Perineal reconstruction with an extrapelvic vertical rectus abdominis myocutaneous flap.
OBJECTIVE
Extensive perineal resections often require autologous tissue reconstruction, especially in wide oncological resections. Local and regional pedicled flaps from the lower extremity and abdominal sites have been described. Defects of the pelvis and perineum rarely require free-tissue transfer. The vertical rectus abdominis myocutaneous (VRAM) flap, traditionally delivered to the perineum through an intraperitoneal transpelvic route, is a workhorse flap for combined pelvic and perineal defects because of its ability to provide substantial coverage of the perineum, reliable vascular supply, and larger volume to obliterate dead space. We propose and describe an extended VRAM flap for vulvar reconstruction delivered to the perineum in an extrapelvic fashion.


METHODS
A 54-year-old woman with a prior history of anal squamous cell carcinoma underwent neoadjuvant chemoradiotherapy followed by abdominoperineal resection, total abdominal hysterectomy, and bilateral salpingo-oophorectomy. Three years later, she developed vulvar squamous cell carcinoma with vascular and lymphatic invasion and underwent radical vulvectomy and distal urethrectomy. The resection defect was 10 × 15 cm, including the distal 1 cm of the urethra, distal vaginal orifice, and wide exposure of the pubic bone. An extrapelvic extended VRAM flap was used for reconstruction.


RESULTS
The flap was harvested and transposed into the defect via a wide suprapubic subcutaneous tunnel. A neovaginal and urethral orifice was created in the flap by splitting the muscle in the direction of its fibers, taking care to protect the vascular pedicle, and inset to the vaginal orifice. There were no postoperative complications. She has maintained urinary continence with follow-up of 38 months.


CONCLUSIONS
Introduction of a rectus abdominis flap to the perineum through an extrapelvic route is preferred if laparotomy is not used for the resection. We successfully report and advocate the use of an extended VRAM flap for vulvar reconstruction delivered to the perineum in an extrapelvic fashion.
Department of Plastic Surgery, The University of Texas M D Anderson Cancer Center, Houston, TX 77030, USA.
John F
JF
Nigriny
Peter
P
Wu
Charles E
CE
Butler
D001005:Anus Neoplasms / Q000473:pathology / Q000601:surgery; D002294:Carcinoma, Squamous Cell / Q000473:pathology / Q000534:rehabilitation / Q000601:surgery*; D005260:Female; D006801:Humans; D008875:Middle Aged; D009132:Muscles; D010388:Pelvis / Q000473:pathology / Q000601:surgery*; D010502:Perineum / Q000473:pathology / Q000601:surgery*; D019651:Plastic Surgery Procedures / Q000379:methods*; D017568:Rectus Abdominis / Q000473:pathology / Q000601:surgery*; D012867:Skin; D013524:Surgical Flaps; D014594:Uterine Neoplasms / Q000473:pathology / Q000601:surgery; D014846:Vulvar Neoplasms / Q000534:rehabilitation / Q000556:secondary / Q000601:surgery*