The primary prevention of pancreatic fistula using a vascularised rectus abdominis muscle flap - A porcine model.

Background: A pancreatic fistula is one of the most devastating complications following a Whipple's procedure. Fistula rates remain high despite various modifications to surgical techniques. We propose the use of a vascularised muscle flap in the primary prevention of pancreatic fistulas. Method: A distal pancreatectomy was performed on 5 pigs in our porcine model. A pancreaticojejunal (PJ) anastomotic leak was simulated. The pigs were divided into treatment (4 pigs) and control groups (1 pig). A left pedicled rectus abdominis flap was wrapped around the PJ anastomosis for the treatment group and omitted for the control group. Serum and drain amylase levels were recorded. The PJ-rectus abdominis flap complex was evaluated histologically. Results: There was no biochemical evidence of anastomotic leak in the treatment group. The drain-serum amylase ratio was less than 1.5 in the treatment group (p=0.006). Microscopically, the muscle adjacent to the anastomotic leak showed mild necrotic changes with an affected muscle depth of less than 10%. Conclusion: The vascularised rectus abdominis muscle is a durable flap to withstand proteolytic pancreatic enzymes. It is able to provide a water-tight seal around the PJ anastomosis and mitigate intraperitoneal haemorrhage and infection caused by erosion from the pancreatic fistula.

Interdisciplinary aspects of abdominal and plastic surgery - what does the (abdominal) surgeon need to know?

Introduction: The aim was to reflect the established interdisciplinary aspects of general/abdominal and plastic surgery by means of a narrative review. Methods: (i) With specific references out of the medical literature and (ii) own clinical and perioperative as well as operating technical and tactical management experiences obtained in surgical daily practice, we present a choice of options for interdisciplinary cooperation that could be food of thought for other surgeons. Content: - Decubital ulcers require pressure relieve, debridement and plastic surgery coverage, e.g., by a rotation flap plasty, V-Y flap or "tensor-fascia-lata" (TFL) flap depending on localization (sacral/gluteal defects, ischiadic tuber). - Coverage of soft tissue defects, e.g., after lymph node dissection, tumor lesions or disturbance of wound healing can be managed with fasciocutaneous or muscle flaps. - Bariatric surgery: Surgical interventions such as butt lift, tummy tuck should be explained and demonstrated in advance and performed commonly after reduction of the body weight. - Abdominoperineal rectum extirpation (APE): Holm's procedure with greater circumferential extent of resection at the mesorectum and the insertion site of the levator muscle at the anal sphicter muscle resulting in a substantial defect is covered by myocutaneous flap plasty. - Hernia surgery: Complicated/recurrent hernias or abdominal wall defect can be covered by flap plasty to achieve functional reconstruction, e.g., using innervated muscle. Thus, abdominal wall can respond better onto changes of pressure and tension. - Necrotising fasciitis: Even in case of suspicious fasciitis, an immediate radical debridement must be performed, followed by intensive care with calculated antibiotic treatment; after appropriate stabilization tissue defects can be covered by mesh graft of flap plasty. - Soft tissue tumor lesions cannot be resected with primary closure to achieve appropriate as intended R0 resection status by means of local radical resection all the time - plastic surgery expertise has to be included into interdisciplinary tumor concepts. - Liposuction/-filling: Liposuction can be used with aesthetic intention after bariatric surgery or for lipedema. Lipofilling is possible for reconstruction and for aesthetic purpose. - Reconstruction of lymphatic vessels: Lymphedema after tumor operations interrupting or blocking lymphatic drainage can be treated with microsurgical reconstructions (such as lympho-venous anastomoses, lympho-lymphatic anastomoses or free microvascular lymph node transfer). - Microsurgery: It is substantial part of modern reconstructive plastic surgery, i.e., surgery of peripheral nerves belongs to this field. For visceral surgery, it can become important for reconstruction of the recurrent laryngeal nerve. - Sternum osteomyelitis: Radical debridement (eventually, complete sternal resection) with conditioning of the wound by vacuum-assisted closure followed by plastic surgery coverage can prevent chronification, threatening mediastinitis, persisting infectious risk, long-term suffering or limited quality of life. Summary: The presented selection of single topics can only be an excerpt of all the options for surgical cooperation in daily clinical and surgical practice. Outlook: An interdisciplinary approach of abdominal and plastic surgery is characterized by a highly developed cooperation in common surgical interventions including various techniques and tactics highlighting the specifics of the two fields.

Robotic Rectus Abdominis Harvest for Pelvic Reconstruction after Abdominoperineal Resection.

The use of robotic surgical systems to perform abdominoperineal resection (APR) has recently become more prevalent. This minimally invasive approach produces fewer scars and potentially less morbidity for the patient. The rectus abdominis muscle is often used for reconstruction after APR if primary closure is not feasible or the surgical site is at high risk of wound complications. Since the traditional open harvest of this flap creates large incisions that negate the advantages of minimally invasive APR, there has been growing interest in harvesting the rectus abdominis in a similarly robotic fashion. This article reviews the technique, benefits, and limitations of this robotic technique. Compared to the traditional open harvest, robotic harvest of the rectus abdominis leaves smaller scars, provides technical benefits for the surgeon, and offers possible morbidity benefits for the patient. These advantages should be weighed against the added expense and learning curve inherent to robotic surgery.

Prevention and Management of Complications of Tissue Flaps.

In this article, we discuss 4 common free flaps performed in reconstructive surgery: the anterolateral thigh flap, the radial forearm flap, the fibula flap, and the transverse rectus abdominis myocutaneous/deep inferior epigastric perforator flap. Donor and recipient complications for each flap type and strategies on how to prevent and manage such complications are discussed.

Ameliorating Effects of ß-Glucan on Epigastric Artery Island Flap Ischemia-Reperfusion Injury.

BACKGROUND: Ischemia-reperfusion injury has been one of the culprits of tissue injury and flap loss after island flap transpositions. Thus, significant research has been undertaken to study how to prevent or decrease the spread of ischemia-reperfusion injury. Preventive effects of ß-glucan on ischemia-reperfusion injury in the kidney, lung, and small intestine have previously been reported. In this study, we present the ameliorating effects of ß-glucan on ischemia-reperfusion injury using the epigastric artery island-flap in rats. MATERIALS AND METHODS: Thirty Wistar-Albino rats were equally divided into three groups: sham, experimental model, and treatment groups. In the sham group, an island flap was elevated and sutured back to the original position without any ischemia. In the experimental model group, the same-sized flap was elevated and sutured back with 8 h of ischemia and consequent 12 h of reperfusion. In the treatment group, 50 mg per kilogram ß-glucan was administered to the rats using an orogastric tube for 10 d before the experiment. The same-sized flap is elevated and sutured back to its original position with 8 h of ischemia and 12 h of consequent reperfusion in the treatment group. Tissue biopsies were taken on the first day of the experimental surgery. Tissue neutrophil aggregation and vascular responses were evaluated by histological examinations. Tissue oxidant and antioxidant enzyme levels are evaluated biochemically after tissue homogenization. Topographic follow-up and evaluation of the flaps were maintained, and photographs were taken on the first and seventh day of the experimental surgery. RESULTS: Topographic flap survival was significantly better in the ß-glucan administered group. The neutrophil number, malondialdehyde, and myeloperoxidase levels were significantly lower while glutathione peroxidase and superoxide dismutase levels were significantly higher in the ß-glucan administered group respective to the experimental model group. CONCLUSIONS: Based on the results of our study, we can conclude that ß-glucan is protective against ischemia-reperfusion injury. Our study presents the first experimental evidence of such an effect on skin island flaps.

Primary reinforcement with rectus abdominis muscle flap-a salvage technique for a tenuous post traumatic duodenal perforation- a case report.

INTRODUCTION: The conventional techniques for management of complex duodenal injuries are duodenal diverticularisation, pyloric exclusion or triple tube decompression. We here present a salvage technique of primary reinforcement with pedicled rectus abdominis muscle flap (RAMF) for a tenuous post traumatic duodenal perforation (PTDP). The majority of the studies in the literature are on the use RAMF for the secondary repair of peptic duodenal perforations. PRESENTATION OF CASE: A 38 year old male presented with an acute abdomen, three days after sustaining a blunt abdominal trauma. The clinical and radiological findings in the abdomen were subtle and not contributory. An emergency laparotomy with a high index of suspicion revealed a large perforation in the anterolateral wall of the second portion of the duodenum with a friable unhealthy wall and shearing of the serosa around the perforation site. The entire omentum was unhealthy, contused with areas of gangrene and omentectomy done. The perforation site was closed using 3.0 vicryl and reinforced with a pedicled right RAMF based on the superior epigastric artery. The patient recovered uneventfully and was discharged. DISCUSSION: The addition of conventional diversion techniques to primary duodenorrhaphy is sophisticated, time consuming and adds morbidity. CONCLUSION: RAMF is a good tissue substitute to buttress tenuous duodenal injuries presenting late with inflamed, friable perforation sites and associated tissue loss, where duodenorrhaphy alone may not be successful. RAMF is a valuable salvage technique when the omentum is not available and the local tissue condition negates the effectiveness of other simpler techniques.

Perineal repair after abdominoperineal excision with rectus abdominis myocutaneous flap / Reconstrução do períneo após amputação abdominoperineal com retalho pediculado do músculo reto abdominal

ABSTRACT Background: Abdominoperineal excision of the rectum (APR) remains the only potential curative treatment for very low rectal adenocarcinoma and squamous cell carcinoma of the anus. Yet, it implies a significant perineal exenteration and has set the attention on the perineal reconstruction. Aim: To present technique used in one case of APR for anal cancer, with resection of the vaginal posterior wall with large perineal defect which has called for the necessity of a flap for reconstruction Method: To cover the large perineal defect and reconstruct the posterior vaginal wall was perform a standardized and reproducible surgical technique using oblique rectus abdominis myocutaneous (ORAM) flap. The overlying skin of this flap is thick and well vascularized by both superficial branches and perforators of the superior epigastric artery and the deep inferior epigastric artery which serves as the vascular pedicle for the ORAM flap. Results: This procedure was applied in a 65-year-old woman with recurrent squamous cell carcinoma of the anus infiltrating the posterior wall of the vagina. Was performed an APR with en-bloc resection of the vaginal posterior wall in order to achieve tumor-free margins. Postoperative course was uneventful and she was discharged home at postoperative day 9. Final pathological report confirmed the oncological adequacy of the procedure (R0) and showed a rypT4N0 lesion. Conclusion: Flap reconstruction is an effective way to cover the perineal wound reducing both perineal complication rate and wound healing delay. The ORAM is particularly interesting for female whose tumors require resection and subsequent reconstruction of the posterior wall of the vagina.

RESUMO Racional: A amputação abdominoperineal do reto (APR) continua sendo o único tratamento curativo nos casos de adenocarcinoma retal muito baixo e carcinoma espinocelular do ânus. No entanto, implica em exenteração perineal significativa e exige atenção na reconstrução perineal. Objetivo: Propor, ilustrando com um caso clinico, proposta de APR para câncer anal com ressecção da parede posterior da vagina com cobertura do grande defeito perineal através de reconstrução com retalho miocutâneo oblíquo do reto abdominal (ORAM). Método: Para cobrir o defeito e reconstruir a parede vaginal posterior, realizou-se técnica de retalho miocutâneo oblíquo do reto abdominal (ORAM). A pele subjacente desse retalho por ser espessa e bem vascularizada por ramos perforantes superficiais da artéria epigástrica superior e pela artéria epigástrica inferior profunda serviu como pedículo vascular. Resultado: Este procedimento foi aplicado em uma mulher de 65 anos com recidiva de carcinoma espinocelular do ânus infiltrado na parede posterior da vagina. Foi realizada APR com ressecção em bloco da parede posterior vaginal com o objetivo de obter margens livres de tumor. O pós-operatório transcorreu sem intercorrências e a paciente recebeu alta hospitalar no 9° dia pós-operatório. O relatório patológico final confirmou a adequação oncológica do procedimento (R0) e mostrou uma lesão rypT4N0 de 6,5 cm. Conclusão: A reconstrução perineal com utilização de retalho é maneira eficaz de fechar a ferida operatória, reduzindo a taxa de complicações perineais e o atraso na cicatrização. O retalho de tipo ORAM é particularmente interessante para mulheres cujos tumores requerem ressecção e subsequente reconstrução da parede posterior da vagina.

Selecting a free flap for soft tissue coverage in lower extremity reconstruction.

BACKGROUND: Goals of lower extremity microvascular reconstruction (LEMR) include the restoration of function, prevention of infection, and optimal cosmesis. Indications for LEMR include large defects that are not amenable to pedicled options, a large zone of injury, and large complex defects. The novice microsurgeon should first master a handful of free flaps to develop an armamentarium of options for addressing such defects. The scope of this review is to provide free flap options for LEMR in any of the thirds of the lower leg. After reading this article, the reader will understand variations, advantages, disadvantages, indications, and tips for raising each of these flaps. METHODS: Six most commonly used free flaps for LEMR are described in this paper, including the anterolateral thigh flap (ALT) and its variations, the radial forearm flap (RFFF), the lateral arm flap (LAF), the gracilis muscle flap, the rectus abdominis flap (RAF) and the latissimus dorsi flap and its variations. Indications, advantages, disadvantages and technique tips are discussed for each flap. Moreover, selection of the recipient vessels, preoperative management along with an algorithm are also provided. CONCLUSIONS: The ALT flap is a workhorse in covering defects of the leg, foot, and ankle. It's the flap of choice at our institution, especially given the number of traumatic wounds seen as a result of motor vehicles, all-terrain vehicles (ATV), lawnmowers, and gunshot wounds (GSW). At times, the lower extremity zone of injury requires a distant donor site. The RAF can also provide coverage for large soft tissue defects but donor-site morbidity remains its main drawback. The LAF and RFFF provide two pliable options, one that provides pliable soft tissue with minimal donor site morbidity and another that provides a long pedicle. The free gracilis flap is an excellent choice for crossing the ankle joint. Lastly, the free latissimus dorsi is indicated for large defects of the lower extremity independently of the location.

Photobiomodulation with polychromatic light increases zone 4 survival of transverse rectus abdominis musculocutaneous flap.

OBJECTIVE: The aim of this study was to evaluate the effect of relatively novel approach of application of polychromatic light waves on flap survival of experimental musculocutaneous flap model and to investigate efficacy of this modality as a delay procedure to increase vascularization of zone 4 of transverse rectus abdominis musculocutaneous (TRAM) flap. METHODS: Twenty-one Wistar rats were randomized and divided into 3 experimental groups (n = 7 each). In group 1 (control group), after being raised, the TRAM flap was sutured back to its bed without any further intervention. In group 2 (delay group), photobiomodulation (PBM) was applied for 7 days as a delay procedure, before elevation of the flap. In group 3 (PBM group), the TRAM flap was elevated, and PBM was administered immediately after the flap was sutured back to its bed for therapeutic purpose. PBM was applied in 48 hours interval from 10 cm. distance to the whole abdominal wall both in groups 2 and 3 for one week. After 7 days of postoperative follow-up, as the demarcation of necrosis of the skin paddle was obvious, skin flap survival was further evaluated by macroscopic, histological and microangiographic analysis. RESULTS: The mean percentage of skin flap necrosis was 56.17 ± 23.68 for group 1, 30.92 ± 17.46 for group 2 and 22.73 ± 12.98 for group 3 PBM receiving groups 2 and 3 revealed less necrosis when compared to control group and this difference was statistically significant. Vascularization in zone 4 of PBM applied groups 2 and 3 was higher compared to group 1 (P = 0.001). Acute inflammation in zone 4 of group 1 was significantly higher compared to groups 2 and 3 (P = 0.025). Similarly, evaluation of zone 1 of the flaps reveled more inflammation and less vascularization among the samples of the control group (P = 0.006 and P = 0.007, respectively). Comparison of PBM receiving two groups did not demonstrate further difference in means of vascularization and inflammation density (P = 0.259). CONCLUSION: Application of PBM in polychromatic fashion enhances skin flap survival in experimental TRAM flap model both on preoperative basis as a delay procedure or as a therapeutic approach. Lasers Surg. 51:538-549, 2019. © 2019 Wiley Periodicals, Inc.

The ongoing emergence of robotics in plastic and reconstructive surgery.

Robot-assisted surgery is more and more widely used in urology, general surgery and gynecological surgery. The interest of robotics in plastic and reconstructive surgery, a discipline that operates primarily on surfaces, has yet to be conclusively proved. However, the initial applications of robotic surgery in plastic and reconstructive surgery have been emerging in a number of fields including transoral reconstruction of posterior oropharyngeal defects, nipple-sparing mastectomy with immediate breast reconstruction, microsurgery, muscle harvesting for pelvic reconstruction and coverage of the scalp or the extremities.

How to deal with penile carcinoma inguinal metastases invading femoral vessels.

Penile cancer accounts for 1-10% of men neoplastic diseases and 30-60% of patients have inguinal metastases at the time of diagnosis. Inguinal metastases of penile cancer with femoral vessel involvement could lead to vascular fistula and hemorrhagic shock. We present 3 consecutive patients with inguinal metastases of penile cancer complicated by infection and hemorrhage from femoral vessels invaded by the tumor. Simultaneous extra-anatomical axillo-femoral bypass graft, wide excision of tumor and groin defect reconstruction was used to achieve "tumor-free" oncologic aim and to save the lower limb. We consider the extra-anatomic axillo-femoral bypass associated with wide inguinal tumor excision and defect covering a feasible surgical solution for improving the life quality and extend life expectancy in patients with lymph node metastasis of penile cancer complicated by necrosis, infection and femoral vessel involvement.

Lengthening the pedicle of the rectus abdominis myocutaneous flap for repair of upper chest and neck defects.

INTRODUCTION The aim of this study was to investigate whether the pedicle of the rectus abdominis flap can be lengthened by resecting the inferior costal cartilage segments or associated muscle when repairing upper body defects. A formula was generated that calculates the expected increase in pedicle length. METHODS Thirty patients underwent computed tomography. The width and thickness of the third to seventh inferior costal cartilage segments as well as the width of the respective intercostal spaces were recorded. Four patients underwent reconstruction of an upper body defect with the relevant flap. RESULTS The expected mean increases in pedicle length were 4.07cm (standard deviation [SD]: 0.31cm) and 4.63cm (SD: 0.54cm) following resection of the left and right sides respectively of the seventh inferior costal cartilage segment, 7.99cm (SD: 0.49cm) and 10.82cm (SD: 0.23cm) following resection of the left and right sides respectively of the sixth and seventh inferior costal cartilage segments while resection of the fourth to seventh inferior costal cartilage segments would equate to increases of 17.48cm (SD: 0.62cm) and 22.05cm (SD: 0.21cm) for the left and right sides respectively. In four patients who required reconstruction, three flaps survived without problems but one flap developed partial necrosis. CONCLUSIONS Resecting inferior costal cartilage segments or associated muscle can lengthen the pedicle of the rectus abdominis flap for reconstruction of defects on the upper chest and neck.

Groin and thigh reconstructions with pedicled rectus abdominis myocutaneous flaps.

BACKGROUND/AIM: Resection of tumors from the groin and thigh regions with safe margins often results in significant soft tissue defects, which preclude primary closure. This study presents a series of rectus abdominis myocutaneous flaps for irradiated thigh and groin wounds with the purpose of evaluating the efficacy and outcomes of these flaps in this population. MATERIALS AND METHODS: From 2008 to 2015, all patients who underwent resection of thigh or groin region tumors and reconstruction with an inferiorly based rectus abdominis myocutaneous flap were retrospectively identified. Medical records of the patients were reviewed. RESULTS: A total of 27 patients, aged 20-67 years, were operated on for defects in the groin and upper thigh region. Nine patients underwent immediate reconstruction. The remaining 18 patients underwent late reconstruction. There was neither total flap loss nor partial flap loss. We chose to utilize 15 ipsilateral and 12 contralateral pedicles. The mean length of stay in hospital was 13.7 days. CONCLUSION: A rectus abdominis myocutaneous flap can be successfully used in patients with groin and upper thigh defects due to its predictable and robust vascular supply, bulky muscle content, wide arc of rotation, and large skin island.

Extensive Chest Wall Tissue Loss and its Management by Vertical Rectus Abdominis Myocutaneous Flap.

Extensive electric burn around the chest in children is rare and this type of injury always poses a great challenge for its management. A 12-year-old male child with extensive electric burn of the chest wall was admitted to hospital. It was a neglected case of 9 days old burn; the young boy was in critical condition having systemic features of toxemia with widespread necrosis of the skin, subcutaneous tissues, and muscles along with exposed bones (ribs and sternum) with the risk of impending rupture of pleura through the exposed intercostal spaces. After initial resuscitation, a thorough debridement of all necrotic tissues was done. Thereafter, a superiorly based vertical rectus abdominis myocutaneous flap was harvested to cover the exposed bones and intercostal spaces. The remaining raw areas were skin grafted. The child made an excellent recovery with good outcome.

Acute choke zone effects: Lessons from radioactive and fluorescent microspheres in a pig model muscle flap.

BACKGROUND: Choke vessels dilate and contract to regulate blood flow between adjacent arterial angiosomes. In skin flap surgery, when arterial inflow to an angiosome is ligated, choke vessels allow blood supply from an adjacent angiosome. In muscle flap surgery, the vascular anatomy is analogous to skin flaps; however, while it is established that the choke vessels will fully dilate irreversibly after two to three days, no study has yet analyzed the acute changes in each vascular region immediately following ligation of one pedicle. OBJECTIVE: To establish whether the choke vessels open or close immediately following ligation of a pedicle, and how this change affects blood flow in the adjacent proximal and distal vascular regions. METHODS: Radioactive and fluorescent microspheres in a pig model were used to study the regional intramuscular blood flow in each anatomical zone of a rectus abdominis flap. Blood flow measurements for each zone were calculated relative to the entire muscle at preligation, ligation and various times (15 min to 90 min) postligation. RESULTS: There was no statistically significant difference in blood flow across choke zones as a result of ligation. This signifies that the choke vessels do not significantly dilate to produce a statistically significant measureable change in blood flow. CONCLUSIONS: Given these results and previous literature findings, the anatomical presence of choke vessels in a muscle is the strongest determining factor for acute flap viability in surgery.

HISTORIQUE: Les vaisseaux anastomotiques se dilatent et se contractent pour réguler le débit sanguin entre les angiosomes artériels adjacents. Dans le cadre d'une chirurgie par lambeau cutané, lors de la ligature du débit artériel vers un angiosome, les vaisseaux anastomotiques assurent un débit sanguin en provenance d'un angiosome adjacent. L'anatomie vasculaire est alors analogue aux lambeaux cutanés. Cependant, bien qu'il soit établi que les vaisseaux anastomotiques se dilatent pleinement et de manière irréversible au bout de deux ou trois jours, aucune étude n'a encore analysé les changements aigus de chaque région vasculaire immédiatement après la ligature d'un pédicule. OBJECTIF: Établir si les vaisseaux anastomotiques s'ouvrent ou se ferment immédiatement après la ligature d'un pédicule et examiner l'effet de ce changement sur le débit sanguin des régions proximales et distales adjacentes. MÉTHODOLOGIE: Les chercheurs ont utilisé les microsphères radioactives et fluorescentes d'un porc pour étudier le débit sanguin intramusculaire régional de chaque zone anatomique d'un lambeau du grand droit. Ils ont mesuré le débit sanguin de chaque zone par rapport au muscle entier avant la ligature, au moment de la ligature et à divers moments (de 15 à 90 minutes) après la ligature. RÉSULTATS: Il n'y avait pas de différence statistiquement significative du débit sanguin dans les diverses zones anastomotiques après une ligature. Ainsi, les vaisseaux anastomotiques ne se dilatent pas au point de produire un changement du débit sanguin pouvant être mesuré de manière statistiquement significative. CONCLUSIONS: Compte tenu de ces résultats et des conclusions de publications scientifiques, la présence anatomique de vaisseaux anastomotiques dans un muscle est le principal déterminant de viabilité aiguë d'un lambeau lors d'une chirurgie.

Anatomical Study for Vascular Distribution of the Perforator of Deep Inferior Epigastric Artery in Koreans

PURPOSE: The pedicle of transverse rectus abdominis myocutaneous(TRAM) flap and deep inferior epigastric arterial perforator flap is deep inferior epigastic artery (DIEA) and accurate anatomic knowledge about perforator of DIEA is very important for the elevation of these flap. The authors investigated a detailed vascular network of perforator of DIEA in Koreans. METHODS: 24 fresh cadavers were studied. Among them, 15 were examined based on the plain X-ray examination for the distribution and location of perforator of DIEA. And 9 fresh cadavers were examined based on the 3-dimensional computed tomography(CT) study for the distance between ending point of perforator of DIEA and mother artery, the distance between most medial mother artery and midline, the distance between most lateral mother artery and midline, and the running type of perforators of DIEA. RESULTS: Based on the plain X-ray examination, suitable(external diameter> or =0.5mm) perforators of DIEA are located between the level of umbilicus and 8cm below it. Based on the 3D-CT study, average distance between the ending point of perforator of DIEA and the mother artery is 30.26mm on the left, 28.62mm on the right, respectively. The average distance between most medial mother artery and midline is 17.13mm on the left, 15.76mm on the right, respectively. The average distance between most lateral mother artery and midline is 56.31mm on the left, 50.90mm on the right, respectively. The main running course of suitable perforators of DIEA is type a, which is a direct musculocutaneous perforator vessel from main vascular axis passing outward to join the subdermal plexus, directly. CONCLUSION:3-dimensional computed tomography study as well as plain X-ray examination provided more accurate and detail informations about perforators of DIEA in Koreans. These informations will help us understand the detailed vascular anatomy and operation with ease and safe in the lower abdomen of Koreans.

Selection Flaps in Chest Wall Reconstruction after Open Drainage for Empyema

The purpose of reconstruction of chest wall defect after open drainage in chronic empyema is the control and prevention of recurrent infection, obliteration of dead space in thoracic cavity, and coverage of open wound. For the obliteration of empyema cavities, latissimus dorsi, pectoralis major or rectus abdominis flaps are commonly used. Among them, latissimus dorsi flap based on thoracodorsal pedicle is most versatile and most reliable. If the latissimus dorsi flap can not be used, the author uses pectoralis major flap or rectus abdominis flap depending on the location and the size of dead space and skin defect. The author reports the results of eight patients who underwent reconstruction of chest wall defect with bronchopleural fistula in empyema using muscle flaps. The author performed 4 latissimus dorsi flaps, 3 pectoralis major flaps, 1 rectus abdominis flap according to various situations. According to the size of dead space and skin defect, the author also performed deepithelized musculocutaneous flap, musculocutaneous flap or muscle flap respectively. During the follow-up period, recurrence of empyema, flap survival, morbidity of donor site and patient's satisfaction were evaluated. There was no recurrence of empyema or wound complication. Also, patients were satisfied with the results of operation. The results demonstrate reliability of various muscle flaps and author's method in selection of reconstruction flap for the chest wall defect after open drainage in empyema.