A 48-year-old woman who had a right modified radical mastectomy for breast cancer was scheduled for transverse rectus abdominis musculocutaneous (TRAM) flap and left breast reduction. The skin island is shown.
The rectus abdominis muscles lie within longitudinal fascial sheaths in the anterior abdominal wall. Their main blood supply comes from the inferior epigastrics (from the external iliacs; see inguinal anatomy) below and the superior epigastrics (continuation branch of the internal mammary; see CABG). The two vessels enter the deep side of the muscle, ramify and anastomose within its substance. Supplementary blood supply comes from intercostal vessels laterally. The dominant blood supply to the skin comes from perforating branches of the vessels to the underlying muscles, the basis of musculocutaneous flaps. Epigastric branches perforating through the anterior rectus sheath supply the overlying skin island used for the TRAM. The multiple perforators around the umbilicus support the TRAM skin island.
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