Surgical Highlightsd

The patient is placed supine. The deep inferior epigastric artery is marked originating superior to the inguinal ligament and entering the deep inferolateral portion of the muscle midway between the umbilicus and pubic symphysis. The lateral extent of the muscle is approximately 10 cm from the midline.

The choice of skin incision depends on whether a muscle-only flap or a muscu-locutaneous flap is required. A muscle-only flap can be harvested through a parame- |

dian vertical incision or a low transverse Pfannenstiel-type incision. A skin paddle can be oriented along the surface of the muscle (vertically) or transversely across the midline, depending on the needs at the recipient site. For example, one option

Figure 27 The rectus muscle free flap freed from its tendinous insertions. Note the position of the deep inferior epigastric vessels coursing superomedially inferior to the arcurate line.

for reconstruction of a total tongue defect requires a musculocutaneous rectus flap with an overlying skin paddle oriented vertically along the surface of the muscle. This allows the transversely oriented tendinous inscriptions to be sutured to the mandible for support of the skin paddle. The skin paddle should be based on an ipsi-lateral periumbilical perforator. If a very long skin paddle is required (> 20 cm) it should be oriented vertically along a line from the lateral border of the muscle to the tip of the scapula (Fig. 32). There is a hardy subdermal plexus along this line that allows the distal paddle to survive.

Harvesting a muscle-only flap does not require sacrifice of the anterior rectus sheath and the risk of postoperative hernia is low. However, skin harvest will require removal of a portion of the anterior rectus sheath and the risk of postoperative hernia formation increases. This is particularly relevant in cases that involve sacrifice of the anterior rectus sheath below the arcuate line where the posterior sheath of the rectus abdominis is deficient. Dehiscence of the anterior rectus sheath is avoided by meticulous dissection around the tendinous inscriptions and sacrificing only the portion of the rectus sheath that immediately surrounds the major perforating arteries. If the anterior rectus sheath is deficient below the arcuate line, a synthetic mesh may be used to reinforce the abdominal wall.

The inferior epigastric artery and its venae comitantes are found along the lateral aspect of the muscle below the arcuate line and dissected inferiorly to their origin

Figure 28 A muscle-only rectus flap is commonly used in skull base surgery to resurface the inferior and inferolateral aspects of the brain, providing separation of the cranial contents from the nose and infratemporal fossa. Typically, the superficial temporal vessels serve to nourish the flap.

at the external iliac vessels. A vascular loop is placed around the vessels and they are divided distal to their origin as a final step in harvesting the flap. A segment of muscle between the tendinous inscriptions may be reanimated by harvesting the intercostal nerve to that segment and connecting it to a motor nerve at the recipient site.

For a muscle-only harvest, the anterior rectus sheet may be split vertically over the middle of the muscle or along its lateral border. The sheath is tightly adherent to the tendinous inscriptions on the muscle and must be sharply divided.

Much of the anterior sheath can be preserved since only the sheath surrounding |

the perforators need be sacrificed. Only a single perforator is required to support a |>

large skin paddle and only a small portion of the anterior sheath surrounding the perforating vessel need be sacrificed.

Advantages o

A two-team approach is possible allowing simultaneous extirpation of a head and neck cancer and harvest of the free flap. The pedicle length is good at 6-8 cm and @

Figure 29 A common use for the musculocutaneous rectus flap is to close extensive complex combined orbit, palate, and maxillary defects. The flap is designed to provide skin coverage over the orbit and cheek, lateral nasal wall, and palate.

the vessel diameters are very large (2-3 mm), making the microvascular portion of the procedure straightforward. In fact, the rectus free flap is the most reliable free tissue transplant in terms of survival. The large adipose component of the musculocutaneous flap can be used for permanent volume replacement because, unlike muscle, revascularized adipose tissue will not atrophy. This is useful if maintenance of bulk is desirable such as in tongue reconstruction. The tendinous inscriptions can be sutured to the mandible to support the neotongue. Although the segmentally oriented motor nerve supply can be used, the minimal movement achieved for tongue reconstruction is probably of no benefit to speech and swallowing.

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