A prepelvic tunnel for the rectus abdominis myocutaneous flap in perineal reconstruction

The use of the transpelvic vertical rectus abdominis myocutaneous (VRAM) flap in pelvic reconstruction is well documented. It can be used to fill large defects after pelvic exenteration, reconstruct the vagina and provide skin coverage in perineal reconstruction. This study examines an alternate prepelvic pathway for the flap to enhance its versatility and reliability.

A female patient with recurrent squamous cell carcinoma in the pelvis, who underwent radical pelvic exenteration and a successful VRAM flap reconstruction with a prepelvic tunnel.

The patient experienced a small area of epithelial tip necrosis over the sacral promontory from shear forces. This healed with dressings within two weeks. There were no major flap complications and the patient had good flap integrity at one-year follow-up. The prepelvic pathway for the VRAM flap is advantageous to the conventional transpelvic course in perineal reconstruction. The more direct, shorter path to the defect allows for a more reliable skin paddle design without the need for de-epithelialisation. A greater area of skin paddle is available and creates a more versatile flap with no tension on the pedicle. This is especially in cases where a skin paddle is needed for vaginal reconstruction or when pelvic organs such as bladder and uterus are left in situ. These advantages may result in less flap complications.