Rectus abdominis muscle-musculocutaneous flap in chest-wall reconstruction

The rapid development of postmastectomy breast reconstruction has shown that the rectus abdominis muscle is a useful carrier for abdominal wall skin. Detailed analysis of the vascular anatomy of the abdominal wall has extended the uses of the transverse rectus abdominis musculocutaneous flap to major chest-wall reconstruction, both as a transposition flap and as a free-tissue transfer. Although the most direct pathway to the paraumbilical perforators that supply the large skin island of the flap is from the deep inferior epigastric artery, numerous collateral pathways exist from above that recruit blood from the intercostal vessels and the internal mammary artery even if it has been ligated or used for myocardial revascularization. Awareness of these collateral pathways and care to preserve them whenever possible, combined with the willingness to supplement blood flow with a microvascular anastomosis of the deep inferior epigastric vessels, allows the surgeon to use the rectus abdominis flap and its variations in almost any major chest-wall reconstruction (Fig. 11).