Aesth. Plast. Surg.

30:120 124, 2006

DOI: 10.1007/s00266-005-0145-6

Delayed Vertical Rectus Abdominis Myocutaneous Flap for Anterior Chest Wall
Reconstruction

Masao Fujiwara, M.D.,1 Yoko Nakamura, M.D.,1 Akira Sano, M.D.,2 Ei Nakayama, M.D.,3
Miyuki Nagasawa, M.D.,3 and Toru Shindo, M.D.3
1

Department of Plastic and Reconstructive Surgery, Tenri Hospital, 200, Mishima, Tenri, Nara, 632-8552, Japan
Department of Radiology, Tenri Hospital, 200, Mishima, Tenri, Nara, 632-8552, Japan
3
Department of Respiratory Surgery, Tenri Hospital, 200, Mishima, Tenri, Nara, 632-8552, Japan
2

Abstract.
Background: Not only is a radiation ulcer nonviable itself,
but the surrounding irradiated tissue also shows poor
healing. Therefore, healing in an irradiated eld cannot be
expected if a ap used for reconstruction fails even partially. For repair of radiation ulcers, a ap with a stable
blood supply is required. A superiorly based vertical rectus
abdominis myocutaneous (VRAM) ap is commonly used
for chest wall reconstruction. Because the VRAM ap is
nourished only by the superior epigastric vessels, the blood
supply to the distal part of the ap often is precarious.
Case Report: A case is reported in which a delayed VRAM
ap was used successfully to treat a radiation ulcer on the
anterior chest wall.
Results: Consecutive angiograms showed that the delay
procedure augmented the blood supply to the VRAM ap.
The ap showed complete take without any postoperative
complications.
Conclusion: A delay procedure may make the VRAM ap
more reliable for anterior chest wall reconstruction. This
ap may be a valuable option for reconstruction of
intractable ulcers such as radiation ulcers, and may be
applicable for breast reconstruction after radiation therapy.
Key words: DelayRectus
apRadiationUlcer

abdominis

myocutaneous

A rectus abdominis myocutaneous (RAM) ap may

be either horizontal or vertical, and the vertical ap

Correspondence to M. Fujiwara M.D.; email: masaofuj@

mth.biglobe.ne.jp

may be based inferiorly or superiorly. Use of a

superiorly based RAM ap has become the standard
method for reconstruction of the anterior chest wall,
including breast reconstruction [3].
The superiorly based vertical RAM (VRAM) ap
would appear to have a better blood supply than the
superiorly based transverse RAM (TRAM) ap,
because the ap is designed over the rectus muscle
[8]. However, the blood supply to the distal part of
the ap often is precarious because the VRAM ap
is nourished only by the superior epigastric vascular
system [1,9,10,13]. Therefore, the standard procedure for mobilizing a VRAM ap sometimes leads
to ischemia or venous congestion in the distal portion of the ap, which can result in graft failure
[9,11]. Shrotria et al. [11] reported that the incidence
of partial necrosis was 12.5% (11/88 cases) when
conventional VRAM aps were used in cosmetic
breast reconstruction, whereas it was 43.8% (7/16
cases) when they were used to cover chest wall
defects.
To our knowledge, there have been only two reports about augmentation of the blood supply to
superiorly based VRAM aps [9,13]. In both reports, microvascular anastomosis was performed
between the inferior epigastric system and the
available vessels from the axillary, brachial, or cervical vascular system [9,13]. Use of a delay procedure to improve survival has been reported for
TRAM aps [2,4], but there have been no reports
about the use of a delay procedure for superiorly
based VRAM aps. Accordingly, this is the rst
report about a delayed superiorly based VRAM
ap. We describe the operative details and discuss
the features of this ap.

M. Fujiwara et al.

121

Fig. 1. The deep inferior epigastric vessels (arrow) have been dissected. In addition to vascular
delay with ligation of the deep inferior epigastric
vessels, partial surgical delay with an incision for
the distal third of the ap was performed.

Operative Procedure
The skin markings are drawn while the patient is
awake preoperatively. The ap may extend from the
xiphoid process to the mons pubis. The level with the
greatest width is determined by skin tension because
the ap should be harvested so that the defect can be
closed directly. The lateral abdominal skin is pushed
medially from both sides to conrm the tension on it.
The delay procedure consists of making the incision
for the inferior one-third of the ap (surgical delay)
and ligation of the deep inferior epigastric artery and
vein (vascular delay), which are accessed via the ap
incision down to the fascia about 2 weeks before the
actual ap transfer (Fig. 1).
After a 2-week delay, the VRAM ap is elevated.
At the graft site, aggressive debridement of the
necrotic soft tissue, bone, and cartilage is performed.
When possible, it is better to remove the entire eld of
radiation-aected tissue before reconstruction [5].
Reconstruction of bony defects is not always necessary. Even very large defects can be covered successfully by using a bulky myocutaneous ap without
skeletal stabilization [6,7] because the thickness of the
ap, subsequent ap brosis, and radiation brosis
all tend to minimize the occurrence of paradoxical
wall motion and to maintain chest wall stability [5].
After the same skin ap incision from the delay
procedure is refreshed, the anterior sheath of the
rectus abdominis is incised, and the rectus muscle is
cut after ligation of the muscle belly. The muscle is
always divided cephalad to the arcuate line to prevent lower abdominal wall herniation [10]. The
blood supply to the skin passes through the anterior
rectus sheath from the rectus abdominis muscle, so
the skin must remain attached to the muscle. After
the incision is also made for the superior two-thirds
of the ap, the abdominal skin is undermined lat-

erally beyond the margins of the rectus abdominis

muscle in the fascial plane. The medial and lateral
borders of the anterior rectus sheath are incised
longitudinally, with care taken to preserve a 1-cm
strip of the sheath along both borders for closure.
Then the ap is elevated as far as the costal margin,
leaving the posterior rectus sheath in situ. The point
at which the superior epigastric vessels enter the
rectus abdominis muscle is the pivot of this ap.
The donor site is closed by approximating the
medial and lateral fascial borders, and a suction
drain is placed in the undermined lateral abdominal
area.
Case Report
A 61-year-old woman presented with an infected
radiation ulcer on the anterior chest. She had
undergone mastectomy 16 years previously, followed
by chemotherapy and radiation therapy. A deep ulcer
(8 11 cm) that exposed necrotic ribs, the sternum,
and the surface of the pericardium had developed
within the radiation eld on the anterior chest wall.
Reconstruction using an ipsilateral latissimus dorsi
myocutaneous ap had been performed, but was
followed by partial necrosis of the distal portion of
the ap. A delayed VRAM ap was planned. The
delay procedure involved both vascular and surgical
delay (Fig. 1). Consecutive selective angiograms via
the right internal thoracic artery showed that the
delay procedure led to augmentation of the blood
supply to the VRAM ap (Fig. 2).
Two weeks after the delay procedure, aggressive
debridement and transfer of a large VRAM ap (13
26 cm) were performed (Fig. 3A). Graft site resection
included portions of three ribs (2nd to 4th) and partial sternectomy, but skeletal repair was not per-

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Delayed VRAM Flap

Fig. 2. Selective angiograms obtained via the right internal thoracic artery before delay (A) and 10 days after delay (B). The
angiogram obtained after delay shows dilation of vessels (arrowhead) in the caudal part of the superior epigastric vascular
system, as compared with that obtained before delay.

Fig. 3. (A) Design of a delayed vertical rectus abdominis myocutaneous ap. A dotted line shows the skin incision. (B)
Appearance 4 months after surgery. Improvement in the waistline is notable, although a longitudinal abdominal scar is
present.

formed. The distal portion of the ap was used to

cover the cephalad part of the ulcer, which exposed
the ribs and sternum. The ap showed complete take,
and neither ail chest nor respiratory insuciency
occurred. Four months after surgery, the patients
wounds were healed completely (Fig. 3B).

Discussion
Infection, scarring, and devascularization from irradiation represent some of the most dicult problems
for reconstructive surgery. Irradiation alters the surrounding tissues and structures in a permanent and

M. Fujiwara et al.

progressive manner. Among the changes to normal

tissues are loss of healing capacity, skin atrophy,
brosis, alterations of the microcirculation, and the
potential for necrosis to occur [5]. Therefore, when
surgery is performed in an irradiated eld, a nonhealing wound with progressive necrosis may be the
result [5]. For reconstruction of radiation ulcers, a
ap with a stable blood supply is required.
The perforators that supply the skin overlying the
rectus abdominis muscle are located predominantly
above the level of the arcuate line, and detection of
more than one perforator below this line is rare [3].
On the basis of dissection and radiographic studies,
Moon and Taylor [8] concluded that the blood supply
to a superiorly based VRAM ap is from the myocutaneous perforators that originate in the deep
superior epigastric artery, as well as from retrograde
lling of perforators from the deep inferior epigastric
artery. The distal 3 to 4 cm of a VRAM ap designed
from the xiphoid process to the mons pubis showed
little contrast enhancement. This area corresponds to
the territory of the supercial external pudendal
artery.
When TRAM aps are used, good ap survival is
obtained by a delay procedure. Erdmann et al. [4]
used a unipedicled TRAM ap for reconstruction of
the breast, nding that combined vascular and partial
surgical delay for 2 weeks before ap transfer resulted
in 6.6% partial necrosis (fat necrosis) and no complete ap necrosis in a series of 76 consecutive cases.
Their delay procedure consisted of partial surgical
delay with a three-fourths inferior ap incision, as
well as vascular delay with bilateral ligation of the
deep inferior epigastric artery and vein [4].
For the reported patient, when angiograms were
obtained 10 days after the delay procedure, the caudal part of the superior epigastric vascular system
was shown to be dilated, as compared with its
appearance before the procedure. Contrast medium
was selectively injected into the superior epigastric
artery by use of a microcatheter, so the angiogram
directly demonstrated blood ow in the superior
epigastric vascular system (Fig. 2).
Anatomically, there are obstructions to ow in
both the muscle and skin of the ap. In the muscle, a
system of small-caliber choke arteries connects the
deep superior and inferior epigastric arteries. In the
skin, many of the veins contain valves directed away
from the muscle pedicle. The choke arteries within
the muscle undergo dilation, and the veins in the skin
and muscle become regurgitant to allow free ow
toward to the superior epigastric pedicle after ligation
of the deep inferior epigastric vessels. The ipsilateral
superior epigastric vessels and deep inferior epigastric
vessels virtually coalesce into one system after the
delay procedure [2,12]. In the reported patient, dilation of caudal vessels after the delay procedure may
indicate improvement in the arterial supply and
venous drainage of the distal part of the VRAM ap
(Fig. 2).

123

When microvascular anastomosis is used for augmentation of the blood supply to a VRAM ap,
additional dissection of the neck or axilla is required
to prepare recipient vessels such as external carotid
artery branches, the internal or external jugular vein,
the thoracodorsal artery, and the thoracodorsal vein
[9,13]. Such additional dissection of the neck or axilla
increases postoperative scarring. The delayed VRAM
ap has the following advantages over the modied
VRAM aps using microvascular anastomosis described earlier. First, the skin incision is the same as
for a conventional VRAM ap because dissection of
recipient vessels is unnecessary. Second, because there
is no microvascular anastomosis, ap failure attributable to thrombosis is unlikely, and positioning of
the ap is not limited by anastomosis, and thus can
be optimized.
On consecutive angiograms, the delayed VRAM
ap showed enlargement of the superior epigastric
vascular system, as compared with the conventional
VRAM ap. In addition, a larger ap that includes
more of the lower abdomen may be harvested by the
delay procedure, as compared with the conventional
VRAM method, because the territory of the supercial external pudendal artery and that of the deep
inferior epigastric artery can be included. Therefore,
there is a simultaneous benecial eect of
abdominoplasty, which improves the waistline.
For both cosmetic reasons and a better blood
supply, a delayed VRAM ap should be regarded as
a valuable option for reconstruction of intractable
ulcers such as radiation ulcers. It also should be
applicable to breast reconstruction after radiation
therapy.
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Delayed VRAM Flap

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