Operative Technique in Plastic Surgery – Kevin C.Chung

caliber sutures around the groin may become infected with wound healing
problems, necessitating removal of the exposed suture.
■ Unsatisfactory scar: symmetrical treatment with sequential, stepwise tissue
excision and avoidance of high tension closure assists in optimizing scar.
Irregular contour of the inner thigh with vertical thigh lift is not uncommon as
posterior thigh tissue is thicker than the anterior tissues, so it is important to not
pull posterior tissue forward.
■ Venous thromboembolism: It is necessary preoperatively to check on any
history or elevated risk as per the modified Caprini scale. Patients must be
encouraged to ambulate after surgery.
■ Infection is not common, and risk can be reduced by optimizing surgical
conditions like addressing efficiency with reduced operative time and
hypothermia, as well as initial dose of antibiotics prior to making incision.
Seromas can become sources of infection and should be treated.
SUGGESTED READINGS
1. Capella JF, Matarasso A. Management of the postbariatric medial thigh
deformity. Plast Reconstr Surg. 2016;137(5):1434-1446.
2. Capella JF. The vertical medial thigh lift. Clin Plast Surg. 2014;41(4):
727-743.
3. Gusenoff JA, Coon D, Nayar H, et al. Medial thigh lift in the massive weight
loss population: outcomes and complications. Plast Reconstr Surg.
2015;135(1):98-106.
4. Pannucci CJ, Barta RJ, Portschy PR, et al. Assessment of postoperative
venous thromboembolism risk in plastic surgery patients using the 2005 and
2010 Caprini Risk score. Plast Reconstr Surg. 2012;130(2):343-353.
5. Richter DF, Stoff A. Circumferential body contouring: the lower body lift.
Clin Plast Surg. 2014;41(4):775-788.
6. Shermak M, Shoo B, Deune EG. Prone positioning precautions in plastic
surgery. Plast Reconstr Surg. 2006;117(5):1584-1588.
7. Shermak MA, Mallalieu J, Chang D. Does thigh plasty for upper thigh laxity
after massive weight loss require a vertical incision? Aesthet Surg J.
2009;29(6):513-522.

22
CHAPTER
Section IV: Reconstruction
of Perineal Defects
Vertical Rectus Abdominis
Myocutaneous Flap for
Perineal Reconstruction
Sahil K. Kapur and Charles E. Butler
DEFINITION
■ The vertical rectus abdominis myocutaneous (VRAM) flap plays a beneficial
role in improving postoperative outcomes for patients with defects created
following abdominoperineal resection (APR) and pelvic exenteration (PE)
surgery.
■ Complications following APR and PE are related to large noncollapsible dead
space, commonly irradiated dead space, with poor vascularity and bacterial
contamination.1
■ The flap provides healthy vascularized tissue to help obliterate the pelvic dead
space—created after the resection. It serves as a barrier between the abdominal
and pelvic cavity, as well as a source of skin and soft tissue for reconstructing
and resurfacing the perineum.
ANATOMY
■ The rectus abdominis muscle originates from the 6th, 7th, and 8th costal
cartilages and inserts on the pubic bone. It measures approximately 6 cm in
width at its origin and 3 cm in width at the insertion.
■ It has a dual codominant blood supply (Type III Mathes/Nahai). Superiorly, it
is supplied by the superior epigastric artery, a branch of the internal thoracic
artery. Inferiorly, it is supplied by the deep inferior epigastric artery a branch of

the external iliac artery.
■ The deep inferior epigastric artery originates from the external iliac vessels at
a point between the inguinal ligament to about 6 cm above it. The vessel enters
the posterior rectus sheath at about the level of the ASIS and the arcuate line (4
to 6 cm above the pubic bone). This artery usually splits into a lateral and
medial branch that supplies the lateral and medial row of myocutaneous
perforators. Knowledge of perforator anatomy is important when attempting
the fascial-sparing approach of VRAM harvest.
■ The skin paddle for the VRAM flap is usually designed to include
paraumbilical myocutaneous perforators. Extension of the skin paddle
superiorly can be carried out without taking additional fascia (extended VRAM
flap as described later). This is possible because the intercostal perforators
supplying the extended portion have direct perforator-to-perforator connections
with the epigastric perforators in the standard skin paddle.2
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Patients are assessed preoperatively to determine risk factors that would
increase complication rates such as obesity, hernia, smoking, steroid treatment,
and prior chemoradiation.
■ A detailed surgical history is important to ensure that the patient has not had
any prior surgeries that could have injured the deep inferior epigastric artery
pedicle. Surgeries such as C-sections have a more medially placed scar and
generally do not lead to pedicle injury. Prior abdominoplasty surgery is a
relative contraindication to the use of a skin paddle because the perforators
have been divided.
■ Physical examination includes an examination of the abdomen and pelvic
region for scars and assessment of hernias.
IMAGING
■ Imaging involving CT or MRI is generally available because most patients
have undergone an oncologic workup. CT images help determine the amount of
diastasis, integrity and bulk of lateral abdominal musculature (in case a
component separation is needed), and the presence of hernias.
■ No special imaging to assess perforators is necessary for this reconstruction.
SURGICAL MANAGEMENT
Preoperative Planning

■ Patients with pelvic or perineal defects benefit from pedicled VRAM flap
reconstruction. The flap is based on the deep inferior epigastric artery. A skin
paddle is used to provide skin resurfacing of the perineum. It can be de-
epithelialized to provide bulk if necessary when the perineal skin is completely
closed.
Positioning
■ Patients are generally positioned in the lithotomy position by the resecting
team. All areas of resection including the perineum and the abdomen beyond
the level of the costal margin are prepped into the field.
Approach
■ In general, two or more teams are involved. The reconstructive team will begin
the operation if a fascial-sparing technique is to be used. The reconstructive
team performs the laparotomy and spares the medial aspect of the anterior
rectus sheath. Following the oncologic resection, the reconstructive team
performs their portion of the procedure.
■ The ostomy(s) are matured after the reconstruction is completed and the
abdomen is closed.
T E C H N I Q U E S
■ Flap Harvest
■ Make a midline skin incision, and dissect down to the linea alba (TECH FIG
1A,B).
■ Once the rectus sheath is identified, begin dissecting laterally, superficial to
the rectus sheath, to locate periumbilical and medial row perforators to the
skin paddle.
■ Incise the anterior rectus sheath 2 to 3 cm lateral to the midline but medial to
the medial row perforators.
■ Retract the rectus abdominis muscle laterally to expose the posterior rectus
sheath.
■ Incise the posterior rectus sheath 2 cm lateral to the midline to gain
intraperitoneal access. Curve the incision back toward the linea alba at the

arcuate line.
■ Advance and suture the posterior rectus sheath to the anterior rectus sheath
to protect the rectus abdominis muscle during the resection component of the
procedure.
■ Resume reconstruction once the resection has been completed. The ostomy
is usually passed through the contralateral rectus abdominis muscle and
matured by the primary team after the reconstruction and abdominal closure.
■ Examine the perineal defect to estimate the bulk and nature of tissue needed.
This information is used to decide if a skin paddle will be used or the perineal
skin will be closed primarily over the flap.
■ Design the skin paddle over the rectus abdominis muscle such that it will
reach the defect once the muscle is transposed.
■ Release the sutures that were previously placed between the anterior and
posterior rectus sheath.
■ Complete the soft tissue dissection to isolate the skin paddle.
■ Dissect the flap from lateral to medial over the anterior rectus sheath to just
lateral to the lateral row perforators.
■ Incise the anterior sheath just lateral to the lateral row perforators.
■ Dissect the lateral aspect of the anterior rectus sheath from the anterior
surface of rectus abdominis muscle using a combination of finger dissection
and electrocautery.
■ Dissect carefully through areas of muscle inscriptions to prevent damage to
the overlying rectus sheath or to the muscle itself.
■ Dissect the rectus muscle off the posterior rectus sheath.
■ Transect the rectus muscle cranial to the skin paddle and ensure the superior
epigastric vascular pedicles are ligated.
■ Rotate the flap medially and transpose it into the abdomen and pelvis.
■ Ensure that the inferior epigastric artery and vein are dissected free from all
soft tissue attachments to prevent compression and kinking of the pedicle.
■ Leave the rectus muscle attached at its origin on the pelvis to prevent tension
on the pedicle (TECH FIG 1C).

TECH FIG 1 • Fascial-sparing approach to the harvest
of a VRAM flap. A. The inner solid lines demonstrate
the area of fascia harvested, red dots demonstrate the
approximate location of perforators, and the area
marked by horizontal lines demonstrates the area of
fascial sparing. B. Important landmarks are indicated.
C. VRAM flap after it has been elevated. The musle is
left connected to its origin at the pubis. (© Charles E.
Butler, MD.)
■ The above described fascial-sparing approach is not advised when previous
midline laparotomies, adjacent hernia sacs, and scarring prevent perforator
identification.
■ Extended Skin Paddle Option
■ In cases where additional bulk or length is needed, the skin paddle of the
flap can be extended in the superolateral direction. Technique is described
below:
■ Make a curvilinear incision starting from the superiormost aspect of the

midline incision extending cephalad toward the inframamary fold and
laterally toward the posterior axillary line. This line approximately parallels
the general direction of the ribs. The inferior aspect of the extended skin
paddle is based on the amount of laxity present to close the donor site
(TECH FIG 2).
■ Do not incise any additional fascia with this superolateral extension. The
extended portion of the flap is elevated in the subcutaneous plane.
TECH FIG 2 • Skin paddle design of the extended
VRAM flap. (© Charles E. Butler, MD.)
■ Flap Inset
■ After the flap has been elevated and transposed into the pelvis, place one or
two 19-French round channel drains into the pelvic space.

■ Inset the flap to maximize dead space fill and minimizes torque on the
pedicle. If vaginal reconstruction is necessary then orient the flap with the
skin paddle facing anteriorly. The skin paddle is oriented to face the anterior
direction, the distalmost tip of the flap ends up posterior.
■ De-epithelialize the skin paddle to the dimension necessary to reconstruct
the skin defect. Use the rest of the epithelialized portion to close the perineal
skin defect (TECH FIG 3A,B).
■ When the perineal skin is closed primarily without a skin paddle, the
VRAM flap is completely de-epithelialized (TECH FIG 3C–E).
■ Anchor the flap to remnant tissue in the pelvis using interrupted 2-0
resoluble sutures.
■ Close the skin in a vest over pants fashion. Use 3-0 resorbable sutures for
buried deep dermal sutures and 3-0 permanent monofilament sutures for the
interrupted skin sutures.
■ Two round channeled drains are used to drain the perineal space.

TECH FIG 3 • A,B. Reconstruction of the perineum
with a VRAM flap and a skin paddle. (© Charles E.
Butler, MD.) C,D. Reconstruction of perineum without
a skin paddle. E. Flap in place with the skin paddle de-
epithelialized. Primary closure of skin over the flap. (©
Charles E. Butler, MD.)
■ Donor Site Closure
■ If primary closure of the rectus sheath is not possible due to excessive
tension, perform ipsilateral component separation by incising the external
oblique aponeurosis and dissecting between the external and internal oblique
muscles. If the fascial integrity is good, component separation will be enough
(TECH FIG 4).
■ However, if the fascial integrity is poor or the fascial closure is tight then a
mesh can be used to reinforce the closure.
■ If primary closure is possible without excessive tension, suture rectus sheath
using interrupted monofilament suture in figure-of-8 fashion. Include both
the anterior and posterior sheath in the closure superior to the arcuate line.
■ Place a round channel drain superficial to the rectus sheath to drain the
subcutaneous space.
■ Approximate the Scarpa fascia with interrupted 2-0 resorbable sutures.
■ Approximate the skin with 3-0 resorbable sutures in a deep dermal fashion

followed by a running subcuticular stitch with 4-0 resorbable sutures.
TECH FIG 4 • A. Diagram of open unilateral
component separation. B. In this operative
photograph, the black line demonstrates the extent of
release. The green arrow indicates the fascial edge of
the external oblique aponeurosis. (© Charles E. Butler,
MD.)
PEARLS AND PITFALLS
Skin
paddle
design
■ Make sure the skin paddle is positioned appropriately such that it will
include the periumbilical perforators and reach the distalmost aspect of
the defect following muscle transposition.
■ If significant amount of bulk at the distal reach of the flap is required,
then the extended skin paddle technique should be used as described in
the techniques section.
Fascial-
sparing
technique
■ Fascial sparing is not advised when previous abdominal surgery,
adjacent hernia sacs, and scarring prevent perforator identification.

Donor-
site
closure
■ Abdominal closure following VRAM harvest should be treated as a
formal abdominal wall reconstruction. The scenario is more complex
than encountered with a standard laparotomy. The central fascial defect
on the side of the VRAM harvest, an ostomy on the contralateral side,
and contamination from colon transection increase risk of wound
complications and morbidity.
POSTOPERATIVE CARE
■ A foam thigh abduction pillow can be used to prevent adduction of the legs
and compression of the skin paddle.
■ Patients are allowed to ambulate on the first postoperative day. No direct
sitting is allowed for the first 3 weeks. Hospital stay ranges from 5 to 7 days.
OUTCOMES AND COMPLICATIONS
■ Perineal wound complication rate following APR ranges from 25% to 60%.3
■ Patients who undergo primary closure of APR defects have a much higher
complication rate than those who undergo VRAM flap reconstruction (44% vs
16%).4
■ Time to perineal wound healing following wound complication is shorter for
patients who undergo VRAM reconstruction compared to patients who
undergo primary closure. (Average time: 65 vs 92 days).4
■ VRAM use is beneficial even if primary closure is possible in patients
undergoing APR following chemoradiation. In these cases, patients who
receive VRAM reconstruction have a significantly reduced rate of perineal
abscess (9% vs 37%), wound dehiscence (9% vs 30%), and need for drainage
procedures for fluid collections (3% vs 25%).1
■ Fascial-sparing techniques in VRAM harvest have reduced abdominal hernia
rates from 11.5% to 1.5 %.5
■ Component separation technique for donor-site closure leads a threefold lower
fascial dehiscence rate and a fourfold lower incisional hernia rate.6
■ The use of an underlay mesh in patients with poor fascial integrity has also
reduced abdominal hernia rates (2.6% vs 5.5%).5
■ Reconstruction of perineal defects with the use of VRAM flaps has significant
advantages over the use of thigh flaps in reducing complication rates (donor-
site or recipient site cellulitis, pelvic abscess, and major wound dehiscence).7
REFERENCES

1. Butler CE, Gundeslioglu AO, Rodriguez-Bigas MA. Outcomes of immediate
vertical rectus abdominis myocutaneous flap reconstruction for irradiated
abdominoperineal resection defects. J Am Coll Surg. 2008;206(4):694-703.
2. Villa M, Saint-Cyr M, Wong C, Butler CE. Extended vertical rectus abdominis
myocutaneous flap for pelvic reconstruction: three-dimensional and four-
dimensional computed tomography angiographic perfusion study and clinical
outcome analysis. Plast Reconstr Surg. 2011;127(1):200-209.
3. Butler CE, Rodriguez-Bigas MA. Pelvic reconstruction after
abdominoperineal resection: is it worthwhile?. Ann Surg Oncol. 2005;12(2):
91-94.
4. Chessin DB, Hartley J, Cohen AM, et al. Rectus flap reconstruction decreases
perineal wound complications after pelvic chemoradiation and surgery: a
cohort study. Ann Surg Oncol. 2005;12(2):
104-110.
5. Campbell CA, Butler CE. Use of adjuvant techniques improves surgical
outcomes of complex vertical rectus abdominis myocutaneous flap
reconstructions of pelvic cancer defects. Plast Reconstr Surg. 2011;
128(2):447-458.
6. Baumann DP, Butler CE. Component separation improves outcomes in
VRAM flap donor sites with excessive fascial tension. Plast Reconstr Surg.
2010;126(5):1573-1580.
7. Nelson RA, Butler CE. Surgical outcomes of VRAM versus thigh flaps for
immediate reconstruction of pelvic and perineal cancer resection defects. Plast
Reconstr Surg. 2009;123(1):175-183.

23
CHAPTER
Gluteal Thigh Flap for
Perineal Reconstruction
David Gerth and Christopher J. Salgado
DEFINITION
■ Gluteal thigh flap is an axial fasciocutaneous flap based on the inferior gluteal
artery.
■ Usually raised as a pedicled flap, but free flap technique has been reported
ANATOMY (FIG 1)
■ Blood supply: Descending branch of inferior gluteal artery1
■ Terminal branch of the internal iliac artery.
■ Course: exits the pelvis through the infrapiriform aperture
■ Supplies the lower aspect of the gluteus maximus muscle and overlying skin
through musculocutaneous perforators2
• These perforators combine with branches of the circumflex femoral arteries
and obturator artery to create the cruciate anastomosis.
• This anastomosis allows the posterior thigh to be adequately perfused even
in the case of an absent inferior gluteal artery.

FIG 1 • Relevant surgical anatomy for the gluteal thigh
flap. Note the relationship of the posterior femoral
cutaneous nerve to the inferior gluteal artery. This
classic relationship is not constant, however.
• Recent study has shown that cutaneous branches supplying the distal
gluteal and proximal posterior thigh can be more regularly identified.
• 108 of 118 specimens had cutaneous branches derived from the descending
branch of the inferior gluteal artery. Ten cases derived from medial or lateral
circumflex femoral artery or from the profunda femoris.3
■ Pedicle is usually spared during radical pelvic ablations.
■ Pedicle is usually outside the area affected by pelvic radiation.4
■ Venous drainage

■ Redundant
• Deep system
• Venae comitantes of inferior gluteal artery
• Venae comitantes of deep femoral perforators
• Superficial venous system
■ Due to substantial drainage, venous congestion rarely occurs.5
■ Innervation: posterior femoral cutaneous nerves (S1-S3)
■ Many fascicles exit the sciatic foramen along with the inferior gluteal artery.
■ Fascicles converge to form a common trunk with the descending branch of
the inferior gluteal artery.4
PATHOGENESIS
■ Most common: Malignancy
■ Infection
■ Traumatic injury6
PATIENT HISTORY AND PHYSICAL FINDINGS
IMAGING
■ No preoperative imaging is necessary.
■ Viability of the flap can be assessed intraoperatively via quantitative
fluoroangiography (FIG 2).
SURGICAL MANAGEMENT
■ Goal of surgery
■ The process of perineal repair is especially difficult due to the necessity to
preserve the anogenital triangle as well as to provide adequate skin coverage
and tissue replacement.
■ Successful repair consists of appropriate reconstruction with vascularized
tissue along with proper anogenital repair without leakage of feces or urine.
■ Indications
■ Perineal or sacral wounds requiring resurfacing without the need of dead
space closure

FIG 2 • Intraoperative quantitative fluoroangiography of
harvested gluteal thigh flap. The patient is administered
indocyanine green (ICG) intravenously, and then, after
3 minutes, the fluoroscope is placed over the flap.
Within 120 seconds, adequate perfusion (if present) will
register on the imaging. Certain systems may permit
quantitation of perfusion relative to surrounding tissues.
■ Preoperative planning
■ Before general anesthesia, the patient should be marked in an upright
position.
■ The gluteal fold should be identified and marked.
■ The inferior gluteal artery can be located as it exits deep to the gluteus
maximus with a mark halfway between the line from the ischial tuberosity to
the greater trochanter of the femur. The course of the inferior gluteal artery
can be verified with a Doppler probe.
■ Positioning (FIG 3)
■ The surgeon may position the patient in either prone or lithotomy position.
The flap can be harvested in either position; positioning is dependent on
location and size of the defect.
■ Approach
■ The flap may be harvested as a pedicled rotation flap or as an island flap.
■ Flap size is directly contingent with thigh size and feasibility of donor-site
closure.
■ The distal tip of the flap should not extend beyond the popliteal crease to
minimize risk of scar deformity and scar contracture.

FIG 3 • Lithotomy positioning for gluteal thigh flap.
Bilateral gluteal thigh flaps were harvested in this
patient and inset for perineal reconstruction.
T E C H N I Q U E S
■ Dissection begins at the distal aspect of the posterior thigh followed by
subcutaneous tissue dissection with cauterization.
■ The surgeon then dissects the flap distal to proximal. Limit is the inferior
border of the gluteus maximus muscle. Proper proximal dissection with
inclusion of the vascular pedicle is important for vitality. Care is taken to
include the deep fascia within the contents of the flap.
■ During flap elevation, the surgeon may place temporary sutures through the
fascia and dermis to prevent shearing of the flap during mobilization. In the
case of larger defects, bilateral flaps may be raised.4
■ The posterior femoral cutaneous nerve is not a good reference for pedicle
orientation due to its distal arborization.
■ Division of the gluteus muscle inferior fibers allows for more proximal
dissection of vessels and therefore a greater flap length, although this
maneuver is rarely needed.
■ Once fully mobilized, a deep subcutaneous tissue tunnel is created between
the posterior thigh and the perineal defect. The flap is then passed through the
tunnel.
■ The surgeon will then mark and de-epithelialize the buried portion of the
flap. Once completed, the flap is then inset into the defect.

■ While avoiding the proximal vascular pedicle area, drains are placed in the
pelvis and donor-site regions.
■ Primary closure of the donor site can be performed or in other cases a skin
graft may be necessary.4
TECH FIG 1 • Elevation of bilateral gluteal thigh flaps.
Patient placed in prone position.
PEARLS AND PITFALLS
Technique
■ Avoid using the posterior femoral cutaneous nerve as a landmark
for the vascular pedicle.
■ Divide distal fibers of the gluteus maximus to increase flap pedicle
length and arc of rotation.
Postoperative
care
■ Offload the perineum and the flap with no sitting for 2–3 weeks.
■ Use an air-fluidized mattress and frequent turns to decrease risk of
pressure sores, especially in the case of a denervated femoral
cutaneous nerve.
POSTOPERATIVE CARE
■ Due to the location of the flap and the location of the reconstruction as a
whole, a 48-hour period of postoperative recovery is recommended before
attempting any sort of strenuous leg movements such as walking.4
■ Patients should not sit at all for the first 2 to 3 postoperative weeks after which

time they can gradually begin to sit again.4
■ A seating cushion with an open space in the middle may be used to offload the
perineum while sitting.
■ Patients may experience pain up to several months after the surgery, which
may impair their ability to sit.7
■ Routine drain care is followed, with care taken to observe output once the
patient becomes mobile. The surgeon must be vigilant of any signs of
infection, such as cloudy or foul-smelling drainage, increased erythema, or
pain.
OUTCOMES
■ Walton et al. reported their case series of 46 patients, with 8 total
complications.
■ There were two cases of flap failure:
■ Thrombosed inferior gluteal artery
■ Attempted free flap with subsequent venous thrombosis
■ Other case series have reported varying outcomes and complication rates,
possibly due to small sample size:
■ Achauer et al. reported two cases of delayed healing in seven flaps.7
■ Friedman et al. reported their case series of 27 flaps.4
• Only one failure was reported.
• 10 of 19 patients experienced delayed wound healing.
■ Saito et al. reported one case of total flap loss and two partial losses in their
series of eight patients.8
COMPLICATIONS
■ Dysesthesia
■ Dysesthesias may result from damage to the cutaneous nerve during surgery.7
This loss of sensation combined with the limited mobility after surgery could
lead to pressure sores. To decrease the chances of a pressure sore developing,
some authors recommend placing patients on a pressure-reducing mattress.
■ Flap necrosis
■ Though necrosis can result from either lack of blood flow or infection, it is
relatively rare with this flap. Any fistulas that may develop need to be
monitored and repaired.8
■ When dealing with cancer patients who are undergoing radiation therapy,

skin grafting may be necessary to promote wound healing.4
REFERENCES
1. Hurwitz DJ. Closure of a large defect of the pelvic cavity by an extended
compound myocutaneous flap based on the inferior gluteal artery. Br J Plast
Surg. 1980;33:256-261.
2. Hurwitz DJ, Swartz WM, Mathes SJ. The gluteal thigh flap: a reliable, sensate
flap for the closure of buttock and perineal wounds. Plast Reconstr Surg.
1981;68:521-532.
3. Windhofer C, Brenner E, Moriggl B, Papp C. Relationship between the
descending branch of the inferior gluteal artery and the posterior femoral
cutaneous nerve applicable to flap surgery. Surg Radiol Anat. 2002;24:253-
257, doi:10.1007/s00276-002-0064-z.
4. Friedman JD, Reece GR, Eldor L. The utility of the posterior thigh flap for
complex pelvic and perineal reconstruction. Plast Reconstr Surg.
2010;126:146-155, doi:10.1097/PRS.0b013e3181da8769.
5. Scheufler O, et al. Anatomical basis and clinical application of the infragluteal
perforator flap. Plast Reconstr Surg. 2006;118:1389-1400,
doi:10.1097/01.prs.0000239533.39497.a9.
6. Mughal M, Baker RJ, Muneer A, Mosahebi A. Reconstruction of perineal
defects. Ann R Coll Surg Engl. 2013;95:539-544.
7. Achauer BM, Turpin IM, Furnas DW. Gluteal thigh flap in reconstruction of
complex pelvic wounds. Arch Surg. 1983;118:18-22.
8. Saito A. et al. Posterior thigh flap revisited: clinical use in oncology patients.
Surg Today. 2014;44:1013-1017. doi:10.1007/s00595-013-0635-0.

24
CHAPTER
Omental Flap for Pelvic
Floor Reconstruction
Carrie K. Chu and Charles E. Butler
DEFINITION
■ Pelvic floor defects may result from colorectal, urologic, and/or gynecologic
extirpation (ie, abdominoperineal resection, pelvic exenteration) for oncologic,
infectious, inflammatory, or traumatic indications.
■ Goals of pelvic floor reconstruction include obliteration of dead space,
prevention of pelvic and perineal hernia, avoidance of deep surgical site
infection and pelvic sepsis, improved perineal wound healing, replacement of
compromised perineal skin if necessary, and vaginal reconstruction when
indicated.
■ The omental flap can provide readily available vascularized tissue for
achievement of many of these reconstructive goals with minimal donor-site
morbidity and operative efficiency.1–3
ANATOMY
■ The male pelvis is typically narrower throughout, from the pelvic brim through
the outlet. The cavity is overall shaped like an inverted cone, in contrast to the
wider female pelvis that more resembles a short, wide cylinder.
■ The greater omentum, also called the gastrocolic omentum, is a curtain of
adipose and lymphatic-rich tissue that extends from the greater curvature of the
stomach and drapes over the large and small intestines while folding under
itself toward the posterior abdominal wall. The posterior aspect of the
reflection apposes the mesentery of the transverse colon (FIG 1).
■ The vascular supply of the omentum derives from the right and left
gastroepiploic arteries. The right gastroepiploic artery is a terminal branch of
the gastroduodenal artery, which comes off of the common hepatic artery

originating from the celiac axis. The left gastroepiploic artery is a branch of the
splenic artery.
■ Along the greater curvature of the stomach, gastric branches arise from both
the right and left gastroepiploic arteries onto the anterior gastric wall, and the
two vessels communicate in this manner. Multiple branches of these vessels
supply the greater omentum (FIG 2).
■ The flap may be based on either the right or left gastroepiploic artery. The
pedicle should be selected based on the likelihood of maximal flap length to
reach the pelvis following full mobilization. The right-sided vessel is often
positioned more favorably for pelvic coverage.
FIG 1 • A,B. The greater omentum extends from the
greater curvature of the stomach and drapes over the
large and small intestines while folding under itself
toward the posterior abdominal wall. The posterior
aspect of the reflection apposes the mesentery of the
transverse colon.

FIG 2 • The vascular anatomy and basis for the
pedicled omental flap.
PATHOGENESIS
■ Following removal of the rectum, the resultant void in the presacral space and
pelvic outlet leaves noncollapsible dead space for fluid accumulation with
infectious potential as well as a route for visceral herniation into the perineum.
The volume of space is increased with additional resection of the bladder,
prostate, uterus, and/or vagina.
■ Secondary defects of the pelvic floor may occur from traumatic, obstetric, or
iatrogenic etiologies.

PATIENT HISTORY AND PHYSICAL FINDINGS
■ Special consideration should be given to the primary disease process and
previous abdominal surgical surgery. Dense abdominal adhesions may render
this flap unusable. Inflammatory processes or infectious complications may
lead to distortion of the omental anatomy. Gynecologic oncologic surgeries
often involve partial or total omentectomies. Prior procedures that may have
compromised the source vessels of the right and left gastroepiploic vessels,
including hepatectomy, pancreaticoduodenectomy, gastrectomy, and
splenectomy, should all be noted.
■ Physical examination should focus on body habitus, abdominal torso length,
abdominal surgical scars, hernias, and evidence of intra-abdominal obesity.
■ Pelvic radiotherapy may severely compromise the quality of the perineal skin.
IMAGING
■ No routine imaging is necessary for preoperative planning for omental flap
harvest. Computed tomography is of limited utility in assessing omental bulk,
though well-timed contrast studies may facilitate visualization of branches of
the celiac artery, superior mesenteric artery, and proximal gastroepiploic
arteries. Magnetic resonance imaging may provide better depiction of omental
volume.
■ However, abdominal and pelvic cross-sectional imaging is often available as
part of the primary disease workup. Review can yield useful information
regarding dimensions of the pelvic inlet and outlet as well as the shape and
depth of the presacrococcygeal space.
SURGICAL MANAGEMENT
■ Omental flaps are most useful for filling of dead space in the pelvic cavity and
separation of the intra-abdominal contents from the perineum. When perineal
skin replacement is necessary due to disease involvement or radiation injury,
omental flap alone will likely not suffice. Consideration should be given to use
of a myocutaneous or fasciocutaneous flap instead of or in conjunction with the
omental flap, depending on the size of the pelvic cavity.
■ The omentum is also suitable for reconstruction of partial vaginectomy defects
and can be used in conjunction with skin grafting for this purpose.4
■ Pelvic floor reconstruction using pedicled omental flaps generally takes place
at the time of the primary extirpative procedure. The usefulness of omental flap
for secondary pelvic reconstruction in cases of delayed wound healing, pelvic

abscess, or wound dehiscence can be limited.
■ There is great individual variability in the bulk and dimensions of the greater
omentum. Based on the characteristics of the omentum and the defect anatomy,
each patient will require intraoperative evaluation and judgment regarding the
appropriateness of this flap for pelvic reconstruction. The omentum may be
used in combination with other myocutaneous flaps to accomplish the
aforementioned goals.5
Preoperative Planning
■ No routine preoperative imaging is indicated, but the aforementioned elements
in the history and physical should be noted in preparation for surgery.
■ Patients should be consented for thigh, gluteal, and abdominal wall donor-site
alternatives, as the suitability of the flap is usually unable to be determined
until the abdomen is opened.
Positioning
■ There are no specific positioning requirements beyond the conventional
lithotomy or, less frequently, supine positions used during primary resection,
though consideration should be given to prepping of alternative sites in case of
inadequate omental mass or reach.
Approach
■ A major advantage of this flap is its intra-abdominal location. Exposure
beyond the extent performed by the primary surgeon is usually unnecessary.
Superior extension of an infraumbilical laparotomy incision is sometimes
required.
■ In the setting of increasingly common laparoscopic or robotic procedures, the
omentum can be similarly harvested using minimally invasive approaches with
or without the assistance of a hand-assisted port for retraction.
T E C H N I Q U E S
■ Omental Flap Harvest With Right Gastroepiploic
Pedicle

■ Omental flaps for pelvic reconstruction are most commonly performed at the
time of primary operation. Upon laparotomy, the integrity, mass, and length
of the omentum are assessed for suitability for pelvic reconstruction.
■ In reoperative cases, omental adhesions to the posterior abdominal wall
and/or viscera may be released to preserve flap integrity.
■ Following completion of the extirpative procedure, the size of the pelvic
space, the dimensions of the pelvic outlet, and the extent of the perineal
defect are examined. The ability of the omental flap to be mobilized into the
pelvis is assessed.
Dissection
■ Dissection of the omental flap begins with its mobilization off the transverse
colon mesentery. The assistant gently lifts the transverse colon and retracts it
inferiorly while the surgeon begins flap elevation with the cautery. Use of the
surgeon’s nondominant hand to lift the omentum away from the lesser sac
with countertraction against the assistant motion will facilitate visualization
of the appropriate plane (TECH FIG 1).
■ The character of the globular omental fat differs in quality from the thick
mesenteric fat, and care should be taken to maintain the avascular plane of
separation to avoid injury to the mesentery. On the other hand, violation of
the filmy attachments throughout the omentum, especially in thin patients,
should be minimized as these can easily result in full-thickness defects
through the omentum.
■ The surgeon should be cognizant of the course of the middle colic artery,
especially in reoperative abdomens, to avoid injury during flap elevation.
■ The avascular plane between the omentum and the mesentery is easily taken
down with cautery. However, any division of the omental tissue should be
cautiously addressed and hemoclips or sutures used generously, as bleeding
from the omentum can be insidious.
■ As the dissection proceeds more posteriorly, the lesser sac posterior to the
stomach is entered.

TECH FIG 1 • The omentum is dissected off the
transverse colon mesentery through the avascular
apposition plane, eventually entering the lesser sac.
■ Once the omentum is elevated posteriorly, the mobilization is continued
toward the left upper quadrant. Although it might be tempting to maximize
the flap harvest in this region to increase flap length, extreme care should be
taken to avoid injury to the short gastric vessels, the spleen, and the
pancreatic tail. A conservative dissection leaving some omentum in the left
upper quadrant is preferred to avoid injuring these vital structures.
Ligation and Division
■ As the dissection approaches the proximal aspect of the greater curve, the
left gastroepiploic artery will be encountered. Manual palpation can be used

to confirm its position. The artery should be doubly ligated with hemoclips
and/or ties prior to division (TECH FIG 2A).
TECH FIG 2 • A. The left gastroepiploic artery is
divided for a right-sided pedicled flap. B. The flap
pedicle running parallel to the greater curve is
mobilized with the flap. Gastric branches are serially
ligated and divided. C,D. Fully mobilized omental flaps
vascularized by the right gastroepiploic artery.
Omental bulk can vary significantly. (© Charles E.
Butler, MD.)
■ The omentum is then sequentially separated from the greater curvature of the
stomach. Serial gastric branches will require ligation and division.
■ Bipolar energy-sealing system [Ligasure, Mansfield, MA] and ultrasonic
coagulation (harmonic scalpel) are increasingly popular contact hemostatic

tools used during this dissection. When larger vessels in excess of 3 mm are
encountered, however, the conventional clamp-and-tie technique should be
used as bleeding from one of these stumps can result in delayed catastrophic
bleeding (TECH FIG 2B).
■ When the thermal agents are used, meticulous care needs to be taken to
avoid collateral injury to the adjacent gastric wall as well as the flap pedicle.
The gastroepiploic arcade is located approximately one fingerbreath parallel
to the greater curve and can be palpated for guidance.
■ If concern arises regarding partial-thickness injury to the gastric serosa,
oversewing can be performed due to the thickness of the gastric wall.
■ Division is continued until the flap is of sufficient length to reach the pelvis
without undue tension. For maximal safe length, the omentum can be safely
mobilized just short of the pylorus, where the right gastroepiploic artery
comes into direct contact with the stomach. The stomach is well vascularized
via the remaining right and left gastric arteries from the lesser curve (TECH
FIG 2C,D).
Flap Positioning
■ A right-sided pedicled flap should generally be passed through the right
paracolic gutter (TECH FIG 3A). If not already performed by the extirpative
surgeon, to facilitate flap positioning, the ascending colon can be mobilized
via release along the white line of Toldt.
■ Alternatively, passage of the flap can be performed via the retrocolic plane
through the transverse mesocolon to the right of the middle colic artery
(TECH FIG 3B). The resultant mesocolonic defect should be repaired to
prevent internal hernia.
■ No suture fixation of the omentum is generally necessary in the pelvis. The
flap should rest in the dependent position without excessive tension (TECH
FIG 3C). Placement of the patient into the reverse Trendelenburg position
may be useful for positioning.
■ If question arises regarding viability of the distal aspect of the flap, options
for flap assessment include handheld Doppler and fluorescein angiography.
■ Should flap length be inadequate for reach into the pelvis without undue
tension, the omentum may be transferred as a free flap using recipient vessels
in the pelvis or lower abdomen.
■ Additional perineal skin closure or flap reconstruction is performed as

indicated.
■ Laparotomy closure is performed as per routine.

TECH FIG 3 • Inset of a right-sided pedicle flap. A.
The omental flap may be passed through the paracolic
gutter following mobilization of the white line of Toldt.
B. Alternatively, the flap may also be passed via the
retrocolic plane through the transverse or ileocolic
mesocolon, across the sacrum, and into the pelvic
defect. C. The pelvic defect is filled with the omental
flap in position.

■ Omental Flap Harvest With Left Gastroepiploic
Pedicle
■ The flap is generally robust off either pedicle. Use of the left gastroepiploic
artery can be required due to altered right upper quadrant anatomy or loss of
the source vessels of the right gastroepiploic artery.
■ Elevation of the omentum off the transverse colonic mesentery and into the
lesser sac is performed in similar fashion as previously described.
■ In the right upper quadrant, the flap is separated from the mesocolon of the
hepatic flexure. As the gastroduodenal junction and the pylorus are
encountered, the right gastroepiploic artery can be palpated. Secure ligation
and division should be performed (TECH FIG 4A).
■ Mobilization of the flap along the greater curvature can then proceed as
described above toward the pedicle.
■ The left gastroepiploic artery is the largest branch of the splenic artery. The
gastric branches off of the left gastroepiploic should be taken down to no
more than the middle third body of the stomach to avoid the splenic, short
gastric, and pancreatic injuries as aforementioned.
■ The mobilized flap can then be positioned along the left paracolic gutter into
the pelvis or transmesocolonic as previously described. In the latter case, it
can then be transposed to the left of the ligament of Treitz toward the pelvis
(TECH FIG 4B,C).

TECH FIG 4 • A. For a left-sided pedicle, the right
gastroepiploic artery is divided. B. Inset of a left-sided
pedicle flap. For a left-sided pedicled flap, the flap can

be transposed within the left paracolic gutter. The
sigmoid colon and rectum have usually been
mobilized. C. The flap may also be passed through
the transverse colonic mesentery to the left of the
middle colic artery and the ligament of Treitz.
■ Laparoscopic Harvest of Pedicled Omental Flap
■ Laparoscopic or robotic-assisted pelvic surgery is increasingly common.
■ The omentum can be harvested laparoscopically with one 10-mm
periumbilical trocar and three additional 5-mm trocars in the lateral
midabdomen to lower abdomen to allow for the concept of triangulation
around the operative target with adequate retraction.6 In some patients,
placement of a hand port may facilitate retraction.
■ The patient is placed into slight reverse Trendelenburg position. The
abdomen is insufflated.
■ While the assistant drives the camera with the nondominant hand and
provides retraction of the transverse colon toward the patient’s feet with a
blunt grasper, the surgeon elevates the omentum toward the anterior
abdominal wall. The hook cautery may be used to raise the flap off the
transverse colon while the surgeons reposition graspers as needed to maintain
adequate traction.
■ Once the lesser sac is reached, the omentum is pulled down gently caudally,
and a LigaSure or Harmonic device can be used to divide the omentum and to
perform the release along the greater curve. Larger vessels are addressed with
hemoclips, including the nonpedicle gastroepiploic vessel.
■ During these steps, if a hand-assist port is in place in the lower abdominal
midline, the surgeon’s nondominant hand may be helpful for caudal
retraction of the omentum with manual confirmation of the gastroepiploic
arcade location.
■ The flap can then be positioned in the pelvis as needed with the patient in
reverse Trendelenburg position.

PEARLS AND PITFALLS
Preoperative
considerations
■ Feasibility of the omental flap for pelvic floor reconstruction is
typically assessed intraoperatively. The surgeon and patient
should be prepared for alternative options from the abdominal
wall, gluteal region, and thighs.
Flap elevation
■ Bleeding from the omentum can be difficult to control with
conventional electrocautery and can be a source of postoperative
hemorrhage. Threshold for secure hemoclip placement or surgical
tying should be low.
■ Correct use of thermal contact vascular sealing devices may be
helpful in flap elevation.
■ Awareness of the course of the middle colic artery is essential to
avoid inadvertent injury.
■ When the right gastroepiploic pedicle is used, mobilization of the
omentum within the left upper quadrant should be cautiously and
conservatively approached so as to avoid injury to the spleen and
pancreatic tail.
Flap inset
■ If tension-free positioning within the pelvis cannot be achieved
following full mobilization, an alternative flap must be
considered. Partial flap necrosis due to excess tension can result
in pelvic sepsis and perineal wound breakdown.
POSTOPERATIVE CARE
■ Traditionally, the dogmatic practice of nasogastric decompression after
omental flap mobilization is thought to decrease gastric distension and manage
expected postoperative ileus. Prevention of gastric distention has also been
theorized to reduce the risk of hemoclip dislodgement from the ligated stumps
of the branches along the greater curve.
■ However, enhanced recovery initiatives are now increasingly prevalent.
Avoidance of empiric postoperative nasogastric tube use unless strictly
indicated is in keeping with the early feeding regimens and prompt patient
mobilization that facilitate quicker recovery without compromising patient
outcomes.
■ If patients become symptomatic with severe nausea, belching, emesis, and/or
bloating, abdominal radiograph may be considered for gastric distension.
Nasogastric tube insertion should then be performed as indicated.

OUTCOMES
■ Comparison of complication rates in patients who were primarily closed
following abdominoperineal resection or pelvic exenteration with those in
patients who received omental flaps consistently demonstrates improved
outcomes in the latter group. In a study of 29 patients with omental flaps either
alone or in combination with another flap, and 41 without omental flaps, the
incidence of major pelvic complications (abscess, dehiscence, hernia, bowel
obstruction, fistula) was greater in the group that did not receive omental flap
reconstruction (61% vs 21%, P < .01).2,7
■ A systematic review of 14 studies (457 proctectomy patients with omental flap
and 332 without) with median follow-up of 13.5 months demonstrated superior
primary wound healing rate (66.8% vs 50.1%), shorter time to wound healing
(24 vs 79 days), and lower wound infection rate (14.4% vs 18.5%) in patients
who underwent omentoplasty.
COMPLICATIONS
■ Bleeding
■ Splenic injury
■ Mesocolon injury, including disruption of the middle colic vessels
■ Pedicle injury during mobilization along the greater curvature
■ Gastric wall injury
■ Partial flap loss
■ Paralytic ileus
■ Pancreatic injury
■ Perineal delayed wound healing
■ Perineal hernia
■ Intestinal obstruction
REFERENCES
1. Hultman CS, Carlson GW, Losken A, et al. Utility of the omentum in the
reconstruction of complex extra peritoneal wounds and defects. Ann Surg.
2002;235:782-795.
2. Hultman CS, Sherrill MA, Halvorson EG, et al. Utility of the omentum in
pelvic floor reconstruction following resection of anorectal malignancy: patient
selection, technical caveats, and clinical outcomes. Ann Plast Surg.
2010;64:559–562.

3. Momoh AO, Kamat AM, Butler CE. Reconstruction of the pelvic floor with
human acellular dermal matrix and omental flap following anterior pelvic
exenteration. J Plast Reconstr Aesthet Surg. 2010;63:2185-2187.
4. Kusiak JF, Rosenblum NG. Neovaginal reconstruction after exenteration using
an omental flap and split-thickness skin graft. Plast Reconstr Surg.
1996;97:775-781.
5. Campbell CA, Butler CE. Use of adjuvant techniques improves surgical
outcomes of complex vertical rectus abdominis myocutaneous flap
reconstruction of pelvic cancer defects. Plast Reconstr Surg. 2011;128:447-
458.
6. Kamei Y, Torii S, Hasegawa T, Nishizeki O. Endoscopic omental harvest.
Plast Reconstr Surg. 1998;102:2450-2453.
7. Killeen S, Devaney A, Mannion M, et al. Omental pedicle flaps following
proctectomy: a systematic review. Colorectal Dis. 2013;14:e634-e645.

25
CHAPTER
Posterior Labial Artery Flap
for Vulvar and Vaginal
Reconstruction
Chris A. Campbell
DEFINITION
■ The posterior labial artery flap commonly known as the Singapore flap or
pudendal thigh flap is a thin fasciocutaneous flap oriented along the groin
crease within the perineum.1
■ The flap’s pedicle, the posterior labial artery, is a branch of the internal
pudendal artery system.
■ Unilateral or bilateral posterior labial artery flaps are commonly used for
vulvar resurfacing and vaginal reconstruction.
ANATOMY
■ The posterior labial artery flap is inferiorly based with its axis along the groin
crease including the thin skin lateral to the labia majora medially and the
medial thigh skin laterally.
■ The flap’s pedicle is the posterior labial artery, which courses above the deep
perineal fascia, arising from the perineal artery as it pierces the Colles
(superficial perineal) fascia. The perineal artery branches off of the internal
pudendal artery that emerges from the pudendal canal located 1 cm medial and
inferior to the ischial tuberosity.
■ The flap’s skin paddle can be up to 15 cm long by 6 cm wide in the adult with
the base of the flap even with the posterior edge of the introitus.2
■ The posterior labial branches of the pudendal nerve innervate the most
posterior aspect of the skin paddle providing sensation to the reconstruction.
PATHOGENESIS

■ Vulvar or vaginal defects resulting from resection of squamous cell
carcinomas, extensive condyloma, lichen sclerosis, fistulas, necrotizing soft
tissue infections, and other cutaneous conditions have been reconstructed with
unilateral or bilateral posterior labial artery flaps.
■ In the pediatric population, bilateral posterior labial artery flaps have been
used for total vaginal reconstruction in cases of vaginal atresia.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ When approaching vulvar or vaginal reconstruction, evaluate the abdomen,
thighs, and inguinal region to maintain rectus and thigh-based flap alternatives
to the posterior labial artery flap, in the event significant tissue bulk is required.
■ If the patient has had pelvic radiation to treat malignancy, the exam should
focus on the quality of the groin and medial thigh skin to determine if it is
within the radiated field. A severely radiated groin crease can increase the risk
of partial flap loss and wound healing complications.
■ Measure the surface area of vulvar skin or vaginal mucosa that requires
resurfacing to ensure that this amount of groin crease skin is redundant to allow
for closure of the donor site.
IMAGING
■ Computed tomography of the pelvis will be part of the standard preoperative
evaluation of patients requiring resection of vaginal abnormalities that will
require subsequent reconstruction.
■ The posterior labial artery flap lacks bulk and as such is used to resurface the
posterior or circumferential vagina or vulvar skin.3 Larger tumors that require
pelvic exenteration will need alternative or additional flaps that provide soft
tissue bulk in addition to skin resurfacing.
SURGICAL MANAGEMENT
■ Unilateral or paired posterior labial artery flaps are used to reconstruct partial
or circumferential vaginal defects, respectively, and to resurface vulvar defects
with thin pliable skin.
■ When total vaginal reconstruction is required, bilateral posterior labial artery
flaps are sewn together and rotated into the pelvic defect producing a natural
physiologic angle of inclination of the reconstructed vagina.4
■ Key considerations for use of the posterior labial artery flap include the ability
to cover the vaginal or vulvar defect surface area with adjacent available groin

skin within the design of the Singapore flap and whether the skin paddles are
within fields of significant pelvic radiation.
Preoperative Planning
■ Pathology findings from prior biopsies and imaging studies should be
reviewed to confirm the planned extirpation involving the vulva and/or vagina.
■ All resections that include the vagina will be preceded by an examination
under anesthesia to determine if there has been disease progression and to
confirm the planned resection and reconstruction.
■ A Foley catheter should be placed to protect urethral structures if total
vaginectomy is required and to assist the patient with recovery.
Positioning
■ The patient is placed in the lithotomy position on the operating table for both
the extirpative portion of the operation and the vulvar and/or vaginal
reconstruction with one or both posterior labial artery flaps (FIG 1A).
FIG 1 • Operative photos of bilateral posterior labial
artery flaps for posterior vaginal reconstruction after

rectal cancer resection. A. The patient is in lithotomy
position with bilateral posterior labial artery flaps
marked. Gluteal advancement flaps are also marked to
obliterate the dead space from the abdominoperineal
resection. B. Bilateral posterior labial artery flaps have
been rotated into the pelvic defect to resurface the
posterior and lateral surfaces of the vagina. C. Six
months after surgery with donor-site incisions
camouflaged within the groin creases and return of
sexual function.
■ If other flap options are being considered for vulvar, vaginal, or perineal
reconstruction, also prep the thighs down to the knees, lower buttocks, and
lower abdomen to include abdominal, buttock, and thigh-based flap options.
Approach
■ For vulvar skin defects and vaginal defects where the wound interrupts the
posterior introitus, the posterior labial artery flaps are rotated directly into the
defect (FIG 1B).
■ For cases where the labial structures are not interrupted by the resection or in
cases of vaginal atresia reconstruction, the posterior labial artery flaps are
tunneled underneath posterolateral structures of the introitus as island flaps
before inset.
T E C H N I Q U E S
■ Posterior Labial Artery Flap Design
■ The flap skin paddle is centered on the groin crease with the base of the flap
being set at the most posterior point of the vaginal introitus.
■ Maximal flap length has been described as 15 cm in the adult female. A skin
paddle that measures 6-cm wide can be closed primarily within the groin
crease of the average adult.

■ Posterior Labial Artery Flap Elevation
■ Incise the skin of apex and medial and lateral edges of the planned skin
paddle passing through subcutaneous fat and the deep perineal fascia and
medial thigh fascia.
■ Elevate the flap from the anterior tip of the skin paddle and then proceed
proximally in a subfascial plane to elevate the posterior labial artery with the
flap. This dissection will continue until the posterior edge of the introitus is
reached (TECH FIG 1A). The transverse fibers of the superficial perineal
musculature will provide resistance to further elevation of the deep fascia at
this level.
■ For flaps elevated as an island flap intended to go underneath an intact edge
of the introitus, additional dissection is performed posterior to the skin
paddle. Dissect in the subcutaneous plane 4 cm beveling posteriorly to free
the proximal edge of the skin paddle for medial tunneling into the defect
(TECH FIG 1B). Do not violate the fascia on the posterior border of the skin
paddle to avoid injury to the pedicle.
TECH FIG 1 • Bilateral posterior labial artery flap
elevation. A. Skin paddles of posterior labial artery
rotation flaps elevated in a subfascial plane from
anterior to posterior stopping at the posterior edge of
the introitus. B. For the design of bilateral posterior
labial artery island flaps, a posterior incision is made
through the skin with posteriorly beveled

subcutaneous dissection for 4 cm. This additional
posterior dissection allows the flap to be able to be
tunneled under the intact posterolateral introitus to
reach the pelvic defect.
■ Posterior Labial Artery Flap Rotation
■ For defects that include a portion of the introitus, the posterior labial artery
flaps are rotated directly into the defect (TECH FIG 2A). For vaginal
reconstruction where the introital opening is intact, subcutaneous tunnels are
created to pass the posterior labial artery flap as an island flap (TECH FIG
2B).
TECH FIG 2 • Bilateral posterior labial artery flap
rotation: A. Bilateral posterior labial artery rotation
flaps will be turned inward to reconstruct the vaginal
defect. B. Bilateral posterior labial artery island flaps
will be tunneled underneath intact skin flaps to
reconstruct vaginal defects where the introitus is intact
or in congenital cases such of vaginal atresia.
■ Posterior Labial Artery Flap Closure and Inset
■ The medial edge of the skin paddles will be sewn to one another to create the
posterior surface of the vaginal canal (TECH FIG 3A). For defects limited to

posterior vaginal reconstruction, the lateral and distal edges of the combined
skin paddle are sewn to the mucosal edges of the defect to complete the
reconstruction.
■ For total vaginal reconstruction, the lateral edges of the skin paddle are sewn
to one another to create the anterior edge of the vaginal canal (TECH FIG
3B).
■ Finally, the flap donor sites are closed in layers. The incision and resulting
scar are camouflaged within the groin crease.
TECH FIG 3 • Bilateral posterior labial artery flap
closure and inset. A. For total vaginal reconstruction,
the medial edges of the skin paddles are sewn
together to produce the posterior aspect of the vagina.
B. The lateral edges of the skin paddles are sewn
together to produce the anterior aspect of the vagina.
PEARLS AND PITFALLS
Preoperative
evaluation
■ It is critical to understand the extent of the planned resection to
know if soft tissue bulk is required. Posterior labial artery flaps are
thin pliable fasciocutaneous flaps. Therefore, another flap should
be chosen for large volume defects.
Physical
■ If the groin skin is firm and darkened from prior pelvic radiation,

examination
another flap should be chosen to avoid partial flap loss and wound
dehiscence.
Technique—
flap elevation
■ The deep perineal fascia overlying the perineal musculature and
the deep adductor fascia overlying the medial thigh should be
elevated with the flap to avoid harm to the neurovascular pedicle.
Technique—
bilateral flap
rotation
■ Subcutaneous dissection proximal to the skin paddle is required to
allow for appropriate rotation of bilateral island flaps beneath the
posterolateral introitus for total vaginal reconstruction. If not
performed, the proximal portion of the skin paddles cannot be
approximated without tension and will alter the incline of the
resulting vaginal angle.
Postoperative
care
■ For patients requiring partial vaginal reconstruction in low
estrogen states, consult with a gynecologic oncologist to determine
if estrogen replacement or inserts may be required to prevent
wound healing trouble due to vaginal mucosal atrophy.
POSTOPERATIVE CARE
■ Maintain single shoulder’s width leg positioning when lying or ambulating for
the first 2 weeks after surgery.
■ If the reconstruction only involves vaginal reconstruction, then brief episodes
of sitting are permitted. A sidesaddle posture of favoring one buttock and then
the other is encouraged. If there is also a perineal reconstruction with suture
lines posterior to the introitus, then limiting head of bed to 45 degrees or less
for 2 weeks without radiation and up to 4 weeks in the presence of preoperative
radiation is required.
■ The patient should wear dry gauze to the surgical site that is changed
frequently to avoid skin maceration. The incision and resulting scar will be
camouflaged within the groin crease (FIG 1C).
■ Daily showering is recommended.
OUTCOMES
■ Sexual adjustment after vaginal reconstruction is only successful in about half
of women, with problems such as dryness, discomfort, or self-consciousness
decreasing success.5
COMPLICATIONS
■ Partial flap loss at the tip of the flap and wound dehiscence of the posterior
vaginal closure and groin crease donor site are infrequent but do occur.

Supportive dressing care is the mainstay of treatment.
■ Premenopausal women following chemotherapy and postmenopausal patients
with vaginal atrophy who require partial vaginal reconstruction may be more
likely to exhibit remnant vaginal narrowing and skin flap dehiscence and may
require estrogen replacement orally or in the form of vaginal inserts in the post-
op period.
■ Foreshortened reconstructed vaginas either due to cicatricial shortening or flap
design may contribute to problems with sexual adjustment requiring vaginal
dilatation.
REFERENCES
1. Wee JTK, Joseph VT. A new technique of vaginal reconstruction using
neurovascular pudendal thigh flaps: a preliminary report. Plast Reconstr Surg.
1989;83:701-709.
2. Gleeson NC, Baile W, Roberts WS, et al. Pudendal thigh fasciocutaneous
flaps for vaginal reconstruction in gynecologic oncology. Gynecol Oncol.
1994;54:269-274.
3. Cordeiro PG, Pusic AL, Disa JJ. A classification system and reconstructive
algorithm for acquired vaginal defects. Plast Reconstr Surg. 2002;110(4):1058-
1065
4. Woods JE, Alter G, Meland B, Podratz K. Experience with vaginal
reconstruction utilizing the modified Singapore flap. Plast Reconstr Surg.
1992;90:270-274.
5. Mericli AF, Martin JP, Campbell CA. An algorithmic anatomical subunit
approach to pelvic wound reconstruction. Plast Reconstr Surg.
2016;137(3):1004-1017.

26
CHAPTER
Vertical Rectus Abdominis
Flap for Perineal
Reconstruction
Dhivya R. Srinivasa and Jeffrey H. Kozlow
DEFINITION
■ Perineal reconstruction is often required after oncologic resections for
anorectal, gynecologic, and/or genitourinary tumors. Other etiologies including
inflammatory bowel disease (IBD), trauma, and necrotizing infections can also
be treated in a similar fashion after control of the destructive process.
■ The defect can be defined in two components: the internal pelvic outlet defect
and the external skin/soft tissue defect.
■ Because radiation therapy is an integral component of locoregional tumor
management, the surgeon must consider the implications of radiation.
■ Although multiple options are available to the reconstructive surgeon, a
pedicled vertical rectus abdominis myocutaneous (VRAM) flap is one of the
workhorse flaps for reconstruction of the perineum. The VRAM flap allows for
harvest of varying combinations of the muscle, fascia, subcutaneous fat, and
skin with tailoring of components to the acquired defect. The soft tissues of the
VRAM are robust and reliable in anatomy, making this an attractive option for
many reconstructive surgeons.
ANATOMY
■ The surgeon must be well learned in pelvic and perineal anatomy including the
following components:
■ Genitourinary: Bladder, seminal vesicles, and prostate
■ Gynecologic: Ovaries, uterus, cervix, and vagina
■ Colorectal: Rectum, levator muscles, and anus
■ FIG 1 depicts a sagittal schematic of the male and female pelvis.

■ In colorectal and perianal resections, the presence or absence of the levator
musculature following extirpation can determine the need for pelvic outlet
volume to fill the defect and close the pelvic floor. Removal of all the soft
tissue in the pelvic outlet will result in a defect that will not collapse down due
to the surrounding bony architecture, resulting in postresection “dead space.”
■ The abdomen is a readily available donor site for perineal reconstruction. It is
remote from the zone of radiation, has a pedicle that originates close to the
pelvis, and commonly has lax soft tissue.
■ In most cases of perineal reconstruction, the donor site can be closed primarily.
Component separation is a useful adjunct if needed to facilitate tension-free
primary fascial closure.1
■ The VRAM flap derives blood supply from the deep inferior epigastric artery
(DIEA), a branch of the external iliac arterial system as depicted in FIG 2.
Dissection of the flap pedicle into the pelvis provides maximal arc of rotation.
The DIEA and venae comitantes are predictably located on the underside of
the rectus muscle, exiting into the pelvis along the lateral aspect of the muscle.
PATHOGENESIS
■ Resection of anorectal and urogenital tumors is most often the impetus for
perineal reconstruction. Although staging and management can be complex, a
significant portion of these tumors undergo surgical therapy along with
radiation for curative intent.
■ The use of neoadjuvant radiation portends approximately a 60% risk of
complications including abscess, wound dehiscence, and enterocutaneous
fistula. The introduction of vascularized, nonradiated tissue to the surgical site
can significantly decrease the risk of major complications.2
■ Subsequent systematic reviews and meta-analyses have confirmed the
benefits of local tissue transfer for perineal reconstruction.3
■ In female patients, rectal tumors can also invade the posterior vagina requiring
an even more complex reconstruction following extirpation. An example of
this type of defect is pictured in FIG 3.
■ Anal tumors are treated primarily with the Nigro protocol, of which radiation
is a key component. However, salvage of recurrent disease requires
abdominoperineal resection with a wide skin margin resulting in a more
significant external defect. Primarily closing the perineal defect is often
wrought with complications due to tension, pressure, and radiation injury.
Thus, soft tissue reconstruction with regional flaps can improve wound healing

and decrease complications.4
■ Primary vulvar and vaginal tumors present similar challenges as do anorectal
tumors but also require consideration of a functional reconstruction. Vulvar and
vaginal tumors can be resected sans radiation, but locally advanced tumors,
high-risk tumors, and positive margins can be treated with external beam
radiation. Specifically for vulvovaginal reconstruction, restoration of
appearance and function has quality of life benefits in addition to decreased
wound healing complications.5,6
■ IBD, namely Crohn disease, can present with fistulas and recurrent abscesses.
■ Recalcitrant disease that fails medical management is often treated surgically,
and abdominoperineal resection is reserved for a severe disease affecting
quality of life.