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Gynecologic Reconstruction with a Rectus Abdominis Myocutaneous Flap: An Update
GYNECOLOGIC ONCOLOGY ARTICLE NO.
61, 364–368 (1996)
0157
Gynecologic Reconstruction with a Rectus Abdominis Myocutaneous Flap: An Update1 JAY W. CARLSON,2 JONATHAN R. CARTER, ANDREW K. SALTZMAN, LINDA F. CARSON, JEFFREY M. FOWLER, AND LEO B. TWIGGS Women’s Cancer Center, Department of Obstetrics and Gynecology, University of Minnesota Hospital and Clinic, Minneapolis, Minnesota 55455 Received July 24, 1995
This series reports the outcomes and significant complications associated with the rectus myocutaneous flap when used for pelvic or inguinal reconstruction in patients with gynecologic cancers. Perioperative variables were retrospectively reviewed to identify social and medical risk factors as well as intraoperative and postoperative complications that predisposed to rectus flap failure. Fifteen patients with gynecologic malignancies underwent reconstructive procedures using a vertically oriented rectus abdominis myocutaneous flap for either vaginal (n Å 14) or inguinal (n Å 1) reconstruction. The patients’ primary cancers were cervical (n Å 11), rectal (n Å 1), ovarian (n Å 1), vulvar (n Å 1), and vaginal (n Å 1). The median age was 50 years. The median follow-up was 17 months. All flaps were mobilized in conjunction with a radical salvage operation. There were no cases of vaginal prolapse and no abdominal wound infections. However, 4 patients (27%) had major postoperative morbidity in this small series. There was one wound dehiscence and three episodes of necrosis of the subcutaneous and cutaneous portions of the flap. All 4 of these patients required additional operative intervention or debridement. Eleven patients had complete healing of the flap. The rectus abdominis myocutaneous flap is a valuable option for gynecologic reconstructive procedures. Perioperative strategies for improving flap viability include the identification of risk factors that may compromise flap perfusions such as prior abdominal incisions, peripheral vascular disease, and obesity. Meticulous surgical technique is required to preserve the vascular pedicle. These strategies may be useful in preoperative counseling, the perioperative evaluation, and the intraoperative management. q 1996 Academic Press, Inc.
INTRODUCTION
The versatility of the rectus abdominis myocutaneous flap allows it to be used for a variety of pelvic reconstructive procedures [1–5]. There are several advantages to using this 1 The opinions contained herein are the views of the authors and are not necessarily the views of the Department of Defense or the United States Army or Navy. 2 To whom reprint requests should be addressed at Dept. of OB/GYN, William Beaumont Army Medical Center, El Paso, TX 79920-5001.
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MATERIALS AND METHODS
Between 1991 and 1994, the vertically oriented rectus abdominis myocutaneous (VRAM) flap was preferentially used for vaginal reconstruction performed in conjunction with an operative procedure for salvage therapy for patients with a gynecologic malignancy at the University of Minnesota Women’s Cancer Center. The operative technique used for the mobilization of the rectus myocutaneous flap was similar in each case and has been previously described [1]. The VRAM flap was also mobilized in a similar fashion for inguinal reconstruction. Records were reviewed retrospectively for pertinent social and medical history, including pertinent intraoperative and postoperative complications.
364
0090-8258/96 $18.00 Copyright q 1996 by Academic Press, Inc. All rights of reproduction in any form reserved.
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flap over other myocutaneous flaps described for gynecologic reconstruction. The most significant is that it has a long vascular pedicle that allows it to be mobilized to virtually anywhere on the vulva or groin or in the pelvis. This flap may easily be incorporated into the midline incision. The Women’s Cancer Center’s initial experience with a rectus abdominis myocutaneous flap for vaginal construction involved seven patients [1]. In that report, both the vertically and the transversely oriented rectus abdominis myocutaneous flaps were used. The procedures were performed at two institutions. The significant complication in that preliminary report was a single wound dehiscence. This report reviews the surgical technique and the clinical outcome of patients who had the vaginal reconstruction using a VRAM flap at a single institution. Unfortunately, there has been considerable flap-related morbidity and flap necrosis observed in some of the more recent patients in whom this flap was used. The objective of this report was to review the outcomes, complications, and morbidity associated with the vertically oriented rectus abdominis myocutaneous flap during reconstructive procedures in gynecologic oncology. Preoperative risk factors and strategies for preventing flap morbidity are also reviewed.
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RECONSTRUCTION WITH A RECTUS FLAP: AN UPDATE
The Quetelet Index (QI) was calculated from the patients’ height in meters and weight in kilograms using the technique previously described [6]. Follow-up was calculated to date of most recent clinic contact or death. Each procedure was performed through a midline vertical skin incision. The right inferior epigastric vessels and rectus abdominis muscle were utilized for all flaps. While mobilizing the VRAM flap, the epigastric vessels were visualized on the posterior aspects of muscle belly. Meticulous surgical technique was used to maintain the integrity of the inferior epigastric vessels as the superior epigastric vessels were divided. When mobilizing the flap for inguinal reconstruction, the contralateral myocutaneous flap was electively utilized. The flap and vascular pedicle were tunneled under the skin to the area of the inguinal ligament and secured to the surrounding skin. Abdominal incisions were closed with delayed absorbable monofilament or permanent monofilament suture. Marlex mesh was used to close the fascial if excessive incisional tension was present. All patients had closed suction drains used in the pelvis. RESULTS
Fifteen patients with an advanced or recurrent gynecologic malignancy underwent a reconstructive procedure using a vertically oriented rectus abdominis myocutaneous flap as part of a radical salvage operation. The median age of the patients was 50 years. The median follow-up was 17 months. The VRAM flap was used for vaginal (n Å 14) or inguinal (n Å 1) reconstruction. The patients’ primary cancers were cervical (n Å 11), rectal (n Å 1), ovarian (n Å 1), vulvar (n Å 1), and vaginal (n Å 1). The VRAM flap was mobilized for vaginal reconstruction in conjunction with a total exenteration (n Å 10), an anterior exenteration (n Å 2), a posterior exenteration (n Å 1), an enterovaginal fistulae repair (n Å 1), and an inguinal reconstruction (n Å 1). There were no cases of vaginal prolapse and no abdominal wound infections. There were four patients (27%) with major postoperative morbidity (Table 1). The first patient, case 3, was a 42year-old with a QI of 40 who had an infraumbilical fascial dehiscence on the 7th postoperative day. The supraumbilical fascia, where the flap was mobilized, was intact. This patient was also presented in the initial series. Three patients had necrosis of a significant portion of their flaps. One of these also had a disruption of the vascular supply to her right leg. These three patients required surgical debridement of the entire subcutaneous and cutaneous portions of the flap. The debridements occurred at Postoperative Days 17, 36, and 45. Each of these patients had medical and surgical risk factors for their flap morbidity that will be reviewed in more detail below. Case 12 was a 52-year-old with a 70-pack-year history of
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smoking and a QI of 29 who had a recurrent cervical cancer treated with a total exenteration. There were no intraoperative complications. On the 4th postoperative day she developed a compartment syndrome of the right lower leg. The symptoms of decreased perfusion to the leg progressed. On the 6th postoperative day, she required a right above-theknee amputation. After the amputation, a necrotic ulcer developed on the left heel. An arteriogram revealed that the patient had a complete occlusion of the aorta just distal to the renal vessels. Perfusion of the left leg was reestablished through collateral circulation in the inguinal area that included the inferior epigastric vessels. Debridement of her flap was performed on 17th postoperative day. The patient had not had a history of claudication or other evidence of severe peripheral atherosclerotic disease. Case 13 was a 75-year-old with a 60-pack-year history of smoking and a QI of 22 with recurrent vaginal cancer who underwent a supralevator total exenteration. The procedure was complicated by a 20-liter blood loss from the presacral veins. This patient also had four previous midline incisions, including an extraperitoneal staging procedure 2 years earlier. The right inferior epigastric artery had been transected during one of these earlier procedures as it was not visualized during flap mobilization. The rectus muscle had also been traumatized during the previous procedures as it was less than half its normal width. The vaginal reconstruction was completed in the usual fashion. A low colonic anastomosis was performed. The patient developed an anastomotic leak and pelvic abscess. Thirty-six days later, the flap was necrotic and required debridement of the subcutaneous and cutaneous portions. Case 14 was a 44-year-old nonsmoker with a QI of 38 and recurrent squamous carcinoma of the cervix who underwent an anterior pelvic exenteration. As the flap mobilization was being completed, the inferior epigastric artery was transected. The flap was brought into the pelvis with the rectus fibers in the sagittal plane, parallel to the direction of the vaginal tube. All previous flaps were mobilized with the muscle fibers in a transverse plane, perpendicular to the direction of the vaginal tube. The procedure was otherwise uncomplicated. Forty-five days later the patient presented with a malodorous watery vaginal discharge. The flap was necrotic and required debridement. Although flap necrosis was encountered in 3 patients, risk factors for peripheral vascular disease or damage to the rectus vascular pedicle were also present in other patients. Six of the 15 patients had a more than 40-pack-year smoking history. Six patients had at least one prior lower abdominal incision (range 0–4) and 4 had two or more prior lower abdominal incisions. Fourteen of the 15 patients had received some form of radiation. All of the patients who had experienced postoperative morbidity had received radiation. The median QI for patients with complications versus those without complications was 34 and 25, respectively. Fourteen of
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50 51 42 46 47 54 50 62 75 32 41 52 75 44 53
1 2 3a 4 5 6 7 8 9 10 11 12a 13a 14a 15
Ovarian Cervical Cervical Cervical Cervical Cervical Rectal Cervical Cervical Vulvar Cervical Vaginal Cervical Cervical Cervical
Primary cancer Fistula repair Total exent. Total exent. Total exent. Ant. exent. Total exent. Post. exent. Total exent. Total exent. Groin recon. Total exent. Total exent. Total exent. Ant. exent. Total exent.
Procedure None None Dehiscence None None None None None None None None Flap necrosis Flap necrosis Flap necrosis None
Wound/flap morbidity 22 30 40 22 30 25 27 26 23 22 31 22 38 29 26
Quetelet index 0 10 75 0 5 75 45 40 30 10 10 70 60 0 0
Smoking (pack/years) 1 2 0 1 1 2 1 0 3 1 0 0 4 0 1
Midline incisions
Follow-up (months) 49 44 38 37 35 22 13 15 2 7 11 17 9 19 9
Radiation IP 32P TT/BT TT/BT TT/BT TT/BT TT/BT None TT/BT TT/BT TT TT/BT TT/BT TT/BT TT/BT TT/BT
NED NED NED NED NED NED NED DOD DID DOD DOD NED DOD NED NED
Current status
Note. All patients underwent vaginal reconstruction with a vertically oriented rectus abdominis myocutaneous flap. A small pudendal flap was also used on patients 2 and 3. a, Patients presented in detail in manuscript; VRAM, vertically oriented rectus abdominis myocutaneous flap; NED, no evidence of disease; DOD, dead of disease; DID, dead of intercurrent disease; IP, intraperitoneal 32P; TT, teletherapy; BT, brachytherapy.
Age
Case No.
Risk factors for flap necrosis
TABLE 1 Summary of Rectus Abdominis Myocutaneous Flap Patients
366 CARLSON ET AL.
RECONSTRUCTION WITH A RECTUS FLAP: AN UPDATE
these patients had received some form of radiation. None of these patients had diabetes. DISCUSSION
The rectus abdominis myocutaneous flap has been a reliable alternative for successful pelvic, inguinal, and vaginal reconstruction [1–5, 7–10]. A major advantage attributed to pelvic reconstruction is the reduction of postoperative complications [11–13]. The risk of intestinal fistulization is reduced from 16 to 5% [12, 13]. Healing may be improved through the neovascularization provided by the vitalized tissue brought into the pelvis. The long vascular pedicle of the rectus-based flap gives it versatility to be used to close defects of the groin as in case 10. The rectus flap has been previously reported to be used for inguinal, vulvar, or vaginal reconstruction [3–5]. Alternatively, the rectus muscle with an attached flap of peritoneum and no cutaneous portion may be mobilized for intra-abdominal, endopelvic, or vaginal procedures [14, 15]. However, the potential benefits of these reconstructive procedures must be weighed against the potential risks of the morbidity related to the mobilization of the flap in certain patient populations. The incidence of flap necrosis in this series was similar to the 20–25% necrosis rate reported with a unilateral rectus flap mobilized for breast reconstruction [16, 17]. It is the authors’ opinion that the flap loss in this series was not related to flap size but to confounding variables that predisposed to compromised flap perfusion. The assessment of risk factors for flap necrosis begins preoperatively with a focused review of systems including a smoking history and signs and symptoms of peripheral vascular disease. The most tragic complication in this series was a leg amputation in case 12 as a possible result of transecting the epigastric vessels. It is probable that this patient was perfusing her right leg by retrograde flow through the inferior epigastric vessels as was identified on the left side by postoperative arteriogram. This collateral flow was interrupted when the superior epigastric vessels were transected during flap mobilization. Unlike the short gracilis that maintains perfusion despite the transection of its vascular pedicle, the rectus abdominis myocutaneous flap appears dependent on an intact vascular bundle [15]. As a result of multiple midline incisions in case 13, not only had the inferior epigastric vessels been previously transected, but the rectus muscle had been damaged as well. In this patient, the vaginal reconstruction was completed suspecting that the VRAM flap was at increased risk for loss. In the event that a portion required debridement, the flap would still prevent the bowel from prolapsing into the true pelvis. The potential for a functional vagina exists even if the cutaneous and subcutaneous portions of the flap are either partially or completely necrosed. Similar to the experience with the gracilis flap, patients who had rectus
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flap necrosis required extensive local wound care [15]. Granulation and epithelialization over the remaining rectus muscle did occur when the cavity was maintained with a vaginal mold. Previous operative reports on patients with abdominal incisions should be reviewed when planning to use a VRAM flap. An absolute contraindication for a rectus abdominis myocutaneous flap is a previous Maylard or Cherney incision with their potential for transection of the inferior epigastric vessels. Any paramedian incision has likely traumatized the rectus muscle or damaged the epigastric vessels. Prior to making a skin incision for the rectus flap, transperitoneal palpation below the arcuate line may assess the integrity of the vascular bundle and the muscle belly. The contralateral side should be palpated for comparison. Pelvic radiotherapy has not been a contraindication to performing a rectus myocutaneous flap. However, the current series may have been too small to assess the role that radiation may have in causing flap necrosis. Obesity is a relative contraindication to performing a rectus-based flap as the flap may be too thick to fit into the pelvic space. Placing a myocutaneous flap into the pelvis under traction from the perineal side may shear the subcutaneous tissue off the rectus sheath and disrupt its vascular supply. The vascular supply to the flap is optimal if the vascular tube is folded so that the rectus muscle belly is in the transverse plane, perpendicular to the vagina. When folded with the muscle fibers in the same plane as the vagina, the perineal traction may more easily shear muscle fibers and further devascularize the edges. The incidence of complications in this series increased as the QI increased. Similar to some laparoscopic recommendations, a QI less than 30 may reduce the incidence of flap complications in the obese patient. Abdominal closure without undue tension becomes difficult in both obese and extremely thin patients. The patient with the greatest QI in this series had a fascial wound dehiscence. Marlex mesh was used in two patients, although their weight was not felt to be a factor. One patient had a large incisional hernia and in the other the anterior rectus sheath was transected close to the right costal margin and mobilization for closure would have required excessive incisional tension. CONCLUSION
The rectus abdominis myocutaneous flap has been established as a versatile option for gynecologic reconstructions. The preoperative identification of risk factors for flap loss will improve perioperative counseling and management. Maintaining the integrity of the vascular pedicle appeared to be critical to this flap’s viability and success. REFERENCES 1. Carlson, J. W., Soisson, A. P., Fowler, J. M., Carter, J. R., Twiggs, L. B., and Carson, L. F. Rectus abdominis myocutaneous flap for primary vaginal reconstruction, Gynecol. Oncol. 51, 323–329 (1993).
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2. Tobin, G. R., and Day, T. G. Vaginal and pelvic reconstruction with distally based rectus abdominis myocutaneous flaps, Plast. Reconstr. Surg. 81, 62–70 (1988). 3. Skene, A. I., Gault, D. T., Woodhouse, C. R. J., Breach, N. M., and Thomas, J. M. Perineal, vulvar and vaginoperineal reconstruction using the rectus abdominis myocutaneous flap, Br. J. Surg. 77, 635–637 (1990).
11.
12.
4. Shepherd, J. H., Van Dam, P. A., Jobling, T. W., and Breach, N. The use of rectus abdominis myocutaneous flaps following excision of vulvar cancer, Br. J. Obstet. Gynaecol. 97, 1020–1025 (1990).
13.
5. Mechaca, A., Akhyat, M., Gleicher, N., Gottlieb, L., and Bernstein, J. The rectus abdominis muscle flap in a combined abdominovaginal repair of difficult vesicovaginal fistulae, J. Reprod. Med. 35, 565–568 (1990).
14.
6. Khosla, I., and Lowe, C. R. Indices of obesity derived from body weight and height, Br. J. Prev. Soc. Med. 21, 122–128 (1967). 7. McCraw, J., Kemp, G., Given, F., and Horton, C. Correction of high pelvic defects with the inferiorly based rectus abdominis myocutaneous flap, Genitourin. Surg. 15, 449–454 (1988). 8. Taylor, G. I., Corlett, R. J., and Boyd, J. B. The versatile deep inferior epigastric (inferior rectus abdominis) flap, Br. J. Plast. Surg. 37, 330– 350 (1984). 9. Lilford, R. J., Johnson, N., and Batchelor, A. A new operation for vaginal agenesis: Construction of a neo-vagina from a rectus abdominis musculo-cutaneous flap, Br. J. Obstet. Gynecol. 96, 1089–1094 (1989). 10. Pursell, S. H., Day, T. G., and Tobin, G. R. Distally based rectus
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15.
16.
17.
abdominis flaps for reconstruction in radical gynecologic procedures, Gynecol. Oncol. 37, 234–238 (1990). Soper, J. T., Berchuck, A., Creasman, W. T., and Clarke-Pearson, D. L. Pelvic exenteration: Factors associated with major surgical morbidity, Gynecol. Oncol. 35, 93–98 (1989). Rutledge, F. N., Smith, J. P., Wharton, J. T., and O’Quinn, A. G. Pelvic exenteration: Analysis of 296 patients, Am. J. Obstet. Gynecol. 129, 881–890 (1977). Miller, B., Morris, M., Gershenson, D. M., Levenback, C. L., Burke, T. W. Intestinal fistulae formation following pelvic exenteration: A review of the University of Texas M. D. Anderson cancer center experience, Gynecol. Oncol. 56, 207–210 (1995). Hockel, M., and Knapstein, P. G. The combined operative and radiotherapeutic treatment (CORT) of recurrent tumors infiltrating the pelvic wall: First experience with 18 patients, Gynecol. Oncol. 46, 20–28 (1992). Soper, J. T., Rodriguez, G., Berchuck, A., and Clarke-Pearson, D. L. Long and short gracilis myocutaneous flaps for vulvovaginal reconstruction after radical pelvic surgery: Comparison of flap-specific complications, Gynecol. Oncol. 56, 271–275 (1995). Jacobsen, W. M., Meland, N. B., and Woods, J. E. Autologous breast reconstruction with use of transverse rectus abdominis musculocutaneous flap: Mayo clinic experience with 147 cases, Mayo Clin. Proc. 69, 635–640 (1994). Shrotria, S., Webster, D. J., Mansel, R. E., and Hughes, L. E. Complications of rectus abdominis myocutaneous flaps in breast surgery, Eur. J. Surg. Oncol. 19, 80–83 (1993).
AP: Gyn Onc
61, 364–368 (1996)
0157
Gynecologic Reconstruction with a Rectus Abdominis Myocutaneous Flap: An Update1 JAY W. CARLSON,2 JONATHAN R. CARTER, ANDREW K. SALTZMAN, LINDA F. CARSON, JEFFREY M. FOWLER, AND LEO B. TWIGGS Women’s Cancer Center, Department of Obstetrics and Gynecology, University of Minnesota Hospital and Clinic, Minneapolis, Minnesota 55455 Received July 24, 1995
This series reports the outcomes and significant complications associated with the rectus myocutaneous flap when used for pelvic or inguinal reconstruction in patients with gynecologic cancers. Perioperative variables were retrospectively reviewed to identify social and medical risk factors as well as intraoperative and postoperative complications that predisposed to rectus flap failure. Fifteen patients with gynecologic malignancies underwent reconstructive procedures using a vertically oriented rectus abdominis myocutaneous flap for either vaginal (n Å 14) or inguinal (n Å 1) reconstruction. The patients’ primary cancers were cervical (n Å 11), rectal (n Å 1), ovarian (n Å 1), vulvar (n Å 1), and vaginal (n Å 1). The median age was 50 years. The median follow-up was 17 months. All flaps were mobilized in conjunction with a radical salvage operation. There were no cases of vaginal prolapse and no abdominal wound infections. However, 4 patients (27%) had major postoperative morbidity in this small series. There was one wound dehiscence and three episodes of necrosis of the subcutaneous and cutaneous portions of the flap. All 4 of these patients required additional operative intervention or debridement. Eleven patients had complete healing of the flap. The rectus abdominis myocutaneous flap is a valuable option for gynecologic reconstructive procedures. Perioperative strategies for improving flap viability include the identification of risk factors that may compromise flap perfusions such as prior abdominal incisions, peripheral vascular disease, and obesity. Meticulous surgical technique is required to preserve the vascular pedicle. These strategies may be useful in preoperative counseling, the perioperative evaluation, and the intraoperative management. q 1996 Academic Press, Inc.
INTRODUCTION
The versatility of the rectus abdominis myocutaneous flap allows it to be used for a variety of pelvic reconstructive procedures [1–5]. There are several advantages to using this 1 The opinions contained herein are the views of the authors and are not necessarily the views of the Department of Defense or the United States Army or Navy. 2 To whom reprint requests should be addressed at Dept. of OB/GYN, William Beaumont Army Medical Center, El Paso, TX 79920-5001.
05-02-96 13:37:29
MATERIALS AND METHODS
Between 1991 and 1994, the vertically oriented rectus abdominis myocutaneous (VRAM) flap was preferentially used for vaginal reconstruction performed in conjunction with an operative procedure for salvage therapy for patients with a gynecologic malignancy at the University of Minnesota Women’s Cancer Center. The operative technique used for the mobilization of the rectus myocutaneous flap was similar in each case and has been previously described [1]. The VRAM flap was also mobilized in a similar fashion for inguinal reconstruction. Records were reviewed retrospectively for pertinent social and medical history, including pertinent intraoperative and postoperative complications.
364
0090-8258/96 $18.00 Copyright q 1996 by Academic Press, Inc. All rights of reproduction in any form reserved.
/ 6d0c$$4316
flap over other myocutaneous flaps described for gynecologic reconstruction. The most significant is that it has a long vascular pedicle that allows it to be mobilized to virtually anywhere on the vulva or groin or in the pelvis. This flap may easily be incorporated into the midline incision. The Women’s Cancer Center’s initial experience with a rectus abdominis myocutaneous flap for vaginal construction involved seven patients [1]. In that report, both the vertically and the transversely oriented rectus abdominis myocutaneous flaps were used. The procedures were performed at two institutions. The significant complication in that preliminary report was a single wound dehiscence. This report reviews the surgical technique and the clinical outcome of patients who had the vaginal reconstruction using a VRAM flap at a single institution. Unfortunately, there has been considerable flap-related morbidity and flap necrosis observed in some of the more recent patients in whom this flap was used. The objective of this report was to review the outcomes, complications, and morbidity associated with the vertically oriented rectus abdominis myocutaneous flap during reconstructive procedures in gynecologic oncology. Preoperative risk factors and strategies for preventing flap morbidity are also reviewed.
goa
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RECONSTRUCTION WITH A RECTUS FLAP: AN UPDATE
The Quetelet Index (QI) was calculated from the patients’ height in meters and weight in kilograms using the technique previously described [6]. Follow-up was calculated to date of most recent clinic contact or death. Each procedure was performed through a midline vertical skin incision. The right inferior epigastric vessels and rectus abdominis muscle were utilized for all flaps. While mobilizing the VRAM flap, the epigastric vessels were visualized on the posterior aspects of muscle belly. Meticulous surgical technique was used to maintain the integrity of the inferior epigastric vessels as the superior epigastric vessels were divided. When mobilizing the flap for inguinal reconstruction, the contralateral myocutaneous flap was electively utilized. The flap and vascular pedicle were tunneled under the skin to the area of the inguinal ligament and secured to the surrounding skin. Abdominal incisions were closed with delayed absorbable monofilament or permanent monofilament suture. Marlex mesh was used to close the fascial if excessive incisional tension was present. All patients had closed suction drains used in the pelvis. RESULTS
Fifteen patients with an advanced or recurrent gynecologic malignancy underwent a reconstructive procedure using a vertically oriented rectus abdominis myocutaneous flap as part of a radical salvage operation. The median age of the patients was 50 years. The median follow-up was 17 months. The VRAM flap was used for vaginal (n Å 14) or inguinal (n Å 1) reconstruction. The patients’ primary cancers were cervical (n Å 11), rectal (n Å 1), ovarian (n Å 1), vulvar (n Å 1), and vaginal (n Å 1). The VRAM flap was mobilized for vaginal reconstruction in conjunction with a total exenteration (n Å 10), an anterior exenteration (n Å 2), a posterior exenteration (n Å 1), an enterovaginal fistulae repair (n Å 1), and an inguinal reconstruction (n Å 1). There were no cases of vaginal prolapse and no abdominal wound infections. There were four patients (27%) with major postoperative morbidity (Table 1). The first patient, case 3, was a 42year-old with a QI of 40 who had an infraumbilical fascial dehiscence on the 7th postoperative day. The supraumbilical fascia, where the flap was mobilized, was intact. This patient was also presented in the initial series. Three patients had necrosis of a significant portion of their flaps. One of these also had a disruption of the vascular supply to her right leg. These three patients required surgical debridement of the entire subcutaneous and cutaneous portions of the flap. The debridements occurred at Postoperative Days 17, 36, and 45. Each of these patients had medical and surgical risk factors for their flap morbidity that will be reviewed in more detail below. Case 12 was a 52-year-old with a 70-pack-year history of
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smoking and a QI of 29 who had a recurrent cervical cancer treated with a total exenteration. There were no intraoperative complications. On the 4th postoperative day she developed a compartment syndrome of the right lower leg. The symptoms of decreased perfusion to the leg progressed. On the 6th postoperative day, she required a right above-theknee amputation. After the amputation, a necrotic ulcer developed on the left heel. An arteriogram revealed that the patient had a complete occlusion of the aorta just distal to the renal vessels. Perfusion of the left leg was reestablished through collateral circulation in the inguinal area that included the inferior epigastric vessels. Debridement of her flap was performed on 17th postoperative day. The patient had not had a history of claudication or other evidence of severe peripheral atherosclerotic disease. Case 13 was a 75-year-old with a 60-pack-year history of smoking and a QI of 22 with recurrent vaginal cancer who underwent a supralevator total exenteration. The procedure was complicated by a 20-liter blood loss from the presacral veins. This patient also had four previous midline incisions, including an extraperitoneal staging procedure 2 years earlier. The right inferior epigastric artery had been transected during one of these earlier procedures as it was not visualized during flap mobilization. The rectus muscle had also been traumatized during the previous procedures as it was less than half its normal width. The vaginal reconstruction was completed in the usual fashion. A low colonic anastomosis was performed. The patient developed an anastomotic leak and pelvic abscess. Thirty-six days later, the flap was necrotic and required debridement of the subcutaneous and cutaneous portions. Case 14 was a 44-year-old nonsmoker with a QI of 38 and recurrent squamous carcinoma of the cervix who underwent an anterior pelvic exenteration. As the flap mobilization was being completed, the inferior epigastric artery was transected. The flap was brought into the pelvis with the rectus fibers in the sagittal plane, parallel to the direction of the vaginal tube. All previous flaps were mobilized with the muscle fibers in a transverse plane, perpendicular to the direction of the vaginal tube. The procedure was otherwise uncomplicated. Forty-five days later the patient presented with a malodorous watery vaginal discharge. The flap was necrotic and required debridement. Although flap necrosis was encountered in 3 patients, risk factors for peripheral vascular disease or damage to the rectus vascular pedicle were also present in other patients. Six of the 15 patients had a more than 40-pack-year smoking history. Six patients had at least one prior lower abdominal incision (range 0–4) and 4 had two or more prior lower abdominal incisions. Fourteen of the 15 patients had received some form of radiation. All of the patients who had experienced postoperative morbidity had received radiation. The median QI for patients with complications versus those without complications was 34 and 25, respectively. Fourteen of
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50 51 42 46 47 54 50 62 75 32 41 52 75 44 53
1 2 3a 4 5 6 7 8 9 10 11 12a 13a 14a 15
Ovarian Cervical Cervical Cervical Cervical Cervical Rectal Cervical Cervical Vulvar Cervical Vaginal Cervical Cervical Cervical
Primary cancer Fistula repair Total exent. Total exent. Total exent. Ant. exent. Total exent. Post. exent. Total exent. Total exent. Groin recon. Total exent. Total exent. Total exent. Ant. exent. Total exent.
Procedure None None Dehiscence None None None None None None None None Flap necrosis Flap necrosis Flap necrosis None
Wound/flap morbidity 22 30 40 22 30 25 27 26 23 22 31 22 38 29 26
Quetelet index 0 10 75 0 5 75 45 40 30 10 10 70 60 0 0
Smoking (pack/years) 1 2 0 1 1 2 1 0 3 1 0 0 4 0 1
Midline incisions
Follow-up (months) 49 44 38 37 35 22 13 15 2 7 11 17 9 19 9
Radiation IP 32P TT/BT TT/BT TT/BT TT/BT TT/BT None TT/BT TT/BT TT TT/BT TT/BT TT/BT TT/BT TT/BT
NED NED NED NED NED NED NED DOD DID DOD DOD NED DOD NED NED
Current status
Note. All patients underwent vaginal reconstruction with a vertically oriented rectus abdominis myocutaneous flap. A small pudendal flap was also used on patients 2 and 3. a, Patients presented in detail in manuscript; VRAM, vertically oriented rectus abdominis myocutaneous flap; NED, no evidence of disease; DOD, dead of disease; DID, dead of intercurrent disease; IP, intraperitoneal 32P; TT, teletherapy; BT, brachytherapy.
Age
Case No.
Risk factors for flap necrosis
TABLE 1 Summary of Rectus Abdominis Myocutaneous Flap Patients
366 CARLSON ET AL.
RECONSTRUCTION WITH A RECTUS FLAP: AN UPDATE
these patients had received some form of radiation. None of these patients had diabetes. DISCUSSION
The rectus abdominis myocutaneous flap has been a reliable alternative for successful pelvic, inguinal, and vaginal reconstruction [1–5, 7–10]. A major advantage attributed to pelvic reconstruction is the reduction of postoperative complications [11–13]. The risk of intestinal fistulization is reduced from 16 to 5% [12, 13]. Healing may be improved through the neovascularization provided by the vitalized tissue brought into the pelvis. The long vascular pedicle of the rectus-based flap gives it versatility to be used to close defects of the groin as in case 10. The rectus flap has been previously reported to be used for inguinal, vulvar, or vaginal reconstruction [3–5]. Alternatively, the rectus muscle with an attached flap of peritoneum and no cutaneous portion may be mobilized for intra-abdominal, endopelvic, or vaginal procedures [14, 15]. However, the potential benefits of these reconstructive procedures must be weighed against the potential risks of the morbidity related to the mobilization of the flap in certain patient populations. The incidence of flap necrosis in this series was similar to the 20–25% necrosis rate reported with a unilateral rectus flap mobilized for breast reconstruction [16, 17]. It is the authors’ opinion that the flap loss in this series was not related to flap size but to confounding variables that predisposed to compromised flap perfusion. The assessment of risk factors for flap necrosis begins preoperatively with a focused review of systems including a smoking history and signs and symptoms of peripheral vascular disease. The most tragic complication in this series was a leg amputation in case 12 as a possible result of transecting the epigastric vessels. It is probable that this patient was perfusing her right leg by retrograde flow through the inferior epigastric vessels as was identified on the left side by postoperative arteriogram. This collateral flow was interrupted when the superior epigastric vessels were transected during flap mobilization. Unlike the short gracilis that maintains perfusion despite the transection of its vascular pedicle, the rectus abdominis myocutaneous flap appears dependent on an intact vascular bundle [15]. As a result of multiple midline incisions in case 13, not only had the inferior epigastric vessels been previously transected, but the rectus muscle had been damaged as well. In this patient, the vaginal reconstruction was completed suspecting that the VRAM flap was at increased risk for loss. In the event that a portion required debridement, the flap would still prevent the bowel from prolapsing into the true pelvis. The potential for a functional vagina exists even if the cutaneous and subcutaneous portions of the flap are either partially or completely necrosed. Similar to the experience with the gracilis flap, patients who had rectus
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flap necrosis required extensive local wound care [15]. Granulation and epithelialization over the remaining rectus muscle did occur when the cavity was maintained with a vaginal mold. Previous operative reports on patients with abdominal incisions should be reviewed when planning to use a VRAM flap. An absolute contraindication for a rectus abdominis myocutaneous flap is a previous Maylard or Cherney incision with their potential for transection of the inferior epigastric vessels. Any paramedian incision has likely traumatized the rectus muscle or damaged the epigastric vessels. Prior to making a skin incision for the rectus flap, transperitoneal palpation below the arcuate line may assess the integrity of the vascular bundle and the muscle belly. The contralateral side should be palpated for comparison. Pelvic radiotherapy has not been a contraindication to performing a rectus myocutaneous flap. However, the current series may have been too small to assess the role that radiation may have in causing flap necrosis. Obesity is a relative contraindication to performing a rectus-based flap as the flap may be too thick to fit into the pelvic space. Placing a myocutaneous flap into the pelvis under traction from the perineal side may shear the subcutaneous tissue off the rectus sheath and disrupt its vascular supply. The vascular supply to the flap is optimal if the vascular tube is folded so that the rectus muscle belly is in the transverse plane, perpendicular to the vagina. When folded with the muscle fibers in the same plane as the vagina, the perineal traction may more easily shear muscle fibers and further devascularize the edges. The incidence of complications in this series increased as the QI increased. Similar to some laparoscopic recommendations, a QI less than 30 may reduce the incidence of flap complications in the obese patient. Abdominal closure without undue tension becomes difficult in both obese and extremely thin patients. The patient with the greatest QI in this series had a fascial wound dehiscence. Marlex mesh was used in two patients, although their weight was not felt to be a factor. One patient had a large incisional hernia and in the other the anterior rectus sheath was transected close to the right costal margin and mobilization for closure would have required excessive incisional tension. CONCLUSION
The rectus abdominis myocutaneous flap has been established as a versatile option for gynecologic reconstructions. The preoperative identification of risk factors for flap loss will improve perioperative counseling and management. Maintaining the integrity of the vascular pedicle appeared to be critical to this flap’s viability and success. REFERENCES 1. Carlson, J. W., Soisson, A. P., Fowler, J. M., Carter, J. R., Twiggs, L. B., and Carson, L. F. Rectus abdominis myocutaneous flap for primary vaginal reconstruction, Gynecol. Oncol. 51, 323–329 (1993).
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2. Tobin, G. R., and Day, T. G. Vaginal and pelvic reconstruction with distally based rectus abdominis myocutaneous flaps, Plast. Reconstr. Surg. 81, 62–70 (1988). 3. Skene, A. I., Gault, D. T., Woodhouse, C. R. J., Breach, N. M., and Thomas, J. M. Perineal, vulvar and vaginoperineal reconstruction using the rectus abdominis myocutaneous flap, Br. J. Surg. 77, 635–637 (1990).
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4. Shepherd, J. H., Van Dam, P. A., Jobling, T. W., and Breach, N. The use of rectus abdominis myocutaneous flaps following excision of vulvar cancer, Br. J. Obstet. Gynaecol. 97, 1020–1025 (1990).
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5. Mechaca, A., Akhyat, M., Gleicher, N., Gottlieb, L., and Bernstein, J. The rectus abdominis muscle flap in a combined abdominovaginal repair of difficult vesicovaginal fistulae, J. Reprod. Med. 35, 565–568 (1990).
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6. Khosla, I., and Lowe, C. R. Indices of obesity derived from body weight and height, Br. J. Prev. Soc. Med. 21, 122–128 (1967). 7. McCraw, J., Kemp, G., Given, F., and Horton, C. Correction of high pelvic defects with the inferiorly based rectus abdominis myocutaneous flap, Genitourin. Surg. 15, 449–454 (1988). 8. Taylor, G. I., Corlett, R. J., and Boyd, J. B. The versatile deep inferior epigastric (inferior rectus abdominis) flap, Br. J. Plast. Surg. 37, 330– 350 (1984). 9. Lilford, R. J., Johnson, N., and Batchelor, A. A new operation for vaginal agenesis: Construction of a neo-vagina from a rectus abdominis musculo-cutaneous flap, Br. J. Obstet. Gynecol. 96, 1089–1094 (1989). 10. Pursell, S. H., Day, T. G., and Tobin, G. R. Distally based rectus
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abdominis flaps for reconstruction in radical gynecologic procedures, Gynecol. Oncol. 37, 234–238 (1990). Soper, J. T., Berchuck, A., Creasman, W. T., and Clarke-Pearson, D. L. Pelvic exenteration: Factors associated with major surgical morbidity, Gynecol. Oncol. 35, 93–98 (1989). Rutledge, F. N., Smith, J. P., Wharton, J. T., and O’Quinn, A. G. Pelvic exenteration: Analysis of 296 patients, Am. J. Obstet. Gynecol. 129, 881–890 (1977). Miller, B., Morris, M., Gershenson, D. M., Levenback, C. L., Burke, T. W. Intestinal fistulae formation following pelvic exenteration: A review of the University of Texas M. D. Anderson cancer center experience, Gynecol. Oncol. 56, 207–210 (1995). Hockel, M., and Knapstein, P. G. The combined operative and radiotherapeutic treatment (CORT) of recurrent tumors infiltrating the pelvic wall: First experience with 18 patients, Gynecol. Oncol. 46, 20–28 (1992). Soper, J. T., Rodriguez, G., Berchuck, A., and Clarke-Pearson, D. L. Long and short gracilis myocutaneous flaps for vulvovaginal reconstruction after radical pelvic surgery: Comparison of flap-specific complications, Gynecol. Oncol. 56, 271–275 (1995). Jacobsen, W. M., Meland, N. B., and Woods, J. E. Autologous breast reconstruction with use of transverse rectus abdominis musculocutaneous flap: Mayo clinic experience with 147 cases, Mayo Clin. Proc. 69, 635–640 (1994). Shrotria, S., Webster, D. J., Mansel, R. E., and Hughes, L. E. Complications of rectus abdominis myocutaneous flaps in breast surgery, Eur. J. Surg. Oncol. 19, 80–83 (1993).
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