Journal of Plastic, Reconstructive & Aesthetic Surgery (2015) 68, 93e97
Reconstruction of the pelvic floor and the vagina after total pelvic exenteration using the transverse musculocutaneous gracilis flap ¨ty c, Ilkka S. Kaartinen a,*, Maarit H. Vuento b, Marja K. Hyo Jukka Kallio d, Hannu O. Kuokkanen a a
Department of Plastic Surgery, Tampere University Hospital, Tampere, Finland Department of Gynaecology and Obstetrics, Tampere University Hospital, Tampere, Finland c Department of Gastroenterology, Tampere University Hospital, Tampere, Finland d Department of Urology, Tampere University Hospital, Tampere, Finland b
Received 3 June 2014; accepted 20 August 2014
KEYWORDS Pelvic exenteration; Vaginal reconstruction; Pelvic floor; TMG flap
Summary Background: Total pelvic exenteration (TPE) is a rare operation in which the pelvic contents are removed entirely. Several options for pelvic floor and vaginal reconstruction have been described including transverse rectus abdominis musculocutaneous (TRAM) or deep inferior epigastric perforator (DIEP) flaps. The transverse musculocutaneous gracilis (TMG) flap has been introduced for breast reconstruction as a free flap. We adopted the pedicled TMG flap for reconstructions after TPE. To the best of our knowledge, this is the first report of this method in the literature. Methods: Between November 2011 and February 2014, 12 patients underwent TPE and reconstruction with unilateral (six patients) or bilateral (six patients) pedicled TMG flaps. Five patients underwent vaginal reconstruction with bilateral TMG flaps. We describe the operative procedure and the outcome of the operation in these patients. Results: The total mean operative times for TPE with or without vaginal reconstruction were 467 12 and 386 59 min, respectively. The TMG flaps had enough vascular tissue and mobility for reconstructing the TPE defects. There was distal edge necrosis in one out of 18 flaps, while the rest survived completely. During the follow-up, complete wound healing with no signs of weakening of the pelvic floor was observed in all cases. Conclusions: Soft-tissue reconstructions are needed to reduce complications associated with TPE, to secure the pelvic floor and to reconstruct the vagina in select patients. The TMG flap
* Corresponding author. Tampere University Hospital, P.O. Box 2000, Teiskontie 35, 33521 Tampere, Finland. E-mail addresses: [email protected], [email protected] (I.S. Kaartinen). http://dx.doi.org/10.1016/j.bjps.2014.08.059 1748-6815/ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
94
I.S. Kaartinen et al. is a logical flap choice that does not lead to functional deficits, complicate the abdominal ostomies or weaken the abdominal wall. It reduces the length of operation compared to that of abdominal flaps. Level of evidence: IV, therapeutic. ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Introduction In 1948, Brunschwig described total pelvic exenteration (TPE) as a treatment for recurrent or locally advanced cervical carcinoma.1 The operation still provides only a curative option in select cases of pelvic malignancies, especially those involving the female reproductive organs. Generally, TPE is considered when it is the only possible curative intervention to treat central residual or recurrent tumours of the vulvar, vaginal, cervical or uterine malignancies after initial surgery, radiation therapy and chemotherapy.2 Bricker developed urinary diversion with a small bowel conduit in 1950, which is still one of the most commonly used reconstructions of the distal urinary tract after TPE.3 Later, methods for reconstructing the pelvic floor were described to reduce the morbidity associated with TPE,4 and, finally, reconstructions of the vagina offered a possibility to preserve sexual function and improve the quality of life in select patients.5e8 In TPE, the pelvic contents including the rectum, bladder, vagina, uterus and adnexes are removed en bloc. The operation results in two permanent ostomies or, in some cases, a urinary diversion and a low rectal anastomosis.9 Without flap reconstruction to replace the missing tissue bulk, only the thin skin of the vulva remains over the emptied pelvis and birth canal, and wound complications are likely to be encountered. Reconstruction of the pelvic floor is also needed to prevent perineal evisceration or hernia. While achieving this, flap reconstruction can also be used to form a neovagina.10 Several options for flap coverage have been described earlier. These include local skin flaps, the gracilis muscle flap or the musculocutaneous flap with a vertical skin island, the transverse rectus abdominis musculocutaneous (TRAM) flap and, most recently, the deep inferior epigastric perforator (DIEP) flap.11e14 The transverse musculocutaneous gracilis (TMG) flap has been described by Schoeller et al. for breast reconstruction and has been also been used for other purposes as a free flap. The experience with TMG breast reconstruction has shown that the vascularity of the transverse skin island is reliable even at the length of 30 cm.15 The proximity of the donor site to the pelvis and external genitalia makes it a logical option for reconstructions after TPE. Harvesting gracilis flaps does not create functional defects for the patient and does not weaken the abdominal wall or complicate the ostomies. That is why since November 2011 we have been using the pedicled TMG flap in pelvic floor and vaginal reconstructions. In this article, we describe the method and review the outcome
in 12 consecutive patients who underwent TPE and reconstruction with unilateral or bilateral TMG flaps at our hospital.
Patients and methods Between November 2011 and January 2014, 12 patients (mean age 62 10.3 years) underwent TPE and TMG flap reconstruction at our hospital. The most frequent malignancy was a cervical carcinoma (Table 1). The patients were informed about the possibility of vaginal reconstruction and received sexual counselling from a specialized nurse. Finally, five patients asked for vaginal reconstruction. One patient had a large recurrent carcinoma of the vulva and needed wide skin resection of the perineum; in this case, bilateral TMG flaps were used to reconstruct the pelvic floor and the defect of the perineum. In the remaining six patients, a unilateral TMG flap was used to reconstruct the pelvic floor without a reconstruction of the vagina. Furthermore, two patients had had previous radical vulvectomy; one patient had previous hysterectomy and salpingo-oophorectomy; and one patient had previous cystectomy, hysterectomy, salpingo-oophorectomy and sigmoidectomy followed by urinary diversion and sigmoidostomy. The patients were followed up at the outpatient clinic for 4e24 months post-operatively.
Operative technique The TPE procedure was performed as presented in the current literature, and it encompassed removing the distal urinary tract, the uterus and adnexes if not removed earlier, and the rectum (Figure 1a).9 In all the patients, a urinary diversion with Bricker’s conduit was performed during the operation, except in case no. 3 (she already had an existing Bricker’s ileal conduit). The extent of excision of the vulva varied depending on the location of the tumour and ranged from partial excision of the labia minora to extensive excision of skin and soft tissue from the perineal and perianal area. The clitoris was spared in 10 out of 12 patients and in all the patients who underwent vaginal reconstruction. The technique to raise the TMG flap has been described in detail in Ref.15 and with further refinements in Ref.16 We mark the patient preoperatively in an upright position. The gluteal crease is marked as the upper border of the cutaneous part of the flap, and the distal end of the flap is located between the middle and lateral thirds of
Reconstruction of the pelvic floor and the vagina Table 1
95
List of patients with total pelvic exenteration and reconstruction with TMG flaps.
Case no:
Diagnosis
Unilateral /bilateral
Vaginal reconstruction
Operating timea
Flap loss
Early complications
Late complications
1 2 3
Vulvar carcinoma Cervical carcinoma Ovarian carcinoma
Unilateral Unilateral Unilateral
No No No
6:35 5:41 4:58
No No No
No No No
4 5 6 7 8 9 10
Vaginal melanoma Vaginal melanoma Cervical carcinoma Vaginal melanoma Vulvar carcinoma Endometrial carcinoma Cervical carcinoma
Unilateral Unilateral Bilateral Bilateral Bilateral Bilateral Unilateral
No No Yes Yes No Yes No
7:36 6:30 7:46 7:49 6:20 8:03 7:15
No No No No Minor No No
11 12
Cervical carcinoma Cervical carcinoma
Bilateral Bilateral
Yes Yes
7:25 7:52
No No
No No No No No No Pulmonary embolism No No
No NO Enterocutaneous fistula No NO NO No No No No
a
No No
Operating time in hours and minutes.
the posterior thigh. The vertical height of the skin island needed for pelvic floor and vaginal reconstruction is 6e7 cm, providing a vaginal circumference of 12e14 cm when bilateral flaps are used. This allows for tension-free closure of the donor site, which could pose problems when the vertical height is greater. If a unilateral TMG flap is used for reconstruction of the pelvic floor only, the vertical height can be 8e10 cm to increase the bulk and without compromising wound closure. The horizontal length of the skin island is around 20 cm. The lower border of the skin island is incised first, and the incision is bevelled inferiorly in the subcutaneous tissue for a few centimetres to secure the circulation of the skin island through the small musculocutaneous perforators and to provide the needed tissue bulk (Video). The gracilis muscle is identified and its pedicle located under the adductor major muscle, approximately 10 cm caudal to the pubic bone. Through the same incision, the gracilis muscle is dissected distally all the way to its insertion, the minor pedicle is ligated and the muscle cut distally. The cranial border of the flap can now be incised and the skin island dissected off the underlying musculature. Care must be taken to include the deep fascia to the flap; otherwise, the blood flow to the distal part of the skin may be compromised. The pedicle is dissected to its source vessels to increase the pedicle length and prevent the pedicle from kinking. Finally, a tunnel, through which the musculocuaneous flap is brought in, is dissected under the labia. The skin island is de-epithelialized at its proximal and distal ends, leaving a segment of 8 cm of intact skin to form the vaginal walls (Figure 1b). The flaps are sutured together to form the neovagina, starting from the anterior wall. Finally, the neovagina is secured to the Cooper’s ligaments and the fascial structures behind the pubic bone to form the pelvic floor and to place the neovagina in a natural position (Figure 1c). The gracilis muscles are inserted behind the neovagina to support it posteriorly and to fill this area. Donor sites are closed directly with drainage. Post-operatively, the patients remain in bed rest for 1 day and avoid sitting for 1 week.
Results There was one major early complication; one patient was diagnosed with an un-symptomatic pulmonary embolism, which was treated successfully by conservative means. During the follow-up, all patients had complete wound healing; in one patient (Pat N:o 12) the vulvar wound was partially opened due to heavy serous fluid excretion during a small bowel obstruction 2 months after TPE. She was operated on and the wound healing was complete thereafter. One of the patients (Pat N:o 3) developed an enterocutaneous fistula caused by damage to the small bowel during the liberation of adhesions from the previous surgery. The lesion was sutured but failed during the first post-operative week. Another patient had a long-standing fistula in the posterior wall of the neovagina, which healed by conservative means (Pat N:o 7). One distal necrosis was encountered in one flap in a patient who had bilateral TMG flaps for coverage of the perineum and pelvic floor after an excision of a large recurrent vulvar carcinoma. The small necrosis was excised and the wound closed directly. All the other flaps survived completely. The total mean operative times for TPE with unilateral or bilateral TMG flap reconstruction was 386 59 and 453 38 min, respectively. For TPE and vaginal reconstruction with bilateral TMG flaps, the total mean operative time was 467 12 min. During the follow-up time, no weakening of the pelvic floor or perineal hernias was detected. The five reconstructed vaginas maintained their original dimensions without stricture formation or shrinking during the follow-up. The TMG flaps provided enough tissue to close off the pelvic cavity and secure the pelvic floor. Two patients had a recurrence with distant metastasis and died during the 2-year follow-up, while the rest remained in remission at the end of this follow-up.
Discussion The usability of the gracilis muscle flap in reconstructive surgery is well known. It was first used as a free flap in 1976
96
I.S. Kaartinen et al.
Figure 1 a) Total pelvic exenteration completed and bilateral flaps outlined. b) Flaps raised and brought to the defect under the labia, the distal and proximal ends de-epithelialized, and proximal borders sutured to form the anterior wall of the vagina. c) Defect and donor sites closed directly with drains in both thighs. d) 4 months post-operatively.
by Harii et al. and remains a feasible option in many indications, including lower-extremity reconstruction and facial reanimation.17 In the literature, the musculocutaneous gracilis flap has traditionally been described with a vertical skin island lying longitudinally on the gracilis muscle.18 However, this type of skin paddle is often associated with distal necrosis.19 Better vascularity of the skin paddle is achieved by placing the skin flap horizontally on top of the proximal third of the gracilis muscle, as shown originally by Yousif et al.20 In addition, this enables the placement of the scar in the gluteal crease where it is the most inconspicuous. More recently, the TMG flap has been used in various cases including head and neck and thorax reconstructions as a free flap.21 After TPE, we suggest that a flap reconstruction should always be performed to prevent dead space formation and perineal evisceration or hernias. Vaginal reconstruction is routinely offered to our patients, and they receive sexual counselling from a specialized nurse. Often, there are several months between the initial visit to the gynaecological oncologist and the operation because of chemotherapy and radiation therapy, and the patients have time to consider the options. After careful consideration, not all patients wish to have a neovagina. Recently, it was reported by Løve et al. in a 2-year follow-up that only 14% of patients who had had vaginal reconstructions were sexually active post-operatively.22 In the worst case, the reconstructed vagina can be a burden for the patient. This is why patient selection is important, and for those who opt not to have a vaginal reconstruction, a unilateral TMG flap can be used for pelvic floor reconstruction.
When compared to a DIEP or TRAM flap, the TMG flap has some considerable advantages. Abdominal flaps are reliable and contain enough vascular tissue for intrapelvic and vaginal reconstruction. In addition, the arc of rotation is sufficient for vertical rectus abdominis myocutaneous (VRAM), TRAM or DIEP flaps. However, the abdominal flaps form a risk of hernia formation or bulging. In addition, the ostomies are preferably brought through the rectus abdominis muscles, and harvesting an abdominal flap may lead to a risk regarding the function of the ostomies. Moreover, the operative time is shorter with the TMG flap. In a report by Qiu et al., the mean total operation length was 605 min for the DIEP flap and 725 min for the TRAM flap for TPE and vaginal reconstruction.12 In our series, the mean operation length for TPE and unilateral TMG flap was 386 min, and 467 min for TPE and bilateral TMG flap with vaginal reconstruction. The shorter operating time compared to the DIEP/ TRAM flap is explained by the somewhat shorter flap harvest time and the possibility of raising the flap simultaneously with the urologist constructing the urinary diversion. Furthermore, TMG flaps can be used when the defect is extended to external genitalia making it a more versatile option than the TRAM/DIEP flap.10 When flap survival is compared to other methods, the pedicled TMG flap seems to be a reliable option in pelvic reconstruction. There was only one partial flap loss (5.6%) and no complete flap losses in our series. Berek et al. reported a mean success rate of 76% in vaginal reconstructions; Qiu et al. had 14.3% total and 23.8% partial flap losses in TRAM flaps but no total or partial flap losses in DIEP flaps.2,12
Reconstruction of the pelvic floor and the vagina
Conclusion In our experience, the pedicled TMG flap is a logical and versatile option for reconstruction of the pelvic floor and perineal area after TPE. Furthermore, bilateral TMG flaps offer a reliable and convenient option for vaginal reconstruction. The donor defect after TMG harvesting is minimal and the scars are well hidden. Based on these reasons, the TMG flap is our choice in reconstructing TPE defects.
Financial disclosure and products This study was financially supported by the Competitive State Research Financing of the Expert Responsibility area of Tampere University Hospital, Grant 9R025. No products, devices or drugs are mentioned in the manuscript. The authors have no financial interest to declare in relation to the content of this article.
Conflict of interest None.
Ethical approval Not required.
Acknowledgement This study was financially supported by the Competitive State Research Financing of the Expert Responsibility area of Tampere University Hospital, Grant 9R025. We would like to acknowledge Dr Maija Kolehmainen for being the first to come up with the idea of using TMG flaps in pelvic floor reconstruction, and for sharing her experience with us. She presented her method in the EURAPS annual meeting in Munich in 2012.
References 1. Brunschwig A. Complete excision of pelvic viscera for advanced carcinoma; a one-stage abdominoperineal operation with end colostomy and bilateral ureteral implantation into the colon above the colostomy. Cancer 1948 Jul;1(2):177e83. 2. Berek JS, Howe C, Lagasse LD, Hacker NF. Pelvic exenteration for recurrent gynecologic malignancy: survival and morbidity analysis of the 45-year experience at UCLA. Gynecol Oncol 2005 Oct;99(1):153e9. 3. Bricker EM, Butcher H, McAFEE CA. Late results of bladder substitution with isolated ileal segments. Surg Gynecol Obstet 1954 Oct;99(4):469e82. 4. Cain JM, Diamond A, Tamimi HK, Greer BE, Figge DC. The morbidity and benefits of concurrent gracilis myocutaneous graft with pelvic exenteration. Obstet Gynecol 1989 Aug;74(2): 185e9.
97 5. Berek JS, Hacker NF, Lagasse LD. Vaginal reconstruction performed simultaneously with pelvic exenteration. Obstet Gynecol 1984 Mar;63(3):318e23. 6. Copeland LJ, Hancock KC, Gershenson DM, Stringer CA, Atkinson EN, Edwards CL. Gracilis myocutaneous vaginal reconstruction concurrent with total pelvic exenteration. Am J Obstet Gynecol 1989 May;160(5 Pt 1):1095e101. 7. Schmidt VJ, Horch RE, Dragu A, et al. Perineal and vaginal wall reconstruction using a combined inferior gluteal and pudendal artery perforator flap: a case report. J Plast Reconstr Aesthetic Surg 2012 Dec;65(12):1734e7. 8. Smeets L, Hendrickx B, Teo TC. The propeller flap concept used in vaginal wall reconstruction. J Plast Reconstr Aesthetic Surg 2012 May;65(5):629e33. 9. Goldberg GL, Sukumvanich P, Einstein MH, Smith HO, Anderson PS, Fields AL. Total pelvic exenteration: the Albert Einstein College of Medicine/Montefiore Medical Center experience (1987 to 2003). Gynecol Oncol 2006 May;101(2):261e8. 10. Pusic AL, Mehrara BJ. Vaginal reconstruction: an algorithm approach to defect classification and flap reconstruction. J Surg Oncol 2006 Nov 1;94(6):515e21. 11. Berger JL, Westin SN, Fellman B, et al. Modified vertical rectus abdominis myocutaneous flap vaginal reconstruction: an analysis of surgical outcomes. Gynecol Oncol 2012 Apr;125(1): 252e5. 12. Qiu SS, Jurado M, Hontanilla B. Comparison of TRAM versus DIEP flap in total vaginal reconstruction after pelvic exenteration. Plast Reconstr Surg 2013 Dec;132(6):1020ee7e. 13. Rieger UM, Pierer G. Extended transpelvic deep inferior epigastric myocutaneous rectus abdominis flap for posterior vaginal wall reconstruction in advanced pelvic malignancy. J Plast Reconstr Aesthetic Surg 2012 Jun;65(6):798e9. 14. Weiwei L, Zhifei L, Ang Z, Lin Z, Dan L, Qun Q. Vaginal reconstruction with the muscle-sparing vertical rectus abdominis myocutaneous flap. J Plast Reconstr Aesthetic Surg 2009 Mar;62(3):335e40. 15. Schoeller T, Huemer GM, Wechselberger G. The transverse musculocutaneous gracilis flap for breast reconstruction: guidelines for flap and patient selection. Plast Reconstr Surg 2008 Jul;122(1):29e38. 16. Fattah A, Figus A, Mathur B, Ramakrishnan VV. The transverse myocutaneous gracilis flap: technical refinements. J Plast Reconstr Aesthetic Surg 2010 Feb;63(2):305e13. 17. Harii K, Ohmori K, Sekiguchi J. The free musculocutaneous flap. Plast Reconstr Surg 1976 Mar;57(3):294e303. 18. Burke TW, Morris M, Roh MS, Levenback C, Gershenson DM. Perineal reconstruction using single gracilis myocutaneous flaps. Gynecol Oncol 1995 May;57(2):221e5. 19. Wong C, Mojallal A, Bailey SH, Trussler A, Saint-Cyr M. The extended transverse musculocutaneous gracilis flap: vascular anatomy and clinical implications. Ann Plast Surg 2011 Aug; 67(2):170e7. 20. Yousif NJ, Matloub HS, Kolachalam R, Grunert BK, Sanger JR. The transverse gracilis musculocutaneous flap. Ann Plast Surg 1992 Dec;29(6):482e90. 21. Del Frari B, Schoeller T, Wechselberger G. Reconstruction of large head and neck deformities: experience with free gracilis muscle and myocutaneous flaps. Microsurgery 2010;30(3): 192e8. 22. Løve US, Sjøgren P, Rasmussen P, Laurberg S, Christensen HK. Sexual dysfunction after colpectomy and vaginal reconstruction with a vertical rectus abdominis myocutaneous flap. Dis Colon Rectum 2013 Feb;56(2):186e90.
Reconstruction of the pelvic floor and the vagina after total pelvic exenteration using the transverse musculocutaneous gracilis flap ¨ty c, Ilkka S. Kaartinen a,*, Maarit H. Vuento b, Marja K. Hyo Jukka Kallio d, Hannu O. Kuokkanen a a
Department of Plastic Surgery, Tampere University Hospital, Tampere, Finland Department of Gynaecology and Obstetrics, Tampere University Hospital, Tampere, Finland c Department of Gastroenterology, Tampere University Hospital, Tampere, Finland d Department of Urology, Tampere University Hospital, Tampere, Finland b
Received 3 June 2014; accepted 20 August 2014
KEYWORDS Pelvic exenteration; Vaginal reconstruction; Pelvic floor; TMG flap
Summary Background: Total pelvic exenteration (TPE) is a rare operation in which the pelvic contents are removed entirely. Several options for pelvic floor and vaginal reconstruction have been described including transverse rectus abdominis musculocutaneous (TRAM) or deep inferior epigastric perforator (DIEP) flaps. The transverse musculocutaneous gracilis (TMG) flap has been introduced for breast reconstruction as a free flap. We adopted the pedicled TMG flap for reconstructions after TPE. To the best of our knowledge, this is the first report of this method in the literature. Methods: Between November 2011 and February 2014, 12 patients underwent TPE and reconstruction with unilateral (six patients) or bilateral (six patients) pedicled TMG flaps. Five patients underwent vaginal reconstruction with bilateral TMG flaps. We describe the operative procedure and the outcome of the operation in these patients. Results: The total mean operative times for TPE with or without vaginal reconstruction were 467 12 and 386 59 min, respectively. The TMG flaps had enough vascular tissue and mobility for reconstructing the TPE defects. There was distal edge necrosis in one out of 18 flaps, while the rest survived completely. During the follow-up, complete wound healing with no signs of weakening of the pelvic floor was observed in all cases. Conclusions: Soft-tissue reconstructions are needed to reduce complications associated with TPE, to secure the pelvic floor and to reconstruct the vagina in select patients. The TMG flap
* Corresponding author. Tampere University Hospital, P.O. Box 2000, Teiskontie 35, 33521 Tampere, Finland. E-mail addresses: [email protected], [email protected] (I.S. Kaartinen). http://dx.doi.org/10.1016/j.bjps.2014.08.059 1748-6815/ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
94
I.S. Kaartinen et al. is a logical flap choice that does not lead to functional deficits, complicate the abdominal ostomies or weaken the abdominal wall. It reduces the length of operation compared to that of abdominal flaps. Level of evidence: IV, therapeutic. ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Introduction In 1948, Brunschwig described total pelvic exenteration (TPE) as a treatment for recurrent or locally advanced cervical carcinoma.1 The operation still provides only a curative option in select cases of pelvic malignancies, especially those involving the female reproductive organs. Generally, TPE is considered when it is the only possible curative intervention to treat central residual or recurrent tumours of the vulvar, vaginal, cervical or uterine malignancies after initial surgery, radiation therapy and chemotherapy.2 Bricker developed urinary diversion with a small bowel conduit in 1950, which is still one of the most commonly used reconstructions of the distal urinary tract after TPE.3 Later, methods for reconstructing the pelvic floor were described to reduce the morbidity associated with TPE,4 and, finally, reconstructions of the vagina offered a possibility to preserve sexual function and improve the quality of life in select patients.5e8 In TPE, the pelvic contents including the rectum, bladder, vagina, uterus and adnexes are removed en bloc. The operation results in two permanent ostomies or, in some cases, a urinary diversion and a low rectal anastomosis.9 Without flap reconstruction to replace the missing tissue bulk, only the thin skin of the vulva remains over the emptied pelvis and birth canal, and wound complications are likely to be encountered. Reconstruction of the pelvic floor is also needed to prevent perineal evisceration or hernia. While achieving this, flap reconstruction can also be used to form a neovagina.10 Several options for flap coverage have been described earlier. These include local skin flaps, the gracilis muscle flap or the musculocutaneous flap with a vertical skin island, the transverse rectus abdominis musculocutaneous (TRAM) flap and, most recently, the deep inferior epigastric perforator (DIEP) flap.11e14 The transverse musculocutaneous gracilis (TMG) flap has been described by Schoeller et al. for breast reconstruction and has been also been used for other purposes as a free flap. The experience with TMG breast reconstruction has shown that the vascularity of the transverse skin island is reliable even at the length of 30 cm.15 The proximity of the donor site to the pelvis and external genitalia makes it a logical option for reconstructions after TPE. Harvesting gracilis flaps does not create functional defects for the patient and does not weaken the abdominal wall or complicate the ostomies. That is why since November 2011 we have been using the pedicled TMG flap in pelvic floor and vaginal reconstructions. In this article, we describe the method and review the outcome
in 12 consecutive patients who underwent TPE and reconstruction with unilateral or bilateral TMG flaps at our hospital.
Patients and methods Between November 2011 and January 2014, 12 patients (mean age 62 10.3 years) underwent TPE and TMG flap reconstruction at our hospital. The most frequent malignancy was a cervical carcinoma (Table 1). The patients were informed about the possibility of vaginal reconstruction and received sexual counselling from a specialized nurse. Finally, five patients asked for vaginal reconstruction. One patient had a large recurrent carcinoma of the vulva and needed wide skin resection of the perineum; in this case, bilateral TMG flaps were used to reconstruct the pelvic floor and the defect of the perineum. In the remaining six patients, a unilateral TMG flap was used to reconstruct the pelvic floor without a reconstruction of the vagina. Furthermore, two patients had had previous radical vulvectomy; one patient had previous hysterectomy and salpingo-oophorectomy; and one patient had previous cystectomy, hysterectomy, salpingo-oophorectomy and sigmoidectomy followed by urinary diversion and sigmoidostomy. The patients were followed up at the outpatient clinic for 4e24 months post-operatively.
Operative technique The TPE procedure was performed as presented in the current literature, and it encompassed removing the distal urinary tract, the uterus and adnexes if not removed earlier, and the rectum (Figure 1a).9 In all the patients, a urinary diversion with Bricker’s conduit was performed during the operation, except in case no. 3 (she already had an existing Bricker’s ileal conduit). The extent of excision of the vulva varied depending on the location of the tumour and ranged from partial excision of the labia minora to extensive excision of skin and soft tissue from the perineal and perianal area. The clitoris was spared in 10 out of 12 patients and in all the patients who underwent vaginal reconstruction. The technique to raise the TMG flap has been described in detail in Ref.15 and with further refinements in Ref.16 We mark the patient preoperatively in an upright position. The gluteal crease is marked as the upper border of the cutaneous part of the flap, and the distal end of the flap is located between the middle and lateral thirds of
Reconstruction of the pelvic floor and the vagina Table 1
95
List of patients with total pelvic exenteration and reconstruction with TMG flaps.
Case no:
Diagnosis
Unilateral /bilateral
Vaginal reconstruction
Operating timea
Flap loss
Early complications
Late complications
1 2 3
Vulvar carcinoma Cervical carcinoma Ovarian carcinoma
Unilateral Unilateral Unilateral
No No No
6:35 5:41 4:58
No No No
No No No
4 5 6 7 8 9 10
Vaginal melanoma Vaginal melanoma Cervical carcinoma Vaginal melanoma Vulvar carcinoma Endometrial carcinoma Cervical carcinoma
Unilateral Unilateral Bilateral Bilateral Bilateral Bilateral Unilateral
No No Yes Yes No Yes No
7:36 6:30 7:46 7:49 6:20 8:03 7:15
No No No No Minor No No
11 12
Cervical carcinoma Cervical carcinoma
Bilateral Bilateral
Yes Yes
7:25 7:52
No No
No No No No No No Pulmonary embolism No No
No NO Enterocutaneous fistula No NO NO No No No No
a
No No
Operating time in hours and minutes.
the posterior thigh. The vertical height of the skin island needed for pelvic floor and vaginal reconstruction is 6e7 cm, providing a vaginal circumference of 12e14 cm when bilateral flaps are used. This allows for tension-free closure of the donor site, which could pose problems when the vertical height is greater. If a unilateral TMG flap is used for reconstruction of the pelvic floor only, the vertical height can be 8e10 cm to increase the bulk and without compromising wound closure. The horizontal length of the skin island is around 20 cm. The lower border of the skin island is incised first, and the incision is bevelled inferiorly in the subcutaneous tissue for a few centimetres to secure the circulation of the skin island through the small musculocutaneous perforators and to provide the needed tissue bulk (Video). The gracilis muscle is identified and its pedicle located under the adductor major muscle, approximately 10 cm caudal to the pubic bone. Through the same incision, the gracilis muscle is dissected distally all the way to its insertion, the minor pedicle is ligated and the muscle cut distally. The cranial border of the flap can now be incised and the skin island dissected off the underlying musculature. Care must be taken to include the deep fascia to the flap; otherwise, the blood flow to the distal part of the skin may be compromised. The pedicle is dissected to its source vessels to increase the pedicle length and prevent the pedicle from kinking. Finally, a tunnel, through which the musculocuaneous flap is brought in, is dissected under the labia. The skin island is de-epithelialized at its proximal and distal ends, leaving a segment of 8 cm of intact skin to form the vaginal walls (Figure 1b). The flaps are sutured together to form the neovagina, starting from the anterior wall. Finally, the neovagina is secured to the Cooper’s ligaments and the fascial structures behind the pubic bone to form the pelvic floor and to place the neovagina in a natural position (Figure 1c). The gracilis muscles are inserted behind the neovagina to support it posteriorly and to fill this area. Donor sites are closed directly with drainage. Post-operatively, the patients remain in bed rest for 1 day and avoid sitting for 1 week.
Results There was one major early complication; one patient was diagnosed with an un-symptomatic pulmonary embolism, which was treated successfully by conservative means. During the follow-up, all patients had complete wound healing; in one patient (Pat N:o 12) the vulvar wound was partially opened due to heavy serous fluid excretion during a small bowel obstruction 2 months after TPE. She was operated on and the wound healing was complete thereafter. One of the patients (Pat N:o 3) developed an enterocutaneous fistula caused by damage to the small bowel during the liberation of adhesions from the previous surgery. The lesion was sutured but failed during the first post-operative week. Another patient had a long-standing fistula in the posterior wall of the neovagina, which healed by conservative means (Pat N:o 7). One distal necrosis was encountered in one flap in a patient who had bilateral TMG flaps for coverage of the perineum and pelvic floor after an excision of a large recurrent vulvar carcinoma. The small necrosis was excised and the wound closed directly. All the other flaps survived completely. The total mean operative times for TPE with unilateral or bilateral TMG flap reconstruction was 386 59 and 453 38 min, respectively. For TPE and vaginal reconstruction with bilateral TMG flaps, the total mean operative time was 467 12 min. During the follow-up time, no weakening of the pelvic floor or perineal hernias was detected. The five reconstructed vaginas maintained their original dimensions without stricture formation or shrinking during the follow-up. The TMG flaps provided enough tissue to close off the pelvic cavity and secure the pelvic floor. Two patients had a recurrence with distant metastasis and died during the 2-year follow-up, while the rest remained in remission at the end of this follow-up.
Discussion The usability of the gracilis muscle flap in reconstructive surgery is well known. It was first used as a free flap in 1976
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Figure 1 a) Total pelvic exenteration completed and bilateral flaps outlined. b) Flaps raised and brought to the defect under the labia, the distal and proximal ends de-epithelialized, and proximal borders sutured to form the anterior wall of the vagina. c) Defect and donor sites closed directly with drains in both thighs. d) 4 months post-operatively.
by Harii et al. and remains a feasible option in many indications, including lower-extremity reconstruction and facial reanimation.17 In the literature, the musculocutaneous gracilis flap has traditionally been described with a vertical skin island lying longitudinally on the gracilis muscle.18 However, this type of skin paddle is often associated with distal necrosis.19 Better vascularity of the skin paddle is achieved by placing the skin flap horizontally on top of the proximal third of the gracilis muscle, as shown originally by Yousif et al.20 In addition, this enables the placement of the scar in the gluteal crease where it is the most inconspicuous. More recently, the TMG flap has been used in various cases including head and neck and thorax reconstructions as a free flap.21 After TPE, we suggest that a flap reconstruction should always be performed to prevent dead space formation and perineal evisceration or hernias. Vaginal reconstruction is routinely offered to our patients, and they receive sexual counselling from a specialized nurse. Often, there are several months between the initial visit to the gynaecological oncologist and the operation because of chemotherapy and radiation therapy, and the patients have time to consider the options. After careful consideration, not all patients wish to have a neovagina. Recently, it was reported by Løve et al. in a 2-year follow-up that only 14% of patients who had had vaginal reconstructions were sexually active post-operatively.22 In the worst case, the reconstructed vagina can be a burden for the patient. This is why patient selection is important, and for those who opt not to have a vaginal reconstruction, a unilateral TMG flap can be used for pelvic floor reconstruction.
When compared to a DIEP or TRAM flap, the TMG flap has some considerable advantages. Abdominal flaps are reliable and contain enough vascular tissue for intrapelvic and vaginal reconstruction. In addition, the arc of rotation is sufficient for vertical rectus abdominis myocutaneous (VRAM), TRAM or DIEP flaps. However, the abdominal flaps form a risk of hernia formation or bulging. In addition, the ostomies are preferably brought through the rectus abdominis muscles, and harvesting an abdominal flap may lead to a risk regarding the function of the ostomies. Moreover, the operative time is shorter with the TMG flap. In a report by Qiu et al., the mean total operation length was 605 min for the DIEP flap and 725 min for the TRAM flap for TPE and vaginal reconstruction.12 In our series, the mean operation length for TPE and unilateral TMG flap was 386 min, and 467 min for TPE and bilateral TMG flap with vaginal reconstruction. The shorter operating time compared to the DIEP/ TRAM flap is explained by the somewhat shorter flap harvest time and the possibility of raising the flap simultaneously with the urologist constructing the urinary diversion. Furthermore, TMG flaps can be used when the defect is extended to external genitalia making it a more versatile option than the TRAM/DIEP flap.10 When flap survival is compared to other methods, the pedicled TMG flap seems to be a reliable option in pelvic reconstruction. There was only one partial flap loss (5.6%) and no complete flap losses in our series. Berek et al. reported a mean success rate of 76% in vaginal reconstructions; Qiu et al. had 14.3% total and 23.8% partial flap losses in TRAM flaps but no total or partial flap losses in DIEP flaps.2,12
Reconstruction of the pelvic floor and the vagina
Conclusion In our experience, the pedicled TMG flap is a logical and versatile option for reconstruction of the pelvic floor and perineal area after TPE. Furthermore, bilateral TMG flaps offer a reliable and convenient option for vaginal reconstruction. The donor defect after TMG harvesting is minimal and the scars are well hidden. Based on these reasons, the TMG flap is our choice in reconstructing TPE defects.
Financial disclosure and products This study was financially supported by the Competitive State Research Financing of the Expert Responsibility area of Tampere University Hospital, Grant 9R025. No products, devices or drugs are mentioned in the manuscript. The authors have no financial interest to declare in relation to the content of this article.
Conflict of interest None.
Ethical approval Not required.
Acknowledgement This study was financially supported by the Competitive State Research Financing of the Expert Responsibility area of Tampere University Hospital, Grant 9R025. We would like to acknowledge Dr Maija Kolehmainen for being the first to come up with the idea of using TMG flaps in pelvic floor reconstruction, and for sharing her experience with us. She presented her method in the EURAPS annual meeting in Munich in 2012.
References 1. Brunschwig A. Complete excision of pelvic viscera for advanced carcinoma; a one-stage abdominoperineal operation with end colostomy and bilateral ureteral implantation into the colon above the colostomy. Cancer 1948 Jul;1(2):177e83. 2. Berek JS, Howe C, Lagasse LD, Hacker NF. Pelvic exenteration for recurrent gynecologic malignancy: survival and morbidity analysis of the 45-year experience at UCLA. Gynecol Oncol 2005 Oct;99(1):153e9. 3. Bricker EM, Butcher H, McAFEE CA. Late results of bladder substitution with isolated ileal segments. Surg Gynecol Obstet 1954 Oct;99(4):469e82. 4. Cain JM, Diamond A, Tamimi HK, Greer BE, Figge DC. The morbidity and benefits of concurrent gracilis myocutaneous graft with pelvic exenteration. Obstet Gynecol 1989 Aug;74(2): 185e9.
97 5. Berek JS, Hacker NF, Lagasse LD. Vaginal reconstruction performed simultaneously with pelvic exenteration. Obstet Gynecol 1984 Mar;63(3):318e23. 6. Copeland LJ, Hancock KC, Gershenson DM, Stringer CA, Atkinson EN, Edwards CL. Gracilis myocutaneous vaginal reconstruction concurrent with total pelvic exenteration. Am J Obstet Gynecol 1989 May;160(5 Pt 1):1095e101. 7. Schmidt VJ, Horch RE, Dragu A, et al. Perineal and vaginal wall reconstruction using a combined inferior gluteal and pudendal artery perforator flap: a case report. J Plast Reconstr Aesthetic Surg 2012 Dec;65(12):1734e7. 8. Smeets L, Hendrickx B, Teo TC. The propeller flap concept used in vaginal wall reconstruction. J Plast Reconstr Aesthetic Surg 2012 May;65(5):629e33. 9. Goldberg GL, Sukumvanich P, Einstein MH, Smith HO, Anderson PS, Fields AL. Total pelvic exenteration: the Albert Einstein College of Medicine/Montefiore Medical Center experience (1987 to 2003). Gynecol Oncol 2006 May;101(2):261e8. 10. Pusic AL, Mehrara BJ. Vaginal reconstruction: an algorithm approach to defect classification and flap reconstruction. J Surg Oncol 2006 Nov 1;94(6):515e21. 11. Berger JL, Westin SN, Fellman B, et al. Modified vertical rectus abdominis myocutaneous flap vaginal reconstruction: an analysis of surgical outcomes. Gynecol Oncol 2012 Apr;125(1): 252e5. 12. Qiu SS, Jurado M, Hontanilla B. Comparison of TRAM versus DIEP flap in total vaginal reconstruction after pelvic exenteration. Plast Reconstr Surg 2013 Dec;132(6):1020ee7e. 13. Rieger UM, Pierer G. Extended transpelvic deep inferior epigastric myocutaneous rectus abdominis flap for posterior vaginal wall reconstruction in advanced pelvic malignancy. J Plast Reconstr Aesthetic Surg 2012 Jun;65(6):798e9. 14. Weiwei L, Zhifei L, Ang Z, Lin Z, Dan L, Qun Q. Vaginal reconstruction with the muscle-sparing vertical rectus abdominis myocutaneous flap. J Plast Reconstr Aesthetic Surg 2009 Mar;62(3):335e40. 15. Schoeller T, Huemer GM, Wechselberger G. The transverse musculocutaneous gracilis flap for breast reconstruction: guidelines for flap and patient selection. Plast Reconstr Surg 2008 Jul;122(1):29e38. 16. Fattah A, Figus A, Mathur B, Ramakrishnan VV. The transverse myocutaneous gracilis flap: technical refinements. J Plast Reconstr Aesthetic Surg 2010 Feb;63(2):305e13. 17. Harii K, Ohmori K, Sekiguchi J. The free musculocutaneous flap. Plast Reconstr Surg 1976 Mar;57(3):294e303. 18. Burke TW, Morris M, Roh MS, Levenback C, Gershenson DM. Perineal reconstruction using single gracilis myocutaneous flaps. Gynecol Oncol 1995 May;57(2):221e5. 19. Wong C, Mojallal A, Bailey SH, Trussler A, Saint-Cyr M. The extended transverse musculocutaneous gracilis flap: vascular anatomy and clinical implications. Ann Plast Surg 2011 Aug; 67(2):170e7. 20. Yousif NJ, Matloub HS, Kolachalam R, Grunert BK, Sanger JR. The transverse gracilis musculocutaneous flap. Ann Plast Surg 1992 Dec;29(6):482e90. 21. Del Frari B, Schoeller T, Wechselberger G. Reconstruction of large head and neck deformities: experience with free gracilis muscle and myocutaneous flaps. Microsurgery 2010;30(3): 192e8. 22. Løve US, Sjøgren P, Rasmussen P, Laurberg S, Christensen HK. Sexual dysfunction after colpectomy and vaginal reconstruction with a vertical rectus abdominis myocutaneous flap. Dis Colon Rectum 2013 Feb;56(2):186e90.
