Abstract
Background
The reconstruction of large defects after abdominoperineal resections and pelvic exenterations has traditionally been accomplished with vertical rectus myocutaneous flaps (VRAMs). For patients requiring two ostomies, robot-assisted abdominoperineal resections (APRs), and to avoid the morbidity of a VRAM harvest, the authors have used the gracilis muscle flap to reconstruct the large dead space in these patients.
Methods
A retrospective analysis of 16 consecutive APRs (10 with concomitant pelvic exenterations) reconstructed with gracilis flaps during a 2-year period was performed. Gracilis muscle flaps were used to obliterate the dead space after primary skin closure was ensured with adduction of the legs.
Results
All 16 patients had locally advanced cancers and had received neoadjuvant chemotherapy and radiation. Of these 16 patients, 10 had pelvic exenterations. All the patients had reconstruction with gracilis flaps (6 bilateral flaps). One major wound complication in the perineum occurred as a result of an anastomotic leak in the pelvis, but this was managed with conservative dressing changes. Three patients had skin separation in the perineum greater than 5 mm with intact subcutaneous closure. No patients required operative debridement or revision of their perineal reconstruction. No perineal hernias or gross dehiscence of the skin closure occurred.
Conclusions
Large pelvic and perineal reconstructions can be safely accomplished with gracilis muscle flaps and should be considered as an alternative to abdominal-based flaps.
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References
Lu JY, Xiao Y, Qiu HZ, Wu B, Lin GL, Xu L, Zhang GN, Hu K. Clinical outcome of neoadjuvant chemoradiation therapy with oxaliplatin and capecitabine or 5-fluorouracil for locally advanced rectal cancer. J Surg Oncol. 2013; 108:213–9.
Foxtrot Collaborative Group. Feasibility of preoperative chemotherapy for locally advanced, operable colon cancer: the pilot phase of a randomised controlled trial. Lancet Oncol. 2012;13:1152–60.
Wiatrek RL, Thomas JS, Papaconstantinou HT. Perineal wound complications after abdominoperineal resection. Clin Colon Rectal Surg. 2008;21:76–85.
Luna-Pérez P, Rodríguez-Ramírez S, Vega J, Sandoval E, Labastida S. Morbidity and mortality following abdominoperineal resection for low rectal adenocarcinoma. Rev Invest Clin. 2001;53:388–95.
Farid H, O’Connell TX. Methods to decrease the morbidity of abdominoperineal resection. Am Surg. 1995;61:1061–4.
Butler CE, Gündeslioglu AO, Rodriguez-Bigas MA. Outcomes of immediate vertical rectus abdominis myocutaneous flap reconstruction for irradiated abdominoperineal resection defects. J Am Coll Surg. 2008;206:694–703.
Chessin DB, Hartley J, Cohen AM, Mazumdar M, Cordeiro P, Disa J, Mehrara B, Minsky BD, Paty P, Weiser M, Wong WD, Guillem JG. Rectus flap reconstruction decreases perineal wound complications after pelvic chemoradiation and surgery: a cohort study. Ann Surg Oncol. 2005;12:104–10.
Shibata D, Hyland W, Busse P, Kim HK, Sentovich SM, Steele G Jr, Bleday R. Immediate reconstruction of the perineal wound with gracilis muscle flaps following abdominoperineal resection and intraoperative radiation therapy for recurrent carcinoma of the rectum. Ann Surg Oncol. 1999;6:33–7.
Nelson RA, Butler CE. Surgical outcomes of VRAM versus thigh flaps for immediate reconstruction of pelvic and perineal cancer resection defects. Plast Reconstr Surg. 2009;123:175–83.
Baumann DP, Butler CE. Component separation improves outcomes in VRAM flap donor sites with excessive fascial tension. Plast Reconstr Surg. 2010;126:1573–80.
Wong S, Garvey P, Skibber J, Yu P. Reconstruction of pelvic exenteration defects with anterolateral thigh-vastus lateralis muscle flaps. Plast Reconstr Surg. 2009;124:1177–85.
Lefevre JH, Parc Y, Kernéis S, Shields C, Touboul E, Chaouat M, Tiret E. Abdominoperineal resection for anal cancer: impact of a vertical rectus abdominis myocutaneus flap on survival, recurrence, morbidity, and wound healing. Ann Surg. 2009;250:707–11.
Shibata D, Hyland W, Busse P, Kim HK, Sentovich SM, Steele G Jr, Bleday R. Immediate reconstruction of the perineal wound with gracilis muscle flaps following abdominoperineal resection and intraoperative radiation therapy for recurrent carcinoma of the rectum. Ann Surg Oncol. 1999;6:33–7.
Buchel EW, Finical S, Johnson C. Pelvic reconstruction using vertical rectus abdominis musculocutaneous flaps. Ann Plast Surg. 2004;52:22–6.
Arnold PG, Lovich SF, Pairolero PC. Muscle flaps in irradiated wounds: an account of 100 consecutive cases. Plast Reconstr Surg. 1994;93:324–7.
Hinojosa MW, Parikh DA, Menon R, Wirth GA, Stamos MJ, Mills S. Recent experience with abdominal perineal resection with vertical rectus abdominis myocutaneous flap reconstruction after preoperative pelvic radiation. Am Surg. 2009;75:995–9.
Hanasono MM, Skoracki RJ, Yu P. A prospective study of donor-site morbidity after anterolateral thigh fasciocutaneous and myocutaneous free flap harvest in 220 patients. Plast Reconstr Surg. 2010;125:209–14.
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Chong, T.W., Balch, G.C., Kehoe, S.M. et al. Reconstruction of Large Perineal and Pelvic Wounds Using Gracilis Muscle Flaps. Ann Surg Oncol 22, 3738–3744 (2015). https://doi.org/10.1245/s10434-015-4435-1
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DOI: https://doi.org/10.1245/s10434-015-4435-1