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Editorial |
1 Department of Plastic Surgery, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas 77030
2 Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Box 444, Houston, Texas 77030
Correspondence: Address correspondence and reprint requests to: Miguel A. Rodriguez-Bigas, MD, FACS; E-mail: mrodbig{at}mdanderson.org.
The management of the perineal wound after an abdominoperineal resection (APR) has represented a challenge to surgeons. Perineal wound complications after APR have been reported to occur in 25% to 60% of cases,1,2 and rates are higher after resection of multiple visceral organs. Thus, general, oncological, colorectal, and other pelvic surgeons, in conjunction with plastic and reconstructive surgeons, have sought innovative ways to reduce perineal wound morbidity. Post-APR reconstruction of the pelvis with a vertical rectus abdominis musculocutaneous (VRAM) flap has been one such method.3
In this issue of Annals of Surgical Oncology, Chessin et al.4 report a modest-sized cohort study comparing patients who underwent reconstruction with a VRAM flap after APR with patients whose perineal wound was closed primarily after APR. All patients in both groups received preoperative chemoradiation. Perineal wound complications were significantly less frequent in the flap group than in the primary closure group (16% vs. 44%, respectively). There were no significant differences between groups in hospital stay or time to perineal wound healing. However, in patients who developed perineal wound complications, the time to perineal wound healing was shorter in the patients who had VRAM reconstruction than in those who had primary closure.
The experience reported by Chessin et al.4 is not unique. In fact, other authors have reported similar results with musculocutaneous flaps such as the rectus abdominis, gracilis, and gluteus maximus flaps.1,2,5 The advantages of musculocutaneous flap reconstruction of the irradiated pelvis and perineal wound include reduction of dead space, interposition of wellvascularized, nonirradiated tissue, and replacement of resected skin. The disadvantages of these flaps include the added time for the surgical procedure, the added costs, and the potential morbidity (such as infections, flap loss, seroma, ventral and perineal hernia, and abdominal bulge) of such procedures. These disadvantages are usually offset by the lower rates of perineal wound complications.
On the basis of the literature and the substantial experience with perineal reconstruction after radiation therapy at our institution, we emphatically agree that the inferiorly based VRAM flap is extremely valuable for post-APR reconstructions, for the reasons proposed by Chessin et al. In fact, its use is becoming the rule rather than the exception at our institution. As the authors point out, the VRAM flap has several advantages over unilateral or bilateral thigh-based flaps such as the gracilis musculocutaneous, posterior thigh, and anterolateral thigh flaps. These advantages include more reliable vascularity and skin viability, greater reduction of dead space, and absence of a separate donor site.
Chessin et al. report several important findings in their study, particularly, the improved perineal wound healing and absence of increased overall and abdominal wall complications with the VRAM flap. An additional benefit of VRAM flap reconstruction that we have observed with prolonged follow-up is a reduction in the incidence of perineal bulge and hernia, which can occur years after APR. As we have experienced in our ongoing study of more than 60 patients who have undergone VRAM flap reconstruction of perineal defects, the design of such a study is challenging and subject to several shortcomings. Despite review over a 12-year period, Chessin et al. identified only 19 patients who had reconstruction with a VRAM flap. This represented only 9% of the 206 patients who underwent APR after chemoradiation. At our institution, the indications for VRAM flap reconstruction of APR defects have expanded over the past 5 years, with a greater percentage of APR cases having VRAM flap reconstruction. Identification of an appropriate control population is difficult. The indications and patientselection criteria for VRAM flap reconstruction may have differed between operations performed early versus later in the period studied. In addition, several important wound-healing factors were not controlled for, including body mass index, tobacco use, nutritional status, and the condition of the surrounding perineal and buttock skin; however, data on these variables may not have been available in this retrospective analysis. There was also no description of the methods used or the follow-up period for detection of abdominal wall complications. Abdominal bulge or hernia frequently occur as late complications, and accurate assessment of these complications would require extended follow-up.
Sound surgical judgment and technique are absolutely critical for the success of VRAM flap reconstruction. Numerous preventable complications can occur because of inexperience and technical imperfection. In addition to techniques described by Chessin et al., we believe that several technical aspects of VRAM perineal reconstruction improve outcome and reduce complications. A detailed discussion of reconstructive techniques is beyond the scope of this editorial, but some concepts deserve mention. Chessin et al. illustrate a vertical skin paddle design that includes the upper abdominal skin. This design is often used because it enables the flap to reach and be positioned into the perineal defect without tension in most patients. Regardless of the skin paddle location and orientation (vertical or oblique), the paddle should include the periumbilical musculofasciocutaneous perforating vessels to ensure adequate vascularity. We have found that extending the skin paddle superolaterally, toward the axilla and just below the inframammary fold (Fig. 1
), is remarkably useful when additional skin and/or bulk is required, particularly at the distal reach of the flap, such as the sacral region. The vascularity of the distal flap segment is usually robust when correctly designed and elevated.
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Even when well-vascularized flap tissue is interposed into the perineal skin defect, wound complications can occur. We have found a vest-overpants skin inset to be helpful in reducing wound complications. The peripheral circumference of the skin paddle is de-epithelialized for several centimeters (Fig. 2), and the de-epithelialized skin edge is secured to the remnant pelvic floor elements, perineal fascia, or both. The perineal skin defect edges are then sutured to the central (epithelialized) aspect of the flap skin paddle. This reliably reinforces the pelvic floor defect and helps prevent wound dehiscence. Furthermore, the early postoperative use of a foam thigh abduction pillow is helpful to prevent compression and congestion of the skin paddle.
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). The anterior fascial incision is transitioned medially to a standard midline (linea alba) incision inferior to the periumbilical region (below the location of the skin paddle). The lateral anterior rectus sheath fascia is incised just lateral to the lateral perforating vessels to spare fascia laterally.
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Received for publication November 11, 2004. Accepted for publication December 7, 2004.
REFERENCES
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