Rectus Abdominis Muscle Flap Research Articles

MP42-14 BIOLOGIC MESH BUTTRESS WITH VERTICAL RECTUS ABDOMINIS MUSCLE FLAP TO REESTABLISH PELVIC INTEGRITY DURING CYSTECTOMY FOR ANTERIOR URINARY FISTULA

You have accessJournal of UrologyCME1 Apr 2023MP42-14 BIOLOGIC MESH BUTTRESS WITH VERTICAL RECTUS ABDOMINIS MUSCLE FLAP TO REESTABLISH PELVIC INTEGRITY DURING CYSTECTOMY FOR ANTERIOR URINARY FISTULA Syed M. Alam, Jordan Stiverson, and Hadley Wyre Syed M. AlamSyed M. Alam More articles by this author , Jordan StiversonJordan Stiverson More articles by this author , and Hadley WyreHadley Wyre More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003280.14AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Post-radiation puboprostatic and pubourethral fistulae are devastating conditions, and surgical intervention remains highly morbid. Here, we describe a novel technique using a mesh buttress and vertical rectus abdominis muscle flap (VRAM) to restore pelvic integrity during cystectomy for anterior urinary fistulae. METHODS: Patients having undergone cystectomy with ileal conduit were identified in a prospectively maintained database. Those having undergone VRAM harvest with placement of a mesh buttress for anterior urinary fistula were selected for analysis. Following supratrigonal cystectomy, all patients underwent a left-sided VRAM harvest. After the bladder plate was fulgurated, a biologic mesh was tailored to the pelvic defect and sutured to the posterior trigone. It was then incorporated circumferentially around the levator muscles and anteriorly to the pubic bone and underside of rectus fascia. Prior to circumferential closure of the underlying space, a VRAM flap was secured in the pelvis. The remainder of the mesh was then secured, creating a tunnel for the flap pedicle. Surgical metrics and post-operative outcomes were evaluated using descriptive statistics. RESULTS: Between 2019-2021, eleven patients underwent this technique, of which five carried a diagnosis of post-radiation anterior urinary fistula with pubic osteomyelitis. The median age was 73 years, and all patients were male. Three patients previously underwent radical prostatectomy, all of whom underwent subsequent endoscopic intervention for vesicourethral anastomotic stenosis. One patient underwent transurethral resection of the prostate after radiation. One patient had no prior surgical history. Median operative time was 387 minutes and median blood loss was 500cc. Average length of stay was five days. No patients developed an immediate post-operative complication. All patients had positive intra-operative bone cultures. No patients reported persistent pubic, groin, or thigh pain after surgery. No fistula recurrence occurred at a median follow-up of 264 days. CONCLUSIONS: The use of a mesh buttress in conjunction with pelvic VRAM flap is a novel technique designed to restore pelvic integrity for patients undergoing cystectomy for an anterior urinary fistula. Source of Funding: N/a © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e573 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Syed M. Alam More articles by this author Jordan Stiverson More articles by this author Hadley Wyre More articles by this author Expand All Advertisement PDF downloadLoading ...

Beyond the abdominal and pelvic cavity: abdominal wall and spinal "Aunt Minnies".

Abdominal wall and spinal soft tissue findings are frequently encountered on CT or MR imaging of the abdomen and pelvis. Many of these entities have specific imaging findings, for which a definitive diagnosis can be made without the need for further work up. These abdominal wall and spinal findings may be diagnostically challenging for sub-specialized abdominal radiologists who are unfamiliar with their appearance and appropriate management. This review article describes and illustrates pathognomonic or characteristic abdominal wall and spinal pathologies, which reside outside the abdominopelvic cavity. The cases selected all have findings that allow a confident diagnosis without further imaging or intervention. The cases presented include myonecrosis, intramuscular abscess, myositis, iliopsoas bursitis, Morel-Lavallée lesion, hydrocele of canal of Nuck, Klippel Trenaunay Weber syndrome, neurofibroma with target sign, perineural cysts, filum terminale lipoma, calvarial bone flap, transverse rectus abdominis muscle (TRAM) flap, liposuction, and hidradenitis suppurativa, among others. Although not all-encompassing, this paper will help abdominal radiologists to accurately diagnose a variety of abdominal and pelvic extra-cavitary soft tissue pathologies by identifying key radiologic findings.

Reconstruction of Extensive Diaphragmatic Defects Using the Rectus Abdominis Muscle and Fascial Flap.

Diaphragmatic reconstruction is required for extensive diaphragmatic defects associated with tumor resection. Methods using artificial mesh and autologous tissues, such as pedicled flaps, have been reported predominantly for diaphragmatic reconstruction. We present the case of a 61-year-old woman who presented with a 14 × 13 × 12 cm tumor in the abdominal cavity of the upper left abdomen on computed tomography. The diaphragm defect measuring 12 × 7 cm that occurred during excision of the malignant tumor was reconstructed using the rectus abdominis muscle and fascial flap. The flap has vertical and horizontal vascular axes; therefore, blood flow is stable. It also has the advantage of increasing the range of motion and reducing twisting of the vascular pedicles. Fascial flap does not require processing such as thinning and can be used during suture fixation. This procedure, which has rarely been reported so far, has many advantages and may be a useful option for diaphragm reconstruction.

Pedicled transverse rectus abdominis muscle (TRAM) flap in obese patients. Single surgeon's perspective

Pedicled transverse rectus abdominis muscle (TRAM) flap in obese patients. Single surgeon's perspective

Using Virtual Reality for Deep Inferior Epigastric Perforator Flap Preoperative Planning.

This prospective case series feasibility study was conducted in two tertiary medical centers. Participants were women slated to undergo free transverse rectus abdominis muscle, unilateral or bilateral deep inferior epigastric perforator flap immediate breast reconstruction. Based on a routine CTA, a 3D VR model was generated. Before each procedure, the surgeons examined the CTA and then the VR model. Any new information provided by the VR imaging was submitted to a radiologist for confirmation before surgery. Following each procedure, the surgeons completed a questionnaire comparing the two methods. Thirty women between 34 and 68 years of age were included in the study; except for one, all breast reconstructions were successful. The surgeons ranked VR higher than CTA in terms of better anatomical understanding and operative anatomical findings. In 72.4% of cases, VR models were rated having maximum similarity to reality, with no significant difference between the type of perforator anatomical course or complexity. In more than 70% of the cases, VR was considered to have contributed to determining the surgical approach. In four cases, VR imaging modified the surgical strategy, without any complications. VR imaging was well-accepted by the surgeons who commented on its importance and ease compared with the standard CTA presentation. Further studies are needed to determine whether VR should become an integral part of preoperative deep inferior epigastric perforator surgery planning.

Soft tissue reconstruction strategy for sacral tumor resection

Objective: To investigate the clinical strategy and effect of soft tissue reconstruction after sacral tumor resection in different planes. Methods: The data of 27 consecutive patients who underwent primary or secondary sacral tumor resection and soft tissue reconstruction from June 2012 to June 2021 at Dongnan Hospital of Xiamen University (the 909th Hospital) were retrospectively analyzed. There were 11 males and 16 females, aged (M(IQR)) (46.2±23.6) years (range: 16 to 72 years). Sacrospinous muscle, gluteus maximus and vertical rectus abdominis muscle flap were selected for soft tissue reconstruction according to the tumor site and the size of tissue defect. the postoperative follow-up was performed. The operative methods, intraoperative conditions, complications and disease outcomes were summarized. Results: Among the 27 patients with sacral tumor, the tumor plane was located in S1 in 8 cases, S2 in 5 cases and S3 or below in 14 cases. There were 12 patients with tumor volume≤400 cm3 and 15 patients with tumor volume>400 cm3. Operation time was 100(90) minutes (range: 70 to 610 minutes), intraoperative blood loss was 800(1 600) ml (range: 400 to 6 500 ml). Soft tissue reconstruction was performed by transabdominal rectus abdominis transfer repair in 2 cases, extraperitoneal rectus abdominis transfer repair in 1 case, gluteus maximus transfer repair in 5 cases, gluteus maximus advancement repair in 13 cases, and sacrospinous muscle transfer repair in 6 cases. Postoperative complications occurred in 6 cases, including 1 case of incision infection, 4 cases of skin border necrosis, and 1 case of delayed infection due to fracture of internal fixator 3 years after operation, all of them were cured. The follow-up time was (35±21) months. Among the patients, 6 patients had recurrence, 2 patients with Ewing sarcoma died of lung metastasis 1 year after operation, 4 patients with metastatic cancer died of primary disease, and the remaining patients survived without disease. Conclusion: Choosing different soft tissue reconstruction strategies according to sacral tumor location and tissue defect size can effectively fill the dead space after sacral tumor resection, reduce postoperative complications and improve the prognosis of patients.

A Case of Multiple Radiation-related Complications during Long-term Follow-up after Sacral Ulcer Surgery

We report the clinical course of a patient who developed a sacral radiation ulcer 19 years after treatment for cervical cancer. The patient's postoperative course after a free latissimus dorsi muscle flap transfer was favorable, but various late radiation complications, including rectal perforation, a rectal fistula, sacral necrosis, a rectointestinal fistula, and sacroiliac joint osteomyelitis, occurred within 11 years. Plastic surgeons who treat such ulcers need to know that patients may develop other serious radiation-related complications. Being aware of these complications will allow appropriate measures to be taken and aid decisions regarding future surgical strategies. More careful assessment of sacral necrosis and bone resection may have ameliorated some of the complications. When encountering similar patients, we believe that careful magnetic resonance imagery (MRI) and intraoperative evaluation are warranted, as sacral necrosis may be detectable in some patients.

Perineal reconstruction after radical pelvic surgery: A cost-effectiveness analysis

BackgroundRadical resection of pelvic and low rectal malignancies leads to complex reconstructive challenges. Many pelvic reconstruction options have been described including primary closure, omental flaps, and various fasciocutaneous and myocutaneous flaps. Little consensus exists in the literature on which of the various options in the reconstructive armamentarium provides a superior outcome. The authors of this study set out to determine the costs and quality-of-life outcomes of primary closure, vertical rectus abdominus muscle flap, gluteal thigh flap, and gracilis flap to aid surgeons in identifying an optimal reconstructive algorithm. MethodsA decision tree analysis was performed to analyze the cost, complications, and quality-of-life associated with reconstruction by primary closure, gluteal thigh flap, vertical rectus abdominus muscle flap, and gracilis flap. Costs were derived from Medicare reimbursement rates (FY2021), while quality-adjusted life-years were obtained from the literature. ResultsGluteal thigh flap was the most cost-effective treatment strategy with an overall cost of $62,078.28 with 6.54 quality-adjusted life-years and an incremental cost-effectiveness ratio of $5,649.43. Gluteal thigh flap was always favored as the most cost-effective treatment strategy in our 1-way sensitivity analysis. Gracilis flap became more cost-effective than gluteal thigh flap, in the scenario where gluteal thigh flap complication rates increased by roughly 4% higher than gracilis flap complication rates. ConclusionOur data suggest that, when available, gluteal thigh flap be the first-line option for reconstruction of pelvic defects as it provides the best quality-of-life at the most cost-effective price point. However, future studies directly comparing outcomes of gluteal thigh flap to vertical rectus abdominus muscle and gracilis flap are needed to further delineate superiority.

P-047 PERINEAL HERNIA: RECTUS ABDOMINIS MUSCLE FLAP REPAIR

Abstract Aim Perineal hernia (PH) is a rare complication of pelvic surgeries. We present two cases of male patients with symptomatic PH following abdominoperineal resection (APR), repaired with rectus abdominis muscle flap. Cases presentation N1: 66-year male, 1 year after laparoscopic-assisted APR was treated with rectus abdominis muscle flap repair (RAM) by open abdominal approach. In postoperative period, heavy bronchitis leaded to the disruption of the muscle flap and need of reoperation. The patient healed completely two months after the repair. No recurrence of PH within 5 years has been registered. N2: 64-year male, underwent chemoradiotherapy and open APR for rectal carcinoma. 2 years later, CT showed a PH and 2cm wide mass suspicious of cancer recurrence in pelvis. By the open abdominal – perineal approach, the mass of recurrence was excised, and PH was repaired with vertical rectus abdominis muscle flap (VRAM). The postoperative period was uneventful and 1 year after the surgery, the patient is cancer and PH free. Discussion Treatment of more advanced carcinomas or wide use of radiotherapy can lead to an increased number of PH. Abdominal, perineal or combined approaches exists. The pelvic floor reconstruction is mostly realized by mesh implantation or flap repair. In our presented cases, we took advantage of long existing cooperation with plastic surgeon team and chose rectus abdominis muscle flap reconstruction. We proved its feasibility and good effect on PH repair. Conclusion Perineal hernia repair is challenging. No consensus regarding the ideal method exists. Every case must be assessed individually.

Bowel seromuscular flaps used to repair pelvic defects in patients undergoing reoperative surgery.

Pedicled seromuscular bowel flaps may serve as an alternative for pelvic floor reconstruction when conventional omental and muscular flaps are not an option in patients undergoing reoperative abdominopelvic surgery. The aim of this study was to evaluate a unique series of bowel seromuscular flaps used to obliterate intrapelvic defects. We conducted a retrospective study on all patients in a single tertiary care institutional database who had undergone pelvic reconstruction with a seromuscular bowel flap from January 2006 to December 2018. The primary outcomes measured were the 30-day morbidity and mortality rates. Twelve patients (6 men 6 women, median age 56.5years [range 33-77years]) underwent reoperative abdominopelvic surgery requiring the use of a native small or large seromuscular bowelflap to obliterate pelvic defects. The indications for surgery included chronic infections, fistulizing Crohn's disease, and cancer. In all cases, no residual omentum was available and rectus abdominis muscle flaps were not feasible due to prior operative scars. Thirty-day morbidity occurred in 5 patients (42%), and included urine leak from ureteral injury, anastomotic leak, acute kidney injury, and superficial surgical site infection. No flaps became ischemic or required removal in the postoperative setting. No mortality was recorded. Bowel seromuscular flaps are a feasible and safe alternative for covering pelvic defects in patients who are undergoing reoperative surgery without the option to use traditional omental and muscular flaps.

Does it Always have to be the Abdomen? Alternative Flaps in Autologous Breast Reconstruction

[English] Deep inferior epigastric artery perforator (DIEP) or muscle-sparing transverse rectus abdominis muscle (ms-TRAM) flaps remain the gold standard for autologous reconstruction in post-mastectomy patients, although many women may not be candidates for abdominally based free tissue transfer. In this scenario, there are several other donor site options based from the thigh (transverse and diagonal upper gracilis flaps, profunda artery perforator flap, lateral thigh flap), trunk (lumbar artery perforator flap), and buttock (superior and inferior gluteal artery perforator flaps). This article will provide insight into the history, relevant anatomy, surgical technique and novel applications (neurotization) for alternative flaps in autologous breast reconstruction.

Tailored concept for the plastic closure of pelvic defects resulting from extralevator abdominoperineal excision (ELAPE) or pelvic exenteration.

No standard exists for reconstruction after extralevator abdominoperineal excision (ELAPE) and pelvic exenteration. We propose a tailored concept with the use of bilateral gluteal V-Y advancement flaps in non-extended ELAPE and with vertical myocutaneous rectus abdominis muscle (VRAM) flaps in extended procedures. This retrospective study analyzes the feasibility of this concept. We retrieved all consecutive patients after ELAPE or pelvic exenteration for rectal, anal, or vulva cancer with flap repair from a prospective database. Perineal wound complications were defined as the primary endpoint. Outcomes for the two different flap reconstructions were analyzed. From 2005 to 2021, we identified 107 patients who met the study criteria. Four patients underwent exenteration with VRAM flap repair after previous V-Y flap fashioning. Therefore, we report on 75V-Y and 36 VRAM flaps. The V-Y group contained more rectal carcinomas, and the VRAM group exhibited more patients with recurrent cancer, more multivisceral resections, and longer operation times. Perineal wound complications occurred in 21.3% in the V-Y group and in 36.1% in the VRAM group (p = 0.097). Adjusted odds ratio for perineal wound complication was not significantly different for the two flap types. Concerning perineal wound complications, our concept yields favorable results for V-Y flap closure indicating that this less invasive approach is sufficient for non-extended ELAPE. Advantages are a shorter operation time, less donor site morbidity, and the option of a second repair. VRAM flaps were reserved for larger wounds after pelvic exenteration or vaginal repair.

Reducing Complications and Expanding Use of Robotic Rectus Abdominis Muscle Harvest for Pelvic Reconstruction.

The rectus abdominis flap has long been a workhorse in perineal reconstruction. Although traditionally approached though an external incision, the morbid nature of the incision and subsequent violation of the anterior rectus sheath has encouraged innovation of minimally invasive approaches for harvest. In this study, we present our experience, evolution, and comparative outcomes of robotic rectus abdominis muscle harvest. A retrospective review of perineal reconstruction was performed for a 6-year period (2014 to 2019). Robotic rectus abdominis muscle flaps were compared to nonrobotic techniques performed during this time. Descriptive statistics and complication profiles were computed. The details of our surgical technique are also described. Thirty-six patients underwent perineal reconstruction. Sixteen were performed using the robotic rectus abdominis muscle and 20 with traditional repairs (12 vertical rectus abdominis myocutaneous flaps and eight gracilis flaps). Demographic profiles were similar between cohorts, including age, body mass index, smoking, diabetes, neoadjuvant radiation therapy, and need for vaginal wall repair. Six robotic patients underwent abdominal wall reinforcement with biological mesh. Length of stay, surgical times, and incidence of major complications were similar between cohorts with a trend toward increased minor complications in traditional reconstructions (55 percent versus 31 percent; p = 0.15). Robotic rectus abdominis muscle harvest is a powerful tool that continues to evolve the potential to mitigate common morbidities and complications of traditional repair and further enhance cosmetic outcomes. This study suggests that greater flexibility for reconstruction can be afforded with harvest of the posterior rectus sheath and complications avoided with prophylactic mesh reinforcement. Therapeutic, III.

Improving the Safety of DIEP Flap Transplantation: Detailed Perforator Anatomy Study Using Preoperative CTA.

Background: Deep inferior epigastric perforator and muscle sparing transverse rectus abdominis muscle flaps are commonly used flaps for autologous breast reconstruction. CT-angiography allows to analyse the perforator course preoperatively. Our aim was to compare the different aspects of perforator anatomy in the most detailed study. Methods: CT-angiographies of 300 female patients with autologous breast reconstruction of 10 years were analysed regarding the anatomy of the deep inferior epigastric artery and every perforator. Results: Overall, 2260 perforators were included. We identified correlations regarding the DIEA branching point and number of perforators and their intramuscular course. The largest perforator emerged more often from the medial branch of the DIEA than the smaller perforators (70% (416/595) vs. 54% (878/1634), p < 0.001) and more often had a direct connection to the SIEV (large 67% (401/595) vs. small 39% (634/1634), p < 0.01). Medial row perforators were larger than the laterals (lateral 1.44 mm ± 0.43 (n = 941) vs. medial 1.58 mm ± 0.52 (n = 1304) (p < 0.001)). The larger and more medial the perforator, the more likely it was connected to the SIEV: perforators with direct connection to the SIEV had a diameter of 1.65 mm ± 0.53 (n = 1050), perforators with indirect connection had a diameter of 1.43 ± 0.43 (n = 1028), perforators without connection had a diameter of 1.31 mm ± 0.37 (n = 169) (p < 0.001). Medial perforators were more often directly connected to the SIEV than lateral perforators (medial 56% (723/1302) vs. lateral 35% (327/941), p < 0.001). A lateral perforator more often had a short intramuscular course than medial perforators (69% (554/800) vs. 45% (474/1055), p < 0.001), which was also more often observed in the case of a small perforator and a caudal exit of the rectus sheath. Conclusion: The largest perforator emerges more often from the medial branch of the DIEA and frequently has a direct connection to the SIEV, making medial row perforators ideal for DIEP flap transplantation.

The Effect of Stromal Vascular Fraction on Scar Formation of Transverse Rectus Abdominis Muscle Flap Donor Sites: A Pilot Study

Background: Stromal vascular fraction (SVF), which plays a substantial role in wound healing, has been discussed in many recent studies concerning its positive effect on scar formation. Our study explored the effects of SVF on scar formation from partially-removed transverse rectus abdominis muscle (TRAM) flaps after inset.Methods: From December 2017 to May 2020, we enrolled 11 patients undergoing breast reconstruction performed by a single surgeon using the free TRAM flap. As a split-body, placebo-controlled study, SVF was subcutaneously injected into one side of the abdomen, and normal saline was injected into the other side of each patient. Scarring was evaluated using the Vancouver Scar Scale (VSS) and Patient Scar Assessment Questionnaire (PSAQ) at 1, 6, and 12 months after surgery, and histology was evaluated with immunofluorescence analysis at 6 months after surgery.Results: No statistically significant differences were noted in the total scores or subcategory score of the VSS and PSAQ between the test and control groups. Some patients showed more positive staining for alpha smooth muscle actin, collagen type I, and type III in the test group than in the control group. However, quantification of positively stained areas showed no statistically significant difference.Conclusion: Intraoperative SVF injection had no demonstrable clinical effect on scar quality. Histology with immunofluorescence analysis also failed to demonstrate any significant effect of SVF on scars at the microscopic level. Despite previous studies indicating the positive effects of SVF on scar quality, this pilot study questions its true effectiveness.

Successful Reconstruction of a Lower Chest Wall Defect with Delayed Fungal Deep Sternal Wound Infection following a Blast Injury in South Korea: A Case Report

Although blast injuries have been considered a problem unique to military practice or warfare, accidental civilian blast-related injuries due to misplaced landmines have been reported in South Korea. A 71-year-old man was admitted to the emergency room due to multiple severe blast injuries after the detonation of an unknown explosive device. After shrapnel that penetrated the pericardium was removed via median sternotomy in an emergency operation, an extensive defect remained on the lower third of the anterior chest wall. After debriding the contaminated wound several times, chest wall reconstruction with a skin-paddled vertical rectus abdominis muscle (VRAM) flap was successfully performed. However, the patient presented a delayed fungal infection of the deep sternal wound 28 days postoperatively. To salvage the previous flap, antifungal agents were administered and negative-pressure wound therapy was performed between serial radical debridement. The previous flap was successfully salvaged with infection control, and the final defect was covered by re-rotating the previous flap. This case presents the successful reconstruction of a chest wall defect using a skin-paddled VRAM flap notwithstanding a delayed sternal wound infection from a rare civilian blast injury in South Korea.

Perineal hernia repair after extralevator abdominoperineal excision, how we do it (PERineal Laparoscopic Sling: PERLS Technique).

Recent shift to radical extralevator abdominoperineal excision (ELAPE) approach has seen an increased incidence of post-operative perineal hernia. However, there is no standardised surgical approach for its repair. The aim of this study was to report intra and post-operative results of the perineal hernia repair by the novel trans-abdominal PERineal Laparoscopic Sling (PERLS) Technique in patients who developed post-operative perineal hernia following ELAPE. This is a retrospective analysis of consecutive patients who underwent perineal hernia repair by laparoscopic PERLS approach. All patients had undergone ELAPE with vertical rectus abdominis muscle (VRAM) flap reconstruction during the index surgery for treatment of rectal cancer. Post-operative complications, operative time, conversion rate to open surgery and incidence of recurrent perineal hernia were noted. Seven patients were operated for perineal hernia. The mean operative time was 105min (range: 87 to 131min). One case needed conversion to the open approach. The incidence of early complications was 57.1% including just single Clavien-Dindo I and two Clavien-Dindo II complications, while recurrence rate was 14.3%. PERLS perineal hernia repair is safe, performed in convenient time duration (mean = 105min) and has reasonably less recurrence rate.

Layer-by-Layer Reconstruction of Abdominal Wall Defect Using Rectus Abdominis Muscle Flap with AlloDerm

Layer-by-Layer Reconstruction of Abdominal Wall Defect Using Rectus Abdominis Muscle Flap with AlloDerm

Laparoscopic pelvic surgery after reconstructive surgery with vertical rectus abdominis muscle flap: A case report.

IntroductionPatients who have experienced vertical rectus abdominis muscle (VRAM) flap reconstruction are under risk of the abdominal incisional hernia (donor site hernia), and laparotomy increases the risk.Presentation of the caseWe present the case of a 71-year-old nulliparous woman who experienced radical vulvectomy against extramammary Paget disease and reconstructive surgery with VRAM flap 7 years ago and developed right ovarian tumor. In this case, right ovarian tumor was removed with laparoscopic surgery, instead of laparotomy, and the risk of incisional hernia was successfully minimized.DiscussionIncisional (donor site) hernia after reconstructive surgery using VRAM flap has been reported in between 2 and 10%. While VRAM flap can fill larger amount of skin and subcutaneous tissue to recipient site, the risk of postoperative incisional hernia of abdominal wall is substantial.ConclusionReconstructive surgery of with VRAM flap is required for extramammary vulvar Paget disease expanding wide range, and develops the risk of incisional hernia.Laparoscopic surgery should be applied in patients who have experienced VRAM flap reconstruction and developed pelvic tumor for avoiding the risk of incisional hernia as long as it can be allowed on oncologic aspects such as recurrence.

Best Solutions for Perineal and Pressure Sore Reconstruction.

After studying this article, the participant should be able to: 1. Understand variations of the myocutaneous rectus abdominis muscle flap as it is used for perineal reconstruction and discuss common and alternative options for perineal defect reconstruction. 2. Review primary options and alternatives to pressure sore reconstruction if the primary option is not available and recognize when pressure sore reconstruction is not feasible. 3. Highlight pertinent anatomy and techniques for the flaps described. Perineal reconstruction following tumor resection is often complicated by irradiated tissue and multiple comorbidities, making reconstruction challenging. Management of these conditions can have complication rates as high as 66 percent, which further compounds the costs and implications of managing these wounds. These complication rates can be significantly decreased using flap closure rather than primary closure. Pressure ulcers also occur in patients with poor overall health, multiple comorbidities, and often numerous prior failed reconstruction attempts. Comprehensive management of pressure sores is a significant burden to the health care system, at a cost of $9.1 to $11.6 billion per year. There exists an extensive body of literature describing the pathophysiology and management strategies for these problems. The focus of this article is to discuss best solutions for perineal and pressure ulcer reconstruction, and to explore alternative options for reconstruction.