Vertical Rectus Abdominis Musculocutaneous Flap Research Articles

A New Technique for Pelvic and Vaginal Reconstruction in Abdominoperineal Rectal Excision: Combination of Gluteus Maximus Flap and Fasciocutaneous Flap.

Resection of advanced rectal cancer might result in significant tissue loss, including pelvic floor and parts of the vaginal wall. Pelvic floor reconstruction using a musculocutaneous flap offers optimized healing abilities and the possibility of vaginal reconstruction. In Skåne University Hospital, two different flap techniques are used to reconstruct the perineum: the vertical rectus abdominis musculocutaneous flap and the gluteus maximus (GM) flap. A combination of a GM flap and a fasciocutanous flap, referred to locally as a GM special (GMS) flap, is used for posterior vaginal wall reconstruction in women undergoing abdominoperineal resections including parts of or the total posterior vaginal wall. The GMS flap was introduced through a national collaboration in Sweden in 2013. The aim of this article is to offer a detailed description and illustrations of the surgical technique used to construct the GMS flap, focusing on the posterior vaginal wall reconstruction. In our experience, the GMS flap is a resilient and cosmetically appealing choice that is technically easily harvested. The flap has acceptable morbidity and long-term results with adequate neovaginal measurements. Collaborative work is further encouraged.

Comparison of inferior gluteal artery perforator flaps versus vertical rectus abdominis musculocutaneous flaps in the reconstruction of perineal wounds

Achieving a healed perineal wound following chemoradiotherapy and abdominoperineal resection (APR) is challenging for surgeons and patients. Prior studies have shown trunk-based flaps, including vertical rectus abdominis myocutaneous (VRAM) flaps, are superior to both primary closure and thigh-based flaps; however, there has been no direct comparison with gluteal fasciocutaneous flaps. This study evaluates postoperative complications after various methods of perineal flap closure of APR and pelvic exenteration defects. Retrospective review of patients who underwent APR or pelvic exenteration from April 2008 through September 2020 was analyzed for postoperative complications. Flap closure techniques, including VRAM, unilateral (IGAP), and bilateral (BIGAP) inferior gluteal artery perforator fasciocutaneous flaps, were compared. Of 116 patients included, the majority underwent fasciocutaneous (BIGAP/IGAP) flap reconstruction (n = 69, 59.6%), followed by VRAM (n = 47, 40.5%). There were no significant differences between group patient demographics, comorbidities, body mass index, or cancer stage. There were no significant differences between BIGAP/IGAP and VRAM groups in minor complications (57% versus 49%, p = 0.426) or major complications (45% versus 36%, p = 0.351), including major/minor perineal wounds. Prior studies have shown flap closure is preferable to primary closure after APR and neoadjuvant radiation but lack consensus on which flap offers superior postoperative morbidity. This study comparing outcomes of perineal flap closure showed no significant difference in postoperative complications. Fasciocutaneous flaps are a viable choice for the reconstruction of these challenging defects.

Surgical treatment of vulvar cancer with perineal defect reconstruction using a VRAM flap. Clinical case

The article presents a clinical case of perineal defect reconstruction using a VRAM flap in a patient with vulvar cancer. Stepwise surgical treatment method is described. A multidisciplinary meeting allows to realize a plan of surgical help for such patients with the goal of treating oncological process and its complications.We have proposed a variant of perineal defect reconstruction through transfer of a vertical rectus abdominis musculocutaneous flap with a vascular pedicle.

Local Recurrence after Abdominoperineal Resection with Vertical Rectus Abdominis Musculocutaneous Flap:A Case Report of Pelvic Exenteration with Preservation of the Flap

Local Recurrence after Abdominoperineal Resection with Vertical Rectus Abdominis Musculocutaneous Flap:A Case Report of Pelvic Exenteration with Preservation of the Flap

Short-term outcomes following beyond total mesorectal excision and reconstruction using myocutaneous flaps: A retrospective cohort study

IntroductionBeyond total mesorectal excision (bTME) offers long-term survival in patients with advanced pelvic malignancy. At Skåne University Hospital (SUS) Malmö in Sweden, the vertical rectus abdominis musculocutaneous (VRAM) and gluteal maximus (GM) flap have been used for perineal reconstruction to promote healing and functional outcomes after significant tissue loss. This study aims to examine 90-day overall and flap-specific complications in patients with advanced pelvic cancer treated with bTME and perineal flap reconstruction. MethodThis retrospective study conducted at SUS included patients undergoing surgery between January 01, 2010 and August 01, 2016. Patients’ data were gathered through medical chart reviews. The Clavien-Dindo (CD) classification system was used to classify surgical and medical postoperative complications. Flap-specific complications were evaluated regardless of CD classification. ResultsOne hundred five patients (51 men, 54 women) underwent bTME surgery with perineal reconstruction, with VRAM flaps used in 27 (26%) patients, GM flaps in 51 (49%) patients and GM flaps with vaginal reconstruction in 27 (26%) patients. The 90-day mortality rate was one (1%), despite surgical CD ≥ III and/or medical CD ≥ II complications affecting 51 (48%) patients. Partial perineal dehiscence was noted in 45 (43%) patients, mostly treated conservatively. At the first outpatient postoperative visit (median, 42 days), flap healing was complete in 47 (45%) patients. ConclusionbTME surgery in pelvic cancer patients with perineal flap reconstruction using VRAM or GM flaps results in high overall and flap complication rates, but low mortality. Most complications can be conservatively treated.

Reconstructive Outcomes of Extensive Soft-Tissue Defects after Palliative Mastectomy for Advanced Breast Cancer

Background: In advanced breast cancer, reconstruction can be performed depending on the patient’s situation, and can improve the subsequent treatment and quality of life. We examined the effect of reconstruction after palliative mastectomy on survival and quality of life.Methods: Between April 2010 and April 2021, 40 patients underwent reconstruction after palliative mastectomy for stage-IV breast cancer. To evaluate postoperative satisfaction, changes in the global health and quality-of-life scores after reconstruction were evaluated using questionnaires by the European Organisation for Research and Treatment of Cancer. The survival rate according to reconstructive surgery was estimated by the Kaplan-Meier survival analysis.Results: Reconstruction methods included free transverse rectus abdominis musculocutaneous (TRAM) flap (n=3), pedicled latissimus dorsi (LD) flap (n=3), pedicled TRAM flap (n=2), pedicled LD with pedicled vertical rectus abdominis musculocutaneous flap (n=1), tissue expander insertion (n=3), and split-thickness skin graft (n=28). There were no major complications or decreased life expectancy due to reconstruction. All patients healed well and started conventional chemoradiotherapy at 31.3 days postoperatively. The quality-of-life scores increased from 37 to 83 after reconstruction. There was no difference in the survival rates between those who underwent reconstruction with split-thickness skin graft and flap operation (P>0.05). The mean survival time postoperatively was 43.9 months.Conclusion: Compared to primary closure, reconstruction of extensive soft-tissue defects after palliative mastectomy did not affect life expectancy or delay postoperative chemoradiotherapy; it led to an improved quality of life. Therefore, the extensive defects expected after palliative mastectomy should not influence indications for reconstruction surgery.

Sacrectomy for sacral tumors: perioperative outcomes in a large-volume comprehensive cancer center

Background ContextSacral tumors are incredibly rare lesions affecting fewer than one in every 10,000 persons. Reported perioperative morbidity rates range widely, varying from 30% to 70%, due to the relatively low volumes seen by most centers. Factors affecting perioperative outcome following sacrectomy remain ill-defined. PurposeTo characterize perioperative outcomes of sacral tumor patients undergoing sacrectomy and identify independent risk factors of perioperative morbidity Study Design/SettingRetrospective cohort study at a single comprehensive cancer center Patient SampleConsecutively treated sacral tumor patients (primary or metastatic) undergoing sacrectomy for oncologic resection between April 2013 and April 2020 Outcome MeasuresPerioperative complications, hospital length of stay, non-home discharge, 30-day readmission, and 30-day reoperation MethodsDetails were gathered about tumor pathology and morphology, surgery performed, baseline medical comorbidities, preoperative lab data, and patient demographics. Stepwise multivariable regressions were conducted to identify independent risk factors of perioperative outcomes while evaluating predictive accuracy. Results57 sacral tumor patients were included (mean age 55.5±13.0 years; 60% female). The complication, non-home discharge, 30-day readmission, and 30-day reoperation rates were 39%, 56%, 16%, and 14%, respectively. Independent predictors of perioperative complications included ASA>2 (OR=10.7; 95%CI [1.3, 86.0]; p=0.026), radicular pain (OR=10.9; p=0.014), platelet count (OR=0.989 per 10³/μL; p=0.049), and instrumentation (OR=10.7; p=0.009). Independent predictors of length of stay included iliac vessel involvement (β=15.8; p=0.005), larger tumor volume (β=0.027 per cm³; p<0.001), a staged procedure (β=10.0; p=0.018), and S1 nerve root sacrifice (OR=15.8; p=.011). The optimal model predictive of non-home discharge included bilateral S3-S5 or higher nerve root sacrifice (OR=3.9; p=0.054), instrumentation (OR=8.6; p=0.005), and vertical rectus abdominis musculocutaneous flap closure (OR=5.3; p=0.067). 30-day readmission was independently predicted by history of chronic kidney disease (OR=26.7; p=0.021), radicular pain (OR=8.1; p=0.039), and preoperative saddle anesthesia (OR=12.6; p=0.026). All multivariable models achieved good discrimination (AUC>0.8 and R2>0.7). ConclusionClinical and operative factors were important predictors of complications and 30-day readmission, while tumor-related and operative factors accounted for most of the variability in length of stay and non-home discharge.

Wide posterior gluteal-thigh propeller flap for reconstruction of perineal defects.

With increasing popularity of minimally invasive approaches to abdominoperineal resection (APR), thigh-based flaps are becoming the preferred option for reconstruction. The gluteal-thigh flap provides sufficient bulk, albeit with a high complication rate. We reevaluated the vascularization and design of the gluteal-thigh flap. The purpose of this study is to highlight the importance of the vascularization of the posterior thigh skin by the descending branch of the inferior gluteal artery (IGA) and the profunda femoris artery (PFA) perforators to design a more reliable and versatile gluteal thigh flap. This flap is indicated in selected cases in which use of vertical rectus abdominis musculocutaneous flap is not feasible. Eleven fresh cadavers were used. The course, distribution, and diameter of IGA and PFA perforators were recorded. A wide posterior gluteal-thigh propeller flap (WPGTPF) was designed including the distance between the ischiatic tuberosity and greater trochanter; and extending it to within 8 cm of the popliteal fossa to improve flap reliability. Ten patients (mean age of 58.7 ± 10.6 years) underwent APR due to anal cancer (2) and rectal cancer (8); the approach was open in 3, laparoscopic in 6, and robotic in 1. All 10 patients received unilateral flap with a width of 12 ± 3.3 cm and surface of 405.5 ± 175.9 cm2 . The descending branch of the IGA was dominant in 72.7% of the specimens. In 22.7% of the specimens, the pedicle of the flap derived from the first or second PFA perforators. In one case, there was a double vascularization. Descending branch of the IGA was mapped at 46 ± 7.96 mm on the X-axis (horizontal line from the ischial tuberosity [IT] to the greater trochanter) and -12.1 ± 17.9 mm on the Y-axis (vertical line from the IT to the Medial Femoral condyle). Its average caliber measured 2.18 ± 0.3 mm. The first and second PFA perforators were located at 101.6 ± 17.9 mm and 104.5 ± 15.5 mm on the X-axis; 35.9 ± 27.1 mm and 89.2 ± 37.6 mm on the Y-axis. Their average diameters were 1.84 ± 0.41 mm and 1.48 ± 0.3 mm. In two cases, the flap was based on the first PFA perforator, the rest were on the descending branch of the IGA. Neither complete nor partial flap necrosis was observed. One patient developed coccyx osteomyelitis treated and resolved with bone debridement and one patient developed a seroma of the lateral thigh that was treated conservatively. Three patients underwent a debulking procedure by a combination of liposuction and resection to improve the gluteal symmetry. All ten flaps survived completely. Harvest of a wide flap that includes the PFA perforators and implementation of the propeller design increase the survival and versatility of the flap.

Novel Technique with Double Free Flap Design for Advanced Mandibular Osteoradionecrosis: A Case Series.

Summary:Advanced mandibular osteoradionecrosis is arguably among the most challenging cases for reconstructive head and neck surgeons. Several reconstructive methods for complex mandibular defects have been reported; however, for advanced mandibular osteoradionecrosis, a safe option that minimizes the risk of renewed fistulation and infections is needed. For this purpose, we present a new technique using a fascia-sparing vertical rectus abdominis musculocutaneous flap as protection for a vascularized free fibula graft (FFG). This technique also optimizes recipient site healing and functionality while minimizing donor site morbidity. Our initial experiences from a 4 patient case series are included. Mean operative time was 551 minutes (SD: 81 minutes). All donor sites were closed primarily. Mean time to discharge was 13 days (SD: 7 days), and mean time to full mobilization was 2 days (SD: 1 days). This double free flap technique completely envelops the FFG and plate with nonirradiated muscle. It allows for the transfer of an FFG without a skin island, thus avoiding the need for split skin graft closure. This results in faster healing and minimizes the risk of fibula donor site morbidity. The skin island of the vertical rectus abdominis musculocutaneous flap has the added benefit of providing intraoral lining, which minimizes contractures and trismus. Although prospective long-term studies comparing this approach to other double flap procedures are needed, we argue that this technique is an optimal approach to safeguard the mandibular FFG reconstruction against the inherent risks of renewed complications in irradiated unhealthy tissue.

Abstract: Comparison of Tumor Recurrence in Oncoplastic Pelvic Reconstruction with Vertical Rectus Abdominis Musculocutaneous (VRAM) versus Omental Flaps: Outcomes Following Ablative Abdominoperineal Resection (APR) and Pelvic Exenteration

BACKGROUND: Little is known about the impact of the type of soft-tissue reconstruction on local tumor recurrence in patients with pelvic malignancy undergoing abdominoperineal resection. Therefore, the purpose of this study is to describe our experience and outcomes in oncoplastic pelvic reconstruction for patients who underwent either vertical rectus abdominis musculocutaneous (VRAM) or omental flap following abdominoperineal resection (APR) at a single tertiary care institution. STUDY DESIGN/METHODS: All patients who underwent oncoplastic reconstruction following APR with either VRAM or omental flaps at the Mayo Clinic in Rochester, Minnesota from January 1992 – January 2017 were retrospectively reviewed. Patient demographics and relevant comorbidities (i.e. hypertension, diabetes mellitus, smoking status) were collected for all patients. Additionally, chemotherapy and radiation therapy (neoadjuvant, intra-operative, or adjuvant) data were collected and analyzed. In addition, margin status at the time of oncologic resection was analyzed. Flap-specific data were collected for each approach, including use of skin paddle and rationale for using one approach over the other (i.e. previous omentectomy or diverting colostomy). Oncologic data collected includes cancer type, stage at time of APR, tumor recurrence within the flap and stage of tumor at time of recurrence. Statistical analysis was performed with SPSS Version 11.0 statistic software package (SPSS, Chicago, IL). Comparisons between groups were performed with analysis of non-parametric test. A value of P < 0.05 was considered statistically significant. Univariate and multivariate analyses were performed. RESULTS: A total of 585 patients were identified who underwent pelvic soft-tissue reconstruction with either VRAM or omental pedicle flaps. Of these, 297 (50.8%) underwent VRAM reconstruction (270, 90.90% with skin paddle) and 288 (49.2%) underwent omental flap reconstruction. All margins were negative at time of cancer ablation surgery. Specific complications and their respective rates of occurrence in each reconstructive approach included bowel obstruction [VRAM=0; Omentum=17(5.9%)], wound dehiscence [VRAM=31(10.4%); Omentum=26(9.0%)], and tumor recurrence within pedicle flap [VRAM=14(4.7%); Omentum=40(13.9%)]. Of the 31 cases (10.4%) of wound dehiscence in VRAM patients, 6 occurred in the abdomen and 25 occurred in the perineum at the skin paddle. Chi-squared test comparing tumor recurrence between these two reconstructive approaches showed a significantly higher recurrence rate in omental flaps compared to VRAM flaps (p= 0.000127). CONCLUSIONS: The results of this study suggest a significantly higher tumor recurrence rate in omental flap pelvic reconstruction compared to patients reconstructed with VRAM flaps. This knowledge has the potential to influence surgical planning and flap selection in oncoplastic pelvic reconstruction.

Vertical Rectus Abdominis Musculocutaneous Flap Repair Improves Perineal Wound Healing after Abdominoperineal Resection for Irradiated Locally Advanced Rectal Cancer

Radiotherapy (RT) and subsequent abdominoperineal resection (APR) for locally advanced rectal cancer (LARC) is associated with significant perineal wound morbidity. The aim of the present study was to investigate if vertical rectus abdominis musculocutaneous (VRAM) flap repair after APR in LARC patients improves perineal wound healing compared with direct perineal wound closure (non-VRAM). LARC patients (n=329) operated with APR between January 2006 and December 2015 after neoadjuvant RT of ≥25Gy were identified, including 260 and 69 patients in the non-VRAM and VRAM groups, respectively. Perineal wound healing was assessed 3months postoperatively, and risk factors for perineal wound complications and associations with short- and long-term outcome were analyzed. Delayed perineal wound healing after 3months was more frequent in the non-VRAM group (31.5%) compared with the VRAM group (10.4%) (p<0.01). In the non-VRAM group, 26.9% of patients developed pelvic abscess, compared with 10.1% in the VRAM group (p<0.01). Significant risk factors for perineal wound morbidity were non-VRAM (odds ratio [OR] 3.94, 95% confidence interval [CI] 1.72-9.00; p=0.02), positive circumferential resection margin (R1; OR 3.64, 95% CI 1.91-6.93; p<0.01), pelvic abscess (OR 3.27, 95% CI 1.90-5.63; p<0.01), and short-course RT (OR 3.81, 95% CI 1.75-8.30; p<0.01). Perineal wound morbidity was not associated with impaired long-term oncologic outcome. VRAM flap reconstruction of the perineum is associated with an increased wound healing rate and may protect against pelvic abscess development. However, procedure-related long-term morbidity is incompletely studied and the procedure should be reserved for selected patients.

Combined Gluteus and Pudendal Thigh Flap Reconstruction of Vaginal Defects following Robotic Abdominoperineal Resection.

Summary:Low-lying rectal cancers are being treated more frequently with robotic-assisted abdominoperineal resection, obviating the need for laparotomy and the ability to raise vertical rectus abdominis musculocutaneous flaps. For female patients, posterior vaginectomy often accompanies the resection. Combined pudendal thigh flaps as an extension of bilateral gluteus advancement flaps allow for posterior vaginal resurfacing with thin pliable fasciocutaneous flaps, which rest on the gluteal flap soft-tissue bulk that obliterates the pelvic dead space. For patients with advanced cancers who have had neoadjuvant chemoradiation, the pudendal skin paddle can be planned more laterally to bring in healthier medial thigh skin. The donor incisions lie within the gluteal cleft and crease and groin creases recapitulating normal perineal anatomy and aesthetics.

Simultaneous reconstruction of orbital defect and parotid contour deformity by a single muscle-sparing VRAM flap with double-skin islands

Reconstruction of complex three-dimensional defects or defects in separate locations after ablative head and neck surgery can be achieved with two simultaneous free flaps, a combination of a free flap and a pedicle flap, or a single multi-island free flap. The rectus abdominis flap is often used for reconstructions with a single multi-island free flap, but the flap is excessively bulky in some cases, leading to the unnecessary sacrifice of muscle. To overcome this issue and to preserve the muscle, we used a single muscle-sparing vertical rectus abdominis musculocutaneous flap with two completely separated skin islands based on two different skin perforators to simultaneously reconstruct separate locations (the orbit and parotid region) after orbital exenteration and total parotidectomy. Our findings highlight the feasibility of simultaneously reconstructing orbit and parotid contour deformities with a single double-island flap.

Outcomes for patients with advanced N3 penile cancer undergoing flap reconstruction and adjuvant chemo/radiotherapy.

419 Background: Patients presenting with advanced penile cancer with significant inguinal disease requiring extensive resection. Reconstruction is required to cover the defect and protect underlying vascular structures when undergoingl adjuvant treatment. Often the performance status or the extent of the disease makes neoadjuvant chemo/radiotherapy difficult. Although this group of patients undoubtedly have a poor prognosis, palliative resection reduces the tumour burden and allows improved wound management and quality of life. The aim of this study was to present the techniques and report the outcomes for patients with N3 disease undergoing flap reconstruction. Methods: Medical records were reviewed for penile cancer patients with fixed inguinal nodal disease either at presentation or recurrence. Resection was performed by a team comprising urological and plastic surgeons. Cancer specific survival and the impact of adjuvant chemo/radiotherapy was recorded. Results: Seventeen patients were included; mean age 62 (range 37–85) years. Nine (53%) patients had a first presentation with penile cancer and advanced nodal disease, with 8 (47%) presenting with inguinal disease recurrence. The majority (n = 13) underwent a vertical rectus abdominis musculocutaneous (VRAM) flap. Of these, 3 required femoral vein reconstruction. Where defects were smaller, a tensor fascia latae (n = 2) or a scrotal advancement flap was used (n = 1). The average length of stay was 23 days (10-45 days) regardless of type of flap. Ten patients had adjuvant radiotherapy, 5 underwent neoadjuvant chemotherapy with a 4 undergoing adjuvant chemotherapy. The disease specific survival was 595 days (range 24-3881). Complications were related to wound healing and managed conservatively. Post operative lower limb lymphoedema occurred in the majority of patients. There were no flap failures and all but one patient was discharged home. Conclusions: Aggressive surgical management for patients with extensive nodal disease and flap reconstruction is feasible. This aids wound management and improves the quality of life for patients. Survival rates can extend to over 12 months following adjuvant treatment.

Focused Arterial Anastomotic Assessment in a Novel Univariate Design of a Vertical Rectus Abdominis Muscle Flap in a Pig Model

Background Microsurgical anastomosis is the basis for free tissue transfer. The goal of this study was to create an animal model that mimics free tissue transfer but would focus on the arterial anastomotic assessment alone, without additional bias of a venous anastomosis. Methods A vertical rectus abdominis musculocutaneous (VRAM) flap based on the left deep superior epigastric artery (DSEA) was raised in six large white pigs. The right DSEA was raised and used as the donor vessel. An arterial end-to-end microsurgical anastomosis was then performed between the right and the left SEA artery. The lateral deep epigastric vein (DIEV) was left intact to drain the flap. Perfusion of the flap was confirmed clinically by laser Doppler and by flowmetry. Results One flap failure was observed in this study that occurred on postoperative day (POD) 5 as a consequence of venous occlusion due to hematoma. There was a significant initial drop in arterial flow across the anastomosis in comparison to preanastomotic flow measurements (p &lt; 0.05); however, this was normalized by the seventh POD (p &gt; 0.05). Flow measurements in the vein significantly increased after the arterial anastomosis was completed and the seventh POD (p &lt; 0.05). Laser Doppler assessment demonstrated adequate tissue perfusion of the skin island flap. Conclusion This modified VRAM flap is a viable procedure to simulate a free flap transfer and assess the arterial anastomosis alone, while maintaining the flap's innate venous drainage. This method can allow the investigation of new arterial anastomosis techniques and devices.

Abstract: The Neighboring Flap Theory: A New Idea for Defect Closure Achieving Both Reducing the Defect and Confirmed Primary Donor Closure

INTRODUCTION: Covering a large defect with minimal donor site morbidity is a challenging task in reconstructive surgery. Recent advances in perforator flaps provides further alternatives. The research for angiosome or perforasome distinguishes the maximum size of each flap.1 The maximum size with direct donor site closure is determined by its position and has individual variation. The size of flap is, of course, measured from the size of the defect. The flap size tends to be slightly larger than the defect to avoid tension on the flap after suture. MATERIALS AND METHODS: Our new idea, flap elevation from adjacent area, enables making the defect smaller and simple in calculating the largest size of flaps. Preoperatively the perforators for flap around the defect should be detected. The pedicle of the flap should be inside the defect. The ligation test is done on the edge of the defect in the direction of the pedicle, and the maximum distance of these ligation points is the flap breadth. The length is decided as needed. RESULTS: From April 2012 to February 2016, 8 malignant tumor excision cases were treated with this method. Among them, 3 cases were anterolateral thigh flaps (ALT) or tensor fasciae latae musculocutaneous flap for inguinal to lateral buttocks. 3 cases were anterior chest wall reconstructions by vertical rectus abdominis musculocutaneous (VRAM) flaps or thoracoacromial perforator flap. 2 cases were latissimus dorsi musculocutaneous flaps (LD) for back. In one of VRAM cases, the 35x15cm size skin paddle was divided into 2 pieces to cover 25x21cm defect. None of the flaps failed. All the donor sites were closed directly. CONCLUSION: There are many studies about reduction in the donor site morbidity.2,3 Especially for large flaps, reducing the width by dividing the skin paddle or combined flap enables direct closure of the donor sites.4,5 To reduce the defect, partial direct closure is useful, but results in big dog ear. Our method enables two advantages by taking the flap from the neighboring area intentionally, because the dog ear is used as flap. If the breadth is less than the defect size, dividing the flap into some pieces is useful especially for LD, VRAM, and ALT. REFERENCES: 1. Taylor GI, Pan WR. Angiosomes of the leg: anatomic study and clinical implications. Plast Reconstr Surg. 1998;102(3):599–616. 2. Arnez ZM, Khan U, Pogorelec D, Planinsek F. Rational selection of flaps from the abdomen in breast reconstruction to reduce donor site morbidity. Br J Plast Surg. 1999;52(5):351–4. 3. Hekner DD, Abbink JH, Van es RJ, Rosenberg A, Koole R, Van cann EM. Donor-site morbidity of the radial forearm free flap versus the ulnar forearm free flap. Plast Reconstr Surg. 2013;132(2):387–93. 4. Sawaizumi M, Maruyama Y, Kawaguchi N. Vertical double flap design for repair of wide defects of the lower limb, using combined ascending scapular and latissimus dorsi flaps. J Reconstr Microsurg. 1995;11(6):407–14. 5. Sawaizumi M, Maruyama Y. Sliding shape-designed latissimus dorsi flap. Ann Plast Surg. 1997;38(1):41–5.

Early rehabilitation after perineal reconstruction with musculocutaneous flaps

Background: Advanced colorectal cancer can lead to abdominoperineal resection (APR) which results in large loss of perineal tissue. The pelvic floor can be reconstructed by replacing the removed tissue with a musculocutaneous flap, which also facilitates the healing process. Several reconstructive options have been described included vertical rectus abdominis musculocutaneous (VRAM) and gluteus maximus musculocutaneous flap (GM).

Intraoral Reconstruction wıth Microsurgical Free Flaps

INTRODUCTION: The authors aimed to evaluate the outcomes of free flap reconstructions performed for intraoral region in a single center.METHODS: Eleven free flaps have been performed for defects of the head and neck over a 4-year period. The patients were evaluated in terms of defects, flaps performed, complications and hospital stays.RESULTS: Seven patients were reconstructed with radial forearm free flap, one patient was reconstructed with free transverse rectus abdominis musculocutaneous flap, two patients were reconstructed with free vertical rectus abdominis musculocutaneous flap and the remaining one was reconstructed with free fibula osteomusculocutaneos flap. None of the flaps required reexploration for anastomotic thrombosis or hematoma. No flap failure occurred. We did not encounter any mortality or major morbidity. The average hospital stay was 21.1 days with a range from 11 to 25 days. DISCUSSION AND CONCLUSION: Multidisciplinary approach should be encouraged for the reconstruction of intraoral defects. The versatility of free tissue transfers allows reconstruction of most complex defects; although it carries significant risks, including longer operative times, donor site morbidity, recipient site complications and microsurgical failure, and longer hospital stays.

Comparison of the complications in vertical rectus abdominis musculocutaneous flap with non-reconstructed cases after pelvic exenteration.

BackgroundPerineal reconstruction following pelvic exenteration is a challenging area in plastic surgery. Its advantages include preventing complications by obliterating the pelvic dead space and minimizing the scar by using the previous abdominal incision and a vertical rectus abdominis musculocutaneous (VRAM) flap. However, only a few studies have compared the complications and the outcomes following pelvic exenteration between cases with and without a VRAM flap. In this study, we aimed to compare the complications and the outcomes following pelvic exenteration with or without VRAM flap coverage.MethodsWe retrospectively reviewed the cases of nine patients for whom transpelvic VRAM flaps were created following pelvic exenteration due to pelvic malignancy. The complications and outcomes in these patients were compared with those of another nine patients who did not undergo such reconstruction.ResultsFlap reconstruction was successful in eight cases, with minor complications such as wound infection and dehiscence. In all cases in the reconstructed group (n=9), structural integrity was maintained and major complications including bowel obstruction and infection were prevented by obliterating the pelvic dead space. In contrast, in the control group (n=9), peritonitis and bowel obstruction occurred in 1 case (11%).ConclusionsDespite the possibility of flap failure and minor complications, a VRAM flap can result in adequate perineal reconstruction to prevent major complications of pelvic exenteration.

Use of the anterolateral thigh and vertical rectus abdominis musculocutaneous flaps as utility flaps in reconstructing large groin defects.

BackgroundGroin dissections result in large wounds with exposed femoral vessels requiring soft tissue coverage, and the reconstructive options are diverse. In this study we reviewed our experience with the use of the pedicled anterolateral thigh and vertical rectus abdominis musculocutaneous flaps in the reconstruction of large groin wounds.MethodsGroin reconstructions performed over a period of 10 years were evaluated, with a mean follow up of two years. We included all cases with large or complex (involving perineum) defects, which were reconstructed with the pedicled anterolateral thigh musculocutaneous or the vertical rectus abdominis musculocutaneous (VRAM) flaps. Smaller wounds which were covered with skin grafts, locally based flaps and pedicled muscle flaps were excluded.ResultsTwenty-three reconstructions were performed for large or complex groin defects, utilising the anterolateral thigh (n=10) and the vertical rectus abdominis (n=13) pedicled musculocutaneous flaps. Femoral vein reconstruction with a prosthetic graft was required in one patient, and a combination flap (VRAM and gracilis muscle flap) was performed in another. Satisfactory coverage was achieved in all cases without major complications. No free flaps were used in our series.ConclusionsThe anterolateral thigh and vertical rectus abdominis pedicled musculocutaneous flaps yielded consistent results with little morbidity in the reconstruction of large and complex groin defects. A combination of flaps can be used in cases requiring extensive cover.