Vertical Rectus Abdominis Musculocutaneous Research Articles

Flaps and Grafts in Robotic Reconstructive Surgery.

The robotic approach is increasingly popular in reconstructive urology. Reconstructive surgeons have commonly used flaps and grafts for obliterating dead space including tissue interposition or as an alternative to mesh in addressing lower urinary tract dysfunction. Advantages of the robotic approach are less incisional pain, excellent visualization in the deep pelvis, and improved surgeon ergonomics. In this literature review, we describe flaps and grafts used in lower urinary tract robotic reconstructive urology, serving as an almanac for these techniques. Omental, peritoneal, vertical rectus abdominis musculocutaneous (VRAM), sigmoid epiploica, gracilis flaps, and Alloderm™ have been reported for tissue interposition during fistula repair. Fascia lata has been described as a mesh alternative for robotic sacrocolpopexy. Besides providing interposition, flaps support native tissue healing and blood supply. Grafts are easy to use with low patient morbidity, but rely on the blood supply at the recipient site. Robotic reconstruction is an emerging field, and more studies are needed to define the best uses for each flap and graft as well as strategies to maximize outcomes and minimize morbidity.

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.

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.

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).

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.

Vertical rectus abdominis musculocutaneous flow‐through flap to a free fibula flap for total sacrectomy reconstruction

The purpose of this report of a small series was to describe the technique of total sacrectomy reconstruction using a pedicled vertical rectus abdominis musculocutaneous (VRAM) flow-through flap anastomosed to a free fibula flap. We reviewed all consecutive total sacrectomy reconstructions performed from 2009 to 2011. Surgical technique and patient outcomes were assessed. Total sacrectomy reconstructions included three two-stage and three-stage VRAM flow-through flap to free fibula flap patients all of which ambulated by discharge. Flap survival was 100%. Pelvic ring defects were reconstructed with A-frame fibula flap struts anastomosed to the distal epigastric vessels of pedicled trans-pelvic VRAM flaps. Complications such as wound healing, infection or hardware failure were not observed. Bony union occurred at an average 2.7 ± 0.6 months. Total sacrectomy reconstruction using a VRAM flow-through flap anastomosed to a two-strut free fibular flap allows initial assessment of the recipient vessels during the first and ensuing operative stages, satisfies the bone and soft tissue requirements of the defect, and provides a durable, functionally optimized reconstruction.

A unique deep inferior epigastric artery perforator and implications for a muscle and fascia sparing vertical rectus abdominis myocutaneous flap: A case report

Despite the sacrifice of rectus abdominis muscle, the vertical rectus abdominis musculocutaneous (VRAM) flap is still a preferred option for perineal reconstruction. This journal has previously reported on the utility of preoperative computed tomographic angiography (CTA) in this setting to identify cases that are both suitable and unsuitable for rectus abdominis flaps after previous surgery. We report a case which highlights a unique example of the benefits of such imaging, with the largest deep inferior epigastric artery (DIEA) perforator described to date identified on imaging, and used to potentiate a donor-site sparing procedure. The use of this dominant perforator was able to limit donor site harvest to only a small cuff of anterior rectus sheath and a small segment of rectus abdominis, potentiating a muscle-sparing and fascia-sparing VRAM flap for perineal reconstruction. As such, preoperative CTA was found to be a useful tool in identifying a unique anatomical variant in the largest DIEA perforator described to date, and was used to potentiate a muscle-sparing and fascia-sparing VRAM flap for perineal reconstruction.

Single-Stage Reconstruction of Composite Central Neck Defects With the Double-Island Vertical Rectus Abdominis Musculocutaneous Flap

A subset of patients with hypopharyngeal cancer has tumors involving the neck skin and soft tissues in addition to vital structures such as the larynx and alimentary tract. Surgical extirpation creates a complex composite deformity for the reconstructive surgeon. The objective of this article is to describe the rationale for closure of these defects with the double-island vertical rectus abdominis musculocutaneous (VRAM) flap. Retrospective chart review of all head and neck reconstructions performed over the past 20 years identified 4 patients who underwent reconstruction of combined defects involving less than 50% of the pharyngoesophageal circumference and anterior neck soft tissues. All wounds were closed in a single-stage with a double-island VRAM. Outcomes and complications were reviewed. Indication for resection was locally advanced disease or recurrence with pharyngocutaneous fistula. Mean age was 54 years with a follow-up time of 2 years. The average external skin defect measured 10 × 15 cm. There was no complete or partial flap loss. No major and 2 minor complications were identified. All patients tolerated an oral diet postoperatively. No revisions have been performed. In contrast to perforator flaps where creation of separate skin paddles may not always be possible, the VRAM's robust axial blood supply facilitates formation of 2 independent skin islands in all cases. The external island serves as a flap monitor and obviates the need for a second flap. In conclusion, the double-island VRAM flap is safe, has minimal donor-site morbidity, and reliably accomplishes reconstruction of composite head and neck defects in a single-stage.

PR41P RECONSTRUCTIVE SURGERY FOR PELVIC EXENTERATION IN ADVANCED MALIGNANCY

Objectives: Extended radical pelvic resection for advanced primary or recurrent pelvic malignancy is an increasingly common procedure in major colorectal units. Aggressive pre operative chemo‐radio therapy creates a cohort of patients with difficult reconstructive variables. We review our plastic surgical reconstructions in this highly heterogeneous population.Method: Utilizing the coding system at our institution we identified a cohort of patients whom underwent Vertical Rectus Abdominis Musculocutaneous (VRAM) reconstruction for exenterative pelvic surgery. A thorough retrospective case note analysis was performed specifically looking at three variable subsets.Demographic data and peri‐operative careReconstructive surgical procedures and complicationsTumour variables and patient survival outcomesResults: Statistical analysis of the patient cohort and subsets will be presentedConclusions: This study has demonstrated the versatility of the VRAM flap in obtaining a stable and supple reconstructive cover in advanced pelvic malignancy surgery. Our series confirms strong support for immediate VRAM reconstruction in all pelvic exenterative procedures. We have shown patients undergoing multi‐visceral resection after prior chemo‐radiotherapy can achieve early, healed and stable perineal closure with low morbidity.

Modified Vertical Rectus Abdominis Musculocutaneous Flap for Limb Salvage Procedures in Proximal Lower Limb Musculoskeletal Sarcomas

Introduction and aim. Management of complicated wounds after tumor extipiration of pelvic and proximal lower limb musculoskeletal sarcoma represents an essential component in the outcome of these patients. The authors present modified vertical rectus abdominis musculocutaneous (VRAM) flap techniques to reconstruct extensive defects after debridment of these complicated wounds. Material and Methods. Over a period of 4 years (2002–2005), 5 men and 2 women were managed. Median age was 21 years (range 15–49). The patients were managed for complicated lower trunk, groin, and upper thigh wounds after resection of three pelvic chondrosarcomas as well as two pelvic and two proximal femur osteosarcomas. The modifications included a VRAM flap with lateral and tongue-like extension design of the skin paddle (5 cases) or a delayed extended VRAM flap (2 cases). Results. All flaps showed complete survival and healing with no ischemic events providing stable coverage. All patients were ambulant with good limb functions in terms of walking and gait after adequate rehabilitation, 2 needed support with crutches. Conclusion. The modified VRAM flaps offer reliable reconstructive tools for coverage of complex groin and thigh defects by providing larger well-vascularized soft tissue with acceptable donor site.

Versatility of vertical rectus abdominis musculocutaneous flaps

The purpose of the study was to demonstrate a variety of indications for the vertical rectus abdominis musculocutaneous (VRAM) flap with respect to donor-site morbidity and alternative procedures. Fifteen VRAM flaps were performed in 15 patients during a 4-year period. The average age of patients was 58 years (range, 34-76 years). Inferiorly based VRAM flaps were used for defect coverage after tumor resection and for penile reconstruction in 7 cases. Superiorly based VRAM flaps were performed in 7 cases for reconstruction of osteocutaneous defects following sternal osteomyelitis and tumor resection. Arterial and venous "supercharging" was necessary in one case. One free VRAM flap was performed in a patient suffering from an osteocutaneous defect after resection of a malignant melanoma metastasis with infiltration of the brain and skull. The reconstructive goals were achieved in all cases using VRAM flap procedures. No total flap loss occurred. Minor complications as well as abdominal wall bulging and hernias were observed in four cases. The pedicled VRAM flap provides a reliable tool for coverage of large soft-tissue defects of the chest wall, groin, hip, and perineum even in a high-risk population, in which a safe and fast forward flap procedure is the primary reconstructive goal. Arterial and/or venous supercharging may be necessary, particularly in superiorly based VRAM flaps. An inferiorly based VRAM flap is a reliable tool for phalloplasty under special circumstances. The indication for free VRAM flaps is given in rare clinical situations. Stabilization of the donor site using artificial mesh is highly recommended.

Formation of Functional Neovagina With Vertical Rectus Abdominis Musculocutaneous (VRAM) Flap After Total Pelvic Exenteration

Pelvic exenteration may be the only curative option for women with recurrent pelvic malignancies. After total pelvic exenteration, the resultant perineal defect heals slowly if left to do so by secondary intention. Reconstruction with the vertical rectus abdominis musculocutaneous (VRAM) flap brings a generous bulk of healthy tissue into the defect, speeding recovery by facilitating primary healing. Six women underwent reconstruction of a neovagina using a vertical rectus abdominis musculocutaneous flap. All 6 had total pelvic exenteration for advanced gynecologic malignancy. Primary diagnosis was cervical carcinoma (n = 3), vulvar carcinoma (n = 1), nonsmall cell vaginal cancer (n = 1), and vaginal melanoma (n = 1). Four patients had received adjuvant radiotherapy preoperatively. All flaps remained 100% viable postoperatively. There were no cases of fistula, infection, or bowel obstruction. Two patients died of cardiovascular arrest postoperatively. The 4 other patients report satisfaction with reconstruction. Three had vaginal intercourse with orgasm. The inferiorly based vertical rectus abdominis musculocutaneous flap is a dependable source of tissue for pelvic reconstruction and is the flap of choice in the Division of Plastic Surgery. In addition to facilitating healing, the VRAM flap (neovagina) improves a woman's psychosocial well-being.

Modification of the Vertical Rectus Abdominis Musculocutaneous (VRAM) Flap for Functional Reconstruction of Complex Vulvoperineal Defects

Radical vulvoperineal ablations present challenging reconstructive dilemmas, especially when local metastatic spread requires distal vaginal and anal resection. Despite advances in vaginal salvage and sphincteroplasty, surface recontouring remains elusive because of the necessity to resurface a large, complex area that includes the mons, vulva, and fourchette. We describe a modification of the inferior-based vertical rectus abdominis musculocutaneous (VRAM) flap where the superior portion is split longitudinally to produce "tongue" flaps, which can resurface complex vulvoperineal wounds. By splitting the flap, one can resurface the vulva, provide an edge to reattach the vaginal cuff, and recreate the fourchette and line the anoderm after anoplasty. This musculocutaneous flap provides adequate contour and protection against radiation injury. Splitting of the flap is based on the vascular territory of the superior epigastric branches and their perforators and can be carried down to the level of their anastomosis, with the inferior system at the level of the umbilicus. The split VRAM flap has been used successfully in 3 patients with complex perineal wounds with excellent results and maintenance of vaginal patency.

Use of transpelvic rectus abdominis musculocutaneous flap for anal cancer salvage surgery.

Perineal wounds following abdominoperineal resection (APR), for persistent or locally recurrent anal cancer, are associated with poor healing secondary to irradiation therapy. The results of APR combined with a vertical rectus abdominis musculocutaneous (VRAM) flap transposed transpelvically to cover the perineal defect are presented. Between 1994 and 2000, 105 patients were diagnosed and treated for anal cancer. Twenty-two (21 per cent) underwent a salvage operation owing to persistent or locally recurrent disease. In eight patients, before 1996, the perineum was closed primarily with serious wound complications in five. In the final 14 patients, primary perineal reconstruction with a VRAM flap was performed. Median age was 65.5 (range 45-78) years. Median follow-up was 14.5 (range 3-41) months. There were no flap-related complications and primary healing was achieved in all patients. Median hospital stay was 17 (range 14-72) days. There were two major complications related to the laparotomy and abdominal closure. Combining the salvage operation with a VRAM flap facilitates primary healing after surgical treatment for persistent or locally recurrent anal cancer. A single-stage primary reconstructive procedure is feasible, with an acceptable complication rate and high level of patient satisfaction.