Outcomes of Immediate Vertical Rectus Abdominis

Myocutaneous Flap Reconstruction for Irradiated

Abdominoperineal Resection Defects
Charles E Butler, MD, FACS, A Özlem Gündeslioglu, MD, Miguel A Rodriguez-Bigas, MD, FACS

BACKGROUND: Perineal wound complications after chemoradiotherapy and abdominoperineal resection (APR)
for anorectal cancer occur in up to 60% of patients, including perineal abscess and wound
dehiscence. Vertical rectus abdominis myocutaneous (VRAM) flaps have been used in an
attempt to reduce these complications by obliterating the noncollapsible dead space with
vascularized tissue and closing the perineal skin defect with nonirradiated flap skin. Many
surgeons are reluctant to use VRAM flaps unless primary closure is not possible.
STUDY DESIGN: All patients who underwent chemoradiotherapy and APR during a 12-year period at the
University of Texas MD Anderson Cancer Center were retrospectively reviewed. Patient, tumor,
and treatment characteristics and surgical complications and outcomes were compared between
patients who underwent VRAM flap reconstruction of wounds that could have been closed
primarily (flap group, n ⫽ 35) and those who had primary closure of the perineal wound
(control group, n ⫽ 76).
RESULTS: Overall, there were no significant differences in the incidence of perineal wound complications
between the groups; the flap group had a significantly lower incidence of perineal abscess (9%
versus 37%, p ⫽ 0.002), major perineal wound dehiscence (9% versus 30%, p ⫽ 0.014), and
drainage procedures required for perineal/pelvic fluid collections (3% versus 25%, p ⫽ 0.003)
than the control group had. Despite flap harvest and the need for donor site closure in the flap
group, there was no significant difference in abdominal wall complications between groups
during the study’s mean patient followup of 3.8 years.
CONCLUSIONS: VRAM flap reconstruction of irradiated APR defects reduces major perineal wound complica-
tions without increasing early abdominal wall complications. Strong consideration should be
given to immediate VRAM flap reconstruction after chemoradiation and APR. ( J Am Coll Surg
2008;206:694–703. © 2008 by the American College of Surgeons)

The standard treatment for locally advanced rectal adeno-
carcinoma is neoadjuvant chemoradiotherapy followed by
surgical resection. If the anal sphincter cannot be preserved
during tumor extirpation, an abdominoperineal resection
(APR) is performed. When APR follows chemoradiother-
apy, perineal wound complications, including abscess,
Competing Interests Declared: None.
This study was funded in part by the Short-Term Scientist Exchange Pro-
gram, National Institutes of Health, National Cancer Institute (to Dr A
Özlem Gündeslioglu).
Received August 21, 2007; Revised December 10, 2007; Accepted December
10, 2007.
From the Departments of Plastic Surgery (Butler, Gündeslioglu) and Surgical
Oncology (Rodriguez-Bigas), University of Texas MD Anderson Cancer Cen-
ter, Houston TX.
Correspondence address: Charles E Butler, MD, FACS, Department of Plas-
tic Surgery, Unit 443, University of Texas MD Anderson Cancer Center, 1515
Holcombe Blvd, Houston, TX 77030. email: cbutler@mdanderson.x
org
wound dehiscence, and delayed wound healing occur in
25% to 60% of patients.1-7 These complications are related
to the presence of a large, noncollapsible dead space,8-10 the
poor vascularity of the irradiated surrounding tissue,11 use
of irradiated skin in the closure, and bacterial contamina-
tion owing to bowel resection.12,13
Local-regional tissue flaps can provide bulky tissue to oblit-
erate dead space, bring vascularized tissue to the irradiated
tumor bed, and provide a skin paddle for cutaneous wound
closure.4-7,10,14-21 Flap reconstruction is well accepted for very
large perineal defects, such as when the skin cannot be closed
primarily or a massive dead space is present (eg, after pelvic
exenteration). The role of “routine” flap use when a skin pad-
dle is not absolutely essential for cutaneous closure of the per-
ineal wound or when a large amount of tissue bulk is not
obviously needed to obliterate a massive pelvic dead space has
not been established. Previous studies demonstrating im-
proved perineal wound healing after APR or pelvic exentera-

© 2008 by the American College of Surgeons ISSN 1072-7515/08/$34.00

Published by Elsevier Inc. 694 doi:10.1016/j.jamcollsurg.2007.12.007
Vol. 206, No. 4, April 2008
Abbreviations and Acronyms
APR ⫽ abdominoperineal resection
IORT ⫽ intraoperative radiotherapy
SCC ⫽ squamous cell carcinoma
VRAM ⫽ vertical rectus abdominis myocutaneous
tion with use of flaps have been limited by their small number
of patients,5,17,19 absence of a control population (similar de-
fects closed primarily),7,22 the heterogeneity of perineal defects
included,5,15,21 and the heterogeneity of flap reconstruction
techniques used.19,23-25 The current study directly compared
outcomes of patients with irradiated APR defects who had
primary closure of the perineal wound versus flap reconstruc-
tion with a standardized technique.
Commonly used flaps for perineal reconstruction in-
clude the greater omentum, gracilis myocutaneous, poste-
rior thigh, and vertical rectus abdominis myocutaneous
(VRAM) flaps. VRAM flaps generally have greater bulk
and a more reliable vascular supply to the skin paddle than
thigh-based flaps.23,26 The greater omentum is frequently
not available or usable, particularly in cases of previous
abdominal operations, and does not provide vascularized
skin for perineal wound closure. The VRAM flap has be-
come the most commonly used technique at our institu-
tion for primary flap reconstruction after APR.
We hypothesized that patients who underwent VRAM
flap reconstruction after preoperative chemoradiation and
APR for rectal or anal carcinoma would have fewer wound
complications than patients with similar resection defects
who had primary perineal wound closure. We also antici-
pated that there might be increased abdominal morbidity
because of flap harvest. In this study, we retrospectively
compared abdominal and perineal wound outcomes of
VRAM flap reconstruction versus primary closure in pa-
tients who underwent APR after neoadjuvant chemoradio-
therapy for rectal or anal malignancies.
METHODS
Patients
All patients with persistent anal squamous cell carcinoma
(SCC) or rectal adenocarcinoma who had preoperative
chemoradiotherapy and underwent APR at the University
of Texas MD Anderson Cancer Center between September
1, 1993, and August 31, 2005, were evaluated for the study.
We retrospectively reviewed prospectively gathered data in
an electronic database and patients’ medical records to
identify patients who had a perineal wound where the skin
and soft tissues could have been closed primarily but was
closed with a VRAM flap. Control patients were those
Butler et al VRAM Flap Perineal Reconstruction 695
whose perineal wounds were closed primarily. Patients were
included in both groups when their resections included an
elliptical resection of a small (⬍ 30% surface area) section
of the posterior vaginal wall that was closed primarily. Pa-
tients treated with total or modified pelvic exenteration or
partial (⬎ 30%) or complete vaginectomy and patients
whose tissue defects required flap reconstruction to close
the perineal skin defect (ie, the defect could not be closed
primarily) were excluded. Patients who underwent recon-
struction with rectus abdominis muscle-only flaps or
whose reconstruction included a thigh-based flap were also
excluded. This study was reviewed and approved by MD
Anderson’s institutional review board.
Data extracted from the databases and medical
records included patient and tumor characteristics, neo-
adjuvant and adjuvant treatment, closure technique,
and surgical wound healing outcomes and complica-
tions (abdominal wall and perineal), length of hospital
stay, and postoperative course.
Patients were divided into two subgroups: flap patients
had undergone immediate reconstruction of the APR de-
fect with a pedicled VRAM flap, and nonflap patients had
undergone primary closure of the perineal wound. The
choice of VRAM flap reconstruction had been based prin-
cipally on surgeon preference for preoperative referral to
the plastic surgical service at MD Anderson.
Surgical technique
The reconstructive technique for flap patients was similar
among all reconstructive surgeons and has been described
previously (Figs. 1-3).27 Briefly, a 5- to 10-cm⫺wide skin
paddle was designed vertically above the right rectus abdo-
minis muscle unless previous scarring or an ostomy was
present, in which case a left VRAM flap was used. Medial
and lateral rows of myocutaneous perforating vessels and
the intervening anterior rectus sheath fascia were included
with the flap. The inferior epigastric pedicle was mobilized
to its origin and separated from all surrounding tissue at-
tachments to prevent kinking or compression. The muscle
insertion on the pelvis was left intact to prevent tension on
the pedicle. The flap was rotated medially and transposed
into the perineal defect to obliterate the maximum amount
of dead space possible and to prevent tension on, and com-
pression of, the flap and vascular pedicle. An elliptical-
shaped skin paddle was marked while the patient was in the
lithotomy position with legs adducted to prevent excessive
flap skin paddle redundancy postoperatively. The flap skin
peripheral to the marked skin paddle was deepithelialized
and sutured to the remnant pelvic floor edges with inter-
rupted permanent sutures. Closed-suction drainage cathe-
ters were placed to drain the pelvic space. The flap skin
paddle was then inset into the skin defect edges.
696 Butler et al VRAM Flap Perineal Reconstruction J Am Coll Surg

Figure 1. Illustration of a vertical rectus abdominis myocutaneous flap harvest and inset after abdominoperineal resection. (A) A vertically
oriented skin paddle overlying the rectus abdominis muscle. (B) The flap includes skin, subcutaneous fat, a cuff of anterior rectus sheath fascia,
and one rectus abdominis muscle. (C) The flap is transposed through the pelvis and the size, shape, and location of the skin paddle (used to
close the perineal skin defect) is marked. The skin is deepithelialized surrounding the marked skin paddle. (D) The flap skin paddle is sutured
to the perineal skin defect. The colostomy is brought through the contralateral side, and the fascia and skin of the donor site and laparotomy
incision are closed primarily. (From: Visual Art, Houston, TX, University of Texas MD Anderson Cancer Center, 2007, with permission.)

The abdominal donor site was subsequently closed after
contralateral colostomy placement. The fascia was closed
with interrupted or running polypropylene sutures with-
out prosthetic mesh. The ipsilateral skin was undermined
lateral to the donor site, advanced medially, and closed over
a closed-suction drain.
Nonflap patients underwent layered closure of their per-
ineal defects with linear closure of the skin edges. They also
had closed-suction drainage catheters placed to drain the
pelvic dead space, but they did not undergo abdominal
skin undermining or subcutaneous drain placement.
In both groups, postoperative positioning included a
pillow placed under the sacrum to limit pressure on the
perineal wound during hospitalization. Patients were al-
lowed to walk on the first postoperative day. Patients were
instructed to put their weight on the lateral gluteal and
ischial regions (not directly on the perineal wound) while
sitting for 2 weeks postoperatively.
Complications and followup
We extracted data on perineal and abdominal wall compli-
cations to compare their occurrence in the two groups.
Vol. 206, No. 4, April 2008
Figure 2. A sagittal cross-section illustration of the vertical rectus
abdominis myocutaneous flap inset. The well-vascularized flap tis-
sue occupies and obliterates much of the irradiated, noncollapsible
pelvic/perineal dead space created by removal of the rectum and
anus. The tissue bulk reduces fluid collection within and intestinal
descent into the pelvic/perineal space. (From: Visual Art, Houston,
TX, University of Texas MD Anderson Cancer Center, 2007, with
permission.)
Data were recorded from the medical record and a prospec-
tively maintained database. Wound dehiscences were cate-
gorized as major or minor. A major wound dehiscence was
defined as skin and subcutaneous tissue breakdown with or
without deep infection requiring additional intervention,
including debridement or drainage and irrigation. A minor
wound dehiscence was a small cutaneous dehiscence with
or without cellulitis requiring only dressing changes. He-
matomas and seromas that required drainage were included
as complications. Pelvic and deep perineal abscess collec-
tions were also considered complications. Other perineal
wound complications included partial or complete flap loss
and perineal hernia, which was defined as a major protru-
sion of abdominal viscera through the perineal pelvic floor
with a visible and palpable bulge. Abdominal wall and
parastomal hernias were defined as a palpable bulge with an
underlying fascial defect, which could also be palpated by
the surgeon or identified on followup CT. Abdominal wall
skin dehiscence was defined as wound breakdown with
full-thickness skin separation for a distance ⬎ 2 cm with or
without infection. Fascial dehiscence was defined as sepa-
rated fascial edges visualized through an open wound re-
quiring reoperation.
Patients were followed up every 1 to 2 weeks until all
wounds were healed and then every 3 to 6 months. The
Butler et al VRAM Flap Perineal Reconstruction 697
percentage of patients alive or dead at last followup was
determined. Time to death for patients who died was cal-
culated from the date of APR to death.
Statistical analysis
We assessed the comparability of the two groups in terms of
patient-, tumor-, and treatment-related factors. An un-
paired, two-tailed Student’s t-test was used to assess differ-
ences in continuous variables, such as age, body mass index,
radiation dose, hospitalization time, and followup time.
Values are expressed as mean and standard deviation. Chi-
square or Fisher’s exact test was used to assess differences in
categorical variables, such as gender, comorbid conditions,
intraoperative radiotherapy (IORT), recurrence, and par-
tial vaginectomy. We then compared the incidence of per-
ineal and abdominal wall complications using chi-square
or Fisher’s exact test. We also assessed the impact of com-
plications on hospital stay using Student’s t-test.
Patient-, tumor-, and treatment-related factors were then
evaluated to identify any independent predictors of the devel-
opment of perineal or abdominal wall complications. Com-
plication end points modeled were any perineal complica-
tion, any major perineal complication (major dehiscence,
perineal abscess, or need for an invasive drainage procedure
for a perineal/pelvic fluid collection), and any abdominal
wall complication. Potential predictive factors used in the
stepwise logistic regression model included patient age,
gender, body mass index, tobacco use, use of IORT,
performance of partial vaginectomy, tumor stage, tumor
type (anal SCC or rectal adenocarcinoma), recurrent
tumor, use of a VRAM flap, and reported history of
these comorbid conditions: diabetes mellitus, chronic
obstructive pulmonary disease, congestive heart failure,
coronary artery disease, hypertension, peripheral vascu-
lar disease, renal insufficiency, hematologic disease,
rheumatologic disease, and endocrine disease. Odds ra-
tio estimates and 95% Wald CI were calculated for pre-
dictive factors. In all statistical analyses, p values ⬍ 0.05
were considered statistically significant.
RESULTS
Patient, tumor, and treatment characteristics
A total of 111 patients were included in the study. Tumors
in the flap group consisted of 30 (24 primary and 6 recur-
rent) rectal adenocarcinomas and 5 (1 persistent and 4
recurrent) anal SCCs. Tumors in the nonflap group con-
sisted of 75 primary rectal adenocarcinomas and 1 recur-
rent anal SCC. A considerably greater proportion of pa-
tients in the flap group had anal SCC, recurrent tumors,
partial vaginectomy, and IORT (Table 1).
698 Butler et al VRAM Flap Perineal Reconstruction J Am Coll Surg

Figure 3. Photographs of a vertical rectus abdominis myocutaneous flap inset. (A) Perineal defect after abdominoperineal resection. (B) The size
and shape of the skin island that will be interposed between the irradiated perineal skin defect edges have been marked, and the remainder of the
peripheral flap skin has been deepithelialized. (C) The skin paddle has been inset into the perineal skin defect. (D) Inferior and (E) posterior views
of the healed perineal skin 3 weeks postoperatively, after the sutures have been removed. (Photographs courtesy of Charles E Butler, MD.)

There were no substantial differences between the flap
and nonflap groups in mean patient age (54.3 ⫾ 13.8 years
versus 56.2 ⫾ 13.6 years, respectively) or body mass index
(26.5 ⫾ 6.5 versus 28.5 ⫾ 5.8). There were also no differ-
ences between the groups in tobacco use, tumor stage, or
the incidence of any comorbid condition (diabetes melli-
tus, coronary artery disease, congestive heart failure, hyper-
tension, peripheral vascular disease, chronic obstructive
pulmonary disease, renal insufficiency, hematologic dis-
ease, rheumatologic disease, or endocrine disease). There
Vol. 206, No. 4, April 2008 Butler et al VRAM Flap Perineal Reconstruction 699

Table 1. Patient, Tumor, and Resection Defect Characteristics

Flap group (n ⴝ 35) Nonflap group (n ⴝ 76)
Characteristic n % n % p Value
Anal SCC 5 14 1 1 ⬍ 0.01
Recurrent tumor 9 26 1 1 ⬍ 0.001
Partial vaginectomy 19 54 4 5 ⬍ 0.001
IORT 10 29 0 ⬍ 0.0001
Rectal Anal Rectal Anal
n % n % n % n %
Tumor stage 1.0*
I 2 6 0 1 1 0
II 13 37 0 45 59 0
III 7 20 1 3 25 33 0
IV 2 6 0 4 5 0
Recurrent 6 17 4 11 0 1 1 ⬍ 0.00003
Pathologic stage of primary tumors based on American Joint Committee on Cancer system (6th ed.).28
*Comparison of tumor stage distribution between flap and nonflap group.
IORT, intraoperative radiotherapy; SCC, squamous cell carcinoma.

was a greater proportion of female patients in the flap (n ⫽ ment and subsequent reconstruction with bilateral pedi-
28; 80%) than nonflap (n ⫽ 23; 30%) group (p ⬍ 0.001). cled gracilis myocutaneous flaps.
The preoperative radiation dose did not differ substantially
between the flap (52.2 ⫾ 12.5 Gy) and nonflap (49.2 ⫾ 3.9 Abdominal wall complications
Gy) groups. Ten patients (29%) in the flap group received Overall, there was no substantial difference in the inci-
IORT (mean 12 Gy; range 10 to 15 Gy) in addition to pre- dence of any abdominal wall complication between the flap
operative external-beam radiotherapy, but none of the patients
in the nonflap group received IORT (p ⬍ 0.001; Table 1).
Table 2. Perineal and Abdominal Wound Complications
Flap Nonflap
Perineal complications group group
Overall, there was no difference in the incidence of any (n ⴝ 35) (n ⴝ76)
perineal wound complication between the flap (46%) and Complication n % n % p Value
nonflap (46%) groups. Fewer patients had severe compli- Perineal complications
cations in the flap group. Incidence of perineal abscess Seroma 0 5 7 0.177
formation (9% versus 37%, p ⫽ 0.002) and major wound Hematoma 0 3 4 0.550
dehiscence (9% versus 30%, p ⫽ 0.014) was considerably Perineal abscess 3 9 28 37 0.002
lower in the flap than the nonflap group (Table 2). Fewer Major wound dehiscence 3 9 23 30 0.014
patients required drainage procedures to treat perineal/ Minor would dehiscence 9 26 9 12 0.065
pelvic fluid collections (seroma or abscess) in the flap (3%) Perineal hernia 2 6 4 5 1
versus nonflap (25%) group (p ⫽ 0.003). The incidence of Complete flap loss 1 3 0 0.2
minor perineal complications—hematoma, seroma, minor Any perineal complication 16 46 35 46 0.97
wound dehiscence, and perineal hernia—did not differ Abdominal wall
substantially between groups. complications
In both groups, the majority of perineal wound dehis- Seroma 0 0 —
cences were treated with wet-to-moist saline-soaked dress- Hematoma 0 0 —
ing changes, with or without bedside debridement. Oper- Infection 0 1 1 1
ative debridement of the perineal wound followed by Skin dehiscence 4 11 11 14 0.772
dressing changes was performed in 8 patients (11%) in the Fascial dehiscence 2 6 2 3 0.589
nonflap group and 3 patients (9%) in the flap group, in- Delayed healing 1 3 8 11 0.276
cluding 1 patient with complete flap necrosis. There were Incision hernia 2 6 6 8 1
no partial flap failures in the flap group, but one patient Parastomal hernia 4 11 12 16 0.772
had necrosis leading to complete flap loss. The patient with Any abdominal wall
complete flap necrosis and loss underwent flap debride- complication 10 29 25 33 0.649
700 Butler et al VRAM Flap Perineal Reconstruction
(29%) and nonflap (33%) groups, nor were there differ-
ences in specific complications (Table 2). Despite harvest
of skin, subcutaneous fat, rectus fascia, and rectus abdomi-
nis muscle from the abdominal wall for the VRAM flaps,
the incidence of abdominal skin or fascial dehiscence and
incisional or parastomal hernia was not substantially differ-
ent in the flap group.
Impact of complications on hospitalization
Overall, there was no substantial difference in mean hospital
stay between the flap (9.1 ⫾ 7.2 days) and nonflap (10.2 ⫾
3.8 days) groups. The occurrence of at least 1 postoperative
abdominal or perineal wound complication increased the
mean hospital stay by 80.4% (p ⫽ 0.039) and 91.3% (p ⫽
0.0002) for flap and nonflap patients, respectively. Mean hos-
pital stay did not differ substantially between flap and nonflap
patients who had a postoperative wound complication de-
velop. Mean hospital stay was 9.3 ⫾ 3.4 days versus 7.4 ⫾ 3.0
days for patients in the flap versus nonflap group with no
postoperative complications and 16.8 ⫾ 13.9 days versus
14.2 ⫾ 10.0 days for those in the flap versus nonflap group
who had at least 1 postoperative complication.
Factors predictive of complications
No patient-, tumor-, or treatment-related factor was found
to be predictive for the development of a perineal or ab-
dominal wall complication. Predictive factors were identi-
fied when development of a major perineal complication
(major dehiscence, perineal abscess, or need for an invasive
drainage procedure for perineal/pelvic fluid collection) was
modeled. The odds ratio of developing a major perineal
complication was 5.5 (95% CI, 1.5 to 16.2; p ⫽ 0.001) for
patients who had 2 or more comorbid conditions. Use of a
VRAM flap was found to be protective: the odds ratio for
development of a major perineal complication was 0.32
(95% CI, 0.11 to 0.9; p ⫽ 0.03) for patients who received
a VRAM flap. No other factors were found to be predictive
or protective for major perineal complications.
Followup and overall survival
There was no substantial difference in mean followup time
between the flap (3.2 ⫾ 2.3 years) and nonflap groups (4.2 ⫾
2.7 years). At last followup, 71% of flap patients and 70% of
nonflap patients were alive; the difference was not substantial.
Among the patients who died during the followup period and
had at least 1 postoperative complication, there was no differ-
ence in the mean time to death after operation between the
flap (4.3 ⫾ 0.9 years) and nonflap (3.6 ⫾ 2.5 years) groups.
DISCUSSION
This study demonstrates that VRAM flap reconstruction of
irradiated APR defects in patients with anal or rectal cancer
J Am Coll Surg
reduces the incidence of major perineal wound dehiscence
and perineal abscess without increasing abdominal wound
complications, as compared with nonflap closure. Obliter-
ation of perineal and pelvic dead space with a VRAM flap
also reduces the need for drainage procedures to treat per-
ineal abscess or seroma.
Previous studies have demonstrated reduced perineal
wound complications using flap reconstruction of perineal
resection defects.5,7,14-19 Perineal defects resulting from pel-
vic exenteration, sacrectomy, and recurrent anal cancer re-
sections are frequently large and often require flap recon-
struction to close the perineal skin defect, obliterate the
pelvic space, or reconstruct a new vagina after complete
vaginectomy. In the current study, perineal defects were
from an APR (with or without partial vaginectomy) and
could all be closed primarily; patients whose defects were a
result of large skin or multivisceral resections or pelvic ex-
enteration were excluded. In the patients studied, flap re-
construction was not absolutely required for wound clo-
sure, so the nonflap group served as a relevant and
appropriate control group with similar defects. Relative
benefits and disadvantages of VRAM flap reconstruction
could be accurately assessed. To our knowledge, this is the
largest controlled study that directly compares VRAM flap
reconstruction with primary closure of irradiated perineal
defects after APR for anal or rectal cancer.
The perineal complication rates in both groups were
relatively high, confirming the morbidity of APR after ra-
diotherapy. The overall perineal wound complication rate
did not differ substantially between the flap and nonflap
patients. However, rate of major perineal complications
was substantially higher in the nonflap group, even though
flap patients had greater incidences of recurrent tumors,
anal cancers, IORT, and partial vaginectomy with the re-
section. Despite a potential bias toward larger or more
complex perineal defects in flap patients, use of VRAM
flaps reduced major perineal wound complications. This
reduction occurred without an increase in early (3.2 years ⫾
2.3 years followup) abdominal wall complications (includ-
ing incisional and parastomal hernias) resulting from flap
harvest.
Our findings are in agreement with previous smaller
studies in which VRAM flaps were used for perineal recon-
struction. Major perineal complications ranging from 25%
to 46% have been reported when irradiated perineal resec-
tion defects are closed without flap reconstruction,1,3-5,7 but
acute perineal wound complication rates have been re-
ported to range from 3.5% to 15.8% after VRAM flap
reconstruction.7,18 Despite removal of abdominal skin,
subcutaneous fat, anterior rectus sheath fascia, and the rec-
tus abdominis muscle with VRAM flap harvest, the early
Vol. 206, No. 4, April 2008
abdominal wall complication rates did not differ between
the flap and nonflap groups. This finding is in agreement
with a smaller previous study involving 19 VRAM flap
patients.28
Unlike previous studies, the longer mean followup pe-
riod of ⬎ 3 years in our study allowed the evaluation of
complications that would be expected to occur later after
operation, such as incisional, parastomal, or perineal her-
nia. Certainly, hernias can occur during additional fol-
lowup. Despite flap harvest from the abdominal wall, there
was a trend toward a lower incidence of early abdominal
(incisional or parastomal) hernia in the flap group (17%
versus 24%), but the difference was not significant. The
lower abdominal wall complication rate further supports
the relatively low morbidity of VRAM flap harvest, even
when the abdominal wall donor site is followed for a mean
of ⬎ 3 years postoperatively.
Although the VRAM flap is well suited for perineal recon-
struction, there are other flap options, including greater
omental and thigh-based flaps (eg, gracilis, posterior thigh,
and anterolateral thigh flaps). An advantage of the VRAM flap
includes its large, reliable skin paddle for perineal skin recon-
struction or vaginal reconstruction, if required. The VRAM
flap also has excellent bulk for dead space obliteration, ade-
quate reach to the perineum and sacrum, reliable vascularity,
consistent anatomy, relative ease of harvest, and no need for
additional scars in a separate donor area. Potential disad-
vantages of the VRAM flap are generally related to the
removal of skin, fascia, and rectus muscle from the abdom-
inal wall. Although not observed in this study, theoretic
consequences of VRAM harvest include greater tension on
the abdominal skin and fascial closure, potentially increas-
ing the risk of wound separation.17,29-31 Absence of one of
the two rectus abdominis muscles in the abdominal wall
also has implications for ostomy placement and potential
replacement in the future.26 Generally, a colostomy is
brought out through the left rectus muscle, and the right
rectus muscle is used for VRAM flap reconstruction. Oc-
casionally, a second ostomy is required during a subsequent
operation, such as an ileal conduit for urinary diversion
after salvage total pelvic exenteration or colostomy reloca-
tion for treatment of parastomal hernia. If one rectus ab-
dominis muscle has been used for flap reconstruction, there
is no intact, virgin rectus muscle through which the ostomy
can be placed. In either situation, we typically place the
new ostomy through the abdominal wall on the flap donor
side, lateral to the empty rectus sheath. Although this tech-
nique has not been formally studied, we have not observed
an increase in ostomy-related complications using it.
The advantages of flap reconstruction might be more
obvious for larger defects, such as those resulting from pel-
Butler et al VRAM Flap Perineal Reconstruction 701
vic exenteration and APR, with extended skin resection for
locally advanced anal SCC or with sacrectomy for rectal
cancer invasion into the sacrum. Previous studies involving
such cases demonstrated relatively few perineal wound
complications and few hospital readmissions and reopera-
tions for wound healing complications by using flap tissue
to reconstruct the perineal defect.7,15,17,21,32 Although the
advantages of flap reconstruction for standard APRs, such
as in our study, might seem less striking than for massive,
multivisceral resections, the overall impact on patients and
surgeons can be momentous, owing to the relative fre-
quency with which these procedures are performed and the
high incidence and morbidity of associated perineal com-
plications. Although most irradiated APR defects can be
closed primarily without flap reconstruction, use of VRAM
flaps in our study was associated with a 4-fold reduction in
major perineal wound dehiscence and a 10-fold reduction
in perineal abscess formation.
Although there was a substantial overall reduction in
major perineal wound morbidity without increased early
abdominal wall morbidity in the flap group, we recognized
that the flap patients might not have encountered perineal
wound complications at all if they had not received a flap.
We used logistic regression to identify any individual fac-
tors predictive of any perineal or abdominal wall compli-
cation. We found no such factors. When modeled for ma-
jor perineal complications, patients with two or more
comorbid conditions were more than five times more likely
to have a major perineal complication develop (one that
required invasive treatment). Even more interesting, pa-
tients receiving VRAM flaps were a third as likely to have a
major perineal complication develop. Unfortunately, this
information is not especially useful for selecting patients
for treatment. The conundrum of factors that truly render
patients to be “high risk” for perineal complications is not
clearly elucidated. Patients truly at high risk will clearly
benefit from VRAM flap reconstruction. It is less clear the
degree of benefit that patients not truly at high risk will
receive from a VRAM flap. A greater number, but not
specific type, of comorbid conditions can indicate poorer
general health, but such a criterion does not directly trans-
late to specific indications for using or not using a VRAM
flap to reconstruct APR defects. Future prospective studies
are needed to identify factors and conditions that can help
select the patients who are truly at high risk for perineal
complications and would benefit the most from flap recon-
struction in this setting.
The strengths of this study include strict inclusion crite-
ria to maximize the perineal defect similarity, an appropri-
ate control group, a relatively large number of patients,
similar extirpative and reconstructive techniques used for
702 Butler et al VRAM Flap Perineal Reconstruction
all patients, and a ⬎ 3-year mean followup period. Despite
the strict inclusion and exclusion criteria, this retrospective
study has some limitations. Patients were not randomly
assigned to receive a VRAM flap or primary closure; the
decision to perform flap reconstruction, rather than pri-
mary closure, was based on surgeon preference. This might
have resulted in some selection bias: the decision to refer a
patient preoperatively to the plastic surgery service might
have been because of the surgeon’s perception that the
defect would be more difficult to heal or of greater magni-
tude. This supposition is supported by the observations
that patients in the flap group had considerably more anal
SCCs, recurrent tumors, partial vaginectomies, and IORT
than those in the nonflap group. This potential bias toward
potentially greater wound severity in the flap group further
supports the benefits of VRAM reconstruction even when
the perineal defect can be closed primarily.
There is a trend at our institution, and other major
cancer centers nationwide, to refer patients who will be
undergoing APR to the plastic surgery service preoper-
atively, regardless of the nature or magnitude of the
planned resection. This is likely largely a result of the
high overall perineal wound complication rates observed
after APR and the commitment at our center to preop-
eratively coordinate multidisciplinary cases with recon-
structive surgeons interested and experienced in these
patients. We strongly believe that patients scheduled to
undergo APR or pelvic exenteration benefit from mul-
tidisciplinary evaluation and treatment from a coordi-
nated team, including medical oncologists, surgical on-
cologists, radiation oncologists, enterostomal therapists,
and reconstructive surgeons. Urologists and gynecologic
oncologists are also included in the team when pelvic
exenteration is considered. Preoperative planning and
communication between members of the treatment
team are critical to optimize patient education, operative
efficiency, and patient outcomes.
In conclusion, VRAM flap reconstruction of irradiated
APR defects reduces major perineal wound complications
without increasing early abdominal wall morbidity. Addi-
tional prospective studies will be important to develop cri-
teria to identify the patients who will benefit most from
flap reconstruction and evaluate abdominal wall morbidity
with a longer followup.
Author Contributions
Study conception and design: Butler
Acquisition of data: Butler, Gündeslioglu
Analysis and interpretation of data: Butler, Gündeslioglu,
Rodriguez-Bigas
J Am Coll Surg
Drafting of manuscript: Butler, Gündeslioglu
Critical revision: Butler, Gündeslioglu, Rodriguez-Bigas
Acknowledgment: We thank Drs Elisabeth Beahm, David
Chang, Pierre Chevray, Steven Kronowitz, Michael Miller,
Scott Oates, Gregory Reece, Geoffrey Robb, Roman Skoracki,
and Ron Yu from the Department of Plastic Surgery for con-
tributing reconstructive cases and Drs John Skibber, George
Chang, Steven Curley, Barry Feig, and Kelly Hunt from the
Department of Surgical Oncology for contributing extirpative
cases to this study. We also thank Joe Ensor, PhD, from the
Division of Quantitative Sciences for assistance with the sta-
tistical analysis.
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