Refinements in vaginal reconstruction using rectus abdominis flaps.

An improved method for vaginal reconstruction after pelvic exenteration or abdominal perineal resection is provided by the distally based rectus abdominis flap. This extended flap carries a skin paddle from the upper abdomen on the rectus abdominis muscle and deep inferior epigastric vascular pedicle. The skin paddle is inversely tubed to form a vaginal pouch and delivered transpelvically to the perineum. In addition to providing a vaginal reconstruction for sexual function, this reconstruction lessens pelvic wound complications in the exenteration patient by filling endopelvic dead space and revascularizing these frequently irradiated wounds. This method provides a neovagina with a single flap and does not involve additional donor sites in the thighs. Transpelvic passage from above not only fills endopelvic dead space better than thigh flaps, but also it allows retention of a vaginal cuff in supralevator resections. Another significant advantage of this reconstruction is its great reliability with minimal incidence of paddle loss. This flap design illustrates a type of flap refinement in which specific flaps can carry tissue from adjacent vascular territories because of anastomotic vessels between the two vascular territories, such as the vascular watershed between the deep inferior epigastric and superior epigastric vessels in this case.