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

Chapter 407
Pectoralis Major Muscle and Musculocutaneous Flaps
S. ARIYAN
EDITORIAL COMMENT
It is important that all the exposed cartilage be removed when debriding the chest wall and prior to coverage
with the pectoralis major muscle. The use of ribs to bridge the bony defect has often been found to be
unnecessary.
The pectoralis major can be used to reconstruct various chest-wall defects. Depending on the circumstances,
either a muscle or musculocutaneous flap can be used.
ANATOMY
See Chapter 135.
OPERATIVE TECHNIQUE
See Chapter 135.
If the wound is not reconstructed during the initial operation, it is imperative that quantitative bacterial counts be
taken to determine that the levels are less than 105 organisms per gram and that the infection is under control.
Rib grafts may be necessary for a flail or unstable rib cage. The chest cage may still remain stable with resection
of the entire sternum if the manubrium is intact. However, rib grafts may still be useful in these patients to provide
some protection to the underlying heart (Fig. 407.1B).
One or two pectoralis major muscles may be used to cover the wound. The humeral insertions of the muscles
may be transected to get more mobility. The anterior rectus fascia also may be elevated in continuity with the
pectoralis major muscle to get more tissue for resurfacing. Once the wound is covered with muscle, it may be
closed with split-thickness skin grafts or advancement of adjacent chest skin.
SUMMARY
The pectoralis major muscle is a very reliable flap with few complications and little or no disability from the
loss of muscle.
FIGURE 407.1 A: Infected open wound after wide resection of skin, sternum, and costal cartilages for

osteogenic sarcoma was treated with topical antibacterials. The wound was debrided, two pectoralis major
muscles were elevated, and the dissection included anterior rectus fascia extension to get more length. B:
Two rib grafts were used to cover and offer protection to mediastinum and heart. (Continued)
FIGURE 407.1 Continued. C: Both pectoralis major-rectus fascia flaps were sutured to the midline to cover
the large defect. D: The muscle-fascia flaps were covered with advancement of the remaining chest skin.
References
See Chapter 135.

Chapter 408
Rotation-Advancement Split Pectoralis (Rasp) Major Muscle
Turnover Flap for Median Chest Wounds and Median Sternotomy
Dehiscence and Infection
D. A. STAFFENBERG
EDITORIAL COMMENT
Surgeons need several options when considering the extent of the deformity in median sternotomy defects.
This and the following chapter show how important it is (a) to have knowledge of what was actually done in
previous surgery and (b) to analyze what vessels are still intact and how to plan appropriately.
The rotation-advancement split pectoralis (RASP) turnover flap is a valuable technique to reconstruct median
sternotomy infections and wounds with large amounts of dead space.
INDICATIONS
Mediastinitis, sternal dehiscence with or without sternal osteomyelitis, is a known complication of
cardiothoracic surgery. The advantages of early diagnosis and reconstruction have been reported (1). If the
wound is divided into vertical thirds, difficulty in providing reliable coverage of the lower third of the chest
wound has led many surgeons to use rectus abdominis muscle flaps or omental flaps to provide reliable
coverage of the wound. This adds the morbidity and pulmonary issues that follow invasion of the abdominal
wall.
The split pectoralis major muscle turnover flap, used in conjunction with a contralateral pectoralis major
muscle island advancement flap, has been a reliable and safe method to reconstruct these complex wounds
completely, while eliminating the need for additional flaps. By splitting the turnover flap along its fibers, we
bring its rotation point closer to the problematic lower third. Once this lower turnover flap is brought into
position, the middle third is filled with the advancement flap from the contralateral side. This technique has
been particularly helpful in cases of cardiac reoperation, in which the incision is extended farther toward the
abdomen, to allow the cardiac surgeon safe reentry into the mediastinum. For smaller wounds, a bilateral
pectoralis myocutaneous flap closure is usually sufficient (2).
ANATOMY
The pectoralis major muscle is a large fan-shaped muscle on the anterior chest wall. The muscle has its origin
from the clavicle and the anterior surface of the sternum, as low as the cartilage of the sixth or seventh rib, and
from the anterior leaf of the rectus abdominis and the aponeurosis of the external oblique muscle. From this wide
origin, the fibers converge laterally toward their insertion at the crest of the greater tubercle of the humerus.
The vascular pedicles that allow its transfer as a muscle flap define the pectoralis major muscle as a type V
muscle (3). The thoracoacromial pedicle extends medially into the muscle from the acromion. The descending
pectoral branch from the thyrocervical trunk emerges from between the clavicle and the second rib in the
midclavicular line. From here, it courses inferiorly and laterally on the undersurface of the muscle within the
subpectoral fat pad. When the pedicle reaches the line drawn between the xiphoid and the acromion, it turns 90

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degrees medially and follows that line (4). Finally, perforators from the internal mammary vessels reach the
medial aspect of the pectoralis major muscle by extending into the undersurface of the muscle in the interspaces
at the lateral border of the sternum.
OPERATIVE TECHNIQUE
The particular vessels used for coronary revascularization must be ascertained, and the reconstructive plan
altered when necessary. Most frequently, the left internal mammary artery
(LIMA) has been used, leaving potentially unreliable perforators on the left side. This is the most common
scenario, and the following description is consistent with such a case. It should be noted that the plan described
could be reversed left to right, in the unlikely event that the right internal mammary artery is used, rather than the
left. The technique described can also be used safely if neither internal mammary artery has been dissected.
FIGURE 408.1 Appearance of the wound after debridement. Flap design is shown.
An advancement flap is designed on the patient's left side (Fig. 408.1). Dissection is carried laterally on the
superficial surface of the pectoralis major muscle to the anterior axillary line, cephalad to within 2 cm of the
clavicle and caudal to the anterior rectus sheath. Next, the surgeon's index finger is placed beneath the
inferolateral border of the pectoralis major muscle to identify the subpectoral space. The caudal and medial
attachments of the muscle are then divided.
Dissection then follows the undersurface of the pectoralis major muscle toward the clavicle. The plane of
dissection must be maintained deep to the subpectoralis fat pad to preserve the pedicle, but the pectoralis minor
muscle is left undisturbed. To advance this muscle beyond the midline, the lateral aspect is divided from the
humeral attachment, with care not to injure the descending pectoral branch as it courses laterally on the
undersurface of the pectoralis major muscle before its medial turn at the imaginary line joining the acromion and
the xiphoid. A lighted retractor and long tip for the electrocautery is helpful. The clavicular attachment is divided
laterally and medially. Because the pedicle is on the deep surface of the muscle, a true island muscle flap can
safely be created with care, if required. This island muscle flap will span the chest defect and cover the middle
third of the wound.
The right pectoralis major muscle flap is used as a turnover flap. Dissection is carried laterally on the superficial
surface of the pectoralis major muscle to the anterior axillary line, cephalad to within 2 cm of the clavicle and
caudal to the anterior rectus sheath. The surgeon's index finger is placed beneath the inferolateral border of the
pectoralis major muscle to identify the subpectoral space. The lateral aspect of the pectoralis major muscle is
divided to provide sufficient length for coverage. Working from lateral to medial, the clavicular attachment is
released, including the descending pectoral branch found under the middle third of the clavicle. The turnover flap
is elevated (Fig. 408.2) and held vertically on gentle stretch between two penetrating towel clamps. The muscle

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is then split along the length of its fibers, resulting in two, now separate, turnover flaps. One perforator for each
flap is adequate for viability. The caudal flap is turned over to cover the caudal third of the wound, whereas the
cephalad flap is turned over to cover the cephalic third of the wound (Fig. 408.3).
FIGURE 408.2 Split pectoralis major muscle flap is elevated.
Suction drains are left laterally in the subcutaneous space, under the flaps in the midline and subcutaneously in
the midline. Viability of the muscle flaps is confirmed, and they are gently secured to each other with 3-0
absorbable sutures. Tension is to be avoided. The skin is then closed primarily with 2-0 undyed absorbable
sutures. Staples or sutures are used for the final layer.
CLINICAL RESULTS
The rotation-advancement split pectoralis major muscle turnover flap technique has proven to be a safe and
reliable method
to reconstruct large infected sternal wounds. Although in the past, the inferior third of the wound frequently
required additional flaps from the abdomen, this has been addressed by dividing the turnover flap to lower
the rotation point. By bringing the rotation point closer to the inferior third defect, reliable coverage has been
provided.
FIGURE 408.3 Split pectoralis major muscle flap is turned over into position, and contralateral advancement
is brought into the middle third of the wound.

SUMMARY
The RASP turnover flap is a valuable technique to reconstruct median sternotomy infections and wounds
with large amounts of dead space. It is a recommended method, especially for treating complex median
sternotomy wounds with sternal osteomyelitis.
References
1. Jurkiewicz MJ, Bostwick J III, Hester TR, et al. Infected median sternotomy wound: successful treatment by
muscle flaps. Ann Surg 1980;191:738.
2. Ascherman JA, Hugo NE, Sultan MR, et al. Single-stage treatment of sternal wound complications in heart
transplant recipients in whom pectoralis major myocutaneous advancement flaps were used. J Thorac
Cardiovasc Surg 1995;110:1030.
3. Mathes SJ, Nahai F. Classification of the vascular anatomy of muscles: experimental and clinical
correlation. Plast Reconstr Surg 1981;67:177.
4. Ariyan S. The pectoralis major myocutaneous flap: a versatile flap for reconstruction in the head and neck.
Plast Reconstr Surg 1979;63:73.

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Chapter 409
Rectus Abdominis Muscle Flaps for Median Sternotomy Infections
M. S. WONG
T. R. STEVENSON
Several options are available for reconstruction of debrided median sternotomy wounds, including rectus
abdominis muscle or musculocutaneous flaps, pectoralis major muscle advancement and turnover flaps, omental
flaps, and latissimus dorsi flaps. The caudal aspect of the debrided sternotomy wound is subject to high stresses
during respiration and is difficult to fill by using pectoralis major or latissimus dorsi musculocutaneous flaps. The
rectus abdominis flap successfully addresses wound-healing concerns in this caudal portion while
simultaneously providing closure for the entire wound.
INDICATIONS
Based superiorly, the rectus abdominis muscle flap provides soft-tissue fill and a robust vascular supply,
both important in the reconstruction of infected median sternotomy wounds. This flap may be elevated,
either as a musculocutaneous or as a muscle flap, depending on soft-tissue requirements of the debrided
sternal wound.
ANATOMY
The paired rectus abdominis muscles are long and flat. These muscles originate from the anterior surfaces of the
fifth to seventh costal cartilages and the xiphoid process. Each muscle measures 6 to 10 cm in width. The rectus
abdominis muscle retains much of this width throughout its course. Narrowing to approximately 5 cm in the lower
hypogastric region, the muscle transitions to a tendon, before terminating at its attachment to the pubis between
the crest and symphysis. The muscle has a total length of 24 to 30 cm. Medial aponeurotic extensions of other
abdominal muscles (the external oblique, internal oblique, and the transversus abdominis) form the rectus sheath
that encloses the rectus abdominis muscles. Several intimate attachments or tendinous inscriptions exist
between the anterior surface of the rectus abdominis muscle and the overlying anterior rectus sheath, not
present on its posterior surface.
A type III muscle, the rectus abdominis has dual blood supplies: the deep superior epigastric artery (DSEA) and
the deep inferior epigastric artery (DIEA). These two arterial systems are connected by a series of intervening
choke vessels. The superior DSEA pedicle is a terminal extension of the internal mammary artery (IMA), whereas
the inferior DIEA pedicle is a branch of the external iliac artery. The DSEA originates beneath the sixth costal
cartilage, courses behind the seventh costal cartilage on the transversus abdominis muscle, and enters the
rectus sheath. Veins (venae comitantes) are usually paired and accompany the similarly named arteries.
Innervation is accomplished by motor branches of the seventh through twelfth intercostal nerves. These paired
muscles assist in abdominal flexion. Unilateral use for sternal reconstruction is well tolerated, with little
detectable loss of function (1).
FLAP DESIGN AND DIMENSIONS
When used for sternal reconstruction, the pedicle is based on the DSEA, allowing easy rotation into the thoracic
defect. If the IMA has been harvested unilaterally (most often on the

left) for a cardiac revascularization procedure, the right rectus abdominis muscle may be used for reconstruction.
If, however, both IMAs have been transected, the DSEAs can be supplied through a rich collateral circulation
from the musculophrenic and lower intercostal arteries (2).
Depending on the skin requirements of the sternal wound, the rectus abdominis muscle may be transposed as
either a muscle or a musculocutaneous flap. The cutaneous portion of the flap may be oriented transversely or
obliquely, based on underlying musculocutaneous perforators. In general, the vertical design is more useful for
sternal wound reconstruction after debridement. When designing a skin island over the rectus abdominis muscle,
it is important to remember that the greatest density of skin perforators is in the periumbilical region.
OPERATIVE TECHNIQUE
Muscle Flap
A paramedian skin incision is used to provide adequate exposure of the entire anterior rectus sheath. The sheath
is incised 1 cm lateral to the linea alba, revealing the rectus abdominis muscle. The medial leaf of the sheath is
dissected off the rectus muscle superiorly and inferiorly, completely exposing the medial border of the rectus
abdominis muscle. Similarly, the lateral leaf of the sheath is dissected in a medial-to-lateral direction, exposing
the lateral border of the muscle. Care is taken when detaching the anterior rectus sheath from the adherent
horizontal inscriptions.
The DIEA and its accompanying veins are isolated, ligated, and divided. These vessels are found entering the
posterior portion of the rectus abdominis muscle along its inferolateral aspect, just deep to the thin transversalis
fascia. The muscle is divided distally and elevated off the transversalis fascia. Superiorly, the dissection is
carried above the arcuate line, ligating and dividing segmental neurovascular structures along the way. As the
costal margin is approached, the DSEA pedicle is visualized originating behind the sixth costal cartilage, coursing
behind the seventh costal cartilage, lying on the transversus abdominis muscle.
The dissected muscle may be turned over or rotated into the debrided sternal defect. Once freed from its
residence within the rectus sheath, the muscle contracts to approximately two thirds to three fourth of its native
length (Figs. 409.1 and 409.2). If the wound requirements demand more superior fill, the muscle may be
stretched by placing segmental tacking stitches to the surrounding tissues of the chest wall. Drains are placed
deep and superficial to the muscle flap, and the skin is closed in layers (Fig. 409.3).
The anterior rectus sheath is repaired primarily over a closed suction drain, and the skin is repaired in layers
over another similar drain. Drains are initially placed on low continuous wall suction, and transitioned to bulb
suction after 48 hours. Suction drainage facilitates adherence of tissues and lessens seroma formation.
Musculocutaneous Flap
Dimensions of the skin paddle required for the sternal wound are determined by measuring the skin deficit (Fig.
409.4). A cutaneous paddle of similar size is drawn over the rectus abdominis muscle, bearing in mind the goal of
primary donor-site skin closure. The medial skin-flap margin is incised, exposing the linea alba and anterior
rectus sheath. The anterior rectus sheath is incised lateral to the linea alba, abutting the cutaneous paddle,
leaving a minimum cuff of 1 cm. If the cutaneous portion of the flap is positioned over the anterior rectus sheath,
such that no such cuff is possible, careful elevation of the skin off the anterior rectus sheath is performed, until
either the first row of medial perforators is encountered or a cuff of 1 cm is established, whichever is achieved
first. This medial rectus sheath incision is carried the full length of the skin paddle. The medial cuff of the anterior
rectus sheath is carefully separated from the rectus abdominis muscle, completely freeing its medial border.

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FIGURE 409.1 Contracted right rectus abdominis muscle flap freed from all rectus-sheath attachments.
FIGURE 409.2 Right rectus abdominis muscle flap turned over to fill the debrided sternal wound.
FIGURE 409.3 Primary skin closure over multiple drains.
The lateral skin incision is made, exposing the abdominal- wall fascia and identifying the lateral edge of the

anterior rectus sheath. A minimum lateral cuff of 2 cm is planned. If the skin paddle precludes this cuff, the skin
component of the flap may be elevated in a lateral-to-medial direction to the level of the first row of lateral
perforators. A vertical incision through the anterior rectus sheath is made, and the lateral cuff of anterior rectus
sheath is dissected off of the rectus abdominis muscle, thus exposing the entire length of its lateral border. The
deep inferior epigastric vessels and the distal muscle are divided, and the flap is elevated, as described earlier
for the muscle flap alone.
The pedicle is identified, and the flap is rotated 180 degrees into position over a drain (Fig. 409.5). Unlike the
muscle flap, the musculocutaneous flap does not contract as significantly, because of tension in the overlying
skin. A layered closure is then performed. The abdominal donor site is similarly closed in layers. The anterior
rectus sheath is closed primarily over a drain. Depending on the quality of the fascial closure, consideration
should be given to using mesh to supplement the closure (3).
FIGURE 409.4 Dehisced inferior aspect of median sternotomy wound.
FIGURE 409.5 Healed musculocutaneous flap used to reconstruct this caudal sternal wound.
CLINICAL RESULTS
In our reported 10-year clinical experience, 34 patients with infected median sternotomy wounds were

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treated with aggressive sternal debridement and reconstruction by using a rectus abdominis
musculocutaneous flap (4). The 17 male and 17 female patients ranged in age from 13 to 82 years (mean,
55 years) and weighed between 42 and 165 kg (mean, 82 kg). Eighty percent of these patients had three or
more medical comorbidities, most commonly diabetes mellitus, hypertension, and atherosclerosis. Twenty-
two (65%) patients had coronary artery bypass grafting procedures, with 60% of these using an IMA as a
vascularized bypass; 10 (29%) patients had cardiac valve replacements; and 3 (9%) patients had tumor
resections requiring median sternotomy.
Flap complications occurred in 10 (29%) patients, including f5 (14%) hematomas and 5 (14%) infections.
Six of these patients required a second operative procedure. Eight patients experienced partial distal skin
flap loss. All eight of these wounds healed secondarily, after local wound care. Two patients experienced
donor-site complications, with one ventral abdominal hernia and one infection. The former patient declined
surgical repair, whereas the latter was successfully treated with incision and drainage, followed by a split-
thickness skin graft. Four patients died within the first postoperative month; none of the deaths was
attributable to the reconstructive procedure. All surviving patients, whether or not they experienced a
postoperative complication, achieved complete sternal wound healing, after rectus abdominis
musculocutaneous flap reconstruction.
Although our small sample size precluded statistical analysis, several trends were noted. Patients with
greater age, weight, number of medical comorbidities, and of female gender, appeared to have more
complications, with 45% of morbidly obese patients experiencing postoperative complications, compared
with 22% of nonobese patients.
SUMMARY
For reconstruction of median sternotomy wounds, the rectus abdominis muscle (or musculocutaneous) flap
is easy to elevate. Further, it offers satisfactory wound coverage in the lower aspect of the sternal wound,
an area difficult to address through transposition of the more commonly used pectoralis major muscle flap.
Inclusion of an overlying skin paddle has the added advantage of transferring vascularized skin to the
sternal wound, decreasing skin tension at the recipient site, and eliminating the need for skin grafting.
Disadvantages of this flap include inconsistent viability of the distal skin island and donorsite morbidity that
includes abdominal-wall weakness or hernia formation. We now reserve use of the rectus abdominis
musculocutaneous flap for nonobese patients, who have large skin or soft-tissue deficits in the inferior
aspect of their sternal wounds.
References
1. Netscher DT, Eladoumikdachi F, HcHugh PM, et al. Sternal wound debridement and muscle flap
reconstruction: functional implications. Ann Plast Surg 2004;51:115.
2. Netscher DT, Eladoumikdachi F, Goodman CM. Rectus abdominis muscle flaps used successfully for
median sternotomy wounds after ipsilateral internal mammary artery ligation. Ann Plast Surg 2001;47:223.
3. Kuntscher MV, Mansouri S, Noack N, Harmann B. Versatility of vertical rectus abdominis
musculocutaneous flaps. Microsurgery 2006;26:363.

4. Oh AK, Lechtman AN, Whetzel TP, Stevenson TR. The infected median sternotomy wound: management
with the rectus abdominis musculocutaneous flap. Ann Plast Surg 2004;52:367.

Chapter 410
Serratus Anterior Muscle and Musculocutaneous Flap
J. C. GROTTING
SEE CHAPTER 155
Regional use of the serratus muscle is more limited than that of the latissimus muscle because it is only one-
fourth the size. The two muscles can be mobilized together for either local use or when a large vascularized free-
muscle flap is required.
The serratus anterior muscle also may be used as a transposition flap to close tracheobronchial fistulas by
passing the muscle through the chest wall. Since many thoracic surgeons retract and save the serratus anterior
muscle during thoracotomy, while dividing the latissimus dorsi, the serratus is usually available for use.

Chapter 411
Rectus Abdominis Muscle and Musculocutaneous Flap
H. LABANDTER
M. I. DINNER
R. V. DOWDEN
EDITORIAL COMMENT
This procedure is becoming increasingly important for coverage of mediastinal wounds, after internal
mammary bypass graft, where the sternum has actually necrosed. The flap can be extended down toward
the pubis and carried with skin and muscle or muscle alone to make it reach the suprasternal notch. It is not
recommended that this flap be used if the patency of the internal mammary on the side of the flap transfer is
not known.
The rectus abdominis musculocutaneous or muscle flap provides a suitable alternative for immediate or delayed
coverage of sternal or other chest-wall defects (1, 2, 3). Most other methods are more complicated and require
several procedures or the sacrifice of major areas of surrounding tissue.
INDICATIONS
In patients requiring upper or lower (4) anterior chest-wall reconstruction extending to the posterior axillary
line laterally or to the sternal notch superiorly, the rectus abdominis muscle or musculocutaneous flap can
be used.
Care must be taken to ascertain that the internal mammary artery on the side of the muscle to be used has
not been damaged, particularly in the case of infected sternum after cardiac surgery, where the artery may
have been used in bypass. The critical factor remains the removal of all the necrotic, infected costochondral
cartilage and ribs. A decision is then made as to whether muscle alone or muscle and skin are required for
closure of the defect, and the flap is raised in the standard manner (Fig. 411.1).
FIGURE 411.1 A: View of the superior pedicle entering and running along the posterior surface of the
muscle. B: The perforators entering medially above the arcuate line.
The rectus flap is usually less complicated than other methods, such as the use of omentum (5, 6, 7),
pectoralis muscle (8, 9, 10), latissimus muscle (11, 12), or local skin flaps (13, 14, 15, 16, 17) and leaves a
more acceptable donor-site appearance (Figs. 411.2 and 411.3). The patient remains in the supine position,
simplifying intraoperative maneuvering.

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ANATOMY
See Chapter 379.
FIGURE 411.2 A: Lower chest wall with chronic infected costochondritis following x-ray therapy and excisions
for recurrent basal carcinoma. B: Following extensive debridement, including resection of diaphragm and pleura,
the flap has been raised and is to be inserted transversely. C: Rectus abdominis musculocutaneous flap in
place.
FLAP DESIGN AND DIMENSIONS
See Chapter 379.
OPERATIVE TECHNIQUE
See Chapter 379.
FIGURE 411.3 A: Infected sternum and costochondral junction following coronary bypass surgery. B: Six
months after repair with the rectus abdominis musculocutaneous flap.

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CLINICAL RESULTS
The rectus abdominis musculocutaneous flap is extremely reliable, and complications can be avoided by
attention to technical detail. Loss of the flap can occur after injury to the indirect perforator system.
Donor-site functional deficit is minimal. In the immediate postoperative period, difficulty is experienced in
sitting from
a recumbent position. However, for a period of 6 weeks, the function is adequately compensated for by the
external oblique muscles.
The development of a hernia is usually related to breakdown of the fascial repair of the anterior abdominal
wall below the arcuate line. Meticulous surgical technique can reduce the incidence of this complication.
SUMMARY
The rectus abdominis muscle and musculocutaneous flaps can be reliably used to close chest-wall defects.
References
1. Drever JM. The epigastric island flap. Plast Reconstr Surg 1977;59:343.
2. Neale HW, Kreilein JG, Schreiber JT, Gregory RO. Complete sternectomy for chronic osteomyelitis with
reconstruction using a rectus abdominis myocutaneous island flap. Ann Plast Surg 1981;6:305.
3. Dinner MI, Labandter HP, Dowden RV. Role of the rectus abdominis myocutaneous flap in breast
reconstruction. Plast Reconstr Surg 1982; 69:209.
4. Mathes SJ, Bostwick J III. A rectus abdominis myocutaneous flap to reconstruct abdominal wall defects. Br
J Plast Surg 1977;30:382.
5. Dupont C, Menard Y. Transposition of the greater omentum for reconstruction of the chest wall. Plast
Reconstr Surg 1972;49:263.
6. Lee AB, Schimert G, Shatkin S. Total excision of the sternum and thoracic pedicle transposition of the
greater omentum: useful stratagems in managing severe mediastinal infection following open heart surgery.
Surgery 1976;80:433.
7. Jurkiewicz MJ, Arnold PG. The omentum. Ann Surg 1977;185:548.
8. Arnold PG, Pairolero PC. Use of pectoralis major muscle flaps to repair defects of anterior chest wall. Plast
Reconstr Surg 1979;63:205.
9. Jurkiewicz MJ, Bostwick J III, Hester TR, et al. Infected median sternotomy wound. Ann Surg
1980;191:738.

10. Arnold PG. Reconstruction of the sternum and anterior chest wall. Clin Plast Surg 1981;8:389.
11. McCraw JB, Dibbell DG, Carraway JH. Clinical definition of independent myocutaneous vascular
territories. Plast Reconstr Surg 1977;60:341.
12. McCraw JB, Penix JO, Baker JW. Repair of major defects of the chest wall and spine with the latissimus
dorsi myocutaneous flap. Plast Reconstr Surg 1978;62:197.
13. Cervino AL, Bales HW, Emerson GL. Tissue transfers for functional reconstruction in thoracic surgery.
Plast Reconstr Surg 1974;54:437.
14. Lewin LR, Guthrie RH, Kovachev D. One-stage coverage of the large chest-wall defect with a giant
bipedicled flap. Plast Reconstr Surg 1975; 56:336.
15. Davis WM, McCraw JB, Carraway JH. Use of a direct, transverse thoracoabdominal flap to close difficult
wounds of the thorax and upper extremity. Plast Reconstr Surg 1977;60:526.
16. Baroudi R, Pinotti M, Keppke EM. A transverse thoracoabdominal skin flap for closure after radical
mastectomy. Plast Reconstr Surg 1978;61:547.
17. Daniel RK, Kerrigan CL, Gard DA. The great potential of the intercostal flap for torso reconstruction.
Plast Reconstr Surg 1978;61:653.

Chapter 412
Intercostal Neurovascular Musculocutaneous-Rib Flap
J. W. LITTLE III
EDITORIAL COMMENT
The complexity of the dissection has made this flap underutilized; most problems can be solved with
microvascular surgery.
The intercostal neurovascular island skin flap has been introduced as a mobile and versatile tissue system for
general and sensory reconstruction of the trunk (1, 2, 3, 4).
An expanded transpleural technique has been recommended that allows one-stage transfer of the entire upper-
quadrant abdominal wall with attached contralateral upper quadrant or ipsilateral lower-quadrant extensions (5,
6). This expansion was designed to allow undelayed transfer of large, extended paddles (see Chapter 472).
This expansion is not required for flaps limited to or slightly beyond the costal margin, as is true of rib-containing
flaps transferred to thoracic defects. However, while the extrapleural technique suffices, I continue to recommend
the transpleural one for greater ease and speed of execution and a greater measure of safety when larger skin
islands are elevated on a single intercostal bundle.
INDICATIONS
A skeletal strut across a significant thoracic defect can serve only to reduce paradoxical motion and would
therefore appear indicated in those defects, where available. Unfortunately, the most disabling functional
defects occur along the anterior thoracic midline after loss of the manubrium, sternum, and costal cartilages
and thus remain out of reach of this flap.
FIGURE 412.1 A: Defect involving loss of anterolateral fourth and fifth ribs; T9 pedicle outlined to transfer
ninth rib (including small portion of tenth). B: Defect stabilized and closed.
Conversely, dorsal defects that are within easy reach rarely demonstrate significant paradoxical impairment
because of the limited excursion of the posterior component of the thoracic bellows, the greater stability of
its heavier musculature and scapula, and the purely bony nature of its ribs.
Therefore, defects most likely to be helped by this technique are those of the anterolateral thorax (Fig.
412.1). Here, in truth, the major impact of skeletal support is likely to be aesthetic rather than functional in
nature. Isolated lateral thoracic defects with significant functional impairment through paradoxical motion
would be of such large size as to effectively exceed the ability of the described flap to achieve meaningful

stabilization.
While the extrapleural technique can be used in raising these shorter flaps, there are certain advantages to
the transpleural method. The rib segment remains protected on its exposed deep aspect by a layer of
parietal pleura, with the soft parts of the paddle covered by fascia. Inclusion of the entire interspace, as well
as abdominal wall, both speeds and simplifies dissection and ensures survival of the larger paddles on a
single bundle. In the primary repair of full-thickness defects, the thorax is already breached and a chest tube
is already a requirement.
Rib also can be transferred to other areas such as the spine, where hard-tissue protection or stabilization
may be desired (Fig. 412.2).
ANATOMY
See Chapter 472.
FLAP DESIGN AND DIMENSIONS
Rib length within the flap is determined by the requirements of the skeletal defect and limited by the requirements
of pedicle length that remains as the difference between total rib length (measured from sacrospinalis to costal
margin) and the desired length for transfer. The skin paddle can extend in length across the midline, but rarely
exceeds much beyond the costal margin. Paddle width is determined by the requirements of the defect. A typical
paddle measures up to 15 × 15 cm. The pivot point of this island flap occurs at the intersection of the selected
interspace with the lateral border of the sacrospinalis muscle, one handbreadth off the spine. The arc of rotation
falls some few centimeters within the free border of the pectoralis major muscle, thus excluding most of the
thorax covered by this muscle, as well as the manubrium, sternum, and xyphoid (Fig. 412.1).
FIGURE 412.2 Planned incision.
OPERATIVE TECHNIQUE
The terminal portion of the ninth, tenth, or occasionally another rib is selected for transfer to the thoracic defect
and is indicated on the chest wall to an appropriate length. The skin paddle is then marked with the rib segment

central and with its length and width expanded to meet skin requirements that may be in excess of skeletal ones.
The intercostal space of the selected rib becomes the flap pedicle, and the spaces above and below are marked
as superior and inferior margins and are blended to the composite paddle (Fig. 412.3).
The pedicle margins are incised to fascia and carried at this level down to the selected rib above and up to its
inferior neighbor below, where they are deepened through muscle and periosteum onto the ribs themselves. The
selected rib is removed subperiosteally from the sacrospinalis muscle to the measured point beyond which the
rib will be maintained and carried in the paddle.
The thorax is entered through the midportion of the periosteal bed over this extent. The superior border of the
lower rib is then freed subperiosteally, and without removing this rib, the superior aspect of its bed is similarly
entered behind the rib.
Once the pedicle has been completed by rapid, full-thickness cuts into the thoracic cavity, the composite paddle
is dissected. That portion overlying the thorax is incised through skin, fat, and fascia onto muscle and is elevated
with the fascia from denuded slips of serratus anterior and external oblique abdominis muscle until reaching the
interspace superior to the selected rib above and the neighboring inferior rib below. That portion extending
beyond the costal margin is incised through skin, fat, and abdominal wall muscle onto peritoneum, except for any
portion overlying rectus muscle. Because the skin paddle of this shortened, composite flap rarely extends to the
midline, it is unnecessary to include rectus muscle within the flap, anterior rectus sheath alone sufficing.
The dissection is carried between transversus abdominis muscle and peritoneum, continuing laterally beneath
the costal margin until the diaphragm is reached. The paddle and the pedicle are then joined. Above, the incision
through periosteal rib bed is shifted upward to the interspace above and is made full-thickness through that
interspace until joined to the abdominal part. Below, the incision continues through the periosteal bed of the
lower retained rib until that structure curves upward at the costal margin to cross the intercostal bundle of the
selected interspace as it leaves the thorax to enter the abdominal wall.
Here, the lower incision is continued at the same transverse level, cutting across the terminal curved portion of
the lower rib and including it within the flap. This situation occurs regularly when the ninth interspace is used,
including a portion of chondral tenth rib in the flap. It does not occur when the lower tenth interspace is used. A
small portion of diaphragmatic muscle is included as thoracic and abdominal portions are joined, ensuring full
inclusion of transversus muscle. The flap can be raised in less than 1 hour.
The thoracic and abdominal defect is closed as described in Chapter 472. As long as the flap has not been
expanded, direct closure of the muscle layers in the abdominal wall should suffice.

FIGURE 412.3 A: A 17-year-old boy with radiation defect of the lumbar spine, with posterior elements of spine
missing and cord unprotected. B: T9 pedicle flap will carry portion of tenth rib to spine. C: Flap elevated with rib
segment indicated; secondary abdominothoracic defect. D: Rib segment will be fixed to remaining laminae over
cord. E,F: Wounds healed at 6 weeks.
CLINICAL RESULTS
Rib-containing flaps have been raised to and beyond the midline in six instances without tissue loss (see
Chapter 472). There have been no complications following the transfer of such rib-containing flaps. All
chest tubes were removed during the first week, following an unremarkable pulmonary course in all
patients. Vertical shortening of the hemithorax through rib resection and intercostal closure has produced no
postural deformity.
SUMMARY

The intercostal neurovascular island skin flap can be extended to include rib for anterolateral and posterior
chest-wall reconstruction. Its application, although limited, is useful when larger flaps (see Chapter 472)
including abdominal wall are deemed unnecessary.
References
1. Dibbel DG. Use of a long island flap to bring sensation to the sacral area in young paraplegics: case
report. Plast Reconstr Surg 1974;54:220.
2. Daniel RK, Terzis JK, Cunningham DM. Sensory skin flaps for coverage of pressure sores in paraplegic
patients: a preliminary report. Plast Reconstr Surg 1976;58:317.
3. Daniel RK, Kerrigan CL, Gard DA. The great potential of the intercostal flap for torso reconstruction. Plast
Reconstr Surg 1978;61:653.
4. Kerrigan CL, Daniel RK. The intercostal flap: Anatomical and hemodynamic approach. Ann Plast Surg
1979;2:411.
5. Little JW, Fontana DJ, McCulloch DT. The upper quadrant flap. Plast Reconstr Surg 1981;68:175.
6. Daniel RK. The upper quadrant flap (Discussion). Plast Reconstr Surg 1981;68:183.

Chapter 413
Local Skin Flaps
W. C. TRIER
EDITORIAL COMMENT
Our better understanding of the blood supply to the abdominal wall permits us to design skin and fascia
flaps based on the superficial epigastric system or the perforating vessels from the deep epigastric arcade.
If a flap is based on the superficial epigastric system, it needs to be elevated just deep to Scarpa's fascia,
since the superficial epigastric vessels course on top of the fascia. There are communications between the
superficial and deep epigastric systems; consequently, flaps could be designed based on perforators from
the deep epigastric system and still be relatively thin by elevating them deep to Scarpa's fascia. Elevation at
the level of the anterior rectus sheath, although secure, may provide too thick a flap for coverage, although
elevation is certainly simpler.
The abdominal wall and groin are more commonly thought of as donor sites for skin flaps and skin grafts rather
than as recipient sites to which transfer of local flaps is required.
INDICATIONS
Abdominal skin is the most appropriate source of a skin flap to another area of the abdomen if the defect is
not too large. Of prime importance is whether or not the deep fasciae of the abdominal wall are intact (1, 2,
3, 4, 5, 6, 7, 8).
Suprafascial Skin Defects
Long experience with use of the abdomen as a donor site for skin flaps makes it quite obvious that when
suprafascial skin defects cannot be closed by simple undermining of the abdominal skin in the fascial-
subcutaneous tissue plane, reconstruction ordinarily should be accomplished using a partial-thickness skin
graft.
In the presence of radiation dermatitis or necrosis, however, skin grafts may fail to vascularize or survive.
Flaps are then required. Local flaps (which carry their own blood supply) not only survive, but remain viable,
since their pedicles do not require division. Furthermore, such flaps may improve blood supply to the
recipient site.
Subfascial Skin Defects
Subfascial abdominal skin defects require reconstruction of the supporting deep fasciae of the abdominal
wall as well as skin coverage. Such defects result from trauma (commonly shotgun wounds), tumor
resection, and radiation necrosis. Free fascial grafts and synthetic allografts of tantalum, Mersilene®, or
Marlex® require cover by well-vascularized skin and subcutaneous tissue (1, 2, 3, 4, 5, 6, 7, 8, 9, 10).
ANATOMY
The skin of the ventral surface of the body is loose and quite mobile over both the thorax and the abdomen, but
more adherent over the flanks and back and just caudal to the inguinal ligaments.

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The more superficial layer of subcutaneous tissue, Camper's fascia, contains adipose tissue of varying
thickness. This layer is continuous with subcutaneous fasciae of the thorax, back, and thighs, becoming tougher
and more dense over the back. The deeper layer, Scarpa's fascia, is described as membranous in nature,
contains little or no adipose tissue, and is composed largely of elastic tissue fibers. Scarpa's fascia forms a
continuous layer over the abdomen and is attached to the linea alba in the center of the lower abdomen as well
as to the investing fascia of the thigh muscles at a level one or two fingerbreadths below the inguinal ligament
(11, 12).
Vascular Anatomy
Cutaneous Arteries
Except for the area of the abdomen and groin supplied by branches of the femoral artery, the only large
cutaneous arteries of the abdominal wall emerge medial to the semilunar lines of the abdomen (11). This
suggests that medially based flaps nourished by these vessels might be similar to such flaps as the deltopectoral
flap, based on perforating branches of the internal mammary artery. Flaps based laterally, anterior to
the latissimus dorsi muscle, appear to be cutaneous (random pattern) in nature (Figs. 413.1 and 413.2).
FIGURE 413.1 To the left (right side of torso) are anterior and lateral perforating branches of the cutaneous
vascular supply of the anterior abdominal wall. Inferiorly, in the inguinal region, are the cutaneous branches of
the femoral, superficial epigastric, superficial circumflex iliac, and superficial external pudendal arteries. To the
right (left side of torso) are the superior deep epigastric and inferior deep epigastric arteries. (Redrawn from
Brown et al., ref. 11, with permission.)
Musculocutaneous Arteries
Transversely disposed segmental series of perforating musculocutaneous branches of intercostal, subcostal,
and lumbar arteries provide blood supply to the subcutaneous tissue and skin across the entire abdominal wall,
except for the area of the abdominal skin overlying the rectus muscles medial to the semilunar lines, which
receive blood from the musculocutaneous branches of the deep superior and inferior epigastric vessels.
The perforating branches of the intercostal, subcostal, and lumbar arteries arise as two main branches, posterior
and lateral. The lateral branches penetrate the oblique abdominal muscles just anterior to the latissimus dorsi
muscle and pass obliquely downward to provide blood supply to the anterior abdominal wall. The posterior

branches supply the back muscles and skin (12), as do the primary arterial pedicles of such muscles as the
latissimus dorsi.
The vertical arterial supply is provided by branches of the superior deep epigastric artery, the continuation of the
internal mammary artery, and from the inferior deep epigastric artery, a branch of the external iliac artery. These
vessels pass through the rectus muscles and their fasciae to the subcutaneous fasciae and skin. Thus flaps,
arterial in type, may be raised transversely based on these perforating vessels, while musculocutaneous flaps
can be raised in the vertical direction.
FIGURE 413.2 To the left (right side of torso) are arterial flaps based on cutaneous arteries, deltopectoral,
thoracoepigastric, groin, and hypogastric, superimposed over their intrinsic arteries. To the right (left side of
torso) are bipedicle advancement flaps (both arterial and cutaneous) and laterally based cutaneous flaps.
(Redrawn from Brown et al., ref. 11, with permission.)
Arterial Flaps
The superficial vertical abdominal and inguinal vascular branches of the femoral artery provide two axial flaps:
the hypogastric flap (13), based on the superficial inferior epigastric vessels, and the groin flap (14, 15), based
on the superficial circumflex iliac vessels (Fig. 413.2).
FLAP DESIGN AND DIMENSIONS
Transposition or rotation flaps based laterally in the lower thorax, back, or upper or lower abdomen must be
considered cutaneous flaps. Local arterial skin flaps, suitable for the reconstruction of suprafascial abdominal
defects, include the deltopectoral (16), thoracoepigastric (17), groin (14, 15, 18), and superficial epigastric flaps
(13, 19). Scrotal flaps can be useful on occasion (20, 21).
The deltopectoral flap may be used to repair upper medial abdominal defects (16) (see Chapter 127). The
thoracoepigastric flap (17), felt to be the equivalent of the medially based deltopectoral flap, is supplied by the
perforating vessels of the rectus abdominis muscle. Measuring up to 12 × 30 cm, it extends distally to the
anterior axillary line. However, its use is avoided when based below the level of the umbilicus, because of the
dominance of the external oblique circulation in that area.
The groin flap (14, 15, 18), based on the superficial circumflex iliac artery, may be prolonged beyond the antero-
superior iliac spine (see Chapter 312). The hypogastric flap

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(13, 19) may be used untubed as a local arterial flap. Based on the superficial epigastric artery, the flap may
measure up to 7 cm in width and 18 cm in length. Adjustment to the point of origin of the medial and lateral
incisions bordering the flap permits rotation of the flap medially or laterally.
SUMMARY
The abdomen and groin are traditional donor areas for skin flaps, both cutaneous and arterial. However,
local skin flaps infrequently may be required for the reconstruction of these areas.
References
1. Wangensteen OH. Repair of large abdominal defects by pedicled fascial flaps. Surg Gynecol Obstet
1946;82:144.
2. McPeak CJ, Miller TR. Abdominal wall replacement. Surgery 1960;47:944.
3. Hershey FB, Butcher HR. Repair of defects after partial resection of the abdominal wall. Am J Surg
1964;107:586.
4. Medgyesi S. The repair of large incisional hernias with pedicle skin flaps. Scand J Plast Reconstr Surg
1972;6:69.
5. Mansberger AR, Kang JS, Beebe HG, Le Flore I. Repair of massive acute abdominal wall defects. J
Trauma 1973;13:766.
6. Pokorny WJ, Thal AP. A method for primary closure of large contaminated abdominal wall defects. J
Trauma 1973;13:542.
7. Wilson JSP, Rayner CRW. The repair of large full-thickness postexcisional defects of the abdominal wall.
Br J Plast Surg 1974;27:117.
8. Earle AS, Blackburn WW. Closure for abdominal hernia with a groin flap lined with a dermal graft. Plast
Reconstr Surg 1975;56:447.
9. Ye RC, Devine KD, Kirklin, JW. Extensive recurrent desmoid tumor of the abdominal wall: radical excision
followed by reconstruction of the abdominal wall with plastic procedure. Plast Reconstr Surg 1953; 12:59.
10. Pridgen JE, Tennison CW. Reconstruction of the entire abdominal wall in the presence of postradiation
changes. Am J Surg 1956;92:54.
11. Brown RG, Vasconez LO, Jurkiewicz MJ. Transverse abdominal flaps and the deep epigastric arcade.
Plast Reconstr Surg 1975;55:416.
12. Nahai F, Brown RG, Vasconez LO. Blood supply to the abdominal wall as related to planning abdominal

incisions. Am Surg 1976;42:691.
13. Shaw DT, Payne RL. One-staged tubed abdominal flaps. In: Grabb WC, Myers MB, eds. Skin flaps.
Boston: Little, Brown, 1975.
14. McGregor IA. The groin flap. In: Grabb WC, Myers MB, eds. Skin flaps. Boston: Little, Brown, 1975.
15. McGregor IA, Morgan G. Axial and random pattern flaps. Br J Plast Surg 1973;26:202.
16. McGregor IA. Skin flaps. In: McGregor IA, ed. Fundamental techniques of plastic surgery, 7th ed.
Edinburgh: Churchill Livingstone, 1980.
17. McCraw JB, Dibbell DG, Carraway JH. Clinical definition of independent myocutaneous vascular
territories. Plast Reconstr Surg 1977;60:341.
18. Bogart JN, Rowe DS, Parsons RW. Immediate abdominal wall reconstruction with bilateral groin flaps
after resection of a large desmoid tumor. Plast Reconstr Surg 1976;58:716.
19. Aston SJ, Pickrell KL. Reconstructive surgery of the abdominal wall. In: Converse JM, ed. Reconstructive
plastic surgery. Philadelphia: Saunders, 1977.
20. Arconti JS, Goodwin WE. Use of scrotal skin to cover wound defects in the groin and pubic area. J Urol
1956;75:292.
21. Lanier VC, Neale HW. Necrosis of penis with decubitus ulcer: Debridement and closure with scrotal flap.
Plast Reconstr Surg 1974;54:609.

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Chapter 414
Transposition Skin Flap to The Groin
M. B. CONSTANTIAN
EDITORIAL COMMENT
Our present knowledge of the vascular supply to the abdomen would indicate that the flow is better if the
flaps are based medially. Most laterally-based flaps may show some embarrassment of the distal tip of the
flap.
A transverse lower abdominal flap can comfortably reach the groin and anterior thigh regions. The flap may be
based medially or laterally, depending on the shape and location of the defect.
INDICATIONS
Deep wounds or pressure ulcers of the anterior trochanteric or anterior thigh regions may require a flap for
repair.
FIGURE 414.1 A: Deep anterior thigh defect resulting from wound dehiscence after proximal femoral
resection. Design of delayed abdominal flap. B: Defect excised, and the flap inset. C: Result 7 months
postoperatively.

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ANATOMY (1)
Perforating muscular branches of the intercostal, subcostal, lumbar, deep epigastric, and superficial inferior
epigastric arteries supply the flap from each end.
FLAP DESIGN AND DIMENSIONS
Based medially, the transverse abdominal flap has an axial blood supply. A surgical delay is not necessary,
providing that the perforating branches of the deep epigastric arcade are preserved.
Based laterally, delay is mandatory if the flap is long. The dimensions required of the flap depend, of course, on
the size and orientation of the defect but can safely approach 10 × 30 cm if the appropriate precautions
regarding delay and tissue handling are observed.
OPERATIVE TECHNIQUE
If a delay is required, it is usually performed in two stages, by first raising the flap as a bipedicle flap and then
sectioning the distal end separately 7 to 14 days later (Fig. 414.1B).
The surgeon should raise the flap at the level of the deep fascia, mobilizing the pedicle only enough for transfer.
The donor site can be closed primarily if the noted dimensions have been observed. Adequate suction drainage
is advisable, since the area of the dissection is large.
CLINICAL RESULTS
The complications that follow this procedure relate to the flap and the defect. The surgeon can minimize flap
loss, seroma, and infection by careful wound preparation and tissue handling, proper drainage, and the use
of antibiotics where indicated (2).
Further, the surgeon should be sensitive to the peculiarities of the defect regarding joint involvement,
heterotopic calcifications, and abnormalities of any of the local bursae (which occur between the greater
trochanter and the gluteus maximus, between the gluteus medius and gluteus minimus muscles, and
between the tendons of the gluteus maximus and vastus lateralis muscles).
SUMMARY
A transposition skin flap from the abdomen can be used to cover groin defects.
References
1. Brown RG, Vasconez LO, Jurkiewicz MJ. Transverse abdominal flaps and the deep epigastric arcade.
Plast Reconstr Surg 1975;55:416.
2. Constantian MB, Jackson HS. In: Constantian MB, ed. Pressure ulcers: principles and techniques of
management. Boston: Little, Brown, 1980.

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Chapter 415
Groin Skin Flap for Coverage of Abdominal Wall Defects
A. S. EARLE
C. VLASTOU
The groin flap (1) is used regularly by many reconstructive surgeons, particularly for covering soft-tissue defects
of the hand. It is also used as a free flap, perhaps more frequently in the past than at present. The groin flap and
related lower abdominal flaps also can be used to resurface abdominal wall defects (1, 2, 3).
INDICATIONS
Extended groin flaps will reach any portion of the abdomen and above the ipsilateral rib margin to include
the lower anterior chest. The groin flap may be the method of choice for covering radiation and other
chronic ulcerations of the abdominal wall.
By including free fascia lata or dermis, the groin flap can be used to repair an associated abdominal wall
hernia (2).
ANATOMY
The groin flap is a vascularized axial flap based on the superficial circumflex iliac artery (SCIA) arising from the
femoral artery just below the inguinal ligament. The SCIA passes through the deep fascia into the subcutaneous
tissues lateral to the fossa ovalis at or close to the lateral border of the sartorius muscle. The artery then passes
diagonally upward and laterally parallel to and 2 to 3 cm below the inguinal ligament. This relationship is
maintained as far lateral as the ligament attachment at the anterior superior iliac spine (ASIS).
The vessel can be dissected or followed with a Doppler probe in many subjects to the point at which it divides
into several branches supplying the skin and subcutaneous tissues. It also anastomoses with branches of the
superficial epigastric artery (SEA), with the deep circumflex iliac artery, and with the lateral femoral circumflex
arterial system.
The superficial circumflex iliac venous drainage is variable laterally, but a discrete vessel follows the proximal
artery. The vein remains in the subcutaneous tissues, however, rather than becoming subfascial and then joins
the saphenous vein in the fossa ovalis.
It should be mentioned that the SCIA and the SEA are parallel arterial systems and that one or the other may be
dominant and able to replace the other vessel to some extent. The higher SEA may be considerably larger and,
at times, is the only one that can be picked up with the Doppler probe. If so, the groin flap may then be designed
to make use of the SEA, rather than the SCIA, as the axial vessel of the flap (see Fig. 415.1).
FLAP DESIGN AND DIMENSIONS
In designing the flap, the inguinal ligament is palpated and marked in its course between the pubic tubercle
medially and the ASIS laterally (Fig. 415.1). The ligament may be found considerably higher than the visible groin
crease, particularly in older or obese patients. Whenever possible, the SCIA is identified with the Doppler probe
and appropriately marked.
(If the SCIA cannot be identified, the SEA may be sought, passing across the inguinal ligament and angling

diagonally upward; see Fig. 415.3).
FIGURE 415.1 The extended (delayed) groin flap and the vascular anatomy are outlined. The arc of rotation
reaching above the ipsilateral margin of the chest wall is also indicated.
FIGURE 415.2 A: This 41-year-old-woman presented with a painful left upper quadrant hernia, the result of a
shotgun wound, repaired with tantalum mesh. The skin over the mesh was paper-thin, with protruding
fragmented wire ends. The proposed large groin flap is outlined below. The area occupied by tantalum mesh is
the larger area above, with the inner circle representing the herniation. B: One year later, the hernia is shown
repaired, with dermal graft-lined extended groin flap. The site of the repair bulges less than the remainder of the
abdominal wall. (From Earle, Blackburn, ref. 2, with permission.)
The flap should then be marked out extending upward and outward, beginning at the projected lateral border of
the sartorius and with the upper and lower borders of the flap 5 cm (more or less as needed) above and below
the vessel axis. Length can then be determined by planning backward from the defect to be covered. An
undelayed flap will survive dependably for at least 5 cm beyond the ASIS and may be used to cover ipsilateral
lower abdominal wall defects. A defect of the upper abdomen or lower anterior chest will require the use of an
extended, delayed flap. If this further length is required, the flap outline may be carried laterally at least to the
lateral margin of the sacrospinalis muscle as a delayed bipedicle flap.

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FIGURE 415.3 A: This 57-year-old woman 10 years earlier received orthovoltage radiation for melanoma with
subsequent development of severe radiation reaction and early ulceration. Note the extent of the radiation
changes reaching from umbilicus to breast. B: An extended flap based in this patient on the SEA rather than the
SCIA was used for coverage of the defect after excision of the radiated area.
OPERATIVE TECHNIQUE
Although the flap is elevated at the level of the deep fascia medially (watch for and avoid injury to the SCIA in
approaching the lateral margin of the sartorius during the medial dissection), this plane is lost laterally in the
flank, where the subcutaneous tissue should be thinned appropriately. In some patients, direct closure of the
donor-site defect is possible, but if the flap is large, the defect will require skin-grafting.
If the groin flap is used for coverage of a hernial defect, support must be provided at the level of the hernial ring.
Free fascia lata or dermis are preferred; synthetic mesh is, in our opinion, a poor second choice. We have
successfully used dermis to line a groin flap in the repair of an upper quadrant hernia with skin breakdown
secondary to fragmentation of tantalum mesh (2) (Fig. 415.2).
CLINICAL RESULTS
Abdominal defects are, in our experience at least, far less common than those of the chest wall. We have
had occasion to use three groin flaps for treatment of sizable abdominal wall defects (one hernia and two
radiation reactions). The flaps have proven successful in each patient. In one of our patients, the flap was
designed above the inguinal ligament, as described earlier, and carried into the flank based on the SEA
vessel, which apparently was a dominant vessel arising from the groin (Fig. 415.3). We have skin-grafted
the donor area in all our patients, but our flaps have necessarily been wide to cover sizable defects. We
have experienced no significant complications.
SUMMARY
The groin flap represents a good and safe method for covering defects of the abdominal wall.
References

1. McGregor IA, Jackson IT. The groin flap. Br J Plast Surg 1972;25:3.
2. Earle AS, Blackburn WW. Closure of an abdominal hernia with a groin flap lined with a dermal graft. Plast
Reconstr Surg 1975;56:447.
3. Bogart JN, Rowe DS, Parsons RW. Immediate abdominal wall reconstruction with bilateral groin flaps after
resection of a large desmoid tumor. Plast Reconstr Surg 1976;58:716.

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Chapter 416
Groin Skin Flap for Contralateral Groin Defects
I. A. McGREGOR
D. S. SOUTAR
The application of groin skin flaps for abdominal wall defects was discussed in Chapter 415. This chapter
illustrates how the groin flap can be used to cover defects in the opposite groin.
INDICATIONS
The indications for local transposition of a groin flap are rare, but it is available for this purpose, should the
need arise.
FIGURE 416.1 A groin flap that is 11 cm wide has been used to cover a contralateral groin defect. Note that
the donor site is being closed primarily.
FLAP DESIGN AND DIMENSIONS
The flap can be transferred within a range approximating a circle around its base, and this would bring the
contralateral groin within its compass (1). With the pivot point of any transfer established, the geometry
necessary to calculate the dimensions of the flap appropriate to the transfer are easy to establish (Fig. 416.1).
For other details of the groin flap, see Chapter 312.
Reference
1. McGregor IA, Jackson, IT. The groin flap. Br J Plast Surg 1972;25:3.

Chapter 417
Omental Flap for Coverage of Exposed Groin Vessels
R. H. SAMSON
EDITORIAL COMMENT
If this procedure is chosen, one must be careful to avoid a hernia where the omentum exits from the perineal
cavity into the groin.
Muscle or fascial flaps are often sufficient for vessel cover, but in certain patients these may not be available. In
such instances, pedicled omental flaps are a valuable alternative. The greater omentum is a unique organ with
multipotential properties based on its rich vascular and lymphatic supplies. Pedicled omentum can survive
transfer to the most ischemic areas and provides an excellent bed for split-thickness skin grafts. Its rich arterial
supply also has been demonstrated to cause neovascularization in the host site, thus improving local tissue
nutrition, a specific property of omental flaps (1). The lymphatic abundance helps in the control of infection and
resorbs extracellular fluid.
INDICATIONS
Maintenance of viable arterial wall structure is dependent on adequate soft-tissue cover. Exposure of an
artery or arterial graft resulting from loss of soft tissue and skin cover can allow vascular infection, with
eventual loss of vessel cot suture line integrity. Severe limb or life-threatening hemorrhage may result. This
potentially lethal complication occurs most commonly in the neck, where infarction and necrosis of skin flaps
following radical neck dissection can result in a denuded carotid artery (1, 2) (see Chapter 191).
A similar situation may develop in the groin after dissection procedures for lymph node clearance. Exposure
of vascular grafts also can occur in the groin when wound infection complicates aortofemoral
revascularization procedures (3). Vascular anastomoses are especially vulnerable to exposure, bacterial
contamination, and disruption. Furthermore, synthetic grafts are not as resistant to infection as autogenous
vessels. Should vascular graft infection occur, the usual treatment involves some form of graft excision,
which may result in limb loss. Accordingly, adequate cover of exposed vessels or synthetic arterial conduits
is essential to prevent infection and disruption.
Omentum can be molded to fill irregular cavities, and large pedicles can be extended easily to groin or neck
(1, 2, 3, 4, 5).
ANATOMY
See Figure 417.1 and Chapter 191.
OPERATIVE TECHNIQUE
All procedures should begin with an exploratory laparotomy, leaving the recipient area undisturbed and, if
possible, excluded from the field. This will decrease the chance of bacterial contamination of the peritoneal cavity
and also allow verification of the adequacy of the omentum. This is especially important in patients who have had
previous abdominal surgery where omentum may have been surgically removed, e.g., in gastrectomy, or where

severe adhesions limit its use. Exploratory laparotomy also allows the opportunity to rule out metastatic disease,
especially when omentum is being used for groin wound cover following nodal dissection for malignancy.
A midline abdominal incision is usually used. Adhesions are carefully lysed, and the embryonic connection to the
transverse colon is detached. The omentum should then be transil-luminated by holding it vertically out of the
abdomen. This allows an inspection of the vascular anatomy, which is important, since any lengthening
techniques will depend on which vessel is dominant, how well the distal arcade is formed, and where it is placed.
Usually, the left gastroepiploic artery is ligated. The omentum is then carefully detached from the greater
curvature of the stomach by dividing and ligating the gastric branches of the gastroepiploic arcade. These
branches should be ligated in continuity, taking care not to injure the arcade. Bleeding into the leaves of the
omentum from an inadequately ligated vessel can cause a large hematoma, obscuring other vessels and
endangering further dissection. All gastric branches should be divided up to the right gastroepiploic vessel, since
if one is left behind, it may be avulsed during the traction on the pedicle (Fig. 417.1).
FIGURE 417.1 Division of the left gastroepiploic artery and detachment of the gastroepiploic arch from the
curvature of the stomach. The right gastroepiploic artery is preserved.
This is usually sufficient to allow the pedicle to reach the groin. If a longer pedicle is needed, as in coverage of
the carotid artery, the gastroepiploic arcade can be divided to the left of the right omental artery and to the right
of the middle omental artery. The omentum is then divided parallel to its lateral edges for a variable distance,
depending on how wide or long the flap is to be. If achieving more length is necessary, the incision through the
omentum becomes transverse, parallel and proximal to the distal arcade, even if this involves sacrificing the
distal middle omental vessels (Fig. 417.2).

FIGURE 417.2 Division of the omental arcade along the dotted line converts the omentum into a long
vascularized pedicle.
The omental flap should not course across the free peritoneal cavity but must be placed in an extraperitoneal
position, whenever possible, to obviate occurrence of obstruction caused by internal herniation or strangulation.
Pedicled omental flaps extended in a caudad direction toward the groin are positioned extraperitoneally by
mobilization of the ascending colon and placement of the flap behind the mesentery of the mobilized bowel.
In women of childbearing age, the pedicle should lie behind the broad ligament to avoid obstruction of the
fallopian tubes. The omentum should then course under the inguinal ligament and into the groin, where it should
be sutured over the exposed vessels (Fig. 417.3). A few sutures between the peritoneum and the pedicle may
decrease the chance of herniation.
The omentum flap is then wrapped around the exposed artery or vascular graft. A few tacking sutures of
absorbable material are used to fix it in place. Only minimal debridement of the host area is required. If infection
is limited, an immediate split-thickness skin graft can be applied.
SUMMARY
Exposure and infection of major arteries or vascular grafts can lead to fatal hemorrhage. Such conditions
may arise in the neck and groin after cancer surgery, especially if radiation also has been employed. The
femoral vessels in the groin also may become exposed when wound infection complicates an aortofemoral
bypass operation. Owing to the inherent ability of an omental pedicled flap to increase tissue vascularity,
absorb extracellular fluid, and combat infection, creation of such a protective flap is an important method of
restoring vascular cover and vessel or graft integrity.

FIGURE 417.3 Use of omentum to cover the exposed limb of an aortofemoral bypass graft.
References
1. Samson R, Pasternak BM. Current status of surgery of the omentum. Surg Gynecol Obstet 1979;149:437.
2. Goldsmith HS, Beattie EJ Jr. Carotid artery protection and pedicled omental wrapping. Surg Gynecol
Obstet 1970;130:57.
3. Goldsmith HS, de los Santos R, Varamee P, Beattie EJ Jr. Experimental protection of vascular prosthesis
by omentum. Arch Surg 1968;97:872.
4. Petit JY, Lacourt J, Margulis A, Reed WP. Indications and results of omental pedicle grafts in oncology.
Cancer 1979;44:2343.
5. Dijkstra R, Sillevis Smitt WC. Transposition of the omentum to close skin defects. Br J Plast Surg
1979;32:116.

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Chapter 418
Rectus Femoris Flap
W. Y. HOFFMAN
G. TRENGOVE-JONES
EDITORIAL COMMENT
Experienced surgeons have made the rectus femoris flap the primary unit for reconstruction of defects in the
lower abdomen or in the suprapubic region. It has supplanted the tensor fascia lata because the unit has
muscle throughout its extent, and the arc of rotation is shorter.
The rectus femoris flap, with its wide arc of rotation, allows reconstruction of the lower abdominal wall, perineum,
and trochanteric regions (1, 2, 3, 4, 5). It can be used with its overlying cutaneous territory or isolated as a free
flap in microvascular transfer (6).
INDICATIONS
The rectus femoris will easily reach the trochanteric, ischial, and perineal regions for closure of pressure
sores. In reconstruction of the lower abdominal wall, the rectus femoris is preferred over the tensor fasciae
latae, which must pivot further laterally and has a less reliable skin island. Several reports refer to the use of
an anterior skin and muscle flap in reconstruction following hemipelvectomy for posterior tumors (4).
Obviously, the femoral vessels must be preserved during dissection to guarantee flap survival. The flap also
has been used for closure of dead space after a failed total hip arthroplasty (5) and as a free neurovascular
flap for replacement of lost forearm muscles (6).
ANATOMY
The rectus femoris is the most anterior muscle of the quadriceps group, originating in two heads from the
anterosuperior iliac spine and the upper crest of the acetabulum and inserting conjointly into the patellar tendon
with the vastus lateralis, medialis, and intermedius. The muscle fibers attenuate into tendon approximately 6 cm
above the upper border of the patella.
The vascular supply is from the descending branch of the lateral circumflex femoral artery (a branch of the
profunda femoris) that is 1.5 to 2.0 mm in diameter, accompanied by paired venae comitantes and located
approximately 8 cm below the level of the inguinal ligament. It enters the muscle on its deep surface. If the main
pedicle is preserved, one or two
minor pedicles distal to the main vascular trunk can usually be divided.

FIGURE 418.1 The rectus femoris muscle is shown with its dominant vascular pedicle, a branch of the profunda
femoris. Note that the pivot point is 8 to 10 cm below the inguinal ligament, and this limits the superior rotation of
the flap.
A branch of the femoral nerve innervates the muscle and enters the muscle at the same level as the vascular
pedicle. The overlying skin is innervated by the intermediate cutaneous nerve of the thigh, a sensory branch of
the femoral nerve that can be used to create a neurosensory flap.
Three to four musculocutaneous perforators that arise in the proximal portion of the muscle and, to a lesser
extent, fasciocutaneous vessels arising in the intermuscular septae vascularize the skin. Thus the lower two-
thirds of the muscle can be disassociated from the underlying muscle to increase the surface-covering capacity
of this flap.
FLAP DESIGN AND DIMENSIONS
This muscle will support a skin island that can include the anterior third of the thigh. Flaps as large as 15 × 40
cm have been reported, and if the skin island is less than 6 to 7 cm wide, primary closure can be achieved. The
skin island is designed directly over the muscle, taking care to include the important proximal musculocutaneous
perforators (2, 3).
The muscle pivots about the neurovascular pedicle located some 8 cm from the inguinal ligament (3); this limits
the arc of rotation somewhat (Fig. 418.1). Within easy reach of the rectus femoris are the trochanteric region, the
perineum, and the pubic symphysis. However, because of the low pivot point, the umbilicus represents the upper
limit of the abdominal wall that can be reconstructed with this flap.
OPERATIVE TECHNIQUE
The skin flap is incised down to the muscular fascia, and the skin edges are sewn to this fascia to prevent
shearing of the important musculocutaneous vessels. The muscle or musculocutaneous unit should be elevated
from distal to proximal and from lateral to medial until the dominant pedicle is identified. By dividing the muscle at
least 6 cm above the patella, the tendinous insertion is preserved. The tendons of the vastus lateralis and
medialis are centralized with stout sutures to preserve full knee extension, and the donor defect is closed

primarily or, if it is too wide to permit direct closure, with a skin graft.
CLINICAL RESULTS
The rectus femoris flap has been shown to be extremely hardy and reliable in a small clinical series of
patients. Skin loss was rare, but a few patients reported some weakness in the terminal extension of their
knees. Most others had no discernible deficits, and all patients were ambulatory.
SUMMARY
The rectus femoris flap can be used even in ambulatory patients to reconstruct defects around the lower
abdominal wall, perineum, and trochanter.
References
1. McCraw JB, Dibbell JB, Carraway JH. Clinical definitions of myocutaneous vascular territories. Plast
Reconstr Surg 1977;60:341.
2. Bhagwat BM, Pearl RM, Laub DR. Uses of the rectus femoris myocutaneous flap. Plast Reconstr Surg
1978;62:698.
3. Mathes SJ, Nahai F, eds. Clinical applications for muscle and musculocutaneous flaps. St. Louis: Mosby,
1982.
4. Sugarbaker PH, Chretien PA. Hemipelvectomy for buttock tumors utilizing an anterior myocutaneous flap
of quadriceps femoris muscle. Ann Surg 1983;197:106.
5. Arnold PG, Witzke DJ. Management of failed total hip arthroplasty with muscle flaps. Ann Plast Surg
1983;11:474.
6. Schenck PR. Rectus femoris muscle and composite skin transplantation by microneurovascular
anastomoses for avulsion of forearm muscles: a case report. J Hand Surg 1978;3:60.

Chapter 419
Rectus Abdominis Flap for Groin Defects
J. BUNKIS
R. L. WALTON
EDITORIAL COMMENT
Extreme care must be taken to avoid an area of potential weakness or frank hernia at the pivot point of the
muscle, particularly if that point is below the semicircular line. At times, it may be better to remove the entire
muscle as an island and thus obtain a more secure closure of the rectus sheath. Consideration should also
be given to a transversely oriented skin paddle.
The rectus abdominis provides ample tissue for closure of groin defects. This arterialized flap can be used either
as a muscle or musculocutaneous flap (1, 2, 3, 4).
INDICATIONS
The inferiorly based rectus abdominis flap can be used to close any lower abdominal wall or groin defect
caused by trauma, radiation injury, or surgical extirpation of tumor or infection. It is particularly useful
following injury to the femoral vessels (with injury to the major vascular pedicles of the common thigh
muscle flaps) or with exposed vascular prostheses as a result of infection or trauma (see Fig. 419.5A). The
island modification allows the flap to reach defects over the greater trochanter. We also have employed the
inferiorly based rectus abdominis musculocutaneous unit as a free flap for more distal lower extremity
defects.
ANATOMY
The rectus abdominis muscles are paired anterior paramedian flexors of the vertebral column (particularly the
lumbar spine), and they also serve to tense the anterior abdominal wall. Each muscle originates from the lateral
head of the pubic crest and the anterior portion of the symphysis pubis (Fig. 419.1). The muscles each insert as
three distinct slips into the costal cartilages of the fifth, sixth, and seventh ribs, deep to the lower origins of the
pectoralis major muscles.
The rectus sheath covers the muscle along its entire length, but at the level of the anterior superior iliac spine,
the posterior sheath ends at the arcuate line. Below this point, the muscles lie directly on a thin layer of
transversalis fascia overlying the parietal peritoneum. Medially, the muscles are separated by the linea alba.
The width and thickness of the rectus abdominis muscle depend on the patient's physique, but generally each
muscle is approximately 8 cm wide and 1 cm thick.
The lateral border of the rectus abdominis curves superiorly from the pubic tubercle through a point midway
between the umbilicus and the anterior superior iliac spine and across the inferior costal margin to the fifth rib.
The muscle is generally slightly broader at its insertion than at its origin.

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FIGURE 419.1 Surgical anatomy of the rectus abdominis muscle. For coverage of groin defects, the flap is
based on the ipsilateral inferior epigastric pedicle.
The rectus muscle is divided into four segments by three transverse tendinous intersections. The lowest
intersection is located at or just below the level of the umbilicus; the other two are equally interspersed superiorly
between the umbilicus and the uppermost insertion into the fifth rib. The motor nerve supply to this muscle is
segmental through branches of the seventh to the twelfth intercostal nerves, which enter the muscle on its deep
surface. These branches are transected during flap elevation, and this will result in subsequent denervation
atrophy of the muscle. Sensibility to the cutaneous territory is provided by anterior and lateral cutaneous nerves
(T8 to T12), which are also transected during flap elevation, making this an insensate flap.
The rectus abdominis flap can be based on the vascular territory of its superior or inferior vascular pedicle. The
superior epigastric artery and vein are continuations of the internal mammary vessels below the costal region.
The inferior epigastric artery branches from the anteromedial surface of the external iliac artery, just above the
inguinal ligament. Venous drainage from the rectus abdominis superiorly and inferiorly parallels its arterial
supply. Inferiorly, two venae comitantes usually accompany the artery and empty into the external iliac vein.
The entire flap can survive on either pedicle, but for coverage of lower abdominal or groin defects, the flap is
based on the ipsilateral inferior epigastric pedicle. This pedicle courses across the floor of the inguinal canal and
continues in a superomedial direction (beneath the internal oblique muscle) to the lateral border of the rectus
abdominis muscle at the level of or slightly below the arcuate line. The vascular pedicle can be seen clearly on
the posterior surface of the muscle to the level of the umbilicus. Above this point, the pedicle enters the
substance of the muscle and continues upward to anastomose with the superior epigastric vessels.
Our cadaver and clinical dissections have demonstrated considerable anatomic variations in the superior
epigastric pedicle at the lower costal margin. At this level, the superior epigastric artery can usually be located
within the medial third of the muscle substance. Just below this level, however, the artery may divide into a
plexus of tiny arterial branches that converge inferiorly within the muscle to form the inferior epigastric artery.
While raising the flap, numerous arterial and venous branches will be encountered piercing the posterior rectus
sheath; these may be safely ligated.
The skin overlying the rectus abdominis is well supplied by musculocutaneous perforators. The abundant
perforators, plus a reliable random territory laterally, allow transverse extensions of the skin and subcutaneous

portions of the flap to be extended to the ipsilateral anterior axillary line without a prior delay procedure.
Experience with superiorly based rectus abdominis musculocutaneous flaps in breast reconstruction has
demonstrated that the cutaneous extension can be safely carried across the midline to the contralateral
midclavicular line (Fig. 419.2).
FLAP DESIGN AND DIMENSIONS
Key anatomic landmarks are the fifth, sixth, and seventh costal cartilages, subcostal margin, xyphoid process,
abdominal midline, pubic tubercle, lateral border of the rectus abdominis muscle (halfway between the umbilicus
and the anterosuperior iliac spine), inguinal ligament, and course of the inferior epigastric vascular pedicle (Fig.
419.1).
The design of the flap varies according to the demands for coverage. Flaps can be designed with lengths of up
to 30 cm and/or with medial or lateral cutaneous extensions, as mentioned above. The flap can be safely
transposed as a peninsular flap or as an island pedicle modification. For coverage of groin defects, it is important
to visualize the insertion of the inferior epigastric vascular pedicle at the lateral border of the rectus abdominis
before elevation of the muscle. Below the level of the umbilicus, there is a danger of separating the vascular
pedicle from the muscle.
FIGURE 419.2 Skin territory that can safely be taken with the right rectus abdominis muscle without a prior delay
procedure. Extensions beyond the borders of the underlying muscle may preclude primary wound closure by
approximation.
As an ipsilateral rectus abdominis flap is rotated toward a groin defect, it passes over the inferior epigastric
vessels and their origins from the external iliac artery and vein. With peninsular flap designs, the origin of the
rectus abdominis muscle from the symphysis pubis will limit the flap reach. A cone of rotation is inherent in this
type of flap and also will limit the reach (Fig. 419.3). Island pedicle modification and dissection of the inferior
epigastric pedicle to the iliac vessels will extend the flap reach an additional 10 cm.
OPERATIVE TECHNIQUE
If a simple muscle flap is chosen, an incision is made along the lateral border of the ipsilateral rectus abdominis.
The anterior rectus sheath is opened along its lateral margin, and the inferior epigastric pedicle is identified
below the arcuate line. The muscle is then sharply dissected from the pocket of the rectus sheath. Posteriorly,
below the arcuate line, the muscle is dissected from the transversus abdominis fascia. Care is exercised to avoid

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injury to the inferior epigastric pedicle and its attachments to the overlying muscle. After the appropriate flap
length is chosen, the muscle is divided superiorly (usually at one of its tendinous insertions) and transposed to
the recipient defect.
Peninsular musculocutaneous versions of this flap incorporate the skin and anterior rectus fascia directly
overlying the rectus muscle. A vertical incision is made along the lateral flap margin and extended through the
lateral margin of the
rectus sheath (Fig. 419.4). After identification of the inferior epigastric pedicle, the medial incision is performed,
and this is extended through the medial edge of the rectus sheath. It is helpful to leave a 1-cm or greater cuff of
rectus fascia medially to provide an adequate margin for subsequent fascial closure.
FIGURE 419.3 Arcs of rotation of superiorly and inferiorly based rectus abdominis peninsular flaps. Note
possible coverage of groin defects with an ipsilateral inferiorly based rectus flap. Island modification based on
the inferior epigastric pedicle will extend the flap reach an additional 10 cm.
Several sutures are then placed through the skin margins medially and laterally to anchor the cutaneous portion
of the flap to the underlying fascia and muscle. The rectus muscle is then dissected from its posterior
attachments, as described above. At this point, it may be wise to occlude the superior epigastric pedicle by finger
pressure and to observe the flap for capillary refill to ensure adequate inflow from the inferior epigastric system.
FIGURE 419.4 Raising the flap. Lateral incision has been carried through the anterior rectus sheath and the
inferior epigastric pedicle has been identified (white arrow). Note continuation of vascular pedicle along
undersurface of rectus muscle and anastomoses with terminal branches of intercostal vessels (black arrows).

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Stay sutures secure the skin to the underlying muscle fibers and anterior rectus sheath.
The flap is then divided superiorly at the appropriate level and transposed to the recipient defect. To avoid a
cone of rotation and gain additional length, the cutaneous portion of the flap can be converted to an island. The
rectus muscle also can be divided at its origin on the symphysis pubis to create a true musculocutaneous island
pedicle flap. The flap pedicle can be lengthened by incising the internal oblique muscle laterally and dissecting
the inferior epigastric vessels to their origin at the external iliac artery and vein.
The cutaneous territory of the rectus abdominis flap can be extended laterally to the anterior axillary line and
medially to the contralateral midclavicular line. Elevation of these flaps begins by dissecting the cutaneous
paddle above the abdominal fascia to the lateral and/or medial margin of the rectus fascia. The flap is then
elevated as described above.
In positioning the flap into the groin defect, care must be taken to avoid twisting or stretching the inferior
epigastric vessels. If a skin bridge separates the defect from the flap, the bridge can be divided or a portion of
the flap can be deepithelialized, and the flap can be passed through a subcutaneous tunnel into the defect.
In most cases, the external oblique muscle, with its overlying fascia, can be advanced medially and sutured to
the medial cuff of rectus fascia and the linea alba. If the donor fascial defect cannot be closed primarily without
tension, it is best to employ a free fascial graft or synthetic mesh repair to avoid a hernia.
If the cutaneous paddle does not extend beyond the lateral borders of the muscle, the skin can usually be closed
by primary approximation. Use of an extended skin island may require a skin graft to close the secondary
cutaneous defect. Generally, transversely oriented cutaneous donor sites are easily closed without complication
(Fig. 419.5).
CLINICAL RESULTS
This is a safe, reliable flap that can be elevated expediently with the patient in a supine position. To date,
we have not lost any of our rectus abdominis flaps. One must exercise caution, however, in the face of
nearby previous surgical incisions. Care also must be taken to identify the inferior epigastric vessels along
the lateral border of the rectus abdominis and to ensure that the vascular pedicle maintains its attachment
to the posterior muscle surface as the flap is elevated.
Attention must be paid to the closure of the donor site, particularly inferiorly, to avoid a hernia. Most
unilateral flap defects can be closed without fascial grafts or mesh, but in one patient, following bilateral
rectus abdominis musculocutaneous flaps, we employed Marlex® mesh to secure closure of the abdominal
wall. If the abdominal wall is closed under some tension, patients will often complain of a temporary
tightness.
The rectus abdominis muscle is used to flex the spine and to tighten the abdominal wall, particularly when
sitting up from the supine position. We have not noticed a clinically significant functional deficit in any
patient following a unilateral procedure. A major disadvantage of this flap is its lack of sensibility.
SUMMARY
The rectus abdominis muscle or musculocutaneous flap is well suited for closing lower abdominal wall or
groin defects.

FIGURE 419.5 A: Right groin defect in 45-year-old female patient following close-range 12-gauge shotgun
injury. The common femoral, superficial femoral, and profunda femoris arteries have been reconstructed
with a combination of autogenous and alloplastic vascular grafts. The grafts were partially covered with
injured adjacent sartorius and adductor longus muscle fibers. Arteriography following vascular
reconstruction demonstrated disruption of major vascular pedicles to lateral thigh muscles. B: An ipsilateral
inferiorly based rectus abdominis peninsular flap has been transposed to provide coverage of the exposed
vascular prostheses. A meshed skin graft was placed on the muscle lateral to the grafts to complete the
reconstruction, and the wounds healed per primum. C: Postoperative result at 7 months.
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. Mathes SJ, Nahai F, eds. Clinical atlas of muscle and musculocutaneous flaps. St. Louis: Mosby, 1979.
4. Nahai F, Bostwick J III, Hester TR. Experiences with the rectus abdominis flap. Plast Surg Forum
1980;3:157.

Chapter 420
Superior Epigastric Artery Perforator (Seap) Flap
MOUSTAPHA HAMDI
BARBARA CRAGGS
EDITORIAL COMMENT
Identifying the perforators is the critical portion this flap design and inferior extension, especially distal to the umbilicus
where partial flap loss may occur.
INDICATIONS
To reduce donor site morbidity in anterior chest wall reconstruction, myocutaneous flaps have been progressively
replaced by perforator flaps, which spare the whole muscle and fascia, for the repair of contour defects and extensive
skin fat replacement. Similarly, just as deep inferior epigastric perforator (DIEP) flaps have evolved from the
transverse rectus abdominis muscle (TRAM) flap, a flap based on perforators of the superficial epigastric artery (SEA)
was developed and successfully applied in a pedicled fashion for locoregional soft-tissue reconstruction of defects of
the anterior chest wall or breast reconstruction, or for abdominal wall reconstructive purposes (1). More specifically,
deep superior epigastric artery-based adipocutaneous flaps offer an attractive alternative in sternal wound coverage
without disrupting the muscular continuity of the abdominal wall. In patients with an intact internal thoracic artery-deep
superior epigastric artery vascular axis, the use of this flap maintains future use of rectus abdominis or pectoralis
major myocutaneous flaps.
ANATOMY
The first anatomic studies of the superior epigastric vascular system were performed by Boyd (2) in 1984, Taylor (3, 4) in
1987 and 2003, and Miller (5) in 1988. Hallock (6) was the first to describe a perforator flap based on the superior
epigastric artery. The vascular basis of the SEAP flap and its clinical applications have been evaluated by means of CT-
angiography scans by Hamdi (1). The superior epigastric artery (2, 3, 4) continues inferiorly along the same line as the
internal thoracic artery and may send a large superficial branch (diameter ≥1.0 mm) through the origin of the rectus
abdominis (RA) muscle, which pierces the rectus fascia directly under the xiphoid to supply the overlying skin (1, 7).
Manchot (8) originally described this branch as the superficial superior epigastric artery. Flaps based on the superficial
branch, therefore, have a reasonably short pedicle length but are still very useful for coverage of presternal defects.
The main trunk of the SEA (or the so-called the deep superior epigastric artery or DSEA) enters the RA muscle on its deep
surface, approximately 7 cm below the costal margin. Several perforators arise from the branches of the SEA, usually just
below the costal margin up to the second tendinous intersection that is situated midway between the costal margin and the
umbilicus. The perforators pierce the rectus muscle or sometimes pierce the sheath beside the lateral border of the
muscle. The artery subdivides into several branches that arborize further to anastomose inferiorly with the DIEA and
laterally with terminal branches of the intercostal arteries. The multidetector computed tomography (MDCT) scan can
easily distinguish between perforators arising from the DSEA and those arising from the intercostal or even those from the
costomarginal artery, which branches out of the lateral division of the DSEA and its anastomosis with the eighth posterior
intercostal artery. Thus, several perforator-based flaps can be raised for trunk reconstruction. Although a diameter of 1 mm
is considered to be sufficient, one should be cautious because this diameter is very often slightly overestimated due to the
partial-volume effect.
Perforator Morphology
Emerging perforators (1, 9) with a caliber of greater than 0.5 mm are most frequently encountered in an area 2 to 6 cm