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Reconstruction of the Abdomen and Perineum in Cancer Surgery
PLASTIC SURGICAL RECONSTRUCTION: POSSIBILITIES IN SURGICAL ONCOLOGY I1
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RECONSTRUCTION OF THE ABDOMEN AND PERINEUM IN CANCER SURGERY R. Jobe Fix, MD, Sarvam P. TerKonda, MD, John Zinsser, MD, and Luis 0. Vasconez, MD
The treatment of extensive malignant tumors, particularly in the trunk and perineum, entails the institution of a multimodality therapy that includes chemotherapy, surgery, and radiation therapy. Surgical challenges of extirpation of postradiation, persistent, and recurrent tumors in the abdominal wall, groin, or perineum are matched by the necessity and the imperativeness of performing an appropriate and safe and reliable reconstruction. It is essential that the reconstructive surgeon have considerable knowledge on the treatment of radiation wounds as well as a multitude of reconstructive methods that is appropriate for any defect created after the extirpation of the tumor. The extirpation of the tumor and the reconstruction of the defect should be considered separately. At no time is it justifiable to sacrifice the extirpation to facilitate the reconstruction. We briefly describe the principles of treatment of radiation wounds and, subsequently, the methods of reconstruction available.
From the Division of Plastic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
SURGICAL ONCOLOGY CLINICS O F NORTH AMERICA
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VOLUME 6 NUMBER 1 JANUARY 1997
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PRINCIPLES OF TREATMENT OF POSTRADIATION WOUNDS OR DEFECTS
Although radiation therapy has advanced considerably with the delivery of high dosages of ionizing radiation to the site of the tumor and sparing the overlying skin as well as the intervening structures, we still see a number of patients with postradiation ulcers in the trunk and perineum. Obviously, there is no sparing of the skin when one is treating a tumor recurrence at the skin level. The principles that we have found clinically applicable to the management of these problems are as follows: 1. Biopsies of ulcerations in a postradiation field, although helpful, are not always reliable. Frequently, the pathologist indicates that a radiation ulcer tumor cannot be ruled out. In any event, the appropriate treatment involves wide removal of the ulceration and the entire field of radiation. The pathologist then completes a definitive report after complete excision. 2. When dealing with a postradiation persistent and recurrent tumor, we find it essential that one not only remove the tumor with adequate margins but also resect the complete field of radiation surrounding the recurrent tumor. That is, one should excise not only the site of the tumor or ulceration but also the entire radiation area that is recognized by the hyperpigmentation of the skin, the lack of skin appendages, and if longstanding, the appearance of skin telangiectasia. If one excises only the tumor and leaves irradiated skin in the defect, it is less likely for the reconstructed flap to adhere and heal to the remaining radiated skin margins. 3. After the wide extirpation of the ulceration and the entire portal of radiation, reconstruction should be undertaken immediately using a flap that brings in its own blood supply, preferably with muscle or omentum or both. The muscle can have overlying skin (musculocutaneous flap), whereas the omentum can be covered with a skin graft. 4. If no appropriate, reliable, adjacent muscle or omentum can be transposed to cover the defect, one immediately should resort to the use of a free flap, whether of omentum or muscle. 5. In dealing with postradiation wounds, the so-called reconstructive ladder does not apply. One should avoid what appears to be a simpler method and instead use the most effective and most reliable method, although it may be technically challenging, such as a free flap. Nonadherence to this precept is likely to result in failure of the reconstruction in a patient who will be further debilitated by surgical exercises and failures.
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6. Parenteral nutrition as well as additional oxygenation by nasal cannula are important adjuncts in the management of these difficult patients. 7. It is essential that one wait a minimum of 6 to 12 weeks after the completion of irradiation before undertaking extirpative surgery and reconstruction. The effects of radiation on the patient continue for a minimum of 6 weeks; therefore, allowing a recovery period for the patient to regain strength and maintain a positive nitrogen balance is necessary. 8. Although successful operations have been performed in the patient who has just completed chemotherapy, one should be conscious of observing the white blood cell count. Before undertaking a major operative procedure, the leukocyte count should return to normal levels.
CANCERS INVOLVING THE TRUNK AND PERINEUM
Challenging tumors of the trunk and perineum that require reconstruction include the following carcinoma^.^,^
Carcinoma of the Abdominal Wall
Extensive and persistent or recurrent tumors involving the right colon and occasionally the left colon often perforate and present as large fungating masses involving the abdominal wall. Management of these tumors requires a massive en bloc type of excision of the abdominal wall, creating full-thickness defects that require immediate reconstruction. As outlined later, the flap of choice for these defects is a rectus femoris myocutaneous flap. Alternative flaps include the contralateral rectus abdominis myocutaneous flap, groin flap, and tensor fascia lata flap.
Carcinoma of the Prostate
Patients with extensive carcinomas of the prostate often receive external radiation and present with postradiation ulcerations in the buttocks and sacrum. This is a debilitating condition in which the patient is unable to sit, sometimes has difficulty walking, and suffers with considerable pain. The treatment for these problems is the V-Y advancement flap of the gluteus maximus.
Carcinoma of the Anus and Rectum
More recently, preoperative or postoperative irradiation has been advocated for a better cure rate of large carcinomas of the anus and the rectum. Although radiation is successful in the treatment of the cancer, radiation injury to the perineum often results in ulceration and pain. Extensive postradiation ulceration or tumor recurrence requires wide resections, including the perineum. The flap of choice is a V-Y type of advancement of the gluteus maximus myocutaneous flaps or a transpelvic rectus abdominis myocutaneous flap. This has been a salvation for these challenging problems that, in the past, appeared to have almost no solution.
Carcinoma of the Uterus and Cervix
Patients with extensive carcinomas of the uterus and cervix undergo pelvic exenteration through an anterior or posterior approach. These patients are treated either preoperatively or postoperatively with irradiation and are likely to present with radiation ulcerations at the level of the pubis and along the sacrum. For the sacrum, the same V-Y gluteus maximus flaps can be used, but for the pubic region, the rectus femoris flap is the most appropriate.
Carcinoma of the Vulva
Extensive carcinomas of the vulva also are treated with radiation and surgery. This treatment is often accompanied by bilateral external inguinal node dissections. Large defects are thus created and require complete coverage with a myocutaneous flap. The flap of choice is the rectus femoris flap, either unilateral or bilateral. Alternatively, the gracilis muscle or myocutaneous flap can be used.
APPLICABLE FLAPS FOR THE RECONSTRUCTION OF THE TRUNK AND PERINEUM
The most common and reliable flaps that we have indicated for the reconstruction of these large, challenging defects are the rectus femoris myocutaneous flaps, the tensor fascia lata flap (which is used less often), the V-Y advancement of the gluteus maximus flaps, and occasionally, the rectus abdominis myocutaneous flap, either inferiorly based or supeWe - ~also should indicate that tissue expansion and free riorly b a ~ e d . ~
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flaps always should be part of the reconstructive surgeon's armamentarium. As indicated earlier, when no appropriate local flap is available, one should not hesitate to use a free flap. The indications as well as arc of rotation of the different flaps are as follows.
Rectus Femoris Flap
The rectus femoris flap is the most reliable and appropriate method for reconstruction of the defects of the lower abdominal wall, the pubis, and the groin.This is in preference to the tensor fascia lata flap, which was initially advocated as the most likely method for the reconstruction of the previously mentioned defects. We prefer the rectus femoris flap over the tensor fascia lata because the rectus femoris flap has an underlying muscle that is appropriate treatment for postradiation wounds. The rectus femoris flap has a greater vertical dimension and a wider arc of rotation than the tensor fascia lata flap. The muscle pivots at the anterior thigh, allowing the rectus femoris flap to extend past the midline across the pubis and above the umbilicus of the ipsilateral abdominal wall. In contrast, the tensor fascia lata, which comes from the lateral aspect of the thigh, has a shorter arc of rotation and a minimal amount of muscle. Clinical experience also has demonstrated that the distal third of the tensor fascia lata flap is often unreliable. Anatomy of the Rectus Femoris Flap
The rectus femoris muscle, which is supplied by the descending branch of the lateral circumflex femoral artery, originates from the anterior superior iliac spine and upper portion of the acetabulum (Fig. 1).The two heads of the muscle then conjoin and insert into the patellar tendon to form a portion of the quadriceps mechanism. The single major vascular pedicle to the muscle is sufficient to supply the entire length of the muscle. However, three to four musculocutaneous perforators arise in the proximal portion of the muscle and supply the overlying skin. This flap can be used as a single musculocutaneous unit or separated into a fasciocutaneous unit comprised of skin and fascia and the underlying muscle. Consequently, if the reconstructive objective necessitates, the fasciocutaneous unit and the underlying muscle can be rotated in separate directions without sacrificing the safety or viability of either unit. The rectus femoris musculocutaneous flap can be converted into an island flap by dividing its origin at the anterior iliac spine. Similarly, the overlying skin and fascia can be divided into an island fasciocutaneous
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Lateral circumflex femoral a.
Figure 1. The rectus femoris muscle is located within the anterior thigh and supplied by the descending branch of the lateral circumflex femoral artery (left side). The fasciocutaneous flap is supplied from a true musculocutaneous perforator located proximally (right side). (From Vasconez LO, McCraw JB, Camargos AG: Muscle, musculocutaneous, and fasciocutaneous flaps. In Smith JW, Aston SJ (eds): Grabb and Smith's Plastic Surgery, ed 4. Philadelphia, Lippincott-Raven Publishers, 1991, pp 1113-1 141; with permission.)
flap through division of the overlying skin down to the fascia as long as one maintains the true musculocutaneous perforator of the flap. Technique
Defects of the lower abdominal wall of the pubis and groin are reconstructed easily with rectus femoris rnusculocutaneous flaps. The skin island is located centrally over the muscle; one should be careful to preserve the proximal musculocutaneous perforators. The skin flap can be designed as large as 15 x 40 cm. The lateral and medial margins of the skin are incised through the level of the fascia. The rectus femoris muscle is then identified as the most anterior muscle of the quadriceps group. The rnusculocutaneous flap is then elevated from a distal to a proximal direction, and one should be careful that the dominant pedicle that lies approximately 8 cm below the level of the inguinal ligament is preserved. Subsequently, the rectus femoris musculocutaneous flaps can be rotated to the trochanteric region, perineum, groin, or lower abdominal wall. Preservation of the distal 6 cm of the patellar tendon allows for recentralization of the vastus medialis and lateralis muscles, which is important to prevent the loss of strength and terminal extension of
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the knee.5The donor defect can be closed primarily, or if necessary, with a skin graft (Figs. 2 and 3).
Tensor Fascia Lata The tensor fascia lata flap is located at the lateral thigh and is supplied by a branch of the lateral femoral circumflex artery. It has only a small segment of muscle at the most proximal third of the flap, and the muscle itself is extended by a long and thickened fascia that inserts into the lateral aspect of the knee. Because of its lateral location, the arc of rotation of this flap is much more restricted for reconstructions of the abdominal wall and the groin. The tensor fascia lata flap can be used for defects of ischium, lower abdomen, and chest wall margin if raised as an island flap.' The lack of muscle throughout the length of the flap is detrimental to the treatment of postradiation wounds. Although initially advocated for reconstruction of defects in the abdominal wall as well as the groin, the tensor fascia lata is secondary to the rectus femoris as a choice for reconstruction. Anatomy
The tensor fascia lata lies between the gluteus medius and sartorius muscles. The muscle originates from the anterior superior iliac spine and the greater trochanter of the femur. The fascia lata extension then inserts into the lateral aspect of the knee as a lateral knee stabilizer. The musculocutaneous flap is supplied by the transverse branch of the lateral femoral circumflex artery. The artery enters the muscle approximately 6 to 8 cm from the anterior superior iliac spine (Fig. 4). Technique
The skin island is based proximally and lies in a line drawn from the greater trochanter distally to the head of the fibula. The distal extent of the skin territory is approximately 8 cm above the lateral femoral condyle. Dissection of the flap involves incisions made through the skin, subcutaneous tissues, and fascia lata. Elevation of the flap begins distally after identification of the fascia lata and proceeds to the proximal tensor fascia lata muscle. The dissection plane is deep to the fascia lata overlying the vastus lateralis. After identification of the vascular pedicle, the origin of the tensor fascia lata can be divided free from the iliac crest. At this point, the tensor fascia lata musculocutaneous flap can be rotated into the desired position. Although the tensor fascia lata donor site can
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Figure 2. See legend on opposite page
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be closed primarily if the flap is no more than 10 cm wide, larger flap designs require closure with split-thickness skin grafts (Fig. 5). V-Y Advancement of the Gluteus Maximus
The gluteus maximus muscle has been a significant and important contribution for the coverage of defects in the perineum as well as postradiation ulcers in the sacrum. The excellent vascular supply to the gluteus maximus permits versatility in flap design as well as promotes primary healing of radiated wounds. The gluteus muscle alone or with skin has been used extensively for coverage of postradiation ulcers of the sacrum or ischium. Although the gluteus maximus myocutaneous flap can be used as a rotational flap, bilateral flaps are more commonly utilized as V-Y advancement flaps. Anatomy
The gluteus maximus muscle is supplied by the superior and inferior gluteal arteries that arise from the internal iliac vessels (Fig. 6). The inferior gluteal artery is the dominant vascular pedicle; however, extensive vascular interconnections allow the gluteus maximus muscle to be based on either vessel. Multiple musculocutaneous perforators supply the overlying skin. The gluteal arteries are relatively short in length and, consequently, there is minimal or no arc of rotation with this muscle. However, it is most effective when it is used bilaterally as an advancement flap in the form of a V-Y. Most large sacral wounds can be closed with bilateral V-Y myocutaneous flaps without division. The gluteus maximus muscle originates from the posterior gluteal line of the ilium as well as the lateral margins of the sacrum and coccyx. Passing anteriorly, the muscle inserts into the greater trochanter and extensively into the iliotibial tract. The gluteus maximus muscle is the primary extender and abductor of the hip. Technique
After the extirpation of the tumor or ulceration in the sacrum or the perineum, large sacral defects are closed by approximating the origins
Figure 2. A, Postradiation, recurrent squamous cell carcinoma involving lower abdomen and vulva. B, Postsurgical defect following radical excision of lower abdomen and vulva. C, Bilateral rectus femoris flaps following transposition into abdominal defect and separation into fasciocutaneous units and underlying muscular units. D, Postoperative appearance of bilateral rectus femoris flaps.
Figure 3. See legend on opposite page
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Figure 3 (Continued). A, This 57-year-old female had a vesicocutaneous fistula in an irradiated suprapubic wound following resection of uterine carcinoma, postradiation therapy, and repair of incisional hernia in the midline with Marlex mesh. Two years after the hernia repair the patient developed an area of induration with persistent, purulent drainage along this sinus tract. 13, Entire area of radiation-damaged skin. Marlex mesh was excised, uncovering a granulated tract that communicated with the urinary bladder. This vesicocutaneous fistula was resected, and the bladder was repaired. The lower abdominal wall defect measured 12 cm in diameter. C, An 11-cm-wide rectus femoris myocutaneous flap was designed on the right thigh. D, Note the entrance of the vascular pedicle into the muscle, 10 cm below the inguinal ligament. E, The transposed flap and the resultant donor defect of the right thigh. F, Inset flap. The donor site is closed by repairing the vastus lateralis to the vastus medialis and closing the skin primarily by advancing the lateral and medial skin edges. G, Two months postoperative appearance with no recurrence of fistula.
of the gluteus maximus muscles along the midline of the defect. Initially, V-type incisions are placed on the overlying skin bilaterally. The skin flaps are elevated superiorly above the iliac crest and inferiorly to the level of the greater trochanter and ischium. After elevation of the skin islands, dissection begins superiorly at the level of the iliac crest, identifying the gluteus maximus from the underlying gluteus medias muscles. Identification is facilitated by noting the transverse direction and quality of the fibers of the gluteus maximus. Dissection continues toward the midline, dividing the origin of the gluteus muscles from the sacrum. Inferomedial dissection of the gluteus maximus along the origin allows identification of the piriform muscle and preservation of the sciatic nerve. As the dissection proceeds laterally, one should identify the superior as well as the inferior gluteal arteries. Complete release from the midline is required for adequate mobilization of the myocutaneous flap. Further mobilization of the flap may be obtained by division of the
circumflex femoral a.
Figure 4. The tensor fascia lata is located at the lateral thigh and supplied by a branch of the lateral femoral circumflex artery. (From Vasconez LO, McCraw JB, Camargos AG: Muscle, musculocutaneous, and fasciocutaneous flaps. In Smith JW, Aston SJ (eds): Grabb and Smith's Plastic Surgery, ed 4. Philadelphia, Lippincott-Raven Publishers, 1991, pp 1113-1 141; with permission.)
insertion of the gluteus maximus into the trochanter. Bilateral mobilization allows closure of the defect at the midline of the defect with interrupted nylon or proline sutures. The overlying skin that has been maintained over the muscle is fairly mobile and easily reapproximated to the contralateral skin flap. Because of the difficult anatomy and often bloody dissection, it is advised that the operative surgeon perform this dissection on a cadaver prior to undertaking this procedure.
Rectus Abdominis Muscle Flap
For defects in the groin or along the trochanter, a useful and underutilized flap is the rectus abdominis flag flap. This is the mirror image of the transverse rectus abdominis musculocutaneous (TRAM) flap. Instead of being based on the superior epigastric vessel, it is based on the deep inferior epigastric vessels. The entire rectus abdominis muscle is
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Figure 5. A, Postradiation, recurrent primary squamous cell carcinoma involving left groin and lower abdominal wall. B, Wide excision of tumor and radiation field with exposure of underlying femoral vessels. C, Elevated tensor fascia lata myocutaneous flap transposed into defect. D, Immediate postoperative appearance of transposed tensor fascia flap with split-thickness skin grafting of donor site. (From Grotting JC, Carriquiry C, Vasconez LO: Abdomen. In Jurkiewicz MJ, Krizek TJ, Mathes SJ, et al: Plastic Surgery: Principles and Practice, vol 2. St. Louis, CV Mosby, 1990, pp 1139-1167; with permission.)
Figure 6. The gluteus maximus muscle is supplied by the superior and inferior gluteal arteries. Perforating branches from the gluteal system supply the overlying skin allowing VY advancements without displacement of the underlying muscle. (From Vasconez LO, McCraw JB, Camargos AG: Muscle, musculocutaneous, and fasciocutaneous flaps. In Smith JW, Aston SJ (eds): Grabb and Smith's Plastic Surgery, ed 4. Philadelphia, Lippincott-Raven Publishers, 1991, pp 1113-1 141; with permission.)
harvested with the island of skin designed at the level of the inframammary fold or just inferior, particularly in women. This large flap has a wide arc of rotation to cover defects in the flanks, the trochanters, and the groin and may reach even upper portions of the thigh. It is imperative that after removal of the entire muscle, the remnants of the anterior rectus sheath be reapproximated to avoid a potential weakness or hernia of the abdominal wall. Conversion into an island flap may be accomplished through division of the muscle inferiorly while preserving the deep inferior epigastric vessels. The rectus abdominis muscle alone can be used for reconstructions of the trochanter, groin, or contralateral abdomen. Occasionally, the rectus abdominis myocutaneous flap has been effective for intrapelvic reconstructions of the perineum or vagina if one maintains the overlying skin either transversely or vertically oriented over the muscle. Anatomy
The rectus abdominis is a long, broad strap muscle arising from the fifth, sixth, and seventh costal cartilages and inserting into the crest of the pubic bone. The muscle fibers of the rectus abdominis are interrupted by three tendinous intersections. The rectus abdominis muscle is en-
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closed in the rectus sheath by the anterior and posterior layers. This muscle has a dual dominant blood supply from the superior epigastric artery as well as the deep inferior epigastric artery. The superior epigastric artery is a terminal branch of the internal mammary artery and descends along the posterior surface of the rectus abdominis muscle. The deep inferior epigastric artery arises from the external iliac artery above the level of the inguinal ligament, traverses upward obliquely, and communicates with the terminal branches of the superior epigastric artery. Multiple musculocutaneous perforators supply the overlying skin in the periumbilical region and should be preserved carefully during dissection (Fig. 7). Technique
The design of the flap varies according to the reconstructive defect. Flaps can be designed vertically or transversely or extended laterally at the superior extent of the flap.6 The flap is initially incised through the skin's subcutaneous tissue and the anterior rectus sheath. Approximately 1 cm of the anterior rectus sheath at the lateral and medial margins is left intact. The remainder of the fascia remains with the muscle and flap. The muscle is then raised from the pocket of the rectus sheath beginning laterally. The deep inferior epigastric artery and the superepigastric artery are well defined at the superior and inferior extents of the muscle. The origin of the muscle is divided carefully, and the dissection of the remaining portion of the rectus muscle is carried from a proximal to a distal direction. Approximately 10 cm above the inguinal ligament, the deep inferior epigastric artery is noted to travel obliquely from the external iliac artery toward the midportion of the rectus abdominis muscle. After complete mobilization, the flap is then transposed to the recipient defect. If necessary, the rectus muscle can be divided at the symphysis pubis to create a true musculocutaneous-cutaneous island pedicle flap. The abdominal wall donor defect is closed with careful reapproximation of the anterior rectus sheath. Excessive tension of the donor site may require placement of marlex mesh, primarily below the arcuate line. The mobility of the overlying skin allows primary closure of the donor defect.
Free Flaps
The reconstructive surgeon should be versed on microvascular freetissue reconstruction. If local flaps are not appropriate for the coverage of the defects, it is imperative that a free flap be used. The most commonly used free flaps for reconstruction of the trunk and perineum
Figure 7. A, Preoperative view of 36-year-old male with recurrent spindle cell sarcoma of the right flank. Note the hyperpigmentation from radiation therapy. B, The resulting fullthickness lateral abdominal wall defect measured 8 cm wide by 12 cm long. Abdominal wall integrity was reconstructed with Marlex mesh, sutured to the internal surface of the abdominal wall through the musculofascial layers and posteriorly to the psoas muscles. C, With the patient in the lateral decubitus position, an ipsilateral inferiorly based rectus abdominis myocutaneous flap was designed. D, The flap was elevated, based on the inferior deep epigastric artery and vein. E, The flap is inset. F, A subsequent, local posterior rotation skin flap was necessary in the area of the tip of the flap to fill deep space. G, Four months postoperative, posterior view. H, Four months postoperative, lateral view. Skingrafted donor site of the rectus abdominis muscle is evident.
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Figure 7 (Continued). See legend on opposite page
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are the latissimus dorsi and rectus abdominis muscle or myocutaneous flaps. Description of the microvascular techniques is provided elsewhere.lO,l1 SUMMARY
Trunk and perineal defects after tumor resection present a challenge to the reconstructive surgeon. When primary closure is not possible, the use of well-vascularized autogenous tissue is required to achieve adequate soft-tissue coverage. Pedicled muscle or myocutaneous flaps provide excellent sources of vascularized tissue for postradiation defects. When local tissues preclude the use of pedicled flaps, free-tissue transfers can be performed. A thorough understanding of radiation wounds and the reconstructive options is essential for treatment of these challenging defects. References 1. Bhathen HM, Kavarana NM: One stage reconstruction of extensive abdominal wall defect with bilateral tensor fascia lata flaps. Indian J Cancer 30:10, 1993 2. Bostwick J, Hill HL, Nahai F: Repairs in the lower abdomen, groin, or perineum with myocutaneous or omental flaps. Plast Reconstr Surg 63:186,1979 3. Brown DM, Sicard GA, Flye MW, et al: Closure of complex abdominal wall defects with bilateral rectus femoris flaps with fascia1 extensions. Surgery 114:112, 1992 4. Burns AJ: Trunk reconstruction. Selected Readings in Plastic Surgery 7:14, 1995 5. Caulfield WH, Curtsinger L, Powell G, et al: Donor leg morbidity after pedicled rectus femoris muscle flap transfer for abdominal wall and pelvic reconstruction. Ann Plast Surg 32:377, 1994 6. Cormack GC, Quaba AA: Case report: Bilobe modification of the deep inferior epigastric artery flap for abdominal wall defect reconstruction. Br J Plast Surg 44:541, 1991 7. Grotting JC, Carriquiry C, Vasconez LO: Abdomen. In Jurkiewicz MJ, Krizek TJ, Mathes SJ, et a1 (eds): St. Louis, CV Mosby, 1990, p 1139 8. Horgan K, Ahamed I, Hughes L: How we manage sarcoma of the abdominal wall. Eur J Surg Oncol 20:240, 1994 9. McCraw JB, Arnold PG: McCraw and Arnold's Atlas of Muscle and Musculocutaneous Flaps. Norfolk, Hampton Press, 1986 10. Neven P, Shepherd JH, Tham KF, et al: Case report: Reconstruction of the abdominal wall with a latissimus dorsi musculocutaneous flap: A case of a massive abdominal wall metastasis from a cervical cancer requiring palliative resection. Gynecol Oncol 49:403, 1993 11. Piza H, Rath T, Hausmaniger C, et al: Wound closure at the trunk by microvascular free flap transfer. Microsurgery 14:260, 1993
Address reprint requests to R. Jobe Fix, MD Division of Plastic Surgery University of Alabama at Birmingham 524 Medical Education Building 1813 Sixth Avenue South Birmingham, AL 35294-3295
1055-3207/97 $0.00 + .20
RECONSTRUCTION OF THE ABDOMEN AND PERINEUM IN CANCER SURGERY R. Jobe Fix, MD, Sarvam P. TerKonda, MD, John Zinsser, MD, and Luis 0. Vasconez, MD
The treatment of extensive malignant tumors, particularly in the trunk and perineum, entails the institution of a multimodality therapy that includes chemotherapy, surgery, and radiation therapy. Surgical challenges of extirpation of postradiation, persistent, and recurrent tumors in the abdominal wall, groin, or perineum are matched by the necessity and the imperativeness of performing an appropriate and safe and reliable reconstruction. It is essential that the reconstructive surgeon have considerable knowledge on the treatment of radiation wounds as well as a multitude of reconstructive methods that is appropriate for any defect created after the extirpation of the tumor. The extirpation of the tumor and the reconstruction of the defect should be considered separately. At no time is it justifiable to sacrifice the extirpation to facilitate the reconstruction. We briefly describe the principles of treatment of radiation wounds and, subsequently, the methods of reconstruction available.
From the Division of Plastic Surgery, University of Alabama at Birmingham, Birmingham, Alabama
SURGICAL ONCOLOGY CLINICS O F NORTH AMERICA
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VOLUME 6 NUMBER 1 JANUARY 1997
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PRINCIPLES OF TREATMENT OF POSTRADIATION WOUNDS OR DEFECTS
Although radiation therapy has advanced considerably with the delivery of high dosages of ionizing radiation to the site of the tumor and sparing the overlying skin as well as the intervening structures, we still see a number of patients with postradiation ulcers in the trunk and perineum. Obviously, there is no sparing of the skin when one is treating a tumor recurrence at the skin level. The principles that we have found clinically applicable to the management of these problems are as follows: 1. Biopsies of ulcerations in a postradiation field, although helpful, are not always reliable. Frequently, the pathologist indicates that a radiation ulcer tumor cannot be ruled out. In any event, the appropriate treatment involves wide removal of the ulceration and the entire field of radiation. The pathologist then completes a definitive report after complete excision. 2. When dealing with a postradiation persistent and recurrent tumor, we find it essential that one not only remove the tumor with adequate margins but also resect the complete field of radiation surrounding the recurrent tumor. That is, one should excise not only the site of the tumor or ulceration but also the entire radiation area that is recognized by the hyperpigmentation of the skin, the lack of skin appendages, and if longstanding, the appearance of skin telangiectasia. If one excises only the tumor and leaves irradiated skin in the defect, it is less likely for the reconstructed flap to adhere and heal to the remaining radiated skin margins. 3. After the wide extirpation of the ulceration and the entire portal of radiation, reconstruction should be undertaken immediately using a flap that brings in its own blood supply, preferably with muscle or omentum or both. The muscle can have overlying skin (musculocutaneous flap), whereas the omentum can be covered with a skin graft. 4. If no appropriate, reliable, adjacent muscle or omentum can be transposed to cover the defect, one immediately should resort to the use of a free flap, whether of omentum or muscle. 5. In dealing with postradiation wounds, the so-called reconstructive ladder does not apply. One should avoid what appears to be a simpler method and instead use the most effective and most reliable method, although it may be technically challenging, such as a free flap. Nonadherence to this precept is likely to result in failure of the reconstruction in a patient who will be further debilitated by surgical exercises and failures.
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6. Parenteral nutrition as well as additional oxygenation by nasal cannula are important adjuncts in the management of these difficult patients. 7. It is essential that one wait a minimum of 6 to 12 weeks after the completion of irradiation before undertaking extirpative surgery and reconstruction. The effects of radiation on the patient continue for a minimum of 6 weeks; therefore, allowing a recovery period for the patient to regain strength and maintain a positive nitrogen balance is necessary. 8. Although successful operations have been performed in the patient who has just completed chemotherapy, one should be conscious of observing the white blood cell count. Before undertaking a major operative procedure, the leukocyte count should return to normal levels.
CANCERS INVOLVING THE TRUNK AND PERINEUM
Challenging tumors of the trunk and perineum that require reconstruction include the following carcinoma^.^,^
Carcinoma of the Abdominal Wall
Extensive and persistent or recurrent tumors involving the right colon and occasionally the left colon often perforate and present as large fungating masses involving the abdominal wall. Management of these tumors requires a massive en bloc type of excision of the abdominal wall, creating full-thickness defects that require immediate reconstruction. As outlined later, the flap of choice for these defects is a rectus femoris myocutaneous flap. Alternative flaps include the contralateral rectus abdominis myocutaneous flap, groin flap, and tensor fascia lata flap.
Carcinoma of the Prostate
Patients with extensive carcinomas of the prostate often receive external radiation and present with postradiation ulcerations in the buttocks and sacrum. This is a debilitating condition in which the patient is unable to sit, sometimes has difficulty walking, and suffers with considerable pain. The treatment for these problems is the V-Y advancement flap of the gluteus maximus.
Carcinoma of the Anus and Rectum
More recently, preoperative or postoperative irradiation has been advocated for a better cure rate of large carcinomas of the anus and the rectum. Although radiation is successful in the treatment of the cancer, radiation injury to the perineum often results in ulceration and pain. Extensive postradiation ulceration or tumor recurrence requires wide resections, including the perineum. The flap of choice is a V-Y type of advancement of the gluteus maximus myocutaneous flaps or a transpelvic rectus abdominis myocutaneous flap. This has been a salvation for these challenging problems that, in the past, appeared to have almost no solution.
Carcinoma of the Uterus and Cervix
Patients with extensive carcinomas of the uterus and cervix undergo pelvic exenteration through an anterior or posterior approach. These patients are treated either preoperatively or postoperatively with irradiation and are likely to present with radiation ulcerations at the level of the pubis and along the sacrum. For the sacrum, the same V-Y gluteus maximus flaps can be used, but for the pubic region, the rectus femoris flap is the most appropriate.
Carcinoma of the Vulva
Extensive carcinomas of the vulva also are treated with radiation and surgery. This treatment is often accompanied by bilateral external inguinal node dissections. Large defects are thus created and require complete coverage with a myocutaneous flap. The flap of choice is the rectus femoris flap, either unilateral or bilateral. Alternatively, the gracilis muscle or myocutaneous flap can be used.
APPLICABLE FLAPS FOR THE RECONSTRUCTION OF THE TRUNK AND PERINEUM
The most common and reliable flaps that we have indicated for the reconstruction of these large, challenging defects are the rectus femoris myocutaneous flaps, the tensor fascia lata flap (which is used less often), the V-Y advancement of the gluteus maximus flaps, and occasionally, the rectus abdominis myocutaneous flap, either inferiorly based or supeWe - ~also should indicate that tissue expansion and free riorly b a ~ e d . ~
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flaps always should be part of the reconstructive surgeon's armamentarium. As indicated earlier, when no appropriate local flap is available, one should not hesitate to use a free flap. The indications as well as arc of rotation of the different flaps are as follows.
Rectus Femoris Flap
The rectus femoris flap is the most reliable and appropriate method for reconstruction of the defects of the lower abdominal wall, the pubis, and the groin.This is in preference to the tensor fascia lata flap, which was initially advocated as the most likely method for the reconstruction of the previously mentioned defects. We prefer the rectus femoris flap over the tensor fascia lata because the rectus femoris flap has an underlying muscle that is appropriate treatment for postradiation wounds. The rectus femoris flap has a greater vertical dimension and a wider arc of rotation than the tensor fascia lata flap. The muscle pivots at the anterior thigh, allowing the rectus femoris flap to extend past the midline across the pubis and above the umbilicus of the ipsilateral abdominal wall. In contrast, the tensor fascia lata, which comes from the lateral aspect of the thigh, has a shorter arc of rotation and a minimal amount of muscle. Clinical experience also has demonstrated that the distal third of the tensor fascia lata flap is often unreliable. Anatomy of the Rectus Femoris Flap
The rectus femoris muscle, which is supplied by the descending branch of the lateral circumflex femoral artery, originates from the anterior superior iliac spine and upper portion of the acetabulum (Fig. 1).The two heads of the muscle then conjoin and insert into the patellar tendon to form a portion of the quadriceps mechanism. The single major vascular pedicle to the muscle is sufficient to supply the entire length of the muscle. However, three to four musculocutaneous perforators arise in the proximal portion of the muscle and supply the overlying skin. This flap can be used as a single musculocutaneous unit or separated into a fasciocutaneous unit comprised of skin and fascia and the underlying muscle. Consequently, if the reconstructive objective necessitates, the fasciocutaneous unit and the underlying muscle can be rotated in separate directions without sacrificing the safety or viability of either unit. The rectus femoris musculocutaneous flap can be converted into an island flap by dividing its origin at the anterior iliac spine. Similarly, the overlying skin and fascia can be divided into an island fasciocutaneous
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Lateral circumflex femoral a.
Figure 1. The rectus femoris muscle is located within the anterior thigh and supplied by the descending branch of the lateral circumflex femoral artery (left side). The fasciocutaneous flap is supplied from a true musculocutaneous perforator located proximally (right side). (From Vasconez LO, McCraw JB, Camargos AG: Muscle, musculocutaneous, and fasciocutaneous flaps. In Smith JW, Aston SJ (eds): Grabb and Smith's Plastic Surgery, ed 4. Philadelphia, Lippincott-Raven Publishers, 1991, pp 1113-1 141; with permission.)
flap through division of the overlying skin down to the fascia as long as one maintains the true musculocutaneous perforator of the flap. Technique
Defects of the lower abdominal wall of the pubis and groin are reconstructed easily with rectus femoris rnusculocutaneous flaps. The skin island is located centrally over the muscle; one should be careful to preserve the proximal musculocutaneous perforators. The skin flap can be designed as large as 15 x 40 cm. The lateral and medial margins of the skin are incised through the level of the fascia. The rectus femoris muscle is then identified as the most anterior muscle of the quadriceps group. The rnusculocutaneous flap is then elevated from a distal to a proximal direction, and one should be careful that the dominant pedicle that lies approximately 8 cm below the level of the inguinal ligament is preserved. Subsequently, the rectus femoris musculocutaneous flaps can be rotated to the trochanteric region, perineum, groin, or lower abdominal wall. Preservation of the distal 6 cm of the patellar tendon allows for recentralization of the vastus medialis and lateralis muscles, which is important to prevent the loss of strength and terminal extension of
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the knee.5The donor defect can be closed primarily, or if necessary, with a skin graft (Figs. 2 and 3).
Tensor Fascia Lata The tensor fascia lata flap is located at the lateral thigh and is supplied by a branch of the lateral femoral circumflex artery. It has only a small segment of muscle at the most proximal third of the flap, and the muscle itself is extended by a long and thickened fascia that inserts into the lateral aspect of the knee. Because of its lateral location, the arc of rotation of this flap is much more restricted for reconstructions of the abdominal wall and the groin. The tensor fascia lata flap can be used for defects of ischium, lower abdomen, and chest wall margin if raised as an island flap.' The lack of muscle throughout the length of the flap is detrimental to the treatment of postradiation wounds. Although initially advocated for reconstruction of defects in the abdominal wall as well as the groin, the tensor fascia lata is secondary to the rectus femoris as a choice for reconstruction. Anatomy
The tensor fascia lata lies between the gluteus medius and sartorius muscles. The muscle originates from the anterior superior iliac spine and the greater trochanter of the femur. The fascia lata extension then inserts into the lateral aspect of the knee as a lateral knee stabilizer. The musculocutaneous flap is supplied by the transverse branch of the lateral femoral circumflex artery. The artery enters the muscle approximately 6 to 8 cm from the anterior superior iliac spine (Fig. 4). Technique
The skin island is based proximally and lies in a line drawn from the greater trochanter distally to the head of the fibula. The distal extent of the skin territory is approximately 8 cm above the lateral femoral condyle. Dissection of the flap involves incisions made through the skin, subcutaneous tissues, and fascia lata. Elevation of the flap begins distally after identification of the fascia lata and proceeds to the proximal tensor fascia lata muscle. The dissection plane is deep to the fascia lata overlying the vastus lateralis. After identification of the vascular pedicle, the origin of the tensor fascia lata can be divided free from the iliac crest. At this point, the tensor fascia lata musculocutaneous flap can be rotated into the desired position. Although the tensor fascia lata donor site can
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Figure 2. See legend on opposite page
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be closed primarily if the flap is no more than 10 cm wide, larger flap designs require closure with split-thickness skin grafts (Fig. 5). V-Y Advancement of the Gluteus Maximus
The gluteus maximus muscle has been a significant and important contribution for the coverage of defects in the perineum as well as postradiation ulcers in the sacrum. The excellent vascular supply to the gluteus maximus permits versatility in flap design as well as promotes primary healing of radiated wounds. The gluteus muscle alone or with skin has been used extensively for coverage of postradiation ulcers of the sacrum or ischium. Although the gluteus maximus myocutaneous flap can be used as a rotational flap, bilateral flaps are more commonly utilized as V-Y advancement flaps. Anatomy
The gluteus maximus muscle is supplied by the superior and inferior gluteal arteries that arise from the internal iliac vessels (Fig. 6). The inferior gluteal artery is the dominant vascular pedicle; however, extensive vascular interconnections allow the gluteus maximus muscle to be based on either vessel. Multiple musculocutaneous perforators supply the overlying skin. The gluteal arteries are relatively short in length and, consequently, there is minimal or no arc of rotation with this muscle. However, it is most effective when it is used bilaterally as an advancement flap in the form of a V-Y. Most large sacral wounds can be closed with bilateral V-Y myocutaneous flaps without division. The gluteus maximus muscle originates from the posterior gluteal line of the ilium as well as the lateral margins of the sacrum and coccyx. Passing anteriorly, the muscle inserts into the greater trochanter and extensively into the iliotibial tract. The gluteus maximus muscle is the primary extender and abductor of the hip. Technique
After the extirpation of the tumor or ulceration in the sacrum or the perineum, large sacral defects are closed by approximating the origins
Figure 2. A, Postradiation, recurrent squamous cell carcinoma involving lower abdomen and vulva. B, Postsurgical defect following radical excision of lower abdomen and vulva. C, Bilateral rectus femoris flaps following transposition into abdominal defect and separation into fasciocutaneous units and underlying muscular units. D, Postoperative appearance of bilateral rectus femoris flaps.
Figure 3. See legend on opposite page
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Figure 3 (Continued). A, This 57-year-old female had a vesicocutaneous fistula in an irradiated suprapubic wound following resection of uterine carcinoma, postradiation therapy, and repair of incisional hernia in the midline with Marlex mesh. Two years after the hernia repair the patient developed an area of induration with persistent, purulent drainage along this sinus tract. 13, Entire area of radiation-damaged skin. Marlex mesh was excised, uncovering a granulated tract that communicated with the urinary bladder. This vesicocutaneous fistula was resected, and the bladder was repaired. The lower abdominal wall defect measured 12 cm in diameter. C, An 11-cm-wide rectus femoris myocutaneous flap was designed on the right thigh. D, Note the entrance of the vascular pedicle into the muscle, 10 cm below the inguinal ligament. E, The transposed flap and the resultant donor defect of the right thigh. F, Inset flap. The donor site is closed by repairing the vastus lateralis to the vastus medialis and closing the skin primarily by advancing the lateral and medial skin edges. G, Two months postoperative appearance with no recurrence of fistula.
of the gluteus maximus muscles along the midline of the defect. Initially, V-type incisions are placed on the overlying skin bilaterally. The skin flaps are elevated superiorly above the iliac crest and inferiorly to the level of the greater trochanter and ischium. After elevation of the skin islands, dissection begins superiorly at the level of the iliac crest, identifying the gluteus maximus from the underlying gluteus medias muscles. Identification is facilitated by noting the transverse direction and quality of the fibers of the gluteus maximus. Dissection continues toward the midline, dividing the origin of the gluteus muscles from the sacrum. Inferomedial dissection of the gluteus maximus along the origin allows identification of the piriform muscle and preservation of the sciatic nerve. As the dissection proceeds laterally, one should identify the superior as well as the inferior gluteal arteries. Complete release from the midline is required for adequate mobilization of the myocutaneous flap. Further mobilization of the flap may be obtained by division of the
circumflex femoral a.
Figure 4. The tensor fascia lata is located at the lateral thigh and supplied by a branch of the lateral femoral circumflex artery. (From Vasconez LO, McCraw JB, Camargos AG: Muscle, musculocutaneous, and fasciocutaneous flaps. In Smith JW, Aston SJ (eds): Grabb and Smith's Plastic Surgery, ed 4. Philadelphia, Lippincott-Raven Publishers, 1991, pp 1113-1 141; with permission.)
insertion of the gluteus maximus into the trochanter. Bilateral mobilization allows closure of the defect at the midline of the defect with interrupted nylon or proline sutures. The overlying skin that has been maintained over the muscle is fairly mobile and easily reapproximated to the contralateral skin flap. Because of the difficult anatomy and often bloody dissection, it is advised that the operative surgeon perform this dissection on a cadaver prior to undertaking this procedure.
Rectus Abdominis Muscle Flap
For defects in the groin or along the trochanter, a useful and underutilized flap is the rectus abdominis flag flap. This is the mirror image of the transverse rectus abdominis musculocutaneous (TRAM) flap. Instead of being based on the superior epigastric vessel, it is based on the deep inferior epigastric vessels. The entire rectus abdominis muscle is
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Figure 5. A, Postradiation, recurrent primary squamous cell carcinoma involving left groin and lower abdominal wall. B, Wide excision of tumor and radiation field with exposure of underlying femoral vessels. C, Elevated tensor fascia lata myocutaneous flap transposed into defect. D, Immediate postoperative appearance of transposed tensor fascia flap with split-thickness skin grafting of donor site. (From Grotting JC, Carriquiry C, Vasconez LO: Abdomen. In Jurkiewicz MJ, Krizek TJ, Mathes SJ, et al: Plastic Surgery: Principles and Practice, vol 2. St. Louis, CV Mosby, 1990, pp 1139-1167; with permission.)
Figure 6. The gluteus maximus muscle is supplied by the superior and inferior gluteal arteries. Perforating branches from the gluteal system supply the overlying skin allowing VY advancements without displacement of the underlying muscle. (From Vasconez LO, McCraw JB, Camargos AG: Muscle, musculocutaneous, and fasciocutaneous flaps. In Smith JW, Aston SJ (eds): Grabb and Smith's Plastic Surgery, ed 4. Philadelphia, Lippincott-Raven Publishers, 1991, pp 1113-1 141; with permission.)
harvested with the island of skin designed at the level of the inframammary fold or just inferior, particularly in women. This large flap has a wide arc of rotation to cover defects in the flanks, the trochanters, and the groin and may reach even upper portions of the thigh. It is imperative that after removal of the entire muscle, the remnants of the anterior rectus sheath be reapproximated to avoid a potential weakness or hernia of the abdominal wall. Conversion into an island flap may be accomplished through division of the muscle inferiorly while preserving the deep inferior epigastric vessels. The rectus abdominis muscle alone can be used for reconstructions of the trochanter, groin, or contralateral abdomen. Occasionally, the rectus abdominis myocutaneous flap has been effective for intrapelvic reconstructions of the perineum or vagina if one maintains the overlying skin either transversely or vertically oriented over the muscle. Anatomy
The rectus abdominis is a long, broad strap muscle arising from the fifth, sixth, and seventh costal cartilages and inserting into the crest of the pubic bone. The muscle fibers of the rectus abdominis are interrupted by three tendinous intersections. The rectus abdominis muscle is en-
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closed in the rectus sheath by the anterior and posterior layers. This muscle has a dual dominant blood supply from the superior epigastric artery as well as the deep inferior epigastric artery. The superior epigastric artery is a terminal branch of the internal mammary artery and descends along the posterior surface of the rectus abdominis muscle. The deep inferior epigastric artery arises from the external iliac artery above the level of the inguinal ligament, traverses upward obliquely, and communicates with the terminal branches of the superior epigastric artery. Multiple musculocutaneous perforators supply the overlying skin in the periumbilical region and should be preserved carefully during dissection (Fig. 7). Technique
The design of the flap varies according to the reconstructive defect. Flaps can be designed vertically or transversely or extended laterally at the superior extent of the flap.6 The flap is initially incised through the skin's subcutaneous tissue and the anterior rectus sheath. Approximately 1 cm of the anterior rectus sheath at the lateral and medial margins is left intact. The remainder of the fascia remains with the muscle and flap. The muscle is then raised from the pocket of the rectus sheath beginning laterally. The deep inferior epigastric artery and the superepigastric artery are well defined at the superior and inferior extents of the muscle. The origin of the muscle is divided carefully, and the dissection of the remaining portion of the rectus muscle is carried from a proximal to a distal direction. Approximately 10 cm above the inguinal ligament, the deep inferior epigastric artery is noted to travel obliquely from the external iliac artery toward the midportion of the rectus abdominis muscle. After complete mobilization, the flap is then transposed to the recipient defect. If necessary, the rectus muscle can be divided at the symphysis pubis to create a true musculocutaneous-cutaneous island pedicle flap. The abdominal wall donor defect is closed with careful reapproximation of the anterior rectus sheath. Excessive tension of the donor site may require placement of marlex mesh, primarily below the arcuate line. The mobility of the overlying skin allows primary closure of the donor defect.
Free Flaps
The reconstructive surgeon should be versed on microvascular freetissue reconstruction. If local flaps are not appropriate for the coverage of the defects, it is imperative that a free flap be used. The most commonly used free flaps for reconstruction of the trunk and perineum
Figure 7. A, Preoperative view of 36-year-old male with recurrent spindle cell sarcoma of the right flank. Note the hyperpigmentation from radiation therapy. B, The resulting fullthickness lateral abdominal wall defect measured 8 cm wide by 12 cm long. Abdominal wall integrity was reconstructed with Marlex mesh, sutured to the internal surface of the abdominal wall through the musculofascial layers and posteriorly to the psoas muscles. C, With the patient in the lateral decubitus position, an ipsilateral inferiorly based rectus abdominis myocutaneous flap was designed. D, The flap was elevated, based on the inferior deep epigastric artery and vein. E, The flap is inset. F, A subsequent, local posterior rotation skin flap was necessary in the area of the tip of the flap to fill deep space. G, Four months postoperative, posterior view. H, Four months postoperative, lateral view. Skingrafted donor site of the rectus abdominis muscle is evident.
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Figure 7 (Continued). See legend on opposite page
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are the latissimus dorsi and rectus abdominis muscle or myocutaneous flaps. Description of the microvascular techniques is provided elsewhere.lO,l1 SUMMARY
Trunk and perineal defects after tumor resection present a challenge to the reconstructive surgeon. When primary closure is not possible, the use of well-vascularized autogenous tissue is required to achieve adequate soft-tissue coverage. Pedicled muscle or myocutaneous flaps provide excellent sources of vascularized tissue for postradiation defects. When local tissues preclude the use of pedicled flaps, free-tissue transfers can be performed. A thorough understanding of radiation wounds and the reconstructive options is essential for treatment of these challenging defects. References 1. Bhathen HM, Kavarana NM: One stage reconstruction of extensive abdominal wall defect with bilateral tensor fascia lata flaps. Indian J Cancer 30:10, 1993 2. Bostwick J, Hill HL, Nahai F: Repairs in the lower abdomen, groin, or perineum with myocutaneous or omental flaps. Plast Reconstr Surg 63:186,1979 3. Brown DM, Sicard GA, Flye MW, et al: Closure of complex abdominal wall defects with bilateral rectus femoris flaps with fascia1 extensions. Surgery 114:112, 1992 4. Burns AJ: Trunk reconstruction. Selected Readings in Plastic Surgery 7:14, 1995 5. Caulfield WH, Curtsinger L, Powell G, et al: Donor leg morbidity after pedicled rectus femoris muscle flap transfer for abdominal wall and pelvic reconstruction. Ann Plast Surg 32:377, 1994 6. Cormack GC, Quaba AA: Case report: Bilobe modification of the deep inferior epigastric artery flap for abdominal wall defect reconstruction. Br J Plast Surg 44:541, 1991 7. Grotting JC, Carriquiry C, Vasconez LO: Abdomen. In Jurkiewicz MJ, Krizek TJ, Mathes SJ, et a1 (eds): St. Louis, CV Mosby, 1990, p 1139 8. Horgan K, Ahamed I, Hughes L: How we manage sarcoma of the abdominal wall. Eur J Surg Oncol 20:240, 1994 9. McCraw JB, Arnold PG: McCraw and Arnold's Atlas of Muscle and Musculocutaneous Flaps. Norfolk, Hampton Press, 1986 10. Neven P, Shepherd JH, Tham KF, et al: Case report: Reconstruction of the abdominal wall with a latissimus dorsi musculocutaneous flap: A case of a massive abdominal wall metastasis from a cervical cancer requiring palliative resection. Gynecol Oncol 49:403, 1993 11. Piza H, Rath T, Hausmaniger C, et al: Wound closure at the trunk by microvascular free flap transfer. Microsurgery 14:260, 1993
Address reprint requests to R. Jobe Fix, MD Division of Plastic Surgery University of Alabama at Birmingham 524 Medical Education Building 1813 Sixth Avenue South Birmingham, AL 35294-3295