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

Vulvar reconstruction in post-RT case using the versatile VRAM flap: reporting the rare extrapelvic approach

Although primary vulvovaginal reconstruction following vulvectomy has a significant chance of improving patient outcomes, flap reconstruction is not a recognised component of the accepted standard of care for vulvar cancer. We provide a case of a patient who underwent successful vulvar reconstruction using the extrapelvic vertical rectus abdominis myocutaneous (VRAM) flap. This musculocutaneous flap offers adequate coverage and bulk to the perineal defect after excision in post-irradiated vulvar cancer.To proceed with sphincter-saving surgery, she was scheduled for neoadjuvant chemoradiation, as the lesion involved the urethra and perineal body. However, she experienced severe grade IV dermatitis after receiving 37 Gy of radiation. Though the lesion had reduced in size, it was still large enough to cause significant perineal deformity.We performed a vulvar reconstructive surgery using the uncommon but reliable extrapelvic VRAM flap. This well-vascularised VRAM flap is particularly useful in irradiated areas prone to poor healing. Postoperatively, the wound healed well and the patient underwent adjuvant therapy 6 weeks later. We emphasise the advantages of well-perfused muscle for the primary repair of prior irradiated perineal lesions.

Perineal Surgery: A Novel Use for the Keller Funnel

What are the effects of radiation therapy on local tissue and structures seen in anterior perineal resection requiring vertical rectus abdominis myocutaneous flap coverage?What are the indications and benefits of the Keller Funnel?What are important factors that affect vertical rectus abdominis myocutaneous flap viability in anterior perineal resection?Why was the Keller Funnel indicated compared with other techniques in the setting of a narrow pelvic inlet?

Personalized Reconstruction of Genital Defects in Complicated Wounds with Vertical Rectus Abdominis Myocutaneous Flaps including Urethral Neo-Orifice

Non-healing extensive wounds in the perineal region can lead to severe soft tissue infections and disastrous complications, which are not manageable with conservative measures. Specifically in recurrent or advanced pelvic malignancies, irradiation often leads to extensive scarring and wound breakdown, resulting in significant soft tissue defects during surgical tumor excision. Among several surgical options to reconstruct the perineum, the transpelvic vertical rectus abdominis myocutaneous (VRAM) flap has proven to be one of the most reliable methods. Specific modifications of this flap allow an individualized procedure depending on the patient’s needs. We modified this technique to include the urethral orifice into the skin paddle of VRAM flaps in three patients as a novel option to circumvent urinary diversion and maintain an acceptable quality of life.

Reconstruction of Pelvic Exenteration Defect with Free Anterolateral Thigh Flap: A Case Report

The pedicled anterolateral thigh flap, with or without the vastus lateralis muscle, has been described for pelvic exenteration defect reconstruction. However, its use as a free flap for this type of defect is not routinely followed. To reconstruct an extensive pelvic defect in the presence of two ostomies, we describe a free anterolateral thigh flap with deep inferior epigastric pedicles as recipient vessels.

Pelvic/Perineal Reconstruction: Time to Consider the Anterolateral Thigh Flap as a First-line Option?

Background:

Abdominoperineal resection (APR) and pelvic exenteration continue to be common procedures for the treatment of colorectal malignancy. The workhorse flap for reconstruction in these instances has been the vertical rectus abdominis myocutaneous flap. The associated donor site morbidity, however, cannot be ignored. Here, we provide a review of the literature and present the senior author’s (A.M.) experience using the pedicled anterolateral thigh (ALT) flap for reconstruction of soft tissue defects following APR and pelvic exenteration.

Methods:

Patients who underwent pelvic/perineal reconstruction with pedicled ALT flaps between 2017 and 2019 were included in the study. Parameters of interest included age, gender, body mass index, comorbidities, history of radiation, extent of ablative surgery, and postoperative complication rate.

Results:

A total of 23 patients (16 men and 7 women) with a median age and body mass index of 66 years (inter-quartile range [IQR]: 49–71 years) and 24.9 kg/m² (IQR: 24.2–26.7 kg/m²) were included in the study, respectively. Thirteen (56.5%) patients presented with rectal cancer, 5 (21.7%) with anal squamous cell carcinoma (SCC), 4 (17.4%) with Crohn’s disease, and 1 (4.3%) with Paget’s disease. Nineteen patients (82.6%) received neoadjuvant radiation. Nine (39.1%) patients experienced 11 complications (2 major and 9 minor). The most common complication was partial perineal wound dehiscence (N = 6 [26.1%]). Stable soft tissue coverage was achieved in all but one patient.

Conclusions:

The ALT flap allows for stable soft tissue coverage following APR and pelvic exenteration without being associated with abdominal donor site morbidity. Consideration to its use as a first-line reconstructive option should be given in pelvic/perineal reconstruction.

An Algorithmic Anatomical Subunit Approach to Pelvic Wound Reconstruction

BACKGROUND

Prior radiation therapy, pelvic dead space, and a dependent location contribute to perineal dehiscence rates as high as 66 percent after primary closure of pelvic wounds. Various regional flaps have been described to reconstruct pelvic defects, but an algorithmic pairing of individual flaps to specific anatomical regions has not been described.

METHODS

A retrospective review of a prospectively maintained database was performed to identify consecutive pelvic reconstructions from 2010 to 2013 with at least 6 months' follow-up. Pelvic defects and resulting flaps were described by anatomical subunits involved: anterolateral thigh flap for mons, gracilis flap for labia majora and introitus, vertical rectus abdominis myocutaneous flap for vagina and/or perineal raphe, and gluteus musculocutaneous flap for isolated perianal defects.

RESULTS

Twenty-seven women and three men underwent consecutive pelvic reconstruction with a mean age of 60 years (range, 26 to 83 years) and a mean body mass index of 28 kg/m(2) (range, 17 to 40 kg/m(2)). Twenty-one patients (70 percent) had prior radiation therapy. In total, 45 flaps were performed according to the subunit principle. Three patients had a minor dehiscence (<5 cm), one patient had a major dehiscence, and one required reoperation for abscess. There were two partial flap losses necessitating débridement and readvancement of the flap. Twenty-five percent of female patients were sexually active after vaginal reconstruction.

CONCLUSIONS

The pelvic subunit principle provides an effective algorithm for choosing the ideal pedicled flap for each region involved in acquired pelvic defects. This algorithm is based on individual attributes that make each flap most appropriate for each subunit. Complications were minimal and patient satisfaction with appearance and function was excellent.

A hundred patients with vertical rectus abdominis myocutaneous (VRAM) flap for pelvic reconstruction after total pelvic exenteration

PURPOSE

We analysed the outcomes of a series of 100 consecutive patients with anorectal cancer with neoadjuvant radiochemotherapy and abdominoperineal exstirpation or total pelvic exenteration, who received a transpelvic vertical rectus abdominis myocutaneous (VRAM) flap for pelvic, vaginal and/or perineal reconstruction and compare a cohort to patients without VRAM flaps.

METHODS

Within a 10-year period (2003-2013) in our institution 924 patients with rectal cancer stage y0 to y IV were surgically treated. Data of those 100 consecutive patients who received a transpelvic VRAM flap were collected and compared to patients without flaps.

RESULTS

In 100 consecutive patients with transpelvic VRAM flaps, major donor site complications occurred in 6 %, VRAM-specific perineal wound complications were observed in 11 % of the patients and overall 30-day mortality was 2 %.

CONCLUSIONS

The VRAM flap is a reliable and safe method for pelvic reconstruction in patients with advanced disease requiring pelvic exenteration and irradiation, with a relatively low rate of donor and recipient site complications. In this first study, to compare a large number of patients with VRAM flap reconstruction to patients without pelvic VRAM flap reconstruction, a clear advantage of simultaneous pelvic reconstruction is demonstrated.

The management of perineal wounds

Management of perineal wounds can be very frustrating as these invariably get contaminated from the ano-genital tracts. Moreover, the apparent skin defect may be associated with a significant three dimensional dead space in the pelvic region. Such wounds are likely to become chronic and recalcitrant if appropriate wound management is not instituted in a timely manner. These wounds usually result after tumor excision, following trauma or as a result of infective pathologies like hideradenitis suppurativa or following thermal burns. Many options are available for management of perineal wounds and these have been discussed with illustrative case examples. A review of literature has been done for listing commonly instituted options for management of the wounds in perineum.

Local Fasciocutaneous Infragluteal (FCI) Flap for Vulvar and Vaginal Reconstruction: A New Technique in Cancer Surgery

Introduction

Soft tissue reconstruction after vulvar, vaginal, or anal cancer resection poses a formidable task for reconstructive surgeons because of the functional, locational, and cosmetic importance of this region. Although numerous flaps have been designed for vulvar reconstruction, each has its disadvantages.

Methods

The authors introduce the local fasciocutaneous infragluteal (FCI) flap for vulvar and vaginal reconstruction after tumor resection, vaginal scar obliteration, and vulvar ulceration in 15 patients operated on between 1999 and 2007. The FCI flap is supplied by the cutaneous branch of the descending branch of the inferior gluteal artery. The sensory supply of this flap comes from side branches of the posterior cutaneous nerve of the thigh. A total of 17 flaps were performed in 15 patients.

Results

Except for one, all flaps survived. One flap necrosis occurred because of false postoperative position with compression and tension to the vascular pedicle. In the remaining patients, we found one local cancer recurrence with necessity of a second flap from the contralateral side. The patients report satisfaction with reconstruction, without one having pain at donor site and recurrent vaginal ulceration.

Conclusions

This article discusses the expanding indications of this versatile flap and the operative technique of the local FCI flap for reconstruction of vulvar and partial vaginal defects. It can be raised in different volume and dimension out of possible irradiated area with an inconspicuous scar.

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.

The anterior Obturator Artery Perforator (aOAP) flap: surgical anatomy and application of a method for vulvar reconstruction

OBJECTIVE

Vulvar reconstruction following oncologic resection is challenging. Some flaps used for reconstruction can show adverse characteristics such as excessive tissue bulk or increased distance to the defect. Region of the sulcus genitofemoralis is of thin and pliable tissue proximate to the vulva. Vasculature and suitability of that region used for vulvar reconstruction were focused in this work.

METHODS

Vascular architecture of the region comprising the sulcus genitofemoralis was examined bilaterally on 10 female corpses (n = 20 specimens). In addition, tissue characteristics and suitability of that region to form a fasciocutaneous flap for vulvar reconstruction were anatomically examined and clinically proven.

RESULTS

Vasculature of the sulcus genitofemoralis is reflected by either a musculocutaneous perforator (80%, 16/20) piercing the gracilis muscle or a septocutaneous perforator (20%, 4/20) passing the posterior border of the gracilis muscle 1.3 ± 0.3 [cm] laterally to the inferior pubic ramus. Both types of perforators derive from the anterior branch of the obturator artery and accompanying vein. This perforator, the anterior obturator artery perforator (aOAP), supplies a skin territory of about 7 × 15 [cm] centered on the sulcus genitofemoralis. The aOAP flap proved its suitability and versatility for vulvar reconstruction.

CONCLUSIONS

The sulcus genitofemoralis is of a constant vascular anatomy reflected by the aOAP vessel. Especially the tunneled aOAP island flap offers outstanding characteristics beneficial for reconstruction of a more anatomically normal vulva. Scars are limited within anatomic borders of the urogenital region improving self-image. The aOAP flap clearly enlarges the surgical options available to restore the form and function of the vulva.

May the rectus abdominis myocutaneous flap be the best option for the reconstruction of complicated large defects of pelvic exenteration for vulvar malignancies after pelvic radiation?

Reconstruction of the large defects that develop after pelvic exenteration with local flaps may result in higher morbidity because of poor perineal wound healing after pelvic radiation. A well vascularised reconstructive flap originating from distant non-irradiated areas is needed. We report two cases of pelvic exenteration and rectus abdominis myocutaneous flap procedure in patients with recurrent vulvar malignancies that had undergone external beam pelvic radiation and subsequently developed pelvic fibrosis, necrosis and fistulas. Both flaps were totally viable postoperatively; the abdominal wound healed without any complication, no perineal wound complications developed with a follow-up of nine months. In conclusions, rectus abdominis myocutaneous flap reconstruction seems to be an ideal option for the large defects resulting from exenteration operations in patients with previous perineal radiation.

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.

Perineum Reconstruction With Pedicled Anterolateral Thigh Fasciocutaneous Flap

Eighteen pedicled anterolateral thigh perforator island flaps were used for complex perineal reconstructions between May 2003 and May 2005. The patients' average age was 48.6 years (range, 32 to 64 years), and the average follow-up period was 8 months (range, 2 to 13). In 7 cases, the perforator was septocutaneous and in 11 it was intramuscular. The application of the pedicled anterolateral thigh fasciocutaneous flap is described perineum reconstruction. The size of the perineum defects ranged from 6 x 9 cm to 16 x 17 cm, and the size of the transferred flap ranged from 8 x 11 cm to 18 x 20 cm. All flaps survived. One patient developed minor wound dehiscence in the posterior aspect of the perineal wound because of fecal contamination and skin maceration. The esthetic appearance of the reconstructed perineum was good. Despite a variable vascular anatomy that can give rise to some surgical challenge in raising the flap, the authors conclude that this is a safe and reliable flap for perineal reconstruction.