Vaginal reconstruction with rectus abdominis myocutaneous flaps after abdominoplasty

Sir,Invaginal reconstruction,autologousflapscanprovide coverageof a critical wound and return of function, which significantlyimproves psychological well-being and quality of life. Manypatients will have multiple reconstructive options for a vaginaldefect; however, there are some cases where an ideal flap existsand the alternatives are either suboptimal or infeasible. Wepresent a case to demonstrate the viability of performing avertical rectus abdominis myocutaneous flap (VRAM) for vag-inal reconstruction in a patient with a prior abdominoplasty.A 61-year-old female with a history of recurrent vaginalcancer after primary resection and radiation therapy presentedfor functional vaginal reconstruction after total pelvic exentera-tion. The patient’s surgical history was significant for a fullabdominoplastywithrectusplicationandumbilicaltransposition10yearspriortopresentation.Theconsiderabledefectcreatedbythe pelvic exenteration (Fig. 1)requiredalargeflaptofillthepelvicdeadspaceandalargeskinpaddletocreatetheneovaginalvault. Given the patient ’s ample abdominal subcutaneous tissue,apedicledVRAMwaschosentorepairthedefect.Askinpaddlewas designed such that the neovaginal vault would have a depthof 11 cm and a diameter of 3 cm. Using the equationcircumference ¼ pi diameter;a width of 9 cm was chosen for the skin paddle. Replacementof perineal skin loss required additional vertical length on theflap. Due to the length of skin needed, the skin paddle wasdesigned beyond the rectus abdominis onto the chest wall.Dissection was carried out in standard fashion with theexception that the entire width and length of fascia under theskinpaddlewasincludedwiththeflap.Thiswasdoneinorderto capture as manymusculocutaneousperforators as possible,maximizing perfusion to the skin paddle. After elevation, theflapmaintainednormalcapillaryrefillanddemonstratedgoodbleeding throughout the entire length of the skin paddle (Fig.2a).Theflapwasthenfoldedonitselftocreatetheneovaginalvault (Fig. 2b) and inset into the pelvis after dissection of thedeep inferior epigastric artery (Fig. 3).The patient was discharged in good condition 3 days later. Ather 6-week follow-up evaluation, the flap revealed a soft andfunctional vaginal opening and no recipient or donor site mor-bidity. The patient was last seen in follow-up 1-year postopera-tively and reported that she was able to have sexual intercourse.There are a number of options for vaginal reconstructionincluding Singapore flaps, posteri or thigh flaps, gracilis flaps,VRAM, colon, and jejunum. In our patient, the size of theperinealdefect,sizeofthedeadspacewithinthepelvis,andneedfor total circumferential reconstruction made the VRAM theoptimal flap for reconstruction. Its perforating myocutaneousvessels concentrated in the periumbilical area allow the utiliza-tion of a large skin paddle [ 1, 2]. Other reconstructive optionswere considered, such as bilater al gracilis flaps. However, therewas concern that they would not be able to provide the requiredsoft tissue and skin needed for the reconstruction. Failure toprovide reliable skin paddles for critical wound coverage couldhave resulted in devastating complications.There is considerable controversy concerning whether it issafe to use an abdominal myocutaneous flap after disruptionof the blood supply to the skin. The principles of flap perfu-sion suggest the possibility of revascularization of the skinfrom the undermined surface. However, the extent and reli-ability of this neovascularization is disputed [ 3].Manyplasticsurgeons would recommend against using abdominally basedflaps after abdominoplasty or liposuction [4, 5]. In addition,some authors recommend consent forms for abdominoplastyto include as a risk the loss of reconstructive options [6].