The Vascular Anatomy of the Anterior Abdominal Wall: The Basis for Flap Design

Abstract

Since plastic surgery evolved as a specialty in the early part of this century, the integument of the anterior abdominal wall has been one of the premier sources of tissue for local and distant flap transfer. It enjoys a robust blood supply, scars are easily concealed, the anatomy is familiar to most surgeons, and there is an abundance of skin and subcutaneous tissue, especially in the parous woman. Perhaps the most coveted expanse of skin and fat is that area below the umbilicus because in most cases the donor defect can be closed by an abdominoplasty procedure, leaving only a suprapubic transverse scar.It is not surprising therefore that for decades attention has focused on the lower abdomen as a potential donor site for reconstruction of the breast following mastectomy. Initially flap transfers were performed as multistaged, tube pedicle procedures, but the pendulum of surgical preference has since swung towards one-stage operations. The first of these was a brief encounter by microsurgeons in which the lower abdominal integument was transferred to the breast as a free flap, designed to be based on the deep inferior epigastric (DIE) vesse1s.l Soon after, proponents of the pedicled musculocutaneous flap advocated a "burrowing" approach from above and Hartrampf, Scheflan, and Black2 introduced the lower transverse rectus abdominis musculocutaneous (TRAM) flap. More recently, the lower abdomen has been reappraised by microsurgeons. Hester et aL3 have transferred this skin paddle based on the superficial inferior epigastric (SIE) system, and Shaw4 has produced a large series of free flap reconstructions of the breast, returning once again to the DIE vessels to nourish the tissue.Unfortunately, none of these operations has proved to be a panacea for all occasions. Free flap operations provide tissue with a good blood supply, but then the surgeon is confronted with anastomotic problems: the SIE vessels are small and the pedicle is short. The DIE vessels are longer and Downloaded by: National University of Singapore. Copyrighted material.

Reviewing the vascular supply of the anterior abdominal wall: Redefining anatomy for increasingly refined surgery

“…This prefix has not been widely adopted in the anatomical literature. The communication between these two systems occurs within rectus abdominis muscle, at a level above the umbilicus (Taylor et al, 1991). The DSEA and DIEA are important vessels in the supply to superiorly based (DSEA) and inferiorly based (DIEA) rectus abdominis flaps (Taylor et al, 1983;Miller et al, 1988;Moon and Taylor, 1988;Taylor, , 1988Itoh and Arai, 1993).…”

“…Major branches were classified according to their size and their anastomosis with equivalent branches of the superior epigastric artery above the umbilicus. Further anatomical studies highlighted that this classification system was based on the size and origin of an ever-present umbilical branch, and whether it arises as a small branch from a Type 1 or from the medial trunk of a Type 2 artery, or whether it is a dominant branch and forms a major trunk as is the case in a Type 3 vessel (Taylor et al, 1991;Taylor, 2002;Rozen et al, 2007a). One subsequent study has attempted a different classification system for the DIEA branching pattern, describing six branching patterns based on their series of embalmed cadaveric dissections, a system not pursued elsewhere in the literature (Kikuchi et al, 2001).…”

Retalho TRAM com dissecção mínima para reconstrução mamária

“…Mantendo-se atenção rigorosa às indicações e contraindicações do TRAM, este tem imensa popularidade, tendo sido empregado largamente em inúmeras reconstruções, mormente nas reconstruções mamárias pós-mastectomia 6,7 . Conforme Taylor et al 8 descreveram, em 1991, o retalho foi confeccionado com marcação de segmento de pele do abdome vascularizado por vasos perfurantes intramusculares que emergem dos músculos reto abdominais dispostos em pares, predominantemente na região periumbilical originados dos vasos epigástricos profundos superiores 8 , o que propiciou a viabilidade de todos os retalhos realizados.…”

Lipoabdominoplastia: redução das complicações em cirurgias abdominais

“…Porém, produziu aumento da morbidade devido à redução considerável do aporte sanguíneo do retalho abdominal 2-5 , visto que a extensão do descolamento lesa os vasos perfurantes abdominais, que representam 80% do aporte sanguíneo da parede abdominal, de acordo com a literatura 6 . Consequentemente, a vascularização remanescente fica por conta das intercostais, circunflexa e perfurantes lombares, situadas nos flancos e no dorso abdominais 7 . A lipoabdominoplastia, desenvolvida em 2000 por Saldanha e publicada em 2001, quando esse termo foi utilizado pela primeira vez na literatura mundial, representa uma opção segura para a associação da lipoaspiração à abdominoplastia.…”