title: Optimizing the pedicled rectus abdominis flap: revised designs and vascular classification for safer procedures.
abstract: BACKGROUND
  The rectus abdominis myocutaneous (RAM) flap is one of the most commonly used flaps in reconstructive surgery, and many designs have been published. The transverse rectus abdominis myocutaneous (TRAM), vertical rectus abdominis myocutaneous (VRAM), and oblique designs (ORAM) are the most common. The most frequent complication with these flaps is partial flap necrosis. We describe a new vascular zoning method and a revised classification of abdominal wall perfusion that is applicable when harvesting pedicled TRAM flaps to make them more secure.
  
  
  METHODS
  From February 2009 to February 2013, we performed 70 pedicled RAM flaps in 68 patients for breast reconstruction (79%) as well as pelvic and inguinal reconstruction after bowel and gynecologic tumor resection. Clinical data about cutaneous vascularization of the flaps along with before and after photos were prospectively collected and analyzed, and results were evaluated retrospectively. We collected observations on partial flap necrosis, reviewed the literature, and made design modifications to exclude doubtful vascular territories.
  
  
  RESULTS
  Of the total number of flaps, 59 were TRAMs, 7 were VRAMs, and 1 was an ORAM flap. Three combined horizontal and vertical flaps, or what we call TV RAM flaps, were performed. No flap-related complications were observed with VRAM, TV RAM, or ORAM flaps. Three instances of partial necrosis (in the same vascular territory) occurred with TRAM flaps; as a result, we changed our approach to these flaps and examined alternatives to the classical vascular zoning.
  
  
  CONCLUSIONS
  We discussed abdominal skin perfusion in accordance with the literature and based on our experience with harvesting pedicled RAM flaps. We proposed safer skin paddles made possible by adopting a revised vascular classification.
  
  
  METHODS
  This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
authors: Medical School of Tunis, Tunis Elmanar University, Tunis, Tunisia, bouraouikotti@yahoo.com.
authors: Bouraoui
authors: B
authors: Kotti
mesh_terms: D000293:Adolescent; D000328:Adult; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D006084:Graft Rejection; D006085:Graft Survival; D006801:Humans; D008297:Male; D008875:Middle Aged; D064827:Myocutaneous Flap / Q000098:blood supply / Q000637:transplantation; D061214:Patient Safety; D011183:Postoperative Complications / Q000503:physiopathology / Q000601:surgery; D019651:Plastic Surgery Procedures / Q000009:adverse effects / Q000379:methods*; D017568:Rectus Abdominis / Q000098:blood supply / Q000601:surgery*; D012189:Retrospective Studies; D018570:Risk Assessment; D013524:Surgical Flaps / Q000098:blood supply*; D013997:Time Factors; D016896:Treatment Outcome; D014945:Wound Healing / Q000502:physiology*; D055815:Young Adult