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The Utility of the Multi-Island Vertical Rectus Abdominis Myocutaneous (VRAM) Flap in Head and Neck Reconstruction
Nima P. Patel, MD, Evan Matros, MD, Peter G. Cordeiro, MD.
Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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.
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