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Pedicled Rectus Abdominus as Flow-Through-Conduit for No-Man-Land Defects of the Lower Middle Back
Joseph S. Khouri, MD, Oren P. Mushin, MD, Jose G. Christiano, MD.
University of Rochester, Rochester, NY, USA.

BACKGROUND: Reconstruction of lower one-third midline back defects after trauma or oncologic resection remains a challenge. Wounds here result from trauma, pressure necrosis, radiation injury, wound dehiscence, wound infection, exposed hardware, and oncologic resection. The upper sacral, lower thoracic midline region has been referred to as the “No-man’s land” of back reconstruction. This is due to the relative scarcity of such wounds, the lack of local tissue options, the small amount of local muscle bulk, as well as the paucity of reliable recipient vessels for free tissue transfer. Previously described options include the pedicled rectus abdominis, free rectus, free latissimus dorsi (and free latissimus flap using vein grafts), reverse latissimus dorsi, pedicled latissimus advancement, omental, and paraspinous flaps. Options for recipient vessels have been the subcostal and intercostal vessels, the superior gluteal vessels, and the inferior gluteal vessels. Interposition grafts of up to 25 cm have been described in order to provide perfusion to free flaps in this region. The authors herein examine the anatomic feasibility of using a subcutaneously tunneled rectus abdominis as a flow-through conduit providing recipient vasculature for a subsequent free-flap reconstruction of “no-man’s land” lower back defects.
METHODS: Anatomic study of cadaveric human abdominal wall was carried out to examine the reach of a rectus abdominis muscle with based on the superior epigastric arteries. A midline abdominal incision was made to harvest the rectus muscle and separate it from the posterior rectus sheath, the muscle was based on the superior epigastric artery supply. The distal epigastric artery was then ligated and the muscle was disinserted from its inferior origin at the pubic crest and symphysis pubis. The muscle was raised and tunneled in a subcutaneous plane over the oblique muscles. A small incision was made in the midline back to allow access to the tunneled rectus muscle. From that posterior incision, measurements were made from the inferior epigastric vessels to the midline of the vertebral column.
RESULTS: A small incision made along the lateral posterior lower back easily exposes the recipient vessels. The pedicled rectus muscle flap brought the inferior epigastric vessels within 7 cm of the vertebral column. The recuts abdominus serves as an excellent conduit to help carry the recipient vessels.
CONCLUSIONS: In the absence of local flap and reliable recipient vessels for free tissue transfer, reconstruction of no-man-land defects of lower midline back can be a challenge to the reconstructive plastic surgeon. The use of a subcutaneously tunneled rectus abdominus muscle based superiorly on the superior epigastric as a flow-through conduit can deliver the exposed inferior epigastric artery and vein as a reliable and formidable blood supply to be used as a recipient vessel for a secondary free tissue transfer.

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