# Modified Vertical Rectus Abdominis Musculocutaneous Flap for Limb Salvage Procedures in Proximal Lower Limb Musculoskeletal Sarcomas

Authors: Haitham H. Khalil; Ahmed El-Ghoneimy; Yasser Farid; Walid Ebeid; Ahmed Afifi; Ahmed Elaffandi; Tarek Mahboub
Journal: Sarcoma
 (2008)

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## Abstract

Introduction and aim. Management of complicated wounds after tumor extipiration of pelvic and proximal lower limb musculoskeletal sarcoma represents an essential component in the outcome of these patients. The authors present modified vertical rectus abdominis musculocutaneous (VRAM) flap techniques to reconstruct extensive defects after debridment of these complicated wounds. Material and Methods. Over a period of 4 years (2002–2005), 5 men and 2 women were managed. Median age was 21 years (range 15–49). The patients were managed for complicated lower trunk, groin, and upper thigh wounds after resection of three pelvic chondrosarcomas as well as two pelvic and two proximal femur osteosarcomas. The modifications included a VRAM flap with lateral and tongue-like extension design of the skin paddle (5 cases) or a delayed extended VRAM flap (2 cases). Results. All flaps showed complete survival and healing with no ischemic events providing stable coverage. All patients were ambulant with good limb functions in terms of walking and gait after adequate rehabilitation, 2 needed support with crutches. Conclusion. The modified VRAM flaps offer reliable reconstructive tools for coverage of complex groin and thigh defects by providing larger well-vascularized soft tissue with acceptable donor site.


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## Body

## 1. Introduction

Limb salvage remains a major objective in contemporary management of
bony and soft tissue sarcomas of the pelvis and lower extremities [1, 2]. Radical oncological salvage procedures performed in this area can develop
significant wound complications that result from a high incidence of infection, dehiscence, or flap necrosis aggravated by the paucity of well-vascularized local soft tissue and systemically immune-compromised patients [3–6]. The reconstruction of extensive
and complex wounds as a secondary event after tumor extipiration represents a
challenging problem for both the orthopaedic and reconstructive surgeons [7].
This would thereby jeopardize the long-term wound healing with delay in the
postoperative adjuvant chemotherapy and eventually the successful outcome. The
authors present two modifications of the standard VRAM flap for coverage of
extensive potentially infected defects after radical debridement of complicated
groin and upper thigh wounds. The modifications included an inferiorly based
VRAM flap with lateral and tongue-like extension design of the skin paddle or a
delayed extended VRAM flap.


## 2. Material and Methods

Seven consecutive patients with complicated wounds secondary to resection of pelvic
and proximal lower extremity musculoskeletal sarcoma were managed with modified VRAM flaps between
2002–2005. The median
age of the patients in this series at the time of surgery was 21 years (range
15–49) and included 5 men and 2 women. The modifications included VRAM flap
with lateral and tongue-like extension design of the skin paddle (5 cases) or a
delayed extended VRAM flap (2 cases). All the patients have been treated with a
multidisciplinary approach; the management of osteosarcoma patients (2 pelvic,
2 proximal femur) included a 4-month course of neoadjavant chemotherapy
followed by resection of the primary tumor and postoperative 3-month course of chemotherapy;
while chondrosarcoma patients (3 pelvic) were offered surgical resection only.
The complications, which necessitated management by the plastic and
reconstructive surgeons, included infection and wound dehiscence with ultimate
exposure of metal prosthesis (4 patients) and necrosis of thigh flaps (3
patients). The median interval duration between the primary operation and the
reconstructive procedure for the complicated wounds was 16 days (range: 13–36).
All patients underwent thorough clinical assessment, adequate debridment and
irrigation of the wounds, followed by immediate coverage of the resultant
defects (median size7×17 cm) using
modified VRAM flaps.


## 3. Details of Modified Techniques

### 3.1. Delayed Extended VRAM Technique (2 Cases) (Figure1)

This technique was used to cover exposed metal plates due
to wound breakdown after osteosarcomas resection of proximal femur where length
of the flap was predominantly required than its width. An ipsilateral
parasternal skin paddle was designed 10 cm cephalic to the costal margin and 2 cm from the lateral sternal edge. The pinch test, originally described by
Taylor et al. [8], was used to determine the maximum width of the
skin              paddle allowing primary closure of the donor site [5]. A complete
semicircumferential incision (surgical delay) was done down to the pectoral
fascia. The parasternal fasciocutaneous flap was then harvested starting 10 cm
cephalic to the costal margin with caudal dissection in suprapectoral fascial
plane. This was followed by transecting the costal origin of rectus muscle and
ligation of the superior epigastric pedicle (vascular delay) leaving the
parasternal extension flap continuous with the skin paddle of the standard
VRAM. The flap was resutured and monitored for 2 weeks to identify the line of
demarcation between augmented perfused and nonperfused skin. The second stage
involved excision of the nonperfused skin (25–30%) of the
parasternal extension flap, refreshing the skin flap incision from the delay
procedure followed by harvesting VRAM flap utilizing the standard principles.
Special attention was paid when incising the medial and lateral borders of the
rectus muscle longitudinally along its entire length so as to leave a 1 cm of
sheath along each border for closure. The inferior epigastric pedicle was
skeletonised; thus providing the pivot point for rotation of the flap. The VRAM
flap throughout its whole length was harvested in continuity with the augmented
parasternal fasciocutaneous component leaving the posterior rectus sheath in
situ providing an additional average length of 7 cm. Tension-free closure of the donor site was
achieved by undermining the abdominal skin laterally beyond the margins of the
rectus abdominis muscle in the fascial plane.(a) A two-week picture after delay procedure (surgical and vascular delay) for extended
inferiorly based VRAM flap. The arrow points to line of demarcation between nonperfused
and augmented perfused skin in the parasternal fasciocutaneous extension of the
VRAM flap. This extension provided additional predictable length of 7 cm for
coverage of exposed plate femur after osteosarcoma resection of the proximal femur. (b) Intraoperative
picture after harvesting of VRAM flap and debridement of necrotic thigh flap.
The VRAM extension marked by the suture markings of the delay procedure
provides the extra length avoiding tension and providing durable coverage. (c) Postoperative
picture 3 months during chemotherapy course showing complete survival of the
flap providing stable coverage and complete healing of the donor site.
(a)(b)(c)


### 3.2. Laterally Oriented VRAM with Tongue-Like Skin Extension Technique (5 Cases)
(Figure2)

This technique was used in cases after resection of
chondrosarcomas and osteosarcomas of the pelvis, which necessitated the
development of large subcutaneous thigh flap to allow adequate exposure and
vascular exploration to achieve adequate oncological resection. Extensive full-thickness
thigh flap necrosis occurred in these patients which necessitated adequate
debridement and coverage of the resultant defect utilizing a contralateral,
laterally oriented VRAM with a tongue-like skin extension. The contralateral
muscle was selected due to the sacrifice of the ipsilateral inferior epigastric
pedicle as part of the radicality of the primary tumor resection. The lateral
orientation of the skin paddle was designed to be oblique (45°) to
the longitudinal axis of the rectus muscle to provide an average extra length
of 5 cm.  The tongue-like extension of
the skin paddle was designed throughout the whole length of the muscle tapering
towards the pivot point of the flap at the entry of the inferior epigastric
pedicle. The fasciomusculocutaneous component of the VRAM flap was harvested
utilizing the standard technique with elevation of the laterally oriented part
of the flap in the fascial plane. The
origin and insertion of rectus muscle were transacted leaving the vascular pedicle as
the sole tether point; this significantly increased the arc of rotation
allowing more muscle mass to be transposed to the wound.  Incising the skin
bridge between the donor and recipient defect to lay open the tunnel connecting
the recipient and the donor site followed this. The tongue-like skin extension provided the roof for
opened tunnel after rotation of the flap to settle to the defect; allowing more
room for the pedicle and providing coverage for the medial part of the defect.(a) Preoperative picture showing the dimensions and design of contralateral, laterally oriented
VRAM with a tongue-like extension. The arrow points to the necrotic thigh flap
advocated achieving adequate oncological resection for pelvic osteosarcoma. (b) Intraoperative
picture showing insetting of flap after debridment of the necrotic area. The
distal muscular component of the flap fills the composite defect which helps
resist infection in this potentially infected area. (c) Intraoperative
picture showing coverage of the defect with application of a split thickness
graft on the remaining muscular bed. The arrow points to the tongue-like skin
extension which avoids tension on the vascular pedicle especially after
dividing the origin and insertion and ensures adequate perfusion to the distal
portion of the flap. (d) Late postoperative picture 6 months after completion of chemotherapy course showing
complete survival of the flap with long-term durability and complete take of
the graft.
(a)(b)(c)(d)In all patients, the donor site was closed primarily
after reinforcement of the abdominal wall using an onlay prolene mesh, suction
drains were used both at the recipient and donor sites. All patients were
mobilized within 2 weeks postoperatively under supervision of the orthopaedic
and physical therapy team. The mean duration to postoperative chemotherapy was
3 weeks. The mean follow-up period was 26 months at which patients were followed up with assessment of the oncological outcome, durability of soft tissue reconstruction, and finally assessing the functional outcome using Enneking system,


## 3.1. Delayed Extended VRAM Technique (2 Cases) (Figure1)

This technique was used to cover exposed metal plates due
to wound breakdown after osteosarcomas resection of proximal femur where length
of the flap was predominantly required than its width. An ipsilateral
parasternal skin paddle was designed 10 cm cephalic to the costal margin and 2 cm from the lateral sternal edge. The pinch test, originally described by
Taylor et al. [8], was used to determine the maximum width of the
skin              paddle allowing primary closure of the donor site [5]. A complete
semicircumferential incision (surgical delay) was done down to the pectoral
fascia. The parasternal fasciocutaneous flap was then harvested starting 10 cm
cephalic to the costal margin with caudal dissection in suprapectoral fascial
plane. This was followed by transecting the costal origin of rectus muscle and
ligation of the superior epigastric pedicle (vascular delay) leaving the
parasternal extension flap continuous with the skin paddle of the standard
VRAM. The flap was resutured and monitored for 2 weeks to identify the line of
demarcation between augmented perfused and nonperfused skin. The second stage
involved excision of the nonperfused skin (25–30%) of the
parasternal extension flap, refreshing the skin flap incision from the delay
procedure followed by harvesting VRAM flap utilizing the standard principles.
Special attention was paid when incising the medial and lateral borders of the
rectus muscle longitudinally along its entire length so as to leave a 1 cm of
sheath along each border for closure. The inferior epigastric pedicle was
skeletonised; thus providing the pivot point for rotation of the flap. The VRAM
flap throughout its whole length was harvested in continuity with the augmented
parasternal fasciocutaneous component leaving the posterior rectus sheath in
situ providing an additional average length of 7 cm. Tension-free closure of the donor site was
achieved by undermining the abdominal skin laterally beyond the margins of the
rectus abdominis muscle in the fascial plane.(a) A two-week picture after delay procedure (surgical and vascular delay) for extended
inferiorly based VRAM flap. The arrow points to line of demarcation between nonperfused
and augmented perfused skin in the parasternal fasciocutaneous extension of the
VRAM flap. This extension provided additional predictable length of 7 cm for
coverage of exposed plate femur after osteosarcoma resection of the proximal femur. (b) Intraoperative
picture after harvesting of VRAM flap and debridement of necrotic thigh flap.
The VRAM extension marked by the suture markings of the delay procedure
provides the extra length avoiding tension and providing durable coverage. (c) Postoperative
picture 3 months during chemotherapy course showing complete survival of the
flap providing stable coverage and complete healing of the donor site.
(a)(b)(c)


## 3.2. Laterally Oriented VRAM with Tongue-Like Skin Extension Technique (5 Cases)
(Figure2)

This technique was used in cases after resection of
chondrosarcomas and osteosarcomas of the pelvis, which necessitated the
development of large subcutaneous thigh flap to allow adequate exposure and
vascular exploration to achieve adequate oncological resection. Extensive full-thickness
thigh flap necrosis occurred in these patients which necessitated adequate
debridement and coverage of the resultant defect utilizing a contralateral,
laterally oriented VRAM with a tongue-like skin extension. The contralateral
muscle was selected due to the sacrifice of the ipsilateral inferior epigastric
pedicle as part of the radicality of the primary tumor resection. The lateral
orientation of the skin paddle was designed to be oblique (45°) to
the longitudinal axis of the rectus muscle to provide an average extra length
of 5 cm.  The tongue-like extension of
the skin paddle was designed throughout the whole length of the muscle tapering
towards the pivot point of the flap at the entry of the inferior epigastric
pedicle. The fasciomusculocutaneous component of the VRAM flap was harvested
utilizing the standard technique with elevation of the laterally oriented part
of the flap in the fascial plane. The
origin and insertion of rectus muscle were transacted leaving the vascular pedicle as
the sole tether point; this significantly increased the arc of rotation
allowing more muscle mass to be transposed to the wound.  Incising the skin
bridge between the donor and recipient defect to lay open the tunnel connecting
the recipient and the donor site followed this. The tongue-like skin extension provided the roof for
opened tunnel after rotation of the flap to settle to the defect; allowing more
room for the pedicle and providing coverage for the medial part of the defect.(a) Preoperative picture showing the dimensions and design of contralateral, laterally oriented
VRAM with a tongue-like extension. The arrow points to the necrotic thigh flap
advocated achieving adequate oncological resection for pelvic osteosarcoma. (b) Intraoperative
picture showing insetting of flap after debridment of the necrotic area. The
distal muscular component of the flap fills the composite defect which helps
resist infection in this potentially infected area. (c) Intraoperative
picture showing coverage of the defect with application of a split thickness
graft on the remaining muscular bed. The arrow points to the tongue-like skin
extension which avoids tension on the vascular pedicle especially after
dividing the origin and insertion and ensures adequate perfusion to the distal
portion of the flap. (d) Late postoperative picture 6 months after completion of chemotherapy course showing
complete survival of the flap with long-term durability and complete take of
the graft.
(a)(b)(c)(d)In all patients, the donor site was closed primarily
after reinforcement of the abdominal wall using an onlay prolene mesh, suction
drains were used both at the recipient and donor sites. All patients were
mobilized within 2 weeks postoperatively under supervision of the orthopaedic
and physical therapy team. The mean duration to postoperative chemotherapy was
3 weeks. The mean follow-up period was 26 months at which patients were followed up with assessment of the oncological outcome, durability of soft tissue reconstruction, and finally assessing the functional outcome using Enneking system,


## 4. Results

All flaps showed complete survival and healing with
no ischemic events, hence providing stable coverage. Mild infection was
observed in 1 patient; no haematomas were detected. All patients were ambulant
with good limb functions in terms of walking and gait after adequate
rehabilitation; 2 needed additional support with crutches. All patients showed
good emotional acceptance; and no pain has been observed during ambulation in
all patients. One patient developed incisional hernia at the donor site that required
repair 1 year later; otherwise, no other donor site morbidity was noted.
Another patient died of haematogenous metastatic spread after complete
resection 15 months later. There was no hypertrophic scar formation or flap
breakdown experienced on long-term follow-up in any of the patients.


## 5. Discussion

Limb preservation has become a more realistic and
necessary goal in the management of patients with musculoskeletal sarcoma of
extremities [9]. Radiation and chemotherapy in addition to limb
preservation through recent refinement in reconstructive surgery have improved
the local, systemic control and the subsequent overall survival [10, 11]. The most common complications of limb salvage procedures for musculoskeletal
sarcomas surgery have been problems with wound healing, flap necrosis, and
wound infections [1, 6]. Infections associated with prosthetic
replacement after tumor resection in these patients are common and serious
complications as they are often subjected to extensive soft tissue dissection and long operating times while
systemically immunocompromised [5, 6, 12].The reconstructive options to provide coverage
following debridment of these complicated wounds would be local, distant flaps,
or free-tissue transfer.  VRAM flaps have
been used successfully in coverage of defects of the chest wall, groin, hip,
perineal, vaginal, and gluteal regions with good functional outcomes [13–17]. The advantages
of pedicled standard VRAM are providing ample
skin, soft tissue bulk, simplicity of execution, low complication rate, and
high success rate [18] in which a safe and fast forward flap procedure
is the reconstructive goal especially in high-risk group. In this study,
modifications have been applied to the standard VRAM flaps in an attempt to
mobilize larger well-vascularized soft tissue for coverage of large defects after
debridment of complicated groin and thigh wound as a secondary event. These
modifications included either a modified laterally oriented VRAM with
tongue-like skin extension or a delayed extended inferiorly based VRAM. The
design of the lateral orientation is based on a well-established vascular
anatomy of inferior epigastric vessels which give rise to large fasciocutaneous
perforators that communicate by means of choke vessels to anterior branches of
lateral intercostals vessels at a 45-degree angle to the anterior axillary
line [8, 19] Also, the superior epigastric artery
divides into 2-3 branches almost immediately upon entering the rectus muscle; the lateral segmental branch
skirts the costal margin in
the neurovascular plane and eventually becomes the eighth intercostal artery. These muscular
branches give rise to musculocutaneous perforators, which also anastomose with
deep inferior epigastric pedicle [20–22]. Buchel et al. have
found that preservation of the origin of the rectus muscle to the pubis
protected the pedicle from undo or twist [16]. The authors believe that
the tongue-like skin extension design also avoids traction injury of the fibrovascular
pedicle, which serves as the sole tether point after transecting the origin and
insertion of the muscle. Therefore, this provides more reliability to the flap while
increasing the arc of rotation. In addition, it ensured adequate perfusion to
the distal portion of the flap through preservation of the continuity of the
subdermal plexus supplied through periumbilical perforators from the inferior
epigastric. Moreover, this extension provided coverage for the medial part of
the defect. Previous studies have introduced modification on the rectus
abdominis muscle flap to provide extralength, such as oblique rectus abdominis
musculocutaneous (ORAM) flap [14]. Harvesting of the ORAM may be easier
with less dissection and morbidity, but the authors believe that providing the
distal muscular component rather than the distal thin fasciocutaneous component
of the ORAM is necessary. The muscular component of the VRAM has been utilized
to fill the cavity, provide adequate blood supply, and act as an antibiotic
delivery system to resist infection [4, 7] in this high-risk
immunocompromosed group of patients.  In addition, the presence of
valves in veins of the inferior epigastric system and intramuscular lymphatic
bundles in the rectus muscle reduces the incidence of venous stasis, oedema,
and lymphoedema in the dependant portion of these large flaps [2, 4].The delayed phenomenon has been used for many years
to enhance functional blood flow through vasodilatation of the arterial network
and avoidance of complete vasoconstriction caused by catecholamine release, and
hence it increases the flap reliability especially in high-risk
patients [23, 24]. The delayed transverse rectus
abdominis musculocutaneous (TRAM)
flap has been widely described in the literature especially for breast
reconstruction in high-risk patients [25]; on the other hand, standard
VRAM flaps have been used for chest wall reconstruction especially for
intractable radiation ulcers [26]. However, to the authors’ best
knowledge, there has been a lack of description for the delayed VRAM flap in
literature being reported only as a case report based on the superior
epigastric for chest wall reconstruction [20].  Accordingly, this would be the first report
about an inferiorly based delayed extended VRAM flap which has been used in two
patients harvesting an additional fasciocutaneous component from the chest wall
in continuity with fasciocutaneous component of VRAM. The standard technique
for harvesting the VRAM may lead to ischemia and venous congestion in the
distal portion with a higher incidence of flap failure [16].  Therefore, performing
the two-stage complete circumferential surgical and vascular delayed technique has provided an additional
safe, reliable, and predictable extralength in this high-risk group without
jeopardizing the wound healing and with no further delay in the postoperative
chemotherapy treatment. The pinch technique described by Taylor et al. [8]  have
shown to avoid any donor site morbidity with excision of the nonperfused skin
demarcated from the augmented perfused skin. The use of the delayed
pre-expanded tissue has not been considered in these patients due to the marked
delay in coverage and postoperative chemotherapy treatment.The authors believe that these modifications will
provide reliable extralength of soft tissue, which is tension free with a wider
arc of rotation, better filling of dead space with well-vascularized tissue so
as to resist infection, and stable coverage with good functional outcome.Other modalities described for management of
complicated infected wounds as skin grafting or vacuum-assisted closure would
not be suitable due to the presence of dead space and exposed hardware
prosthesis after debridement [2, 4, 27]. The local effects of
infections and/or surgical trauma create a dearth of local soft tissue
available to provide stable coverage of these complex wounds. In previous
studies, trials have reported to cover proximal lower limb defects with either
single or combined large lower extremities flaps [28, 29]. The local
muscle flaps in this region are often hypovascular and fibrotic rendering them
insufficient to provide sufficient soft tissue coverage, in addition, the use
of local muscle flaps may result in loss of
extremity and joint stability [7, 18, 27]. The authors believe that
the use of these muscles may further compromise an already weakened extremity,
making distant flaps as rectus abdominus muscle a better choice for reconstruction.The use of free-tissue transfer is rare in these
clinical scenarios; on the other, hand-free osteocutaneous fibular flaps were
performed for primary skeletal reconstruction after tumor extipiration of
sarcoma of the lower extremities [30] rather than soft tissue
reconstruction for complicated groin wounds as a secondary event. While microvascular
options could be considered, the limited availability of recipient vessels with
higher incidence of vascular complications, proximity of anastomosis to
potentially infected zone following previous radical surgery, opening new
dissection plane, and lengthy operative time in immunocompromosed patients would preclude the use of
this option in these settings as the first option [2, 4, 27]. In addition, venous drainage and tissue oedema may also be more problematic with such flaps
in dependant portion of the lower extremity [2].


## 6. Conclusion

In conclusion, the modified VRAM flaps would offer
reliable reconstructive tools for coverage of complicated primary wound with
necrosis and breakdown after radical resection of pelvic and proximal lower
limb musculoskeletal sarcoma. They offer larger well-vascularized soft tissue
with acceptable donor site, more durable coverage with no delay in the
postoperative adjuvant therapy, good functional outcome, together with overall
improvement in the survival.



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*Source: 781408-2008-03-12.xml*