At this point, loop magnification is essential
for the remainder of the dissection.
FIGURE 380.2 Perforators are marked according to the MRA, and the flap is designed beneath the buttocks.
FIGURE 380.3 Positioning: the surgeon harvests the PAP flap from the opposite side of the table. The leg, which
is prepped into the field, is externally rotated and abducted, and the table is placed into Trendelenburg.

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FIGURE 380.4 The incision is made down to the posterior edge of the adductor tendon, avoiding the saphenous
vein. A branch to the flap from the saphenous vein is often encountered and ligated.
FIGURE 380.5 After the fascia over the magnus is entered, the appropriate perforator is selected and dissected
into the muscle.
When the appropriate perforator is identified, the dissection then follows the perforating vessel into the magnus
muscle all the way to its take-off at the profunda vessels (Fig. 380.5). The dissection requires multiple self-
retaining retractors and frequent repositioning of the retractors and the patient.
It is important to pursue the dissection all the way to the refund of vessels. At that point, a space will be entered
where fatty tissue surrounds the take-off of the perforators. It is at that point that the artery will be of adequate
diameter for anastomosis to the internal mammary artery.
The pedicle is then dissected free from its deep muscular attachments such that it is connected now only to the
profundus vessels and the flap tissue (Fig. 380.6). At that point, the flap can be stapled back into position
anteriorly so that the
posterior flap harvest can be undertaken with the pedicle still intact. With experience, the surgeon gains the
confidence to harvest the pedicle prior to removing the flap from its posterior muscular attachments. However,
until several flaps have been completed successfully, it is recommended to do the final pedicle ligation as the last
step of the flap harvest.

FIGURE 380.6 The pedicle is dissected all the way to the take-off at the profunda vessels, then freed from all
muscular attachments.
FIGURE 380.7 The flap is a crescent shape, and the pedicle is 8 to 12 cm in length.
The posterior and lateral flap harvest is made by adducting and internally rotating the leg such that the lateral
incision can be made more easily. The PAP pedicle is typically 8 to 12 cm in length (Fig. 380.7). The average
arterial diameter is 2.2 mm and the vein is typically 2.7 mm in diameter. The internal mammary vessels are used
as recipient vessels in the majority of cases.
Insetting of the PAP flap usually involves some manipulation of its shape. The long crescentic shape of the flap
allows for coning of the flap and creating a breast that is well projected (Fig. 380.8). Harvest time is usually 40
minutes to an hour.
The donor site is closed in a standard fashion over drains. Antibiotic irrigation is used prior to closure. The
patient is sent to the recovery room for 1 to 2 hours and then transferred to the floor for flap monitoring. The IV
and Foley catheter are removed on the morning of postoperative day 1. The patient will be ambulating on
postoperative day 1, and the patient is discharged 2 to 4 days after surgery.

FIGURE 380.8 The flap can be coned for excellent projection.
CLINICAL RESULTS
In almost 300 cases, the PAP flap has proven to be a very reliable and successful operation. The failure
rate is less than 1%, and donor site problems occur in about 10% to 15% of cases. These include infection,
seroma, and wound breakdown. We have also seen areas of flap fat necrosis in about 10% of cases. PAP
flaps can also be combined with other flaps for patients who need more volume in breast reconstruction.
Two flaps can be used for one breast, and a PAP flap can be combined with a hemiabdominal DIEP flap, or
a lateral thoracic flap. These flaps can also be augmented with autologous fat injection. The long pedicle
length of the PAP flap makes insetting uncomplicated. The crescent shape of the PAP flap allows for
shaping and positioning of the flap for maximal projection and optimal shape.
We have routinely been able to provide adequate flap volume relative to that of the mastectomy weight in
thin women. In avoiding the inguinal area, we have not seen any cases of lymphedema. We have been able
to innervate the flap using a branch of the posterior femoral cutaneous nerve.
Since its introduction into 2010, the PAP flap has rapidly become an outstanding option in perforator flat
breast construction.
Clinical Case 1
Preoperative BRCA+ patient (Figs. 380.9 and 380.10)
Postoperative after bilateral nipple-sparing mastectomies (NSM) (Fig. 380.11) and PAP reconstruction
(Fig. 380.12)
Clinical Case 2
Preoperative and postoperative BRCA+ patient after bilateral NSM and PAP breast reconstruction
(380.13)

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FIGURE 380.9 Clinical Case 1. Preoperative view of breasts.
FIGURE 380.10 Clinical Case 1. Properative view of donor sites.
FIGURE 380.11 Clinical Case 1. Postoperative result.

FIGURE 380.12 Clinical Case 1. Postoperative view of donor site scars.
FIGURE 380.13 Clinical Case 2. Preoperative (left) and postoperative (right) views.
SUMMARY
The PAP flap is an excellent option for any patient who is a candidate for GAP flap breast reconstruction,
with the significant advantage of having a scar that is well hidden in the buttock crease, without being
detrimental to the shape or size of the buttock. The PAP flap is a true perforator flap with no muscle
sacrifice. As such, the PAP flap is to the TUG flap what the DIEP is to the transverse rectus abdominis
muscle (TRAM).
References
1. Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg
1994;32(1):32-38.
2. Allen RJ, Tucker C Jr. Superior gluteal artery perforator free flap for breast reconstruction. Plast Reconstr
Surg 1995;95:1207-1212.
3. Levine JL, Granzow JW, Allen RJ. The in-the-crease inferior gluteal artery perforator flap for breast
reconstruction. Plast Reconstr Surg 2006;118(2):333-340.
4. Allen RJ, Haddock NT, Ahn CY, et al. Breast reconstruction with the profunda artery perforator flap. Plast
Reconstr Surg 2012;129(1):16-23.

5. Chernyak V, Rozenblit AM, Greenspun DT, et al. Breast reconstruction with deep inferior epigastric artery
perforator flap: 3.0-T gadolinium-enhanced MR imaging for preoperative localization of abdominal wall
perforators. Radiology 2009;250(2):417-424.

Chapter 381
Transverse Abdominal Island Flap
C. R. HARTRAMPF JR.
L. F. ELLIOTT
EDITORIAL COMMENT
Unquestionably, the introduction of this flap, a most innovative and creative one, changed the field of breast
reconstruction, particularly since one could reconstruct a breast of variable size, with the provision of
excellent shape and symmetry with the contralateral breast and without the use of an implant. The flap is
most reliable when it is pedicled, if one delimits to the ipsilateral half. As extension beyond the midline
occurs, the incidence of partial necrosis increases.
In a single operation, the transverse abdominal island flap can produce a completely autogenous breast of
practically any size. The donor defect after closure results in an acceptable transverse abdominal scar.
INDICATIONS
The transverse abdominal island flap was devised in response to a perceived need to reconstruct breasts
after mastectomy for carcinoma with entirely autogenous tissue (1). Other uses for the flap are replacement
of breast tissue after simple and subcutaneous mastectomy and correction of congenital chest-wall defects
such as Poland's syndrome.
Since its introduction for breast reconstruction, this flap has been used for additional reconstructive
problems. These include sternal wound infection after coronary artery bypass, chest-wall ulcers after
irradiation, and the persistent thoracic cavity defect after closure of bronchopleural fistula. The flap also can
be based inferiorly for use in pelvic and perineal defects as well as superior thigh and groin defects.
Using microsurgical technique, the transverse abdominal island flap can be transferred to distant sites to
provide generous amounts of well-vascularized skin and fat to resolve unsightly contour deformities or to
close the problem wound that requires free-flap coverage. The donor site for this free flap is excellent, and
the potential size is enormous.
The only absolute contraindication to the use of the transverse abdominal island flap is previous extensive
abdominal wall dissection such as abdominoplasty that has disturbed the musculocutaneous perforators
essential for the survival of the overlying fat and skin. Abdominal scars limit the availability of flap tissue,
since tissue distant to the scarring is unreliable. However, scarring, such as the right subcostal incision, is
not necessarily a contraindication to the transverse abdominal island flap based on the right rectus muscle,
since it could be transferred as a free-tissue transfer based on the right inferior epigastric pedicle.
Relative contraindications to this procedure include obesity, history of smoking, and the presence of chronic
illness or malnourishment.
ANATOMY
The blood supply to the transverse abdominal island flap is through large perforator vessels from the superior
and inferior epigastric system coursing through the rectus muscles (Fig. 381.1). The superior and inferior

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epigastric vessels are branches of the internal thoracic and external iliac arteries, respectively. The
communication between the two vessels is usually an arborized plexus in the rectus muscle at the level of the
umbilicus. The larger inferior epigastric artery and vein enter the rectus laterally, near the arcuate line. Below the
arcuate line there is a paucity of perforators, while above it, generally in the periumbilical region, there are many
perforators. Pressure gradients may not allow flow between the superior and inferior systems in the normal state.
However, when one system is ligated proximally, it is perfused by the other. This accounts for the extensive flow
throughout this large flap after the superior epigastric vessels are isolated and the inferior epigastric artery and
vein are ligated.
The rectus muscle itself is divided by three or four transverse tendinous intersections spaced evenly throughout
its length. These intersections segment the muscle into individual sections so that if the muscle is transected, it
will not completely contract but will maintain its length as long as muscle is attached to a tendinous intersection.
The nerve supply to the rectus muscle and the abdominal wall enters laterally and is from the lower six or seven
thoracic
nerves as well as the iliohypogastric and ilioinguinal nerves. These are severed in elevating the island flap; thus
this flap is not innervated.
FIGURE 381.1 Diagrammatic representation of the epigastric arcade composed of the superior and deep inferior
epigastric vessels as well as the segmentally oriented intercostal vessels.
FLAP DESIGN AND DIMENSIONS
Lines of proposed incisions should be drawn on the patient prior to the operation, with the patient preferably in
the standing position (Fig. 381.2). Measurements of the desired breast should be guided either by the
contralateral breast, if it is suitable to the patient, or by a planned size previously agreed upon. An estimation of
skin needed from the abdomen should be based on the pathology report regarding the previously resected
mastectomy skin. The dimensions of the needed tissue should then be transferred to the patient's abdomen with
the patient in a standing position. In using the flap for problems other than breast reconstruction, the defect
should again be measured carefully and transferred exactly to the abdomen, since any excess tissue will prove
bulky in the final result.

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FIGURE 381.2 A: Preoperative photograph of the planning for reconstruction of the right breast. The takeoff of
the breast is determined from the normal contralateral one and is depicted by the dotted line. The flap will be
deepithelialized to provide fill in the infraclavicular area. Point A corresponds to the medial aspect of the
inframammary fold, and as the flap is rotated, it will correspond to the area of the umbilicus. Point B is similarly
marked. The area marked “turn under” is usually deepithelialized and corresponds to the lower and lateral
portion of the breast. It will serve to provide bulk and projection to the reconstructed breast. B: Postoperative
result demonstrating the reconstructed breast as well as the abdominal wall closure at 1 year.
Planning of the abdominal incision is based on a number of factors: (1) the amount of skin and soft tissue
determined by the measurements previously made, (2) the surgeon's judgment with regard to the mass needed
to produce the desired breast versus the mass of fat available for transfer, and (3) the presence and location of
abdominal scars. For example, a lower midline scar precludes taking the contralateral wing of tissue on one
muscle. However, the flap can be developed on both rectus muscles if both sides of the flap are needed for bulk
(2).
The horizontal length of the flap is governed by the vertical dimension. However, with the vertical dimension of
14 to 18 cm, the length from the umbilicus in each direction can be 20 to 25 cm to the tip of the flap in each flank.
It is safe to retain this prolonged length on the contralateral side without delay in the superiorly located flap. The
viable length of the contralateral wing of the lower flap without delay is uncertain at present but probably is not
past the lateral border of the rectus sheath on the contralateral side. Observation after fluorescein injection and
gross examination of bleeding surfaces can aid in deciding how much of the flap is viable, particularly on the
contralateral side.
We prefer to use the rectus muscle that is contralateral to the chest defect. This allows a less twisted route of the
pedicle from the costal margin to the chest wall (3). The axis of rotation is near the xiphoid. This generally allows
a pedicle length that is more than adequate for the infraclavicular hollow as well as the anterior axillary fold.
However, for even more distant filling, resection of the lower costal cartilages can be employed so as to provide
for a longer vascular leash.
OPERATIVE TECHNIQUE
The degree to which the transverse island can be inferiorly placed depends on a number of factors and is
planned preoperatively. Factors such as a history of smoking, lower abdominal scarring, and the need for
extensive lateral survival of the flap would encourage the operating surgeon to move the abdominal ellipse more
cephalad on the abdominal wall.

The abdominal incision is beveled away from the flap to gain additional adipose tissue and needed perforators,
particularly at the superior aspect of the flap near the midline over the rectus muscle, which will become the
pedicle. The lateral wings are elevated off the external oblique fascia medially to the lateral aspect of the rectus
sheath and to the midline on the opposite side if a single-pedicled unilateral reconstruction is planned.
The rectus sheath is then opened at the level of the arcuate line approximately 1 cm medial to the lateral border
of the rectus or where the first large perforators are noted. The inferior epigastric vessels are located by splitting
the muscle at this location and are ligated and divided. A generous section of rectus muscle is divided at this
point, leaving approximately one-fourth of the muscle in situ, both medially and laterally.
The flap is retracted carefully as the muscle is dissected up from the posterior sheath, gradually taking more and
more muscle medially, up to the next tendinous intersection. Above this point, all the muscle medially is taken
with the flap. A cuff of anterior rectus sheath is left both medially and laterally for closure. As the dissection
proceeds superiorly, the pedicle can be avoided by determining the precise location of the arterial channel or
channels using the intraoperative Doppler device.
The umbilicus is isolated and left with the abdominal wall for later relocation, as with an abdominoplasty. There
are a number of perforators in this area, and therefore, dissection of the periumbilical area should be kept to a
minimum.
FIGURE 381.3 A: Intraoperative photograph showing the large flap with the relatively small amount of rectus
muscle that has been included. (Note that the rectus muscle is transected at the level of the semicircular line and
segments of muscles are left in place medially and laterally in the abdominal wall.) B: Mastectomy defect and
tunnel planning. Note that the tunnel extends to the contralateral side and spares disruption of the inframammary
line. C: The flap, passed under the tunnel, can be rotated either way, although most often the contralateral tip
that is to be discarded extends toward the axilla (see text). D: Shaping of the flap by turning under a wing for
projection.
Once the flap is elevated to the costal margin, the anterior rectus sheath is opened medially, near the midline, up
over the costal margin to the fifth rib. The rectus muscle insertion into the lower costal segments can then be
divided, with the superior epigastric vessels in view, so as to create a true island flap (Fig. 381.3A).
The old mastectomy scar is excised, and an adequate pocket is formed. A tunnel is made from the breast pocket

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over the rectus origin to the abdominal dissection plane and is widened to allow flap passage (Fig. 381.3B). The
flap is delivered through the tunnel and into the pocket (Fig. 381.3C). One must avoid shearing and tearing of the
delicate tissue planes during this passage. An examination of the pedicle for unnecessary kinking, twisting, or
pressure is necessary at this point.
Tailoring of the flap is performed to fill the deficient areas appropriately. This is the most demanding and time-
consuming aspect of the operation (4) (Fig. 381.3D).
The flap can be placed with either wing up in the axilla, but it is usually best oriented with the wing contralateral
to the blood supply up toward the axilla to enhance venous drainage. The dermis can be either deepithelialized
or excised. The flap should be sparingly sutured around the upper circumference of the pocket from the anterior
axillary fold and humerus across the infraclavicular space. The flap may be folded on itself or debulked,
depending on the exigencies of the situation.
Chest skin below the mastectomy scar may be discarded to a new inframammary line to relieve pressure on the
pedicle, to enhance the cosmetic appearance of the new breast, and to preserve superior skin, so that the upper
scar will be well below the blouse line (see Fig. 381.2A).
FIGURE 381.4 A: Abdominal wall defect after harvest of bilateral rectus pedicles. B: Direct primary closure of
bilateral defect using overlapping no. 1 nylon without mesh support.
When only a single rectus muscle is used for the pedicle, the abdominal wall defect can usually be closed
directly using the cuff, or sheath, carefully spared on the initial dissection (5). Lateral and medial muscle portions
left below the umbilicus assist in closure as well. The periumbilical portion provides the most resistance to direct
closure.
Bilateral rectus pedicles leave larger fascial defects. However, in many patients, these defects also can be
closed directly (Fig. 381.4). It is a good idea to attempt closure as far as it is possible in all patients in order to
more accurately restore preoperative abdominal anatomy. However, if the surgeon is uncertain of the stability of
this closure, mesh can be added for security.
Closed suction drains are left subcutaneously in both the chest and abdominal planes of dissection. We also
drain the tunnel region where the pedicle passes through to the chest.

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FIGURE 381.5 A: Patient who had undergone a bilateral mastectomy and also had a lower midline vertical scar.
B: Postoperative result following reconstruction of both breasts simultaneously, with bilateral transverse island
abdominal flaps, at 1 year.
In patients with abdominal scarring possibly disruptive to the blood supply in the lower abdominal ellipse, one
should consider moving the ellipse higher up on the abdomen. Also, for those requiring quite large flaps or those
for whom the location of the scar is of less concern, the higher ellipse may be preferred. The midabdominal
transverse scar is acceptable and may be safer in some patients (6, 7).
CLINICAL RESULTS
The unilateral mastectomy defect is the most common indication for this flap's use. However, the bilateral
deformity is also suited to this flap technique (Fig. 381.5). The flap can be used either immediately at the
time of mastectomy in selected patients or delayed after healing of the mastectomy site.
The most common causes of immediate postoperative problems are hematoma and kinking of the pedicle.
At reexploration, kinking can be managed by rotating the flap in the opposite direction, changing the angle
of the pedicle, or, if all else fails, returning the flap to the abdomen.
We routinely use nifedipine, oxygen, and steroids on an empirical basis for assistance in flap survival.
Complications thus far encountered include partial loss of the flap, hematoma, seroma, inequality of size of
the breasts, abdominal weakness, and firmness in the breasts. Ventral hernias have been avoided by
careful attention to sound twolayer closures of the abdominal wall. If the defect is securely closed, the
function deficit is minimal, since the oblique muscles and remaining rectus muscles are adequate for flexing
the torso.
SUMMARY
The transverse abdominal island flap has provided a dramatic alternative to existing techniques for breast
reconstruction as well as other difficult reconstructive problems on the chest wall, pelvis, and distant sites.
The benefits of avoiding implant material for breast reconstruction as well as the frequently generous, well-
vascularized supply of fat and skin make this flap an attractive answer to a myriad of difficult reconstructive

problems.
References
1. Hartrampf CR, Sheflan M, Black PW. Breast reconstruction with the transverse abdominal island flap.
Plast Reconstr Surg 1982;69:216.
2. Ishii CH Jr, Bostwick J, III, Rain TJ, et al. Double-pedicle transverse rectus abdominis myocutaneous flap
for unilateral breast and chest-wall reconstruction. Plast Reconstr Surg 1986;76:901.
3. Vasconez LO, Psillakis J, Johnson-Giebink R. Breast reconstruction with contralateral rectus abdominis
myocutaneous flap. Plast Reconstr Surg 1983;71:668.
4. Elliott LF, Hartrampf CR Jr. Tailoring of the new breast using the transverse abdominal island flap. Plast
Reconstr Surg 1983;72:887.
5. Hartrampf CR Jr, Bennett KG. Abdominal wall competence in transverse abdominal island flap operations.
Ann Plast Surg 1984;12:139.
6. Hartrampf CR Jr, Bennett KG. Autogenous tissue reconstruction in the mastectomy patient: a critical
review of 300 patients. Ann Surg 1987;205:508.
7. Hartrampf CR Jr. Breast reconstruction with the transverse abdominal island flap. Perspectives Plast Surg
1987;1:123.

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Chapter 382
Transverse Rectus Abdominis Musculocutaneous Flap From The
Scarred Abdomen
J. M. DREVER
EDITORIAL COMMENT
Dr. Drever supplies proven and reliable methods for transferring the TRAM flap, even in patients who have
very scarred abdomens. Readers are encouraged to study this chapter for the safe performance of what
otherwise would be a difficult procedure.
The transverse rectus abdominis musculocutaneous flap gives most satisfying results in breast reconstruction. It
not only has enabled us to create a breast with autogenous tissues that remain soft and supple and identical to
the opposite, but it also improves the looks of the abdomen. It is a torsoplasty in the real sense of the word (1, 2,
3, 4, 5, 6, 7).
INDICATIONS
Transverse rectus abdominis musculocutaneous (TRAM) flaps are not the answer for every patient who
needs a breast reconstruction. They are for the woman who is physically fit
and who would benefit from an abdominal lipectomy. A lean young woman of childbearing age would do
better with the expander-implant reconstruction.
It is most important that the patient be free of any disease that might contribute to postoperative
complications. Since we are dealing with an elective flap transfer, the patient must have a good pulmonary-
cardiovascular status. I do not operate on patients with a previous history of vascular problems, such as
hypertension, peripheral vascular disease, strokes, myocardial infarcts, chronic smoking, or any pulmonary
insufficiency that might have reduced their vital capacity.
It is a good idea to prepare the patient for this operation by asking her to walk 2 to 3 miles per day or to do
the equivalent exercise of her choice. If the patient is obese, make her lose weight through exercise and
have her lower her pulse rate. Also, the patient should be psychologically prepared, meaning she should be
keen and enthusiastic and well informed of how the operation is done and the possible complications. I
show patients preoperative and postoperative photographs and get them in touch with other patients who
have had TRAM flap reconstructions done. This communication with someone who has had a first-hand
experience is very reassuring. Patients arrive at their surgery with a very positive attitude.
ANATOMY
The rectus abdominis muscle pedicle can feed a random flap of the anterior abdominal skin practically in any
direction or shape (see Chapter 379), provided there are enough perforators on the deep epigastric vascular
system to the skin. Therefore, it is very important to conserve undisturbed the vascular integrity of this pedicle.
This means that our dissections should be carried through natural planes, avoiding even coming near these
feeding vessels and maintaining as many musculocutaneous perforators as possible in the base of our flap.

The rectus abdominis muscle pedicle should be a 4- to 5-cm-wide musculofascial strip removed from the most
medial side of the rectus abdominis muscle with the entire rectus fascia attached to it completely. The muscle
and fascia are sectioned transversely at the lower end of the skin flap. In this way, one can preserve the
maximum number of perforators available to the skin flap. This muscle-fascia pedicle carries the circulation of
two territories: the superior epigastric and the deep inferior epigastric arteries. These traverse the undersurface
of the pedicle from the medial side above to the lateral side below. They are both relatively medium sized arteries
(with venae comitantes) until they divide and lose themselves as thin arterioles within the substance of the rectus
muscle. This occurs at the height of the middle transverse septa area, where one has to be most careful with
handling of the muscle pedicle by always keeping it protected by the overlying fascia.
FLAP DESIGN AND DIMENSIONS
The best indication for a TRAM flap for breast reconstruction is the middle-aged woman who is healthy and
would benefit from an abdominal lipectomy. These patients have an average age of 51 years. Often they have
had previous abdominal operations that have transected the right superior epigastric artery. Subcostal scars or
other scars can decrease both the pliability and/or the viability of some parts of the flap. Therefore, when I
choose the design of the flap, I have to reach a basic compromise between the best possible lipectomy with the
most viable flap design. Naturally, the best lipectomy is the one that leaves the shortest and lowest abdominal
scar, and the most viable flap design is the midabdominal. Also, whenever possible, I try to use the contralateral
muscle pedicle. With these parameters in mind, I will analyze the different choices of flaps in patients with
scarred abdominal walls.
Vertical Midline Supraumbilical and the Paramedian Supraumbilical Scar
My first choice in these patients is the lower abdominal transverse rectus abdominis musculocutaneous flap
coupled with a vertical excision of the scar above the flap (Fig. 382.1). The vertical component of this scar is
closed with Z-plasties. This technique gives a good lipectomy, and it is an easier operation because when I
remove the vertical preexisting scar, it gives me a direct approach to the muscle pedicle right up to the xiphoid. In
patients with a vertical paramedian scar, the contralateral muscle pedicle should be used. A scarred muscle
almost invariably has an impaired circulation and should never be used as a pedicle.
Vertical Midline Infraumbilical Scar
This is a very frequently found scar in this age group. It puts out of bounds the contralateral side of a lower
abdominal flap, but the choices are as follows:
1. Using the ipsilateral side of a lower abdominal transverse flap (Fig. 382.2). This is a good choice if there is
enough abdominal wall volume to reconstruct the missing breast. In these patients, I leave this scar in the flap
and suture it to the inframammary fold, because this scar is often contracted and helps give a round fullness in
the lower quadrants of the breast.
2. Using a midabdominal flap when a larger breast is to be reconstructed, necessitating the use of both sides of
the flap (Fig. 382.3). This is a well-vascularized flap, and both sides will survive even if there is still some
remaining scar below the umbilicus. Closure of the abdominal wall is done by creating Z-plasties in the
remaining scar in the suprapubic area.
Infraumbilical Paramedian Scar
When presented with this scar, one has to gauge if there is enough volume in the lower abdomen to use a
LATRAM flap (Fig. 382.4). Naturally, I always use the side opposite to this scar as the muscle carrier. When this
scar is located on the same side as the mastectomy, as it is brought up to the chest, it should be placed in the
desired position and observed. Usually not more than one or two fingerbreadths distal to the scar acquire a

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somewhat pale, cyanotic tinge. All this part should be discarded.
When this scar is on the opposite side of the mastectomy, one is forced to use an ipsilateral muscle carrier. In
these patients, I leave the scar on the flap and suture it to the inframammary fold, which contributes to a nice
round fullness in the lower quadrants.
If a larger mound is desired, such as that provided by an unscarred flap, then I use the midabdominal flap and
close the abdomen by creating Z-plasties in the paramedian scar.
FIGURE 382.1 A: Patients who have vertical, median, or paramedian supraumbilical scars. Use the opposite
muscle pedicle, excise the scar in an inverted V-shaped fashion, and use the lower abdominal transverse flap. B:
The reconstructed breast. The vertical component of the abdominal incision has been closed with Z-plasties.
FIGURE 382.2 A: In patients with a vertical midline infraumbilical scar, I use the ipsilateral side of the lower
abdominal transverse flap if there is enough volume there to reconstruct the missing breast. Vertical mastectomy
scars are excised in an inverted-T fashion, making an incision on the proposed inframammary fold and
undermining the area cephalad to it. B: Appearance 6 years postoperatively. Notice how the nipple in the
reconstructed breast tends to descend and in the reduced breast with inferior pedicle technique tends to ascend.

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FIGURE 382.3 A: When there is a vertical midline infraumbilical scar but both sides of the flap are needed for a
reconstruction, use a midabdominal flap. Closure of the abdominal skin is done by creating Z-plasties in the
remaining scar in the suprapubic area. B: Appearance 2 years postoperatively with some hypertrophic scarring
that will settle down with time.
FIGURE 382.4 A: An infraumbilical paramedian scar. Since there is enough volume to make a breast, I use a
LATRAM flap. Always use the opposite side of this scar as the muscle carrier. Suturing the scar to the
inframammary fold helps give a nice roundness in the lower quadrants of the breast. B: Appearance 5 years
postoperatively. Notice how a nice, well-balanced ptosis is achieved.
Pfannenstiel Scar
The flap of choice here is obviously the lower abdominal transverse, but it is necessary to find out what type of
operation was done through the Pfannenstiel incision because, occasionally, some surgeons, after doing the
transverse skin incision, undermine the anterior rectus sheath off the subcutaneous tissue and therefore sever
important perforators that feed a LATRAM flap (Fig. 382.5). This may lead to surprising and abundant fat
necrosis.
McBurney Scar
This is a frequently found scar that presents no major problems. If it is foreseen that this scar might be included
in the new breast area, it is better to use the opposite muscle carrier.
Kocher Scar
This right subcostal scar is the LATRAM flap's worst enemy. The left rectus muscle must be used as the carrier.
The breast flap will be viable, but there is a very high chance of necrosis developing in the periumbilical area.

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The best choice of flap is the midabdominal flap with the upper incision following the subcostal scar or very near
to it (Figs. 382.6 and 382.7).
FIGURE 382.5 A: In patients with Pfannenstiel scars, before using the LATRAM flap, find out if the previous
surgeon has undermined the area of the perforators. B: Appearance 6 years postoperatively after doing all the
balancing procedures, such as suction lipectomy, nipple-areola reconstruction, and opposite breast reduction.
Another possibility when confronted with Kocher scars is to use the left vertical flap. It is very useful when a
somewhat conical and ptotic breast is desired.
Patients with Multiple Scars
These situations can pose a real challenge to one's imagination. Every patient is different, and one has to plan
for the maximum viability of the flap, coupled with cosmetic improvement to the abdomen and breast. In general,
patients in late middle age do not like large breasts; they prefer a better-balanced figure. In fact, one of the most
common complaints is their difficulty in finding proper clothing. Also, in the surgeon's favor is the fact that since
they already have several scars, they do not mind too much about the location of the next one. This, in fact,
allows the surgeon to place the lipectomy excision in practically any direction. Therefore, all redundant
abdominal fat and skin should be removed either through vertical and/or horizontal excisions. Always use the
muscle pedicle that is not scarred. Finally, consider that two pedicles have a better viability than one, but be well
aware that with the use of a double pedicle, the patient must be warned that she will have
noticeable difficulty for many months moving from a lyingdown to a sitting-up position. This weakness diminishes
with lots of exercise in patients who are really determined, because the action of the rectus is taken over by the
combined efforts of the superior fibers of the external oblique and the psoas muscles.

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FIGURE 382.6 A: The Kocher or subcostal scar. Use the midabdominal flap, making your superior incision
following the subcostal scar. Always use the contralateral muscle carrier. B: Appearance 1 year postoperatively.
The Obese Patient
The obese patient is not a good surgical candidate because the thick fatty layer is associated with decreased
vascularity coupled with an increased friability of the flap (see Fig. 382.7). Also, obese patients usually have a
poor cardiovascular-pulmonary status which contributes to increased postoperative complications. Nevertheless,
you sometimes find an obese person who has great determination and a relatively good cardiovascular status in
spite of being overweight.
FIGURE 382.7 A: The obese patient with a Kocher and an infraumbilical scar. Use the safest flap, which is the
midabdominal, and make the breast only with the tissue overlying the muscle pedicle. B: A recent postoperative
result. The patient still needs contralateral reduction.
Before operating on the obese patient, I do a simple cardiovascular fitness test. If the patient passes this, I
choose the safest flap, which is the midabdominal flap, and I make the breast with only the ipsilateral side of skin
and fat and discard the great majority of the contralateral side.
Obese patients will usually indicate that they want small breasts and as much as possible removed from the
abdomen. This allows one to make a round mound using only the skin and fat directly over the
musculocutaneous perforators (zone 1). Since this fatty subcutaneous layer is so thick, I keep the undermining of
the abdominal wall to a minimum. Once the flap is in the breast area, there is usually no need to deepithelialize
skin because the thick panniculus itself makes the mound. Therefore, suturing can be done edge to edge and
still result in an adequate looking mound. It is important to place these patients on perioperative wide-spectrum
antibiotics.
OPERATIVE TECHNIQUE
Raising the Flap
The operation is performed simultaneously by two teams. The mastectomy scar is excised, and a pocket
cephalad to this scar is undermined over the pectoralis major fascia. The abdominal island is incised, and the fat
is beveled in all areas except over the pubis to bring with the flap as much fat as possible. Then the abdominal
wall is undermined until both anterior rectus sheaths are exposed to a height transversely across the base of the
xyphoid. Then both surgeons, helping each other, fashion a tunnel right over the anterior rectus sheath from the

medial half of the inframammary fold down to the undermined area in the abdomen. A closed fist should pass
easily through this tunnel.
Then two vertical lines are marked over the chosen muscle pedicle, one on the lateral edge of the linea alba from
the base of the xyphoid down to the umbilicus (or to the upper end of the flap). Another line is then marked
parallel to this first one and 4 to 5 cm away, starting at the same horizontal height as the previous, which means
4 or 5 cm above the costal margin, and extending down to the upper end of the flap.
The contralateral side of the skin island flap is then undermined off the anterior rectus sheath and the external
oblique aponeurosis up to the midline. All the perforators are clipped; cautery is not used on the flap itself.
The ipsilateral tail side of the island flap is then elevated. This should be done carefully right over the shiny
fascia. I stop when I am at the same line of the previously marked lateral incision on the rectus sheath.
The anterior rectus fascia is then incised on the previously marked lateral line that should extend up to the costal
margin and down to the lower end of the flap. As the rectus fascia is incised, above the umbilical transverse
septa the rectus muscle is seen, but below this septa there is another fascia that must be incised. It corresponds
to the internal oblique. It is incised at the same level.
When the umbilical part of the rectus muscle is exposed, it is split along its fibers or slid along its lateral border,
and here, floating in the preperitoneal fat, the inferior epigastric artery with its venae comitantes can be seen.
They are clipped and divided at this level. The rectus muscle is split, continuing upward toward the umbilical
transverse septa and right underneath it. The neurovascular bundle is identified, clipped, and divided.
Many times, above the umbilical transverse septa, the muscle fibers run slightly obliquely to the fascial incision.
They should be divided at the same level. On its undersurface, two more lateral neurovascular bundles are
identified and divided. Once the middle transverse septa is reached, the splitting of the muscle is continued at
the same level as the fascial incision. Two more neurovascular bundles are then seen lying right on the shiny
transversus fascia. These are clipped and divided. The muscle is split upward, and the upper transverse septum,
which is located just at the level of the costal margin, is divided. The muscle fiber splitting is continued to where
the previous fascial incision ends.
Access to the undersurface of the muscle from the lateral side is now available. It is retracted medially by simple
blunt dissection, taking care to preserve the already clipped neurovascular bundles attached to the
undersurface of the muscle. This will indicate that the dissection is in the correct plane. The dissection is
continued as far as it will go medially until the linea alba is reached. Control of the lower limits of the
musculofascial pedicle is obtained at this stage by placing fingers in this space. The lower end of the rectus
abdominis muscle and the anterior rectus fascia are divided transversely across just at the lower limits of the skin
flap.
The next step consists of separating the muscle and fascia from the linea alba. This is best done by retracting
the flap and the undersurface of the muscle toward the contralateral side. The anterior rectus sheath is then cut
from its undersurface right at its medial junction with the linea alba. As this is being done, one or two veins above
the semicircular line of Douglas that perforate the posterior rectus sheath near the midline around the umbilical
area are encountered. These are the capitus meducae veins. They should be clipped and divided. The anterior
rectus fascia around the umbilical stalk is divided.
Then the medial edge of the fascia is divided from the linea alba above the umbilicus. For this, heavy Mayo
scissors are used to cut the anterior rectus sheath right at the junction with the linea alba by placing one tip of
the scissors next to the muscle and feeling with it where the medial junction lies.
At this stage, all three edges of the musculofascial pedicle are divided. The next step consists of lifting it from the
posterior rectus sheath. This can be done by careful blunt dissection, leaving all the areolar tissue attached to

P.1028
the undersurface of the muscle. The posterior rectus sheath (transversus tendon or fascia transversalis) above
the semicircular line of Douglas should appear shiny and devoid of any areolar fatty tissue. When the costal
margin is reached, the seventh intercostal neurovascular bundle is identified right under its edge. Ideally, a
selective neurotomy of the nerve should be performed, leaving the artery and veins undisturbed. This is possible
when doing a lower abdominal flap, but when taking a midabdominal flap, the whole neurovascular pedicle must
be sacrificed in order to avoid tenting from this pedicle. It is not convenient to look for, or dissect, the area of the
superior epigastric (internal mammary) pedicle. This might create regrettable vasospasm. The fascia or muscle
should never be divided transversely above the costal margin.
The flap is transferred by passing first the contralateral point facing cephalad. The skin surface is moistened
thoroughly and pushed into the prepared mastectomy area. If it will not pass easily, the tunnel must be enlarged.
Closing the Donor Area
Since a 4- to 5-cm-wide muscle-anterior rectus fascia strip has been removed from the base of the xiphoid down
to the lower end of the skin flap, the incised edges should be returned to the preoperative position. Closing a 4-
to 5-cmwide aponeurotic gap directly will result in a very tight closure that will change the tone of the oblique
muscles, increase the possibility of dehiscence, create considerable postoperative pain, and shift the umbilicus
to one side. Only patients with marked fascial laxity can be closed primarily.
Mersilene mesh is preferable because it is strong, pliable, and does not shred. Prolene is too wiry, and Marlex is
too hard and can be felt through the skin. The Mersilene comes in sheets that measure 20 × 20 cm. They can be
doubled, resulting in a long rectangle (20 × 10 cm).
Below the umbilical transverse septa, it is important to notice that the internal oblique and the transversus
abdominis aponeurosis tendons have a tendency to retract deep to the external oblique. They should be drawn
back and sutured to the edge of the mesh and thus incorporated into the repair. I believe that a running stitch
distributes the forces better than multiple separate stitches because it acts essentially as a complex pulley
system. When doing this closure with mesh, the
patient should be in a straight supine position and flexed only when the skin is about to be sutured.
The umbilicoplasty is done with a V incision of the abdominal skin in order to avoid a circular contracture. A
marked cosmetic benefit can be obtained by removing the fat from the undersurface of this V incision in a radius
of about 5 to 7 cm in a tapered fashion.
In patients in whom the two rectus abdominis muscle pedicles have been used, closure is done following the
same principles. The area of the fascia, including the linea alba, is replaced with one piece of double Mersilene
mesh. The umbilicus is retrieved through a hole in the mesh.
Making the Breast Mound
The first step is to excise the old mastectomy scar, coupled with an incision along the future inframammary fold. If
this scar is transverse or slightly diagonal, it is excised together with the skin between it and the inframammary
fold, taking into account that the inframammary fold will drop 2 to 3 cm when doing the abdominal closure (see
Figs. 382.1A, 382.3A, 382.4A, and 382.5A). If the mastectomy scar is vertical, it is excised and coupled with an
incision on the future inframammary fold, which means that the skin that is removed will have an inverted-T
shape (see Fig. 382.2A).
The pocket cephalad to this scar excision is created in an area symmetrical to that occupied by the opposite
breast. The undermining is always done in the subcutaneous layer. (See the dotted line on the upper quadrants
of part A of all the figures.)

Once the flap is passed into the mastectomy defect, it is rotated in several directions until the ideal position is
found, always considering that the side with the muscle pedicle should be facing downward. In general, when
using a LATRAM flap, the periumbilical area of the flap is sutured to the most medial extremity of the
inframammary fold incision.
The rest of the flap, the ipsilateral end, is tucked under and a curved line is marked exactly where it falls on the
inframammary fold. Naturally, all the buried part of skin is deepithelialized, and the inframammary fold is sutured.
Once this has been done, the amount of the contralateral side (which is going to form the upper quadrants) that
is going to be discarded must be determined.
The upper edge of the chest skin is somewhat tight on the flap, and this is released by making a dart in the area
of the anterior axillary fold (see Fig. 382.5A). The length of this dart is usually 2.5 to 3 cm. The corresponding
skin edge over the flap is then removed from the pocket and deepithelialized. A drain is placed in the operative
site.
In cases of bilateral reconstruction, the flap is transferred ipsilaterally, and the inframammary fold is sutured to
what used to be the midline in the abdominal area.
Secondary Procedures
As early as 6 weeks after a TRAM flap reconstruction, one can do the ancillary procedures that will
enhance the results. These usually consist of a nipple and areola reconstruction, a better definition of the
inframammary fold, the opposite breast reduction, and suction lipectomy to the epigastric and donor-scar
areas.
Nipple and Areola Reconstruction
Before marking the future nipple placement, consider that the reconstructed breast tends to descend about
1 to 2 cm over the course of 1 year, whereas the nipple placement in a reduced breast with the inferior
pedicle technique tends to ascend 1 to 2 cm over the course of 1 year. In general, I choose a place on the
reconstructed breast mound and move the opposite nipple to the symmetrical place marked on the
reconstructed one, taking into account the previously mentioned variations.
The technique of choice to make a nipple is to share half the opposite one. Naturally, this can be done only
if there is sufficient projection of the donor. If there is not, in order of preference, I use composite grafts of
labia minora, local flaps, or earlobe grafts.
The technique of choice to reconstruct the areola is a full-thickness graft of the perimeter of the opposite
areola when it is excessively wide. Adequate color matching also can be obtained by full-thickness grafts
removed from the inner surface of the upper thighs. A simpler technique that gives adequate results is
tattooing. The light brown or tan pigments should be used in Caucasians, and the opposite areola should
also be tattooed. This will result in a much better match. Pigment also can be placed directly on the dermis
of a split-thickness skin graft, thus obviating the need for a tattoo machine. It also gives a very even result.
Definition of the Inframammary Fold
With a patient in the standing position, I mark on the reconstructed breast a symmetrical line to the opposite
inframammary fold. I then do a lipolysis of the deep and superficial fat along the marked line. I then make a
2-cm incision beveled down to the deep dermis but not through it. Then, using a large needle with O
Prolene, I take a bite of the deep fascia and suture it to this exposed dermis and then bury the knot. The
inframammary fold should be fixed like this at least in two spots, in the middle and medially.
Opposite Breast Reduction
Depending on the size of the opposite breast, I do either a mastopexy, an inferior or central pedicle

P.1029
reduction, or a free nipple graft. Very frequently I choose the free-nipple graft technique because it is the
most versatile with regard to the shape of the breast and placement of the nipple-areola complex. It also
removes the central and lower quadrants of the breast tissue with a consequent oncologic and psychologic
benefit for the patient.
Suction Lipectomy Touch-ups
Autogenous breast reconstructions can be looked on as a torsoplasty where cosmetic improvements are
brought to the breast and the abdominal area. Suction lipectomy is the ideal technique to complement a
TRAM flap reconstruction. Suction can be used to soften up areas of fat necrosis in the reconstructed
breast and to define the inframammary fold as described. It is used commonly to decrease the bulge created
by the twisted muscle pedicle in the epigastrium and to enhance a natural depression in the periumbilical
area. Another favorite place for suction is the area just above the transverse abdominal scar and on both
flanks.
SUMMARY
TRAM flap breast reconstruction is intended to be a torsoplasty, a combined thoracoabdominoplasty with
the inherent benefits to both areas. It is done on the mastectomy patient who is healthy and who would
benefit from an abdominal lipectomy. Maximum viability of the flap is obtained by preserving as many of the
musculocutaneous perforators as possible under the skin flap and removing the muscle with the fascia
attached to it. The operation is performed by a team, thus allowing each surgeon to concentrate in his or
her own area of expertise, with a marked reduction in the operating time.
References
1. Drever JM. The epigastric island flap. Plast Reconstr Surg 1977;59:343.
2. Mathes SJ, Bostwick J III. A rectus abdominis myocutaneous flap to reconstruct abdominal wall defects. Br
J Plast Surg 1977;30:282.
3. Hartrampf CR, Sheflan M, Black PW. Breast reconstruction with the transverse abdominal island flap.
Plast Reconstr Surg 1982;69:216.
4. Elliott LF, Hartrampf CR Jr. Tailoring of the new breast using the transverse abdominal island flap. Plast
Reconstr Surg 1983;72:887.
5. Vasconez LO, Psillakis J, Johnson-Giebink R. Breast reconstruction with contralateral rectus abdominis
myocutaneous flap. Plast Reconstr Surg 1983;71:668.
6. Ishii CH Jr, Bostwick J III, Rain TJ, Coleman JJ III, Hester TR. Double-pedicle transverse rectus abdominis
myocutaneous flap for unilateral breast and chest-wall reconstruction. Plast Reconstr Surg 1986;76:901.
7. Hartrampf CR Jr. Breast reconstruction with the transverse abdominal island flap. Perspectives Plast Surg
1987;1:123.

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Chapter 383
Microvascular Free Transfer of A Groin Skin Flap
K. HARII
EDITORIAL COMMENT
Although Dr. Harii no longer performs breast reconstruction with a free groin flap, the editors felt that the
inclusion of this chapter is warranted, as it was one of the first flaps that reconstructed the breast without an
implant.
Advances in musculocutaneous flaps over the past several years have brought about easy and reliable
procedures for reconstruction of breast defects. However, such secondary problems as scars and disfigurement
of donor sites after removal of both muscle and skin may occur. For these reasons, the free groin flap becomes a
good candidate for reconstruction of the female breast and chest wall, even though the operative procedure is
more complex than for musculocutaneous flaps (1, 2, 3).
OPERATIVE TECHNIQUE
The most important key to satisfactory results is selection of the recipient vessels (4), because it is usually
difficult to expose suitable vessels in the axillary region after a radical mastectomy. Also, vessels may be heavily
irradiated and degenerative. Interpositional vein grafts from the axillary artery with end-to-side anastomoses have
been used (1) to create a new recipient artery that can form a bridge between the axillary artery and the
superficial circumflex iliac artery of the groin flap placed in the breast defect. However, this procedure appears to
be hazardous and risky.
In patients in whom recipient vessels are not available in the axillary region, I recommend use of the
gastroepiploic vessels. Through an upper median laparotomy, the gastroepiploic vessels are dissected from their
attachment to the stomach as a long vascular cord and are transposed to the recipient chest wall through the
abdominal wall. A new vascular stump is thus created at an adequate site in the recipient bed (Fig. 383.1).
Taking the complex vascular anatomy into consideration, a free groin flap of required size is elevated (see
Chapter 136). If the patient requires reconstruction of the breast mound after radical mastectomy, as much as
possible of the fatty tissue in the groin should be included in the flap to augment the chest wall. Planning usually
includes placing a silicone implant of suitable size beneath the flap in a second stage procedure to obtain breast
mound symmetry (Fig. 383.2).

FIGURE 383.1 A 32-year-old woman with breast loss and unstable scars following radical surgery for carcinoma.
There was no evidence of recurrence. A: Preoperative view. B: Defect after debridement and transposed
gastroepiploic vessels. The diameters of the artery and vein at the distal stump of the vascular stalk were 1.8
and 2.0 mm, respectively. (Continued)
FIGURE 383.1 Continued. C: A groin flap 10 × 14 cm was elevated, along with excess fatty tissue, and
transferred with vascular anastomoses between the superficial epigastric artery and the cutaneous vein. D:
Appearance 6 months postoperatively. (From Harii et al., ref. 2, with permission.)

FIGURE 383.2 A: Result following radical mastectomy. Note that the defect was extensively covered with a split-
thickness skin graft. B: Postoperative result. The recipient vasculature was the axillary artery and venae
comitantes. Note the correction of the infraclavicular hollow. The implant and nipple-areola reconstruction are
each completed in separate stages. (From Serafin et al., ref. 5, with permission.)
SUMMARY
A free groin flap is an alternative to other methods of breast reconstruction.
References
1. Serafin D, Given, KS. Reconstruction of the thorax and breast following radical mastectomy. In: Serafin D,
Buncke HJ, eds. Microsurgical composite tissue transplantation. St. Louis: Mosby, 1979;541.
2. Harii K, Ohmori S, Torii S, et al. Free groin skin flaps. Br J Plast Surg 1975;28:225.
3. Harii K. Free-Flap Surgery. In: Jackson IT, ed. Recent advances in plastic surgery. Edinburgh: Churchill
Livingstone, 1981;67.
4. Harii K, Ohmori S. Use of the gastroepiploic vessels as recipient or donor vessels in the free transfer of
composite flaps by microvascular anastomoses. Plast Reconstr Surg 1973;52:541.
5. Serafin D, Georgiade NG, Given KS. Transfer of free flaps to provide well-vascularized, thick cover for
breast reconstructions after radical mastectomy. Plast Reconstr Surg 1978;62:527.

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Chapter 384
Microvascular Free Superficial Inferior Epigastric Artery (Siea)
Flap
R. J. ALLEN
MARY E. LESTER
EDITORIAL COMMENT
If the SIEA is present, this is an excellent technique and completely avoids muscle dissection.
Breast reconstructive surgeons have long recognized the advantages of the lower abdomen as a donor site. In
1982, Dr. Hartrampf (1) introduced the transverse rectus abdominis myocutaneous (TRAM) flap. More recently,
the use of the lower abdominal tissues sparing the rectus muscle has reduced donor-site morbidity while
providing adequate amounts of tissue for breast reconstruction. A flap based on the superficial inferior epigastric
artery (SIEA) harvests tissue superficial to
the rectus sheath and provides a direct cutaneous blood supply, allowing more versatility in surgical planning
and application.
INDICATIONS
The SIEA flap was first described by Wood (2) as a pedicled flap for burn contracture of the hand in 1863. It
was mentioned for use in the lower extremity as a free flap or in the thigh as an island flap (3). As limb
reconstruction frequently demands a large, thin, pliable flap, the SIEA flap provides a large area of skin with
variable subcutaneous thickness, depending on the body habitus of the patient. The large surface area is
useful in covering head and neck defects. Koshima (4)described a deepithelialized SIEA flap to correct
facial contour in hemifacial atrophy and other defects. The SIEA flap has been used to reconstruct the
trunk, as a pedicled flap to correct contralateral abdominal wall defects, pelvic floor defects, and pressure
sores (3). It is ideal for use in breast reconstruction, including partial breast reconstruction (5).
ANATOMY
The superficial inferior epigastric artery is a direct cutaneous artery that supplies the skin of the lower abdominal
wall. The SIEA networks with other vessels supplying the abdominal wall, including the superficial and deep
circumflex iliac arteries, superior and inferior deep epigastric arteries, and external oblique perforators. Taylor (6)
believes that it is this network of choke vessels that allows the entire lower abdomen to be supported by a
unilateral deep inferior epigastric artery or SIEA.
Taylor also found the SIEA present in 65% of 46 cadaver dissections. Allen and Heitland's study of 100 cadaver
dissections (7) found a 72% presence of the SIEA. In 58% of cadavers, the SIEA was present bilaterally. The
average pedicle diameter at the inguinal ligament was 1.6 mm (range, 0.75 to 3.5 mm), and at the origin was 2.9
mm (range, 2.0 to 4.0 mm). Pedicle length can vary between 7 and 11 cm.
The pedicle most commonly shares an origin with the superficial circumflex iliac artery, present in 79% of
cadaver dissections, but can also have a separate origin from the femoral artery. In either case, the origin is 2 cm

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caudal to the inguinal ligament. The artery courses superficially and cephalad through the femoral sheath and
pierces the cribriform fascia (8). It then travels just superficial to Scarpa's fascia toward the inguinal ligament. It
crosses the inguinal ligament lateral to the midpoint between the pubic tubercle and anterior superior iliac spine
(ASIS). It then continues just superficial to Scarpa's fascia as it travels cephalad. The course of the SIEA then
varies, as it can travel toward the umbilicus or laterally toward the ASIS.
The superficial inferior epigastric vein (SIEV) supplies venous drainage of the abdomen along with the venae
comitantes of the SIEA. The SIEV lies more superficial than the SIEA, often just underneath the skin. It is also
found medial to the midpoint between the ASIS and pubic tubercle. Its origin is the saphenous bulb. The comitant
vein is more commonly used for anastomosis.
Problems can be encountered when the pedicle diameter is inadequate for flap harvest. The pedicle diameter at
the trunk is unknown until the end of the dissection, when the presence or absence of a common trunk is seen.
However, the lower abdominal tissue can also be harvested with the deep inferior epigastric artery or the
contralateral SIEA. An SIEA of 1 mm or greater at the level of the inguinal ligament is adequate for flap viability
(9). Another difficulty can be previous abdominal surgery, including liposuction. We have not offered DIEP or
SIEA flaps to patients with previous liposuction. Patients with lower-midline scars are precluded from carrying the
entire abdomen with one pedicle; however, most are able to have a DIEP or SIEA if the vessel has not been
transected. Preoperative bedside Doppler examination can aid in identifying the presence of the SIEA but is
unreliable in assessing its size.
FLAP DESIGN AND DIMENSIONS
The most common flap design is horizontal because the parous patient frequently has an excess of lower
abdominal skin and fat. The flap design is drawn on the standing patient from the ASIS to above the umbilicus to
the contralateral ASIS. The second portion of the ellipse is drawn from the ASIS to just above the pubic hairline
to the ASIS, similar to a standard abdominoplasty incision. However, if less tissue is needed, the cephalad mark
can be drawn below the umbilicus, avoiding umbilical transposition (Fig. 384.1).
The flap design is drawn on the patient 1 day before surgery. The patient is then placed supine for Doppler
examination. The SIEA, SIEV, and deep inferior epigastric perforators are marked. Vertical and oblique patterns
have also been described but are typically used with the pedicled technique. These designs are based on the
path of the superior inferior epigastric artery determined by Doppler examination.
OPERATIVE TECHNIQUE
The procedure is performed with a two-team approach. If the reconstruction is performed immediately, flap
harvest can begin simultaneous with the mastectomy. The second team prepares the skin envelope and the
internal mammary recipient
vessels. The skin envelope is inspected at the inframammary fold and lateral aspect of the breast. If necessary,
these can be recreated with tacking sutures. The internal mammary vessels are exposed by separating the
pectoralis major muscle along its fibers above the third rib. The internal mammary perforators are examined and,
if of sufficient size, they are then used for recipient vessels. If the internal mammary perforators are inadequate,
then the second interspace is explored.

FIGURE 384.1 Modified horizontal flap design with smaller flap design. Superficial inferior epigastric artery
(SIEA) marked in red. Patient had a congenital breast deformity and underwent an augmentation with an SIEA
flap. She did not need umbilical transposition.
The medial border of the pectoralis major is incised from the sternum, and the second interspace is entered. The
intercostal muscles are removed from the second interspace while the dissection remains superficial to the fat
pad overlying the internal mammary artery and vein. The artery and vein are then exposed after intercostal
muscle removal. Rib cartilage can be removed for a narrow interspace or access to a branching internal
mammary vein.
Flap harvest is begun by incising the lower portion of the flap design. The SIEV is preserved because it is
frequently used to aid in drainage of venous congestion that occurs in either SIEA or DIEP flaps. The SIEV is
usually very superficial and can be seen underneath the skin. Under loupe magnification, the SIEV is dissected
to the level of the inguinal ligament. The SIEA, which lies lateral to the SIEV, is frequently deep within the
superficial layer of subcutaneous tissue just superficial to the Scarpa fascia. It is dissected to the level of the
inguinal ligament. It takes a sharp turn deep into the subcutaneous tissue around the inguinal ligament as it
travels toward its origin. Typically, the superficial circumflex artery joins the SIEA before its origin at the common
femoral artery. If the SIEA is inadequate, then the contralateral SIEA or deep inferior epigastric artery is explored.
Further flap design depends on the type of reconstruction (i.e., unilateral or bilateral). If bilateral reconstruction is
performed, the flap can be divided in the midline from the contralateral side. Flap harvest is then performed in a
similar fashion. If unilateral reconstruction is performed, the flap is elevated from the anterior rectus sheath, and
the superior flap design is incised. The flap is weighed to compare with the mastectomy specimen weight and to
aid in size approximation.

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FIGURE 384.2 A: Left hemiabdomen. Flap is weighed and then used to reconstruct the patient's right breast. B:
The left hemiabdomen is rotated 180 degrees and secured to the patient with sutures for microvascular
anastomosis. C: The left hemiabdomen is rotated 90 degrees counterclockwise for inset. The caudal edge of the
flap is now medial, and the lateral corner of the flap points toward the axillary tail of the breast.
The extent to which the SIEA flap can cross the midline depends on the course of the SIEA within the abdominal
tissue. The network of vessels supplying the abdominal wall (10) can allow the flap to survive past the midline.
Traditionally, zones I, II, and III, as described by Rickard (11) and Holm and colleagues (12), survive, and zone IV
is in question. However, Ulusal (9) reports good survival rates of zone IV with 92.3% of the abdomen used for
SIEA donor vessels. Most authors agree that a previous midline incision precludes extending the SIEA flap
across the midline; however, low transverse incisions usually do not interfere with the blood supply of the SIEA
or DIEP.
Routinely, the contralateral side is used for flap inset. The flap is rotated 180 degrees clockwise so that the
caudal edge of the flap with donor vessels is cephalad. This edge (caudal edge of the flap) is temporarily
secured to the breast skin during the anastomoses (Fig. 384.2). The venous and arterial anastomoses are
performed under the operating room microscope. The venous anastomosis is frequently performed with the aid
of the Synovis Microvascular Anastomotic Coupler System (Synovis Life Technologies, Minneapolis, MN). The
flap is turned 90 degrees counterclockwise for inset, so that the caudal edge of the flap is now medial, and the
lateral edge of the flap points toward the axillary tail of the breast.
Skin paddles are used for flap monitoring, if a skin Doppler signal can be identified. Ancillary staff are trained to
check Doppler signals, color, turgor, capillary refill, and temperature. If a skin signal cannot be found, an
implantable Doppler
probe is placed. The breast skin incisions are closed with subcuticular sutures and Dermabond glue; no
dressings cover the breast. Breasts are drained with closed suction drainage distant from anastomosis. Surgical
bras are placed on patients with pendulous breasts to prevent separation of pedicle from recipient vessels. The
abdominal donor site is closed in standard abdominoplasty fashion over suction drainage.

FIGURE 384.3 A: Preoperative photograph of 51-year-old patient undergoing delayed reconstruction for breast
cancer. B: Postoperative photograph of same patient after delayed reconstruction with SIEA.
Other options for flap harvest include the bilateral inferior epigastric artery flap (BIEF) or thinning of the flap. The
BIEF is a large flap and involves dissection of the SIEA, superficial circumflex iliac artery, and deep inferior
epigastric artery (13). The SIEA flap can be thinned relatively safely by relying on its anatomy. The SIEA is
superficial to the Scarpa fascia, and therefore, the subcutaneous tissue deep to the Scarpa fascia can be
removed.
CLINICAL RESULTS
Microsurgical free flaps are associated with a learning curve that is dependent on surgeon expertise. The
SIEA can be challenging, but the dissection of a direct cutaneous artery is less demanding than that of a
perforator flap. As SIEA flap applications have increased, the reliability and predictability have also
improved. The first reports of the SIEA as a free flap are case reports from the 1970s. One of the earlier
series by Hester (3) demonstrated 16 SIEA free-flap attempts with two failures (12.5%). One flap was lost,
and one did not have suitable vessels. More recent series show failure rates between 0 and 8.3% (14, 15).
Our experience includes 233 flaps for breast reconstruction and augmentation since 1997 with one total flap
loss (0.43% flap-loss rate). The age range for patients is 15 to 70 years. Indications include augmentation
for symmetry with cancer reconstruction and for congenital breast deformities. Breastreconstruction cases
include immediate and delayed breast reconstruction with 121 and 78 flaps, respectively (Fig. 384.3).
Reconstruction after previous failed implant attempts has been performed with the SIEA in 34 cases.
Bilateral SIEA flap procedures have been performed in 35 patients.
SUMMARY
The SIEA free flap is an ideal flap for breast reconstruction. It allows harvest of a large amount of skin and
fat from the lower abdomen while minimizing donor-site morbidity and eliminating the risk of hernia. Its
location also allows alternative procedures, such as the DIEP, if the pedicle is inadequate. It has a fairly
consistent pedicle that is present in 76% of groins. Its direct cutaneous supply allows a versatile and thin
flap that can be applied to many soft-tissue defects.
References

1. Hartrampf CR, Scheflan M, Black W. Breast reconstruction with a transverse abdominal island flap. Plast
Reconstr Surg 1982;69:216.
2. Wood J. Extreme deformity of the neck and forearm. Med Chair Trans 1863;46:161.
3. Hester TR, Nahai F, Beegle PE, Bostwick J. Blood supply of the abdomen revisited, with emphasis on the
superficial inferior epigastric artery. Plast Reconstr Surg 19847;4:657.
4. Koshima I. Short pedicle superficial inferior epigastric artery adiposal flap: new anatomical findings and the
use of this flap for reconstruction of facial contour. Plast Reconstr Surg 2005; 116:1091.
5. Rizzuto RP, Allen RJ. Reconstruction of a partial mastectomy defect with the superficial inferior epigastric
artery (SIEA) flap. J Reconstr Microsurg 2004;20:441.
6. Taylor GI, Daniel RK. The anatomy of several free flap donor sites. Plast Reconstr Surg 1975;56:243.
7. Allen R, Heitland A. The superficial inferior epigastric artery flap for breast reconstruction. Semin Plast
Surg 2002;16:35.
8. Ninkovic M. Superficial inferior epigastric artery perforator flap. In: Blondeel PN, Morris SF, Hallock GG,
Neligan PC, eds. Perforator flaps: anatomy, technique and clinical applications. St. Louis: Quality Medical
Publishing, 2006;405-419.
9. Ulusal BG, Cheng MH, Wei FC, et al. Breast reconstruction using the entire transverse abdominal
adipocutaneous flap based on unilateral superficial or deep inferior epigastric vessels. Plast Reconstr Surg
2006;117:1395.
10. Taylor GI. Discussion: Blood supply of the abdomen revisited, with emphasis on the superficial inferior
epigastric artery. Plast Reconstr Surg 1984;74:667.
11. Rickard R. TRAM and DIEP flap zones. Br J Plast Surg 2001;54:272.
12. Holm C, Mayr M, Hofter E, et al. Perfusion zones of the DIEP flap revisited: a clinical study. Plast
Reconstr Surg 2006;117:37.
13. Buncke H. Bilateral inferior epigastric artery flap (BIEF). In: Microsurgery: transplantation-replantation.
An atlas text. Philadelphia: Lea & Febiger, 1991;167-186.
14. Stern HS, Nahai F. The versatile superficial inferior epigastric artery free flap. Br J Plast Surg
1992;45:270.
15. Chevary PM. Breast reconstruction with superficial inferior epigastric artery flaps: a prospective
comparison with TRAM and DIEP flaps. Plast Reconstr Surg 2004;114:1077.

Chapter 385
Microsurgical Free Transfer of A Latissimus Dorsi
Musculocutaneous Flap
D. SERAFIN
D. J. GOODKIND
EDITORIAL COMMENT
Although generally supplanted by the free Transverses Rectus Abdominal Flap (TRAM), this flap still has a
place in some selected patients for breast reconstruction.
Breast reconstruction following mastectomy has become a major concern of the plastic surgeon during the past
two decades. In recent years, women have been reluctant to accept the mutilating consequence of an ablative
mastectomy. As new methods have become available, patients have sought consultation for reconstruction in
increasing numbers (1).
INDICATIONS
A radical mastectomy with ligation of the neurovascular pedicle does not preclude the safe transfer of an
ipsilateral latissimus dorsi musculocutaneous flap (2, 3). Viability of the muscle is ensured, provided a
vascular pedicle from the serratus anterior muscle is included with the transferred latissimus dorsi muscle.
The muscle is usually atrophic, however, and is less suitable for reconstruction of large defects. The
quantitative deficiency that exists following radical mastectomy is accentuated by postoperative irradiation.
In these patients, one can sometimes detect upper extremity edema with limitation of abduction and external
rotation, radiation osteitis, osteoradionecrosis, and brachial plexus neuropathy (4). Thus the combination of
both qualitative and quantitative deficiencies of the anterior thoracic wall would render such a defect not
amenable to reconstruction with the ipsilateral latissimus dorsi musculocutaneous flap.
Recently, the rectus abdominis musculocutaneous flap has been popularized for breast reconstruction (5,
6). This flap has proven its reliability and is a viable alternative to the latissimus dorsi musculocutaneous
flap. In past publications, it was felt that approximately 9 percent of patients requiring reconstruction would
benefit most from the microvascular method (7). It would appear that there are fewer indications for the
microvascular method following the recent introduction of the rectus abdominis musculocutaneous flap.
The rectus abdominis musculocutaneous flap has an unacceptable flap morbidity rate under certain
circumstances: (1) in extremely obese patients, and (2) in patients with midtransverse or lateral oblique
abdominal incisional scars (i.e., the longitudinal blood supply of either the ipsilateral or the contralateral
rectus abdominis muscle is interrupted).
Finally, with severe qualitative and quantitative deficiency of the anterior thoracic wall, muscle or
musculocutaneous flap reconstruction might be indicated to restore an adequate blood supply to this
relatively avascular area. Thus patients with skin breakdown, osteoradionecrosis, or brachial plexus
neuropathy are best treated with microsurgical muscle transplantation. The rectus abdominis
musculocutaneous flap would not be suitable for reconstruction in these patients primarily because of the
extensive undermining that is a necessary part of the dissection and the relatively scarce blood supply in
the transferred cutaneous paddle.

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Another reason to select the microsurgical method is the previous failure of a conventional
musculocutaneous flap. In spite of meticulous preoperative preparation, flap morbidity and failure occur with
a predictable rate. Salvage of the reconstructive effort can be accomplished with the microsurgical method.
ANATOMY
The latissimus dorsi is a broad, flat muscle that originates from the lower six thoracic vertebrae, the posterior
layer of the lumbar fascia, and the medial aspect of the iliac crest. From this extensive origin, the fibers course
superolaterally toward the axilla, inserting into the intertubercular groove of the humerus.
The dominant blood supply to the latissimus dorsi muscle is the thoracodorsal artery, a branch of the
subscapular artery (Fig. 385.1). The subscapular artery arises from the second portion of the axillary artery. At its
origin, it is approximately 4 to 5 mm in external diameter. At approximately 2 to 3 cm from its origin, the
subscapular artery divides into the
circumflex scapular artery, which courses through the triangular space posteriorly, and the thoracodorsal artery,
which continues inferiorly and laterally to supply the latissimus dorsi and serratus anterior muscles.
FIGURE 385.1 Illustration depicting the vascular anatomy of the latissimus dorsi muscle or musculocutaneous
flap. Note that the effective pedicle length is 8 to 9 cm.
Average diameters of the thoracodorsal artery and vein are approximately 2.7 to 3.4 mm, respectively, at their
origin and approximately 1.6 mm as they enter the muscle. The length of the vascular pedicle is approximately 9
cm. In 86 percent of dissected muscles, the artery was found to branch immediately upon entering the muscle
body (8). A lateral or longitudinal branch was found to course toward the iliac crest approximately 2.1 cm from the
lateral muscle edge. An upper transverse or horizontal branch was noted to course medially 3.5 cm from the
upper edge of the muscle. In approximately 14 percent of dissected specimens, no transverse branch could be
identified.
The nerve to the latissimus dorsi muscle, the thoracodorsal nerve, arises from the posterior cord of the brachial
plexus and can usually be identified approximately 3 cm medial to the subscapular artery in the axillary dissection

(8, 9, 10).
FLAP DESIGN AND DIMENSIONS
Preoperative markings are always performed with the patient upright and awake. The contracting, viable
latissimus dorsi muscle should be identified by palpation and inspection. The proper size of the cutaneous
paddle is outlined according to the requirements of the recipient defect. If a cutaneous paddle greater than 9 to
10 cm in width is required, then the donor site cannot be closed primarily. Since postoperative donor-site
morbidity is much greater following split-thickness skin grafting, every effort is made to close the donor site
primarily.
OPERATIVE TECHNIQUE
The cutaneous paddle and associated muscle on its vascular pedicle can always be isolated through the
posterior thoracic incision. The most posterior extent of the donor site is then closed, and the patient is then
rotated to a more supine position.
Recipient vasculature can usually be identified in one of three locations: (1) the axilla, (2) the costochondral
junction, and (3) the neck. Patients who have satisfactory abduction of the ipsilateral extremity and minimal
edema are candidates for axillary exploration of the recipient vasculature (Fig. 385.2). The latissimus dorsi
musculocutaneous flap has a lengthy pedicle, as outlined previously. This facilitates end-to-side anastomoses to
the axillary artery and/or vein. Frequently, an axillary vena comitans accompanies the axillary artery and can be
isolated. An end-to-end anastomosis is then performed between the thoracodorsal vein and the vena comitans. A
frequent finding during axillary exploration is that the thoracodorsal artery was previously ligated, but that the
circumflex scapular artery is patent. This permits an end-to-end anastomosis between the thoracodorsal artery of
the flap and the recipient circumflex scapular or subscapular artery.
Every attempt is made to identify and isolate the donor nerve to the latissimus dorsi muscle. A neural coaptation
is then performed between the transplanted donor tissue and the thoracodorsal nerve following neuroma
excision.
Occasionally, recipient vasculature can be isolated at the costochondral junction. A portion of the rib cartilage is
excised, exposing the internal mammary artery. Frequently, two veins accompany the artery. This may present
some difficulty when the venous anastomosis is performed. The thoracodorsal vein is usually not duplicated and
is of large external diameter.
Patients with radiation changes should have the initial exploration for isolation of the recipient vasculature in the
neck. This can be accomplished through a transverse incision exposing branches of the external carotid artery
and superficial facial veins. An end-to-end anastomosis is performed to the thoracordorsal artery and vein of the
flap. The lengthy vascular pedicle is sufficient to permit placement of the composite tissue on the thorax,
obviating the use of an interpositional vein graft.
CLINICAL RESULTS
Using the microsurgical method of reconstruction, the latissimus dorsi musculocutaneous flap has been
transplanted in 15 patients without any flap morbidity or failure. This method is both useful and reliable
when performed on a certain subgroup of patients requiring reconstruction of the breast and thorax.
SUMMARY

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The primary indication for reconstruction of the breast and thorax using the microsurgical method is the
failure to employ the ipsilateral island latissimus dorsi musculocutaneous flap and/or either rectus abdominis
musculocutaneous flap. Patients with an extensive qualitative and quantitative deficiency of cutaneous
cover associated with sequelae secondary to irradiation are best treated with the microsurgical method.
FIGURE 385.2 A: Preoperative photograph of a patient who had undergone a previous left radical
mastectomy with subsequent wound breakdown and healing by secondary intention. The patient also
received postoperative irradiation. The latissimus dorsi muscle could not be palpated, indicating injury to the
thoracodorsal nerve at the time of mastectomy. B: Intraoperative photograph demonstrating the cutaneous
paddle attached to the underlying latissimus muscle prior to transplantation. C: Illustration depicting transfer
of the latissimus dorsi musculocutaneous flap. Note end-to-side anastomosis of the thoracodorsal artery to
the axillary artery and end-to-side anastomosis of the axillary vein to the thoracodorsal vein. The neuroma
of the thoracodorsal nerve was excised and an anastomosis performed. (Insert) Completed reconstruction
with silicone prosthesis placed beneath the latissimus muscle. D,E: Late postoperative result.

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References
1. Clifford E, Clifford M, Georgiade N. Breast reconstruction following mastectomy: I. Social characteristics of
patients seeking the procedure. Ann Plast Surg 1980;5:341.
2. Bostwick J, Vasconez LO, Jurkiewicz MD. Breast reconstruction after radical mastectomy. Plast Reconstr
Surg 1978;61:682.
3. Muhlbauer W, Olbrisch R. The latissimus dorsi myocutaneous flap for breast reconstruction. Chir Plast
1977;4:27.
4. Serafin D, Deland M, Lesesne C, et al. Reconstruction with vascularized composite tissue in patients with
excessive injury following surgery and irradiation. Ann Plast Surg 1982;8:35.
5. Hartrampf CR Jr, Scheflan M, Buck PW. Breast reconstruction with a transverse abdominal island flap.
Plast Reconstr Surg 1982;69:216.
6. Marino H Jr, Dogliciti P. Mammary reconstruction with bipedicle abdominal flap. Plast Reconstr Surg
1981;68:933.
7. Serafin D, Voci VE, Georgiade NG. Microsurgical composite tissue transplantation: indications and
technical considerations in breast reconstruction following mastectomy. Plast Reconstr Surg 1982;70:24.
8. Tobin GR, Schusterman BA, Peterson GH, et al. The intramuscular neurovascular anatomy of the
latissimus dorsi muscle: the basis for splitting the flap. Plast Reconstr Surg 1981;67:637.
9. Bartlett SP, May JW Jr, Yaremchuk MJ. The latissimus dorsi muscle: a fresh cadaver study of the primary
neurovascular pedicle. Plast Reconstr Surg 1981;67:631.
10. Maxwell GP, Manson PN, Hoopes JE. Experience with 13 latissimus dorsi myocutaneous free flaps. Plast
Reconstr Surg 1979;64:1.

Chapter 386
Microvascular Free Transfer of A Gluteal Musculocutaneous Flap
T. FUJINO
EDITORIAL COMMENT
This chapter and the next cover the same subject. Because they were felt to complement each other, they
have been left intact as separate chapters.
The gluteus maximus musculocutaneous flap has been proven worthwhile as an alternative technique in breast
reconstruction (1, 2, 3).
INDICATIONS
Primary indications for the use of this procedure are (1) congenital unilateral absence of the breast, (2)
primary reconstruction of the breast after standard radical mastectomy, and (3) secondary reconstruction of
the breast after standard radical mastectomy.
ANATOMY
The major gluteal muscle, the largest and most superficial muscle in the region, is a broad and thick quadrilateral
mass forming the prominence of the buttock. It arises from the posterior gluteal line of the ilium and the rough
area of bone, including the crest immediately above and behind it, from the aponeurosis of the erector spinae,
from the dorsal surface of the lower part of the sacrum and the side of the coccyx, from the sacrotuberous
ligament, and from the gluteus aponeurosis fascia covering the gluteal medius.
The fibers descend obliquely and laterally. The upper and larger part of the muscle, together with the superficial
fibers of the lower part, ends in a thick, tendinous lamina that passes lateral to the greater trochanter and is
attached to the iliotibial tract of the fascia lata. The deeper fibers of the lower part of the muscle are attached to
the gluteal tuberosity between the vastus lateralis and adductor magnus. Its superficial surface is related to a thin
fascia that separates it from subcutaneous tissue, its deeper surface to the ilium, sacrum, coccyx, and
sacrotuberous ligament, part of the gluteus medius, piriformis, gemelli, obturator internus, greater trochanter, and
the attachments of biceps femoris, semitendinosus, semimembranosus, and adductor magnus.
The superficial division of the superior gluteal artery reaches the deep surface of the muscle between the
piriformis and gluteus medius. Then it creeps along the deep surface of the major gluteal muscle and perforates
through the muscle, distributing the perforating branches to the subcutaneous adipose tissue and skin.
The major gluteal muscle is innervated by the inferior gluteal nerves L5 and S1 and S2.
FLAP DESIGN AND DIMENSIONS
The upper third of the major gluteal muscle, attached with the subcutaneous adipose tissue and skin, is used as
a free musculocutaneous flap. The skin flap is designed within the skin territory of the superior gluteal artery, and
its long axis runs from the upper sacrum to the greater trochanteric region (Fig. 386.1). It measures 15 cm in
length, 10 cm in width, and 10 cm in thickness.

The donor flap is outlined in an elliptical fashion from the upper sacrum to the greater trochanteric region. The
amount of skin is equal to the proposed skin defect for a standard radical mastectomy. The adipose tissue taken
is greater than that of the overlying skin and enough to fill up the subcutaneous tissue defect following the
radical mastectomy (Fig. 386.2).
OPERATIVE TECHNIQUE
Dissection is started from the upper edges of the ellipse, going to, beyond, and returning to the upper edge of
the major gluteal muscle. Then blunt dissection is carried out between the major and middle gluteal muscles from
the sacral region toward the greater trochanteric region and then split off the upper third of the major gluteal
muscle toward the sacrum. The superior gluteal artery and vein are exposed between the middle gluteal muscle
and piriformis muscles near the sacrum. The superior gluteal vessels are prepared, and the major gluteal muscle
proximal to them is then severed (Fig. 386.3).
FIGURE 386.1 Free flap designed within the skin territory of the superior gluteal artery.
Congenital Unilateral Absence of the Breast
Preoperative angiography is performed in order to determine the size and location of the recipient vessels.
Usually, the thoracoacromial vessels are chosen. The thoracoacromial vessels are dissected out through a
lateral thoracic incision. The entire anterior chest is undermined by a combination of sharp and blunt dissection
techniques. Complete hemostasis is secured prior to microvascular anastomosis (Fig. 386.4A).
FIGURE 386.2 Free musculocutaneous gluteal flap. Preoperative design on hip. Skin incision corresponds to the