Vertical Rectus Abdominis Myocutaneous Flap Research Articles

Trans Oblique Ileal Conduit Technique Has a Low Risk of Parastomal Hernias

ObjectivesTo outline our surgical technique and outcomes of a ipsilateral "transoblique" ileal conduit performed during pelvic exenteration with a Vertical Rectus Abdominis Myocutaneous flap. We report hernia rates in a transrectus group as reference. MethodsWe identified patients from January 2007 to August 2020. The transoblique conduit is placed on the ipsilateral side as the VRAM, through the internal, external oblique, and transverse abdominis muscles. Stomal hernias were assessed radiologically. Transrectus patients were those undergoing radical cystectomy matched based on surgery date, age, and sex in a 3:1 ratio. We employed a Kaplan-Meier plot to visualize the duration between surgery and hernia. We calculated the hernia rate two years after surgery. Additionally, we present the 30-day postoperative complication rate. Results50 underwent transoblique conduits and we matched them to 190 transrectus patients. 67% were men with a median age of 62. 10/50 patients in the transoblique and 44/190 in the transrectus group developed a hernia, with a median follow-up of 2.2 years (IQR 0.8, 4.0). The two-year KM-estimated parastomal hernia rate was 14% (95% CI 1.6%, 25%) for the transoblique conduits, 21% (95% CI 15%, 28%) for the transrectus and 24% (95% CI 6.5%, 39%) for colostomies. Among the transoblique patients, 22 (44%) experienced at least one postoperative complication. ConclusionsA transoblique ileal conduit is safe in patients undergoing a right VRAM flap during a pelvic exenteration with a low parastomal hernia and complication rates.

Development of a Porcine VCA Model Using an External Iliac Vessel-Based Vertical Rectus Abdominus Myocutaneous Flap.

Vascularized composite allotransplantation (VCA) involves transplanting a functional and anatomically complete tissue graft, such as a hand or face, from a deceased donor to a recipient. Although clinical VCA has resulted in successful outcomes, high rates of acute rejection and increased requirements for immunosuppression have led to significant long-term complications. Of note, immunosuppressed graft recipients are predisposed to infections, organ dysfunction, and malignancies. The long-term success of VCA grafts requires the discovery and implementation of unique approaches that avoid these complications altogether. Here, we describe our surgical technique and initial experience with a reproducible heterotopic porcine VCA model for the preclinical assessment of approaches to improve graft outcomes. Six heterotopic porcine allogeneic vertical rectus abdominis myocutaneous flap transplants were performed using Sinclair donors and Yucatan recipients. Immunosuppressive therapy was not used. Each flap was based on the left external iliac vessel system. Animals were followed postoperatively for surgery-related complications. The six pigs underwent successful VCA and were euthanized at the end of the study. Each flap demonstrated complete survival following vessel anastomosis. For the allogeneic recipients, on average, minimal erythema and healthy flap color were observed from postoperative days 1 to 4. There were no surgery-related animal deaths or complications. We have developed a reproducible, technically feasible heterotopic porcine VCA model based on the left external iliac vessel system. Our results demonstrate this model's potential to improve VCA graft outcomes by exploring tolerance induction and rejection biomarker discovery in preclinical studies.

En-bloc excision of sacral squamous cell carcinoma with immediate reconstruction.

Sacral squamous cell carcinoma is an uncommon condition that may arise in scars following burns or in chronic wounds, such as an untreated pilonidal cyst. The aim of the present technical note is to describe a surgical technique aimed at minimizing local recurrence rates by en-bloc resection as well as providing immediate plastic reconstruction: 1. right-sided extended vertical rectus abdominis myo-cutaneous (VRAM) flap; 2. abdomino-perineal excision of the rectum with end colostomy; 3. en-bloc excision of the mass inclusive of gluteus maximus muscles and distal sacrectomy; 4. sacrectomy defect covered with VRAM flap; 5. bilateral gluteal defects covered with single-layer dermal substitute of bovine collagen and elastin hydrolysate followed by immediate split-thicknessskin grafting from bilateral thigh donor sites, and negative pressure wound therapy dressings. This approach resulted in a favorable outcome at 2-year follow-up in a male patient presenting with a large locally advanced sacral squamous cell carcinoma involving the external anal sphincter muscle.

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.

Commentary on “30 days postoperative outcome associated with vertical rectus abdominis myocutaneous (VRAM) flap reconstruction after pelvic surgery” by Thomsen TV, Warming P, Hasanbegovic E, Rindom MB &amp; Stolle LB

Commentary on “30 days postoperative outcome associated with vertical rectus abdominis myocutaneous (VRAM) flap reconstruction after pelvic surgery” by Thomsen TV, Warming P, Hasanbegovic E, Rindom MB &amp; Stolle LB

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.

Intraoperative Blood Flow Analysis of Free Flaps with Arteriovenous Loops for Autologous Microsurgical Reconstruction

Background: Arteriovenous (AV) loops help to overcome absent or poor-quality recipient vessels in highly complex microvascular free flap reconstruction cases. There are no studies on blood flow and perfusion patterns. The purpose of this study was to evaluate and compare intraoperative hemodynamic characteristics of AV loops followed by free tissue transfer for thoracic wall and lower extremity reconstruction. Methods: this prospective clinical study combined Transit-Time Flowmetry and microvascular Indocyanine Green Angiography for the assessment of blood flow volume, arterial vascular resistance and intrinsic transit time at the time of AV loop construction and on the day of free flap transfer. Results: A total of 11 patients underwent AV loop creation, of whom five required chest wall reconstruction and six required reconstruction of the lower extremities. In seven of these cases, the latissimus dorsi flap and in four cases the vertical rectus abdominis myocutaneous (VRAM) flap was used as a free flap. At the time of loop construction, the blood flow volume of AV loops was 466 ± 180 mL/min, which increased to 698 ± 464 mL/min on the day of free tissue transfer (p &gt; 0.1). After free flap anastomosis, the blood flow volume significantly decreased to 18.5 ± 8.3 mL/min (p &lt; 0.001). There was no significant difference in blood flow volume or arterial vascular resistance between latissimus dorsi and VRAM flaps, nor between thoracic wall and lower extremity reconstruction. However, a significant correlation between the flap weight and the blood flow volume, as well as to the arterial vascular resistance, was found (p &lt; 0.05). Conclusion: This is the first study to perform intraoperative blood flow and hemodynamic measurements of AV loops followed by free tissue transfer. Our results show hemodynamic differences and contribute to deeper understanding of the properties of AV loops for free flap reconstruction.

Perineal wound complications after vertical rectus abdominis myocutaneous flap and mesh closure following abdominoperineal surgery and pelvic exenteration of anal and rectal cancers: A meta-analysis.

A meta-analysis research was implemented to appraise the perineal wound complications (PWCs) after vertical rectus abdominis myocutaneous (VRAM) flap and mesh closure (MC) following abdominoperineal surgery (AS) and pelvic exenteration (PE) of anal and rectal cancers. Inclusive literature research till April 2023 was done and 2008 interconnected researches were revised. Of the 20 picked researches, enclosed 2972 AS and PE of anal and rectal cancers persons were in the utilized researchers' starting point, 1216 of them were utilizing VRAM flap, and 1756 were primary closure (PC). Odds ratio (OR) and 95% confidence intervals (CIs) were utilized to appraise the consequence of VRAM flap in treating AS and PE of anal and rectal cancers by the dichotomous approach and a fixed or random model. VRAM flap had significantly lower PWCs (OR, 0.64; 95% CI, 0.42-0.98, p < 0.001), and major PWCs (OR, 0.50; 95% CI, 0.32-0.80, p = 0.004) compared to PC in AS and PE of anal and rectal cancers persons. However, VRAM flap and PC had no significant difference in minor PWCs (OR, 1; 95% CI, 0.54-1.85, p = 1.00) in AS and PE of anal and rectal cancer persons. VRAM flap had significantly lower PWCs, and major PWCs, however, no significant difference was found in minor PWCs compared to PC in AS and PE of anal and rectal cancers persons. However, caution needs to be taken when interacting with its values since there was a low sample size of most of the chosen research found for the comparisons in the meta-analysis.

Mesenchymal Stem Cells and Regenerative Therapy with Bilateral Gracilis Flaps for Perineal Reconstruction of a Wound Infection in the Setting of Anal Squamous Cell Carcinoma.

Many patients are affected by HIV/AIDS, and these conditions are highly prevalent worldwide. Patients with HIV/AIDS can experience debilitating wound infections that often require flap reconstruction and become challenging for surgeons to treat. In the past 5 years, mesenchymal stem cells have been tested and used as regenerative therapy to promote the growth of tissues throughout the body because of their ability to successfully promote cellular mitogenesis. To the authors' knowledge, the use of mesenchymal stem cell grafting following necrosis of a myocutaneous gracilis flap (as part of perineal wound reconstruction) has never been reported in the literature.In addition, the use of mesenchymal stem cells and regenerative medicine combined in the setting of squamous cell carcinoma of the anus with prior radiation (along with comorbid AIDS) has not been previously documented.In this report, the authors outline the case of a 60-year-old patient who had a recipient bed (perineum) complication from prior radiation therapy. Complicating the clinical picture, the patient also developed a Pseudomonal organ space infection of the pelvis leading to the failure of a vertical rectus abdominis myocutaneous flap and myocutaneous gracilis flaps. As a result, the patient underwent serial operative debridements for source control, with the application of mesenchymal stem cells, fetal bovine dermis, porcine urinary bladder xenograft, and other regenerative medicine products, achieving a highly successful clinical outcome. A procedural description for future use and replication of this method is provided.

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.

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

Summary: 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.

Anatomical Considerations and Plastic Surgery Reconstruction Options of Sacral Chordoma Resection.

Introduction Chordomas are slow-growing malignant bone tumors arising from remnant embryonic notochord cells with predilection for the sacrum. They rarely metastasize, and early surgical resection with clear margins is the treatment of choice followed by plastic surgery reconstruction supplemented with adjuvant radiotherapy based on the local treatment protocol or in cases with a contaminated surgical field. Aim The aim of the present study is to present our experience in surgical management of sacral chordomas and propose a surgical reconstruction algorithmconsidering anatomical parameters after partial or total sacrectomy. Materials and methods Twenty-seven patients with sacral chordomas were treated in our Orthopaedic Surgery Department between January 1997 and September 2022, and 10 of them had plastic surgery reconstruction. Patients were divided into groups based on the type of sacrectomy, sacrum anatomical vascular or neural variations, partial or total, and the type of soft tissue reconstruction. The postoperative complications and the functional outcomes in each patient were assessed. Results Bilateral gluteal advancement flaps or gluteal perforator flaps are the first choice in patients with partial sacrectomy, intact gluteal vessels, and without preoperative radiotherapy followed by transpelvic vertical rectus abdominis myocutaneous flap or free flaps in those patients with near total sacrectomy and preoperative radiation therapy. Conclusion There are four reliable options for patients after sacral chordomaresection: direct closure, bilateral gluteal advancement flaps, transpelvic vertical rectus abdominis myocutaneous flaps,and free flaps. Each time, tumor-free margins and a good reconstructive plan according to the defect and patient characteristics are mandatory.

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.

30 days postoperative outcome associated with vertical rectus abdominis myocutaneous (VRAM) flap reconstruction after pelvic surgery

30 days postoperative outcome associated with vertical rectus abdominis myocutaneous (VRAM) flap reconstruction after pelvic surgery

Analysis of the Chest Wall Reconstruction Methods after Malignant Tumor Resection.

Background The chest wall defects can be caused by various reasons. In the case of malignant tumor resection of the chest wall, it is essential to reconstruct the chest wall to cover the vital tissue and restore the pulmonary function with prevention of paradoxical motion. With our experience, we analyzed and evaluated the results and complications of the chest wall reconstructions followed by malignant tumor resection. Methods From 2013 to 2022, we reviewed a medical record of patients who received chest reconstruction due to chest wall malignant tumor resection. The following data were retrieved: patients' demographic data, tumor type, type of operation, method of chest wall reconstruction of the soft and skeletal tissue and complications. Results There were seven males and six female patients. The causes of reconstruction were 12 primary tumors and one metastatic carcinoma. The pathological types were seven sarcomas, three invasive breast carcinoma, and three squamous cell carcinomas. The skeletal reconstruction was performed in six patients. The series of the flap were eight pedicled latissimus dorsi (LD) myocutaneous flaps, two pectoralis major myocutaneous flap, two vertical rectus abdominis myocutaneous free flap, and one LD free flap. Among all the cases, only one staged reconstruction and successful reconstruction without flail chest. Most of the complications were atelectasis. Conclusion In the case of accompanying multiple ribs and sternal defect, skeletal reconstruction would need skeletal reconstruction to prevent paradoxical chest wall motion. The flap for soft tissue defect be selected according to defect size and location of chest wall. With our experience, we recommend the reconstruction algorithm for chest wall defect due to malignant tumor resection.

Radiological incidence of donor-site incisional hernia and parastomal hernia after vertical rectus abdominus myocutaneous flap-based reconstruction following colorectal surgery.

A 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 50% when detected radiologically. The aim of this study is to accurately determine the radiological incidence of donor-site incisional and parastomal hernia following VRAM reconstruction. This was a 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 the presence and size of midline incisional and/or parastomal hernias. Parastomal hernias were classified based on the European Hernia Society (EHS) classification. One hundred and seventy three patients were included in the analysis. The median age was 67 years (range 29-88 years) and the median length of follow-up was 49 months (interquartile range 24.3-71.0months). The cumulative incidence of donor-site incisional hernia after VRAM at 1, 2 and 5 years was 15.1%, 25.4% and 29.1%, respectively. The cumulative incidence for PSH at 1, 2 and 5 years was 33.1%, 46.6% and 53.3%, respectively (95% CI 45.4%-60.5%). Most patients who develop donor-site incisional hernia and parastomal herniation following VRAM tend to do so within the first 2 years. Although the use of CT imaging improves the diagnosis of donor-site incisional and parastomal hernias, the clinical significance of this is unknown.

62 (PB-062) Poster - A comparative analysis between vertical rectus abdominis myocutaneous (VRAM) flap and transverse rectus abdominis myocutaneous (TRAM) flap as options for post-mastectomy chest wall reconstruction

Background: Oncoplastic breast reconstruction prevents the chest wall deformities occurring after a mastectomy or occurring after chest irradiation following lumpectomy. It offers lower morbidity, higher quality of life and a more natural aesthetic outcome than traditional breast reconstruction techniques. Free flaps offer great cosmetic results and also prevent donor site morbidity but they require advanced microsurgical techniques that may be difficult in institutions with constraints of resources.

Component Separation Reduces Donor-Site Morbidity in High-Risk Patients Undergoing Abdominally Based Breast Reconstruction.

Donor-site morbidity has been a key driver in the evolution of abdominally based breast reconstruction, resulting in the now widespread use of the deep inferior epigastric artery perforator flap. At the donor site, plastic surgeons have applied principles of abdominal wall reconstruction, including underlay subfascial or submuscular mesh placement with primary fascial closure, due to fundamental similarities between donor site and laparotomy defects. One core technique of abdominal wall reconstruction that has not been previously described in abdominally based breast reconstruction is component separation. As with patients undergoing laparotomy, some patients undergoing abdominally based breast reconstruction are predisposed to develop a bulge or hernia as a result of both patient factors (e.g., obesity) and surgical factors (e.g., perforator anatomy), even when there is no fascial defect, making component separation a logical consideration in these patients.1 We hypothesized that component separation may reduce donor-site morbidity in abdominally based breast reconstruction, particularly in patients with risk factors for donor-site complications. In 2016, the senior author (A.H.C.) began performing anterior component separation in select patients with obesity (body mass index > 30.0) undergoing abdominally based breast reconstruction. The rationale for this application was the fact that obesity is one of the most well-established risk factors for the development of a ventral hernia in laparotomy patients, and its incidence continues to rise in the United States.2,3 In this institutionally approved study, we compared this cohort of patients (2016 to 2021) with a matched historical cohort of obese patients who underwent abdominally based breast reconstruction without component separation (2011 to 2016 control group) by a single surgeon, all with a minimum of 6 months of follow-up. A total of 226 patients met inclusion criteria, with 124 patients in the 2016 to 2021 group and 102 patients in the 2011 to 2016 control group. There were no significant differences in preoperative or surgical characteristics. The average body mass index of the 2016 to 2021 group was 39.8 ± 7.2, compared to 38.4 ± 6.5 in the 2011 to 2016 control group (p = 0.85). The overall donor-site complication rate was 21.2 percent. The rates of use of mesh for donor-site closure were similar (p = 0.10). Patients who underwent component separation, however, were more likely to be able to undergo primary fascial closure than those who did not (98.4 percent versus 83.3 percent, respectively; p = 0.0001). Patients who underwent component separation experienced a similar rate of overall donor-site complications than those who did not, but they experienced a lower incidence of abdominal bulge (0.8 percent versus 9.8 percent, respectively; p = 0.003) and wound dehiscence (8.1 percent versus 17.6 percent, respectively; p = 0.04). Our results suggest that the use of component separation can reduce donor-site morbidity in high-risk patients undergoing abdominally based breast reconstruction, possibly by facilitating the ability to achieve primary fascial closure. This finding is consistent with prior descriptions of component separation used for closure of vertical rectus abdominis myocutaneous flap donor sites in pelvic reconstruction.4 Borrowing from the principles of abdominal wall reconstruction, the select use of component separation may further optimize outcomes in patients undergoing abdominally based breast reconstruction and it is a technique that can be readily performed with the exposure provided in abdominally based breast reconstruction. Further study is needed to better define the use of component separation in this patient population.

Surgical Outcomes of VRAM vs. Gracilis Flaps in Vulvo-Perineal Reconstruction Following Oncologic Resection: A Proportional Meta-Analysis.

Simple SummaryThe rate of perineal complications after abdominoperineal reconstruction for the treatment of cancers ranges from 25% to 60% in the literature. It is well-established in current literature that direct closure has a higher complication rate than closure with a flap. Several reconstructive options have been proposed to fill the dead space with well-vascularized tissue. Every surgeon would like to be comfortable in selecting which flap has superiority in terms of surgical outcome. In the absence of a meta-analysis on the subject due to the scarcity of RCT and comparative studies, we used a proportional meta-analysis to analyze the surgical outcomes after reconstruction with either VRAM flap or gracilis flap following oncologic resection of the vulvo-perineal region.Pelvic exenteration and abdominoperineal resection are radical techniques commonly used for locally advanced or recurrent pelvic malignancy with high morbidity due to large pelvic defects. Flaps can help provide healthy, well-vascularized, non-irradiated tissues to fill pelvic dead space. We conducted a proportional meta-analysis to compare surgical outcomes of vertical rectus abdominus myocutaneous flap (VRAM) vs. gracilis flap for vulvo-perineal reconstruction following oncologic resection. A comprehensive literature search was conducted in the MEDLINE, PubMed, Embase, Google Scholar, and Cochrane Library databases. Proportional meta-analysis was performed to compare the surgical outcomes of using VRAM or gracilis flaps. Our review yielded 16 eligible studies. The pooled resolution rate of overall donor site complications for VRAM flap (pooled proportion = 0.576 [95% CI 0.387, 0.754]) was significantly higher than the pooled rate of overall donor site complications of gracilis flap (pooled proportion = 0.160 [95% CI 0.058, 0.295]). Partial and total flap necrosis were similar in both groups. There was no statistically significant difference between minor and major complications for both flaps. 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.