Vertical Rectus Abdominis Myocutaneous Flap VRAM

The VRAM flap allows coverage of large defects and utilizes tissue which is well away from any previously irradiated area. The fact that it is a pedicled vascularized flap reduces the probability of flap failure provided that the inferior epigastric complex has been preserved and not involved in the disease. The technique has been extensively utilized in our own series of patients to cover groin defects following extensive resections.17

A template of the groin defect is made which is then used to mark out the size of the VRAM flap. Once marked out the skin and underlying rectus abdominis is mobilized and detached superiorly (Fig. 7.21). An incision is then made along the medial border of the rectus fascia and the skin island is deepened toward the superior portion of the flap until the linea alba is seen. The left rectus abdominis muscle can be visualized under the rectus fascia. The lateral incision parallels the incision in the rectus fascia keeping intact a 5-cm width of rectus fascia to be taken with the flap. This ensures that the perforators coming off the anterior surface of the muscle through the rectus fascia are not damaged and the underlying rectus abdominis is mobilized and detached superiorly. The inferior epigastric vessels can be seen emerging from the lateral portion of the rectus muscle. The flap is mobilized on the inferior epigastric vascular pedicle and tunneled in order to cover the groin defect.

A synthetic mesh is then used to reconstruct the abdominal wall and the skin is closed primarily (Figs. 7.22-7.23).

Fig. 7.21 Preoperative marking of a recurrent lesion in the right groin which is to be removed and the defect covered with a VRAM flap

Fig. 7.22 Mobilization of the VRAM flap in order to cover the skin defect

Fig. 7.22 Mobilization of the VRAM flap in order to cover the skin defect

Fig. 7.23 Closure of the abdominal and groin wound has been performed

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