title: Reconstruction of the pelvic floor and the vagina after total pelvic exenteration using the transverse musculocutaneous gracilis flap.
abstract: BACKGROUND
  Total pelvic exenteration (TPE) is a rare operation in which the pelvic contents are removed entirely. Several options for pelvic floor and vaginal reconstruction have been described including transverse rectus abdominis musculocutaneous (TRAM) or deep inferior epigastric perforator (DIEP) flaps. The transverse musculocutaneous gracilis (TMG) flap has been introduced for breast reconstruction as a free flap. We adopted the pedicled TMG flap for reconstructions after TPE. To the best of our knowledge, this is the first report of this method in the literature.
  
  
  METHODS
  Between November 2011 and February 2014, 12 patients underwent TPE and reconstruction with unilateral (six patients) or bilateral (six patients) pedicled TMG flaps. Five patients underwent vaginal reconstruction with bilateral TMG flaps. We describe the operative procedure and the outcome of the operation in these patients.
  
  
  RESULTS
  The total mean operative times for TPE with or without vaginal reconstruction were 467 ± 12 and 386 ± 59 min, respectively. The TMG flaps had enough vascular tissue and mobility for reconstructing the TPE defects. There was distal edge necrosis in one out of 18 flaps, while the rest survived completely. During the follow-up, complete wound healing with no signs of weakening of the pelvic floor was observed in all cases.
  
  
  CONCLUSIONS
  Soft-tissue reconstructions are needed to reduce complications associated with TPE, to secure the pelvic floor and to reconstruct the vagina in select patients. The TMG flap is a logical flap choice that does not lead to functional deficits, complicate the abdominal ostomies or weaken the abdominal wall. It reduces the length of operation compared to that of abdominal flaps.
  
  
  METHODS
  IV, therapeutic.
authors.affiliation: Department of Plastic Surgery, Tampere University Hospital, Tampere, Finland. Electronic address: ilkka.kaartinen@pshp.fi.
authors.forename: Ilkka S
authors.initials: IS
authors.lastname: Kaartinen
authors.affiliation: Department of Gynaecology and Obstetrics, Tampere University Hospital, Tampere, Finland.
authors.forename: Maarit H
authors.initials: MH
authors.lastname: Vuento
authors.affiliation: Department of Gastroenterology, Tampere University Hospital, Tampere, Finland.
authors.forename: Marja K
authors.initials: MK
authors.lastname: Hyöty
authors.affiliation: Department of Urology, Tampere University Hospital, Tampere, Finland.
authors.forename: Jukka
authors.initials: J
authors.lastname: Kallio
authors.affiliation: Department of Plastic Surgery, Tampere University Hospital, Tampere, Finland.
authors.forename: Hannu O
authors.initials: HO
authors.lastname: Kuokkanen
mesh_terms: D000368:Aged; D005260:Female; D005387:Finland; D005833:Genital Neoplasms, Female / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D006084:Graft Rejection; D006085:Graft Survival; D006801:Humans; D008875:Middle Aged; D064827:Myocutaneous Flap / Q000098:blood supply / Q000637:transplantation*; D009364:Neoplasm Recurrence, Local / Q000401:mortality / Q000473:pathology; D061646:Operative Time; D010385:Pelvic Exenteration / Q000379:methods* / Q000401:mortality; D011183:Postoperative Complications / Q000453:epidemiology / Q000503:physiopathology; D019651:Plastic Surgery Procedures / Q000009:adverse effects / Q000379:methods*; D012189:Retrospective Studies; D018570:Risk Assessment; D012494:Sampling Studies; D015996:Survival Rate; D014621:Vagina / Q000601:surgery*; D014945:Wound Healing / Q000502:physiology
keywords: Pelvic exenteration; Pelvic floor; TMG flap; Vaginal reconstruction