Back to 2011 Program

Title: The Utility of the Multi-Island Vertical Rectus Abdominis Myocutaneous (VRAM) Flap in Head and Neck Reconstruction
Background: Head and neck cancer extirpation frequently creates complex three-dimensional defects involving both intraoral and external tissues. Reconstruction of extensive composite defects can be accomplished either with use of two separate flaps or a single soft tissue folded flap with multiple skin islands. Herein the outcomes and rationale for reconstruction of multi-laminar head and neck defects using the VRAM flap are reported.
Methods: A retrospective review was performed of a prospectively collected database of all head and neck reconstructions completed by a single surgeon between 1992-2011. Forty-six patients were identified who underwent reconstruction of composite defects using VRAM flaps with more than one skin islands. Oncologic defects were classified into 3 categories based on location: mid-face, lower third of the face, and central neck. Indications and outcomes were reviewed.
Results: Patient ages ranged from 7-84 years with two-thirds being male. Forty-five percent had pre-op radiation. Average VRAM skin paddle size was 9 x 25.5 cm. 96% and 4% of cases used two and three skin-islands respectively. 59% (27/46) of reconstructions were performed in the mid-face for maxillectomy or composite cheek defects. 30% (14/46) of cases included the mandible or floor of mouth and external skin. 11% (5/46) cases involved reconstruction of hypopharyngeal defects with overlying neck skin. There was no complete flap loss. One patient had loss of the external skin island requiring a regional flap for coverage. Two patients required reoperation for hematoma evacuation. 9/46 (19.6%) required secondary procedures for flap contouring, the majority of which were for mid-face defects. 1/46 (2.2%) had delayed wound healing at the donor site. 21/46 (46%) patients advanced to an unrestricted PO diet. Average follow-up time was 2.3 years.
Conclusion: Reconstruction of extensive composite head and neck defects can be accomplished using simultaneous free flaps or a free flap combined with a regional flap. Alternatively, a single double-island soft tissue flap is a straightforward solution which saves time and eliminates a second donor site. When compared to free flaps like the ALT which have a limited number of perforators, the robust VRAM blood supply ensures safe creation of multiple skin islands in all instances. Reconstruction of composite head and neck defects with the multi-island VRAM flap is a safe and reliable technique.