Extended vertical rectus abdominis myocutaneous flap for pelvic reconstruction: Three-dimensional and four-dimensional computed tomography angiographic perfusion study and clinical outcome analysis

Background: The extended vertical rectus abdominis myocutaneous (eVRAM) flap includes skin and subcutaneous fat extending from the costal margin to the anterior axillary line. The reliability and vascularity of this distal extension have been questioned. The authors hypothesized that the eVRAM flap would have adequate perfusion throughout the extended portion and be reliable for pelvic reconstruction. To evaluate this, the authors conducted a perfusion study on eVRAM flaps from cadavers and a retrospective clinical study of outcomes in patients. Methods: In the perfusion study, seven eVRAM flaps were harvested from fresh cadavers. Iodinated contrast material was injected into the deep inferior epigastric artery of each flap, and three- and four-dimensional computed tomography (three-dimensional and four-dimensional computed tomography) angiography was performed. In the clinical study, the surgical outcomes of all patients who underwent repair of pelvic defects with a pedicled eVRAM flap between 2004 and 2008 were retrospectively evaluated. Results: Three-dimensional and four-dimensional computed tomography demonstrated connections between adjacent intercostal and superior epigastric artery vascular territories that provided a robust blood supply to the flap extension. In the eight patients included in the clinical study, all flaps demonstrated excellent vascularity and survived completely. Two minor complications occurred: a lateral perineal dehiscence and hypertrophic scarring of the abdomen. Conclusions: Four-dimensional computed tomography angiography demonstrated vascular perfusion throughout the eVRAM flaps. Low rates of donor-site and recipient-site complications and good distal flap perfusion were observed when a pedicled eVRAM flap was used for pelvic reconstruction. The eVRAM flap is a reliable option for pelvic reconstruction requiring large tissue volume and/or additional flap reach.