Salvage VRAM Flap Reconstruction After Singapore Flap Failure Following Abdominoperineal Resection: A Case Report

Salvage reconstruction of perineal and vaginal defects following initial flap failure is a challenging and rarely reported clinical scenario. While the vertical rectus abdominis myocutaneous (VRAM) flap is a well-established technique for primary perineal reconstruction, its role as a salvage option following failure of initial flap reconstruction is seldom described. This case report presents a 54-year-old woman diagnosed with low rectal adenocarcinoma (cT4b, N+) with invasion of the sphincter complex, posterior vaginal wall, and rectovaginal fistula. After total neoadjuvant therapy (TNT) consisting of chemoradiotherapy with capecitabine followed by nine cycles of consolidation FOLFOX, the patient underwent abdominopelvic resection with initial vaginal wall reconstruction using bilateral Singapore (pudendal thigh) flaps. Postoperative bilateral flap necrosis at 14 days necessitated revision surgery, during which a pedicled VRAM flap, based on the deep inferior epigastric artery, was used for neovagina reconstruction and pelvic dead space obliteration. Pathological analysis confirmed ypT4bN0 (0/12 lymph nodes), modified Ryan tumor regression grade 2, with lymphovascular and perineural invasion. At a 17-month follow-up, there was no evidence of disease recurrence, and the reconstructed vagina and perineum demonstrated satisfactory healing. To our knowledge, no prior reports describe salvage VRAM reconstruction specifically following bilateral Singapore flap failure for vaginal reconstruction after abdominoperineal resection (APR) in an irradiated field. This case illustrates the application of a reconstructive algorithm for perineal and vaginal defects, highlighting the limitations of fasciocutaneous flaps in irradiated fields and the versatility of the VRAM flap as a reliable salvage option when initial reconstruction fails.