Modification of the Vertical Rectus Abdominis Musculocutaneous (VRAM) Flap for Functional Reconstruction of Complex Vulvoperineal Defects

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Abstract
Radical vulvoperineal ablations present challenging reconstructive dilemmas, especially when local metastatic spread requires distal vaginal and anal resection. Despite advances in vaginal salvage and sphincteroplasty, surface recontouring remains elusive because of the necessity to resurface a large, complex area that includes the mons, vulva, and fourchette. We describe a modification of the inferior-based vertical rectus abdominis musculocutaneous (VRAM) flap where the superior portion is split longitudinally to produce “tongue” flaps, which can resurface complex vulvoperineal wounds. By splitting the flap, one can resurface the vulva, provide an edge to reattach the vaginal cuff, and recreate the fourchette and line the anoderm after anoplasty. This musculocutaneous flap provides adequate contour and protection against radiation injury. Splitting of the flap is based on the vascular territory of the superior epigastric branches and their perforators and can be carried down to the level of their anastomosis, with the inferior system at the level of the umbilicus. The split VRAM flap has been used successfully in 3 patients with complex perineal wounds with excellent results and maintenance of vaginal patency.