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V O L 4 2019 I S S U E
vascularized tissue tilted our choice towards
Pedicled, Inferiorly based Vertical Rectus
Abdominis Myocutaneous (VRAM) flap with
Gluteus Maximus Myocutaneous Flap. Also, the
need to change the position for the completion
of resection facilitated our approach for the
aforementioned flaps.
Patient was placed in the supine position first
and through a midline laparotomy incision the
oncosurgeon completed the abdominal part of
APR, leaving the closed distal end of colon in
the pelvic cavity.
Then VRAM was harvested and was rotated
180° on DIEA pedicle and was tunneled via
an intraperitoneal, rectovesical route into the
pelvis. Tunneling the flap intraperitoneally
increased its usable length. [4]
The patient was turned into jack-knife position
and oncosurgery team performed the wide
local excision and completed the perineal part
of APR along with the resection of S3, S4 and
coccyx and we were left with a sizeable defect.
Figure 7
Figure 7 Bilateral Gluteus Maximus Flap
was planned and incision made over the
superolateral aspect of the gluteal region.
Insetting of flaps was done in a manner in
which VRAM was positioned in the centre
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over sacrococcygeal defect with rectus muscle
filling the pelvic cavity and Gluteus maximus
flaps closing the lateral aspect of defect.
Figure 8
Figure 8 Post operative day 7
Bilateral Gluteus maximus flap based on the
superior gluteal artery provides adequate
tissue for coverage of sacral defects up to 12
cm. The flap is usually transferred as a rotation
flap with a 25–40° arc of rotation. The pivot
point is in the medial third of the base. In GM
musculocutaneous pedicled flaps, sectioning
of the lateral insertion of the GM on the greater
trochanter, partially or totally, provides a larger
arc of rotation. The flaps are then advanced in
V-Y fashion. [5]
Successful perineal reconstruction provides
wound coverage, facilitates healing, employs
vascularized tissue with sufficient bulk, maintains
urogenital and anorectal function, and helps
sustain upright posture and ambulation. [6]
Message
Reconstructing a complex oncological defect is
just like solving a Rubik’s cube. One should not
be afraid to accept challenges and should do
his/her homework well, dig deep into literature,
where you will always find a similar problem.
Planning is 50% work in such complex defects,
50 % is then execution and post operative care.
References Consent
Patients have given their consent for the
pictures to be published academically.
[1] Kiricuta I. The use of the great omentum
in the surgery of breast cancer. Presse Financial support & sponsorship
Med. 1963;5(71):15–7
Nil
[2] Weinzweig N, Yetman R. Transposition of
the greater omentum for recalcitrant median Conflicts of interest
sternotomy wound infections. Ann Plast Surg There are no conflicts of interest.
1995;34:471–7
[3] Das SK. The size of the human omentum and
methods of lengthening it for transplantation.
Br J Plast Surg 1976;29:170–4
[4] Coombs DM, Patel NB, Zeiderman MR,
Wong MS. The Vertical Rectus Abdominis
Musculocutaneous Flap As a Versatile and Viable
Option for Perineal Reconstruction. Eplasty.
2017;17:ic2
[5] Allen RJ, Tucker C. Superior gluteal artery
perforator free flap for breast reconstruction.
Plast Reconstr Surg 1995;95:1207–12
[6] Mathes JM, Nahai F, editors. Clinical
applications for muscle and musculocutaneous
flaps. St Louis: Mosby; 1982. p. 426–32
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