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Shortcut Vascular Augmented Long Rectus Abdominis Musculocutaneous Flap Transfer Using the Intercostal Perforator for Complex Oropharyngocutaneous Defects

Okazaki, Mutsumi M.D.; Asato, Hirotaka M.D.; Okochi, Masayuki M.D.; Suga, Hirotaka M.D.; Kinoshita, Mikio M.D.

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Plastic and Reconstructive Surgery: April 2008 - Volume 121 - Issue 4 - p 220e-221e
doi: 10.1097/01.prs.0000305383.60403.3e
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Sir:

We present a new concept: a shortcut technique involving vascular augmented free long rectus abdominis musculocutaneous flap transfer anastomosing the intercostal perforator with the lateral branch of the deep inferior epigastric vessels of the flap itself. Using this method, a patient with a complex oropharyngocutaneous defect was reconstructed.

A 77-year-old man presented with a recurrent cancer of the tongue base, with orocutaneous fistula accompanied by a “frozen neck.” Extensive resection was performed (Fig. 1). A long, gourd-shaped rectus abdominis musculocutaneous flap was elevated based on the deep inferior epigastric vessels, including the eighth intercostal perforator in the distal part of the flap (Fig. 2). The oropharyngeal space was reconstructed with the proximal part of the flap, and the neck skin was reconstructed with the distal part. After the flap artery and vein were anastomosed to the left external carotid artery and internal jugular vein, respectively, in an end-to-side fashion, the eighth intercostal perforator (vein and artery) was then anastomosed to the lateral branch of the deep inferior epigastric vessels of the flap itself (Fig. 3). The flap survived perfectly without leakage or abscess formation.

Fig. 1.
Fig. 1.:
The defect after the extensive cancer ablation. The defects involved the oral floor, middle and hypopharynx, cervical esophagus, lower lip, and cervical skin. The scar formation was spread all over the neck region, and branches of external carotid or subclavian arteries were unavailable for the recipient artery.
Fig. 2.
Fig. 2.:
The distal part of the rectus abdominis musculocutaneous flap. The eighth anterior intercostal neurovascular bundles pierce the serratus muscle and give branches medially and laterally that nourish the distal part of the flap.
Fig. 3.
Fig. 3.:
Finding just after the additional vascular anastomosis between the lateral branch of the deep inferior epigastric vessels (arrowhead) and the intercostal perforator (arrow).

Offman et al.1 reported that the principal source vessels of the lateral flank region contributed a mean of 33 perforators per hemitrunk. The total area of skin supplied directly by these perforators was a mean 1200 cm2, equal to an average of 37 cm2 (1200/33) per perforator. As a single perforator is estimated to supply much more than 37 cm2 on average, an additional lateral branch of the deep inferior epigastric vessels–intercostal perforator anastomosis may be effective for the vascular augmentation of the distal part of the rectus abdominis musculocutaneous flap. The “frozen neck” is one of the challenging problems in the secondary reconstruction.2,3 Our shortcut vascular augmentation method using intercostal perforator–lateral branch of the deep inferior epigastric vessel anastomosis is advantageous in that the extremely long oblique rectus abdominis musculocutaneous flap can be transferred based on a single recipient artery and vein, and can therefore even be applied in cases of frozen neck. The deep inferior epigastric perforator flap can be similarly transferred using this concept. The shortcoming of this method is that it can only be used when the distal part of the flap is near the proximal region. The probable indication of this method, therefore, is in the reconstruction of full-thickness (oro-)pharyngocutaneous defects or circumferential defects of the extremities, and so on. Oki et al.4 reported use of the intercostal perforator for vascular augmentation of the pedicled large and thin flap. Ohjimi et al.5 reported a free transverse rectus abdominis musculocutaneous flap with “in-flap vascular augmentation methods” using deep inferior epigastric perforator–contralateral deep inferior epigastric perforator anastomosis. However, our shortcut vascular augmentation method using the lateral branch of the deep inferior epigastric vessels–intercostal perforator anastomosis, to our knowledge, has not previously been presented in the literature.

Mutsumi Okazaki, M.D.

Hirotaka Asato, M.D.

Masayuki Okochi, M.D.

Hirotaka Suga, M.D.

Mikio Kinoshita, M.D.

Department of Plastic and Reconstructive Surgery

Kyorin University

Tokyo, Japan

REFERENCES

1. Offman, S. L., Geddes, C. R., Tang, M., et al. The vascular basis of perforator flaps based on the source arteries of the lateral lumbar region. Plast. Reconstr. Surg. 115: 1651, 2005.
2. Okazaki, M., Asato, H., Sarukawa, S., et al. Availability of end-to-side arterial anastomosis to the external carotid artery using short-thread double-needle micro-suture in free-flap transfer for head and neck reconstruction. Ann. Plast. Surg. 56: 171, 2006.
3. Yu, P. The transverse cervical vessels as recipient vessels for previously treated head and neck cancer patients. Plast. Reconstr. Surg. 115: 1253, 2005.
4. Oki, K., Hyakusoku, H., Murakami, M., et al. Dorsal intercostal perforator (DICP) augmented scapular “super-thin flaps” for the reconstruction of extensive scar contractures in the axilla and anterior chest: A case report. Burns 31: 105, 2005.
5. Ohjimi, H., Era, K., Haraga, I., et al. In free transverse rectus abdominis musculocutaneous free flap vascular augmentation methods. J. Jpn. Soc. Reconstr. Microsurg. (Japanese) 17: 172, 2004.

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