Rectus Abdominis Myocutaneous Research Articles

Trunk Muscle Function and Core Stability in Women Who Had Muscle-Sparing Pedicled Transverse Rectus Abdominis Myocutaneous Flap Breast Reconstruction.

The long-term effects of the unilateral muscle-sparing pedicled transverse rectus abdominis myocutaneous (TRAMmsp) flap procedure on trunk muscle performances and core stability were investigated in women with breast cancer. Forty women (mean age = 42.6years) who had received breast reconstruction with the unilateral TRAMmsp flap procedure no less than 6months earlier (mean = 10.3 [SD = 4.9] months) (TRAM group) participated, and 30 women who were healthy and matched for age (mean age = 41.2years) served as controls (control group). Their abdominal and back muscle strength was assessed using the curl-up and prone extension tests, respectively, and their static abdominal muscle endurance and back extensor endurance were assessed using the sit-up endurance test in the crook-lying position and the Biering-Sørensen test, respectively. Core stability strength was assessed using a 4-level limb-lowering test (abdominal muscle test) and core stability endurance was assessed while lying supine with both flexed legs 1 inch off the mat while keeping the pelvis in a neutral position with a pressure biofeedback unit. Compared with the control group, trunk muscles of the TRAM group were weaker, showing less endurance, as were their core stability strength and endurance. Static trunk muscle endurances and trunk flexion strength were associated with core stability in both groups. Women exhibit trunk flexor and extensor weakness along with poor endurance and impaired core stability even after an average of 10months from receiving the TRAMmsp flap procedure. Immobilization after surgery, with possible systemic inflammatory effects from surgery and chemotherapy, might have further contributed to the generalized weakness subsequent to the partial harvesting of the rectus abdominis. Women after breast reconstruction with the TRAMmsp flap procedure show long-lasting deficits of strength and endurance in abdominal muscles, back extensors, and core stability. Proactive measures including early detection and evaluation of impairments as well as timely intervention targeting these clients are important to minimize the dysfunction and support their return to community participation.

Soft-tissue reconstruction with pedicled vertical rectus abdominis myocutaneous flap after total or high sacrectomy for giant sacral tumor

BackgroundThe large soft tissue defect after total or high sacrectomy for giant sacral tumor induces high incidence of wound complications. It remains a huge challenge to reconstruct the soft tissue defect with a preferred clinical outcome. MethodsA total of 27 patients undergoing one-stage total or high sacrectomy for giant sacral tumor between 2016 and 2021 in a tertiary university hospital were retrospectively reviewed. Thirteen patients underwent a pedicled vertical rectus abdominis myocutaneous (VRAM) flap reconstruction while 14 patients underwent a conventional wound closure. Patient’s clinical characteristics, surgical duration, postoperative complications and outcomes were compared between the two groups. ResultsPatients in VRAM and Non-VRAM group were similar in baseline characteristics. The mean tumor size was 12.85cm (range: 10~17cm) in VRAM group and 11.79cm (range: 10~14.5cm) in Non-VRAM group (P=0.139). The most common giant sacral tumor is chordoma. Patients in VRAM group had shorter length of drainage (9.85 vs 17.14 days), postoperative time in bed (5.54 vs 17.14 days), and total length of stay (19.46 vs 33.36 days) compared to patients in Non-VRAM group. Patients in VRAM group had less wound infection and debridement than patients in Non-VRAM group (15.4 vs 57.1%, P<0.001). ConclusionThis study demonstrates the advantages of pedicled VRAM flap reconstruction of large soft tissue defects after high or total sacrectomy when using the anterior-posterior approach. This choice of reconstruction is better than direct wound closure in terms of wound infection, length of drainage, and total length of stay.

Surgical Outcomes of Vertical Rectus Abdominis Myocutaneous Flap Pelvic Reconstruction.

The vertical rectus abdominis myocutaneous (VRAM) flap has emerged as the workhorse flap for perineal and pelvic reconstruction. We aimed to evaluate outcomes of VRAM flap over a 20-year period and the role of mesh abdominal wall reinforcement following VRAM flap-based reconstruction. We conducted a retrospective review of all consecutive patients who underwent pelvic reconstruction with a VRAM flap between January 2001 and March 2021. Our primary outcome measure included recipient and donor surgical site occurrences (SSOs). We identified a total of 546 patients (55% females) with a mean age was 58 years and mean BMI was 27 kg/m 2. Mesh was used at the time of VRAM reconstruction to reinforce the abdominal donor site in 36% of patients. Recipient-site SSOs occurred in 38% of patients while donor-site SSOs occurred in 17% of patients. Hernia was identified in 9.9% of patients while bulge developed in 6.4% of patients. Cox proportional hazards regression model for hernia occurrence identified age, BMI, tobacco use (HR 2.03, 95% CI [1.02 - 4.04]) and use as an extended VRAM (HR 2.13, 95% CI [1.04 - 4.36]). The use of mesh or component separation were not independent protective factors for hernia occurrence. The pedicled VRAM flap is versatile and is our preferred flap for reconstruction of pelvic and perineal defects. The use of mesh/component separation to allow for fascial closure was not shown to reduce donor site hernia occurrence.

Oncological Skull Base Reconstruction with Microvascular Tissue Transplantation in Advanced Relapsed Cases

Introduction: Tumors involving the skull base are real challenges to reconstructive surgeons. Many articles have been published about these reconstructions, especially in primary cases. In tumor relapses after previous surgeries or irradiation, the surgical options for reconstruction are extremely narrowed and is our opinion that microvascular autologous tissue transplantation is specially indicated in those patients, even though it requires a technically demanding procedure. Materials and Methods: We analyzed retrospectively all patients treated at our institution between March 2014 and December 2018 and that met all the inclusion criteria: 1) oncological surgery for a tumor involving the skull base; 2) previous surgical treatment for that tumor; 3) cranial base bone resection; 4) dural exposure or defect; 5) reconstruction done with a free flap. The patient's age, comorbidities, number of previous surgeries and/or irradiation, oncological excisional procedures, type of defect, type of reconstruction, postoperative complications and mortality were reviewed. Results: Fifteen flaps were used in the 14 patients that met all the inclusion criteria. The used flaps were: Anterolateral Thigh (ALT) perforator or chimeric ALT/Vastus Lateralis (VL) (n=6), profunda artery perforator (n=3), muscular Rectus Abdominis (n=2), Vertical Rectus Abdominis Myocutaneous (VRAM) (n=2), chimeric osteomuscular scapular tip/Latissimus Dorsi (LD) (n=1) and radial forearm (n=1). Dural defects were reconstructed with Pericranial or fascia Lata grafts in 7 patients. No total flap failures or vascular thrombotic events were noted and just one case of partial flap necrosis was registered (treated conservatively). There was one case of cerebrospinal fluid leakage, one diffuse cerebral edema and one donor site wound dehiscence, all successfully treated with conservative measures. The only complication that required a second operation was a cranioplasty prosthetic exposure that required a second free flap. One patient had a tracheostomy bleeding followed by a pneumothorax and died 8 weeks postoperatively with a nosocomial pneumonia. In the follow-up period, one patient died 19 months postoperatively with a local relapse and another with a metastatic disease (at month 15). Conclusion: Secondary or multiple relapsed cases in the skull base require reconstructions that are technically demanding and the defects are often extensive. The surgical options are extremely reduced by previous treatments and if the basic concepts of cranial base reconstruction were strictly respected, the microsurgical free flaps can offer the best chance to avoid severe complications. However, it is not without some postoperative complications and mortality can be significant in the follow-up because of the advanced stage of the oncologic disease.

Prospective Clinical Trial of Premastectomy Radiotherapy Followed by Immediate Breast Reconstruction for Operable Breast Cancer

Radiation delivered prior to mastectomy and autologous breast reconstruction may avoid the adverse effects of radiation on autologous donor tissue while providing the psychologic benefit of immediate reconstruction. We aimed to study the feasibility of premastectomy radiation therapy (PreMRT). A total of 50 women enrolled in a prospective trial of preoperative radiation to the breast and regional nodes followed by mastectomy with axillary evaluation and immediate breast reconstruction. The trial was embedded in a randomized trial of hypofractionated versus conventionally fractionated regional nodal irradiation (NCT02912312). Eligible women enrolled from 2018-22, had cT0-T3 N0-3 breast cancer, and a pre-operative recommendation for radiation. The primary outcome was frequency of complete free flap loss. Mastectomy skin flap necrosis was assessed by validated SKIN grading score. The Satisfaction with Breast Cosmetic Outcomes Scales evaluated patient satisfaction with cosmetic result. Descriptive statistics and 95% exact confidence intervals were calculated. One patient withdrew prior to any treatment and one elected not to have breast reconstruction. Median age of the 48 women completing PreMRT and reconstruction was 48 [range 31-72]. Most had ER-positive HER2-negative (77%), cT3 (54%) or cT2 (38%), cN1 (79%) disease and received 50 Gy in 25 fractions (n = 24) or 40.05 Gy in 15 fractions (n = 23). Four received 10-16 Gy internal mammary or infraclavicular boost. 35% VMAT, 48% matched photon-electron, and 17% partially-wide-tangent technique. Median time to surgery was 23 days [14-85]. Skin reaction delayed surgery for one patient. Most had skin-sparing mastectomy (92%) and axillary lymph node dissection (67%). 12 surgeons performed the reconstructions: 35 deep inferior epigastric perforators; 4 profunda artery perforator; 2 muscle-sparing transverse rectus abdominis myocutaneous; 1 latissimus dorsi (LD); 2 LD/implant; 2 LD/tissue expander (TE); and 2 subpectoral (SP) TE. There were no complete flap losses. Two patients (4.4%, 95% CI 0.5%-14.8%) with free flaps had partial flap loss with revision surgery. Both patients with SP TEs had infections and unplanned reoperation. The protocol was subsequently amended to not allow SP TE reconstruction. Eight patients had skin flap necrosis: 5 partial and 3 full thickness necrosis; only 1 required operative debridement. Seven had pathologic complete response. At six months 19/31 (61%) reported being "quite a bit" or "very much" satisfied with how they looked in the mirror clothed. There are no recurrences with a median follow up of 33 months [5-119]. Radiation treatment of the breast and lymph node basins prior to mastectomy with immediate autologous reconstruction is feasible. There were no autologous flap loses and complication rates are similar to reconstruction after radiation series. This promising strategy reduces time to autologous reconstruction and merits further prospective study.

Effect of Post-Mastectomy Autologous versus Implant Reconstruction on Body Image and Quality of Life among Egyptian Women

Abstract Purpose The ultimate goal is to evaluate patient satisfaction with autologous versus implant breast reconstruction, as well as the influence of these surgeries on the quality of life and body image of women who have had a mastectomy for breast cancer. Method A multicenter, retrospective, cross-sectional study included 117 patients who underwent mastectomy and subsequent breast reconstruction surgery at El Demerdash University Hospital and Alexandria Main University Hospital between January 2017 and March 2021. A BREAST-Q 2-0 Reconstruction module questionnaire was given to each patient. Result 117 patients were divided into two groups: autologous breast reconstruction ABR (n = 77) and implant-based breast reconstruction IBR (n = 40). The ABR group was operated on using Transverse Rectus Abdominis Myocutaneous (TRAM) or latissimus Doris (LD) flaps. The average age of the participants in the study was 44.51 ± 6.88. Patients with silicone implants were younger on average than those with LD or TRAM flaps. The patient's quality of life in the two areas evaluated (psychosocial and physical well-being) was excellent in implant repair but poor in TRAM flap, according to our findings. In TRAM flap, we also discovered that overall satisfaction with the breast was low. Conculsion TRAM flap produces a low quality of life and overall satisfaction with the breast, whereas implant reconstruction provides a high quality of life.

Vertical Rectus Abdominis Myocutaneous Flap for Reconstruction of Forequarter Amputation Defect after Shoulder Soft Tissue Sarcoma Resection: Technical Consideration

Forequarter amputations in advanced local malignancy or trauma cases often leave a large defect that is challenging to reconstruct. Options for defect closure are varied. A vertical rectus abdominis myocutaneous (VRAM) flap could be an alternative to close a significantly large defect, which is relatively easier than the more technically demanding free flap. This case presents a 64-year-old man with a soft tissue sarcoma in the left shoulder that was treated by forequarter amputation and subsequent defect closure using a VRAM flap. The VRAM flap was initially used to reconstruct the chest and abdominal walls. There have been no reported uses for the shoulder defect. The repair site defect was viable even with a less aesthetic donor site, and all of the defects were closed without any signs of infection. The VRAM flap is a good option for a large defect closure at the shoulder region, particularly after forequarter amputation.

The Vertical Rectus Abdominis Myocutaneous Flap for Complex Abdominal Wall Reconstruction on a Relapse Case of Monophasic Synovial Sarcoma

Introduction: Vertical Rectus Abdominis Myocutaneous (VRAM) flap is a chosen method for a large wound closure instead of Anterolateral Thigh (ALT) flap. Both versatile and highly vascularized flaps share almost similar advantages for large wound closure. In our case, the site and size of the wound are the points of consideration. Case Presentation: A 16-year-old girl with a chief complaint of a large progressive lower abdominal mass enlarged since January 2021 that has grown back from the same site. Abdominal CT-Scan shows a tumor in the right lower abdomen infiltrated to the pelvic cavity and spanning from the lower abdominal area all the way to the groin area. Histopathology interpretation suggests a Monophasic Synovial Sarcoma. The patient underwent a second tumor resection with VRAM flap as the wound closure. The benefits of this versatile flap are excellent dead space obliteration and low Surgical Site Occurrence (SSO’s). Conclusion: As postulated in many studies VRAM flap is an excellent flap for a CAWR procedure. The expected SSO’s is non-existence during the postoperative follow-up

Surgical Outcomes of VRAM vs Gracilis Flaps in Vulvoperineal Reconstruction following Oncologic Resection: A Proportional Meta-Analysis

Introduction: Pelvic exenteration and abdomino perineal resection are radical techniques commonly used for locally advanced or recurrent pelvic malignancy. Neo-adjuvant chemotherapy and/or radiotherapy has been shown to decrease local recurrence rates and increase cancer-specific survival by allowing resection of locally advanced neoplasm. However, it leads inevitably to increased morbidity rates due to large pelvic defects Healthy, well vascularized, non-irradiated tissues are required to fill the pelvic dead space and minimize complication rates. We conducted a proportional meta-analysis to compare Vertical Rectus Abdominus Myocutaneous flap (VRAM) vs Gracilis flap for vulvo-perineal reconstruction following oncologic resection. Materials and Methods: A systematic review of Embase, PubMed, Cochrane Library, Research gate and Google Scholar was conducted aiming at all articles reporting VRAM and gracilis surgical outcomes after oncologic abdomino-perineal resection. Proportional meta-analysis of surgical outcomes was performed using the Freeman-Tukey transformation and random-effect model. Results are expressed in proportions with a 95%CI. Pooled proportions were compared between VRAM and Gracilis using a two-sided Z-test. Results: Our review yielded 17 eligible studies (11 for VRAM and 6 for Gracilis), involving 898 patients (756 VRAM and 142 Gracilis). Pooled proportion of overall donor site complications for VRAM flap is 0.584 [95% CI 0.521, 0.647], which is significantly higher than Gracilis flap rate (0.154[95% CI 0.066,0.266]). The pooled rate of overall recipient site complications for VRAM is 0.387 [95% CI 0.305, 0.473], similar to that of the Gracilis flap (0.313 [95% CI 0.194, 0.444]). Pooled flap failure rate were low for VRAM (0.025 [95% CI 0.012-0.042]) and Gracilis (0.064 [95% CI 0.003-0.171]). There was no statistically significant difference between the minor and major complications for both flaps. Conclusion: We demonstrate that both flaps can be used safely for vulvo perineal reconstruction following oncologic resection with similar recipient site outcomes, although the VRAM flap will have more donor site complications than the gracilis flap.

Absorbable Barbed Continuous versus Nonabsorbable Nonbarbed Interrupted Suturing Methods for Donor-site Closure of the Rectus Abdominis Myocutaneous Flap.

This study included 145 patients who underwent free RAMC flap reconstruction after head and neck cancer surgery at Kobe University Hospital between January 2012 and March 2020. The nAnBI method was selected between January 2012 and August 2016, and the ABC method was selected between September 2016 and March 2020. The incidence of abdominal incisional hernia and the average time required for donor-site closure were compared between the two groups. Of the 145 patients surveyed, 116 (57 and 59 in the nAnBI and ABC groups, respectively) were followed-up for at least 90 days after the surgery. The incidence rates of abdominal incisional hernia were 0% and 5.1% (n = 3) in the nAnBI and ABC groups, respectively, with no significant differences (p = 0.244). The average donor-site closure times were 127.6 and 111.3 minutes in the nAnBI and ABC groups, respectively, with no significant differences (p = 0.122). No significant differences in the incidence of abdominal incisional hernia and donor-site closure time were observed between the nAnBI and ABC groups. However, there was a tendency for increased hernia occurrence and shorter wound closure time in the ABC group. A randomized prospective multicenter study is warranted to validate our findings of the ABC method.

DESMOID TUMOUR OF ANTERIOR ABDOMINAL WALL: A CASE REPORT

Desmoid tumours are broblastic neoplasms which show aggressive inltrative behaviour and can cause mass effect. They should be monitored for asymptomatic patient as there is a possibility of spontaneous regression. For patients with rapidly growing or symptomatic tumors resection is recommended. If complete pathologic resection is not achievable without signicant morbidity, more modest resection is recommended along with treatment with adjuvant therapies. A 36-year-old female presented to the surgery OPD with the complaint of lump in left iliac fossa for last 2 years, initially 3 x 2 cm in size but gradually increasing in size with stable vitals and examination nding of lump palpable in left iliac fossa of size 20 x 15cm, hard in consistency, not xed to skin, mobile, non-tender and becoming prominent on leg raising test. MRI pelvis was suggestive of 17.1 x 12.8 x 11.4cm, T2 hypointense lesion in left hemipelvis with extension into the hypogastrium and left iliac fossa, inltrating the left anterior abdominal wall in the left iliac fossa and hypogastrium and reaching to skin surface via large defect in the abdominal wall size, abutting and displacing the urinary bladder and left external and internal iliac vessels with the angle of contact less than 90 degrees with the vessels and left ovary not visualised separate from the lesion. FNAC was suggestive of spindle cell tumour. The patient successfully underwent wide local excision along with left oopherectomy, mesh repair and transverse rectus abdominis myocutaneous (tram) ap. Conclusion: Since, desmoid tumors are locally aggressive and invasive, timely surgical intervention with resection in this patient prevented further progression of the tumour and the high probability of invasion and involvement of major blood vessels thus signicantly reducing the fatality.

Outcomes of perineal wound closure techniques after abdominoperineal resections in rectal cancer: an NSQIP propensity score matched study

Perineal defects following abdominoperineal resections (APRs) for rectal cancer may require myocutaneous or omental flaps depending upon anatomic, clinical and oncologic variables. However, studies comparing their efficacy have shown contradictory results. We aim to compare postoperative complication rates of APR closure techniques in rectal cancer using propensity score-matching. The American College of Surgeons Proctectomy Targeted Data File was queried from 2016 to 2019. The study population was defined using CPT and ICD-10 codes for patients with rectal cancer undergoing APR, stratified by repair technique. Perioperative demographic and oncologic variables were controlled for by propensity-score matching. Multivariate logistic regression analysis was performed for wound and major complications (MCs). Of the 3291 patients included in the study, 85% underwent primary closure (PC), 8.3% rectus abdominis myocutaneous (RAM) flap, 4.9% pedicled omental flap with PC, and 1.9% lower extremity (LE) flap repair. Primary closure rates were significantly higher for patients with stage T1 and T2 tumors (p < 0.001). RAM and LE flaps were most used with multi-organ resections, 24% and 25%, respectively (p < 0.001). Similarly, cases with T4 tumors used these flaps more frequently, 30% and 40%, respectively (p < 0.001). After propensity score matching for comorbidities and oncologic variables, there was no significant difference in 30-day postoperative wound or MC rates between perineal closure techniques. The complication rates of the different closure techniques are comparable when tumor stage is considered. Therefore, tumor staging and concurrent procedures should guide clinical decision making regarding the appropriate use of each technique.

T-INVERTED SHAPED RECTUS ABDOMINIS MYOCUTANEOUS (TI-RAM) FLAP FOR CHEST WALL RECONSTRUCTION

We present a case report of a 46-year-old man with a chest wall mass suspected for sarcoma who underwent wide surgical resection and reconstruction. The patient was treated with a large mass chest wall resection followed by a reconstruction using the myocutaneous rectus abdominis flap with a T-inverted shape skin paddle (Ti-RAM flap). This original flap design allowed us to cover a large chest wall defect due to a very extensive oncological resection while achieving an easier closure of the abdominal donor area.

Postoperative Complications in Patients Undergoing Nonabdominal Wall Flap Reconstruction after Laparoscopic or Robotic Abdominoperineal Resection

INTRODUCTION: Abdominoperineal resection (APR) is the treatment of choice for patients with rectal cancer. Typically, reconstruction after APR is done with a rectus abdominus myocutaneous (RAM) flap. Given the increased management with laparoscopic APRs, abdominally based flap reconstruction is inappropriate because of its invasiveness and significant abdominal wall morbidity. Therefore, a nonabdominal wall based free flap alternative, such as an anterior lateral thigh flap, gluteal flap, or gracilis flap, may be a superior approach looking forward. The aim of this study is to evaluate postoperative short- and long-term complication rates in patients undergoing nonabdominal wall flap reconstruction after laparoscopic or robotic APR. METHODS: We conducted a review of the literature to include adults with rectal cancer and looked at short-term complications such as increased healing time, seroma, hematoma, surgical site infection, dehiscence rates, reoperation rates, as well as long term complications such as perineal hernia rates. RESULTS: Our study included 64 articles and 306 flaps. The overall wound complication rate was 15.0%. In the short-term, 23 patients experienced hematomas, 16 patients experienced surgical site infection, 3 patients dehisced, and 4 required reoperations. The ALT flap offered the lowest rate of complications at 9.3%. CONCLUSION: In conclusion, the wound complication rate of 15.2% was comparable with literature findings of 14.3% in patients with RAM flap reconstruction. Nonabdominal wall-based flap reconstruction is effective after APR. Owing to its low complication rate, the ALT flap may serve as a superior treatment option for laparoscopic or robotic APR in patients with rectal cancer.

TH5.8 Use of Botulinum Toxin A infiltration in conjunction with negative pressure wound dressing and mesh-mediated traction in the management of the ‘open abdomen’

Abstract Aims Botulinum Toxin A (BTA) is widely used in complex abdominal wall reconstruction (CAWR). It temporarily paralyses the oblique muscles allowing medialisation of the rectus sheath and decreases tension on the closure. This analysis presents the use of BTA in management of the ‘open abdomen’ (OA). Methods Retrospective series of patients with OA where BTA was used in conjunction with AbtheraTM negative pressure wound therapy (NPWT) and polypropylene mesh-mediated traction (MMT) to attempt fascial closure. BTA was performed by Anaesthetists with experience of BTA use in CAWR using Dysport® 600 IU. Results We include 5 patients since 2020. Median age at index operation was 55 years (range 39–81); four were male. Index operations were intra-abdominal catastrophe where fascia closure impossible (n=2), dehiscence after Vertical Rectus Abdominis Myocutaneous (VRAM) flap for pelvic malignancy (n=2) and colectomy for obstructing colorectal cancer complicated by rectus sheath necrotising fasciitis (n=1). There were no immediate complications from BTA infiltration. All patients achieved primary fascial closure with a median of five re-looks (range 3–7). There were no full-thickness dehiscences after final closure. One patient died within 1 month from unrelated cause. One patient had no clinically palpable incisional hernia at six months and a further two had no incisional hernia at six and 12 months, respectively, on cancer surveillance CT. Conclusion BTA in the setting of the OA in conjunction with NPWT and MMT appears safe and effective in achieving fascial closure, and can potentially reduce the risk of incisional hernia. Further studies are welcomed.

TH8.1 Radiological incidence of donor-site incisional hernia and parastomal hernia after Vertical Rectus Abdominus Myocutaneous Flap-based reconstruction following colorectal surgery

Abstract Aims The vertical rectus abdominis myocutaneous (VRAM) flap is commonly used to reconstruct perineal defects for low rectal and anal cancer. The incidence of midline incisional hernias after VRAM reconstruction varies from 3.6% when detected clinically to up to 50% when detected radiologically. The aims of this study is to accurately determine the radiological incidence of donor-site incisional and parastomal hernia following VRAM reconstruction. Methods Retrospective cohort study of patients undergoing colorectal surgery requiring VRAM reconstruction over 10 years. Data were collected on patient demographics, indication for surgery and surgical procedure including details of any hernia repair. Images from surveillance CTs were reviewed for presence and size of midline incisional and/or parastomal hernias. Parastomal hernias were classified based on the European Hernia Society (EHS) classification. Results 173 patients were included in the analysis. The median age was 67 years (range 29 – 88 years) and median length of follow up was 49 months (IQR 24.3 – 71.0 months). The overall radiological incidence of incisional hernia was 27.6%. The radiological incidence of donor-site incisional hernia after VRAM at 1, 2 and 5 years was 16.8%, 25.2% and 18.5%. The parastomal hernia incidence at 1, 2 and 5 years was 37.9%, 44.1% and 29.8% (48.6% overall). Conclusions The majority of patients who develop donor-site incisional hernia and parastomal herniation following VRAM tend to do so within the first two years. Although the use of CT imaging improves the diagnosis of donor-site incisional and parastomal hernias, the clinical significance of this is unknown.

The "Nipple-Licus": the Everted Umbilicus for Immediate Nipple Reconstruction in Mid-Abdominal Transverse Rectus Abdominis Myocutaneous Breast Reconstruction

The "Nipple-Licus": the Everted Umbilicus for Immediate Nipple Reconstruction in Mid-Abdominal Transverse Rectus Abdominis Myocutaneous 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.

OP5: First Reported Cases of Robotic Assisted Harvest of Vertical Rectus Abdominis Myocutaneous (VRAM) Flap for Pelvic Wound Coverage

OP5: First Reported Cases of Robotic Assisted Harvest of Vertical Rectus Abdominis Myocutaneous (VRAM) Flap for Pelvic Wound Coverage

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.