Technique:
- The surgery was conducted in a supine position after mastectomy was
performed. Lymph node dissection was done simultaneously with the flap
procedure.
- A sterile pen was used to mark the incision site which extended from
the inferomedial corner of the skin defect towards the midline upto
the umbilicus as shown in figure 1.
- Sparing the umbilicus, a diagonal incision was made half way (upto mid
clavicular line) from the umbilicus towards the ipsilateral anterior
superior iliac spine.
- An undercut incision from the tip of the diagonal limb of the incision
to create a V was reserved, if an additional excursion of flap was
required.
- The incision was taken down to the linea alba, then laterally where
the anterior rectus fascia was identified and lifted off of the rectus
abdominis muscle. Care was taken so as to not to breach the fascia at
the aponeurotic regions of the rectus.
- The dissection was taken laterally upto the linea semilunaris. Here
the medial border of the external oblique muscle and its aponeurosis
were identified.
- The EOM muscle and its aponeurotic fascia were then carefully raised
along with the flap.
- The dissection proceeded from proximal to distal. The excursion and
adequacy of flap was checked at all times and dissection stopped when
deemed ok.
- If a larger excursion of the flap was required, the undercut on the
diagonal limb was made along with severing of upper and lower most
fibres of the EOM.
- The apex and the farthest points of the flap were sutured onto the
defect under tension while intermittent absorbable sutures were placed
between these as shown in figure 2. The rectus sheath, when harvested,
provided a tough undersurface for suturing.
- Multiple 16 Fr romovac drains were placed underneath the flap to
prevent dead space and seroma formation.