OBJECTIVES: Extensive perineal resections often require autologous tissue reconstruction, especially in wide oncological resections. Local and regional pedicled flaps from the lower extremity and abdominal sites have been described. Defects of the pelvis and perineum rarely require free-tissue transfer. The vertical rectus abdominis myocutaneous (VRAM) flap, traditionally delivered to the perineum through an intraperitoneal transpelvic route, is a workhorse flap for combined pelvic and perineal defects because of its ability to provide substantial coverage of the perineum, reliable vascular supply, and larger volume to obliterate dead space. We propose and describe an extended VRAM flap for vulvar reconstruction delivered to the perineum in an extrapelvic fashion. METHODS: A 54-year-old woman with a prior history of anal squamous cell carcinoma underwent neoadjuvant chemoradiotherapy followed by abdominoperineal resection, total abdominal hysterectomy, and bilateral salpingo-oophorectomy. Three years later, she developed vulvar squamous cell carcinoma with vascular and lymphatic invasion and underwent radical vulvectomy and distal urethrectomy. The resection defect was 10 x 15 cm, including the distal 1 cm of the urethra, distal vaginal orifice, and wide exposure of the pubic bone. An extrapelvic extended VRAM flap was used for reconstruction. RESULTS: The flap was harvested and transposed into the defect via a wide suprapubic subcutaneous tunnel. A neovaginal and urethral orifice was created in the flap by splitting the muscle in the direction of its fibers, taking care to protect the vascular pedicle, and inset to the vaginal orifice. There were no postoperative complications. She has maintained urinary continence with follow-up of 38 months. CONCLUSIONS: Introduction of a rectus abdominis flap to the perineum through an extrapelvic route is preferred if laparotomy is not used for the resection. We successfully report and advocate the use of an extended VRAM flap for vulvar reconstruction delivered to the perineum in an extrapelvic fashion.
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机译：目的：广泛的会阴切除术通常需要自体组织重建，尤其是在广泛的肿瘤切除术中。已经描述了来自下肢和腹部部位的局部和区域蒂蒂皮瓣。骨盆和会阴部的缺陷很少需要自由组织转移。垂直腹直肌肌皮瓣（VRAM）通常通过腹膜内经骨盆腔途径输送到会阴，是用于合并骨盆和会阴缺损的主力皮瓣，因为它能够提供对会阴的实质性覆盖，可靠的血管供应和更大的容积消灭死空间。我们提出并描述了一种扩展的VRAM瓣，用于以骨盆外的方式输送到会阴部。方法：一名54岁有肛门鳞状细胞癌病史的妇女接受了新辅助放化疗，随后进行了腹部手术切除，全腹子宫切除术和双侧输卵管卵巢切除术。三年后，她发展出具有血管和淋巴管浸润的外阴鳞状细胞癌，并接受了根治性外阴切除术和远端尿道切除术。切除缺损为10 x 15厘米，包括尿道远端1厘米，阴道远端孔口以及耻骨的广泛暴露。骨盆外延伸的VRAM瓣用于重建。结果：皮瓣被收集，并通过一条耻骨上皮下广泛的隧道转移到缺损中。沿皮瓣纤维方向分裂肌肉，在皮瓣上形成一个新阴道和尿道口，注意保护血管蒂，并插入阴道口。没有术后并发症。她已进行了38个月的随访，保持了尿失禁。结论：如果不进行剖腹手术，最好通过腹外途径将腹直肌皮瓣引入会阴。我们成功地报告并主张将扩展的VRAM瓣用于盆腔外方式输送至会阴的外阴重建。
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