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Background The vertical rectus abdominis myocutaneous (VRAM) flap has been frequently used for perineal reconstruction given the high potential for wound complications associated with direct closure of this area. However, the relationship between defect size and postoperative complications remains undefined. Methods A retrospective chart review of the last 20 years for VRAM flaps was performed. Defect size, age, body mass index (BMI), cause of defect, sex, radiation, and flap donor laterality were recorded. Complications of infection, partial flap loss, total flap loss, minor wounds, treated nonoperatively, and major wound, which required reoperation, were analyzed with respect to defect size. Descriptive statistics were used to summarize the demographic and clinical characteristics of the included patients. Associations were assessed using binary logistic regression analysis, and difference in means for compared groups was assessed using the independent samples t test. P values were set at 5% for all comparisons. Results There were 65 patients with VRAM flaps identified during the review period. Mean defect size was 204.71 cm2. Mean age was 63.97, and mean BMI was 27.18. History of prior radiation was noted in 90.77% of patients (n = 59). When adjusted for age and BMI, mean defect area was significantly different for patients with minor or major wounds. Larger perineal defects were associated with increased risk of major wound complications (odds ratio, 1.012; 95% confidence interval, 1.003-1.022). Conclusions The vertical rectus abdominis flap has been a workhorse flap for perineal reconstruction. Defect size does not affect risk of partial flap necrosis, complete flap loss, infection, abdominal fascial dehiscence, ventral hernia, or seroma, which supports the utility of VRAM flap for perineal reconstruction. Larger perineal defects are associated with increased risk for major wound complications, which required reoperation, regardless of age or BMI. Future studies should be performed to determine if there is a maximum defect size cutoff that limits the utility of VRAM flap reconstruction or to develop a predictive model to assess the risk of major wound complications based on defect size.

Summary:. Carbon ion radiotherapy (CIRT) has been used for malignant tumors that are difficult to excise surgically, such as sacral chordoma, and the success of its outcomes is attributable to the high dose concentration and biological effects. CIRT has produced successful clinical outcomes, and it is considered to have fewer adverse effects on surrounding normal tissues; moreover, complications have been rarely reported. We describe a 75-year-old woman with a full-thickness sacral defect, who had received CIRT for sacral chordoma 3 years earlier. Computed tomography showed sacral bone destruction, and a colonoscopy revealed rectal necrosis. Rectectomy in addition to sacral bone resection was necessary, which resulted in a huge sacral defect of slightly anxious viability. We performed reconstruction of the sacral defect by using pedicled vertical rectus abdominis myocutaneous (VRAM) flap, obliterating sacral defects and intrapelvic dead space that occurred after rectectomy. Six months after surgery, the wound had healed well, and no complication was observed. Sacral complications after CIRT may affect surrounding normal tissues such as the rectum, and it would be difficult to reconstruct the resulting complications. The vertical rectus abdominis myocutaneous flap is considered useful for the simultaneous obliteration of sacral defects and intrapelvic dead space after CIRT.

The serratus anterior muscle was used as a free tissue transfer to reconstruct complex craniofacial defects in 5 patients. Serratus anterior muscle alone and serratus anterior muscle with rib were the transfers made. All flaps survived and scapular winging did not occur. The serratus anterior muscle has several advantages for the reconstruction of medium-sized craniofacial defects. Because of its position, a two-team approach is possible. It has a consistent pedicle anatomy and low donor site morbidity. It has a large caliber vessel and a long pedicle. When compared with the commonly employed rectus abdominis flap for moderate-sized defects, the serratus muscle offers greater versatility in design and has the option of incorporating bone and innervated muscle without increasing significant donor site morbidity.

From 1985 through 1987, five of eight infants with thoracic wounds at Yale-New Haven Hospital underwent chest-wall reconstruction. In total, the eight infants underwent 17 procedures (including multiple open resuscitations) exclusive of the reconstructive operations. Patients undergoing reconstruction ranged from 1 to 10 months of age and 3 to 7 kg in weight. All reconstructed patients underwent bilateral pectoralis major advancement flaps, with three of the five patients each requiring the simultaneous use of a rectus abdominis flap. With 2 to 18 months of follow-up, healing was complete in all five of the reconstructed patients, with two prosthetic pulmonary-systemic shunts and two outflow tract patches thus salvaged. These patients were found to be distinct from their adult counterparts, with special critical care requirements and expectedly delicate muscular anatomy. The gratifying results now expected in adults with sternal wound complications can be achieved in their infant counterparts. Furthermore, the group of patients whose chests cannot initially be closed owing to resultant cardiac compression may look to sternocostal debridement and flap reconstruction as a means of not only achieving wound closure, but of effectively increasing their mediastinal volume and compliance. Questions about skeletal development remain unanswered and demand further follow-up.

Remarkable advances have been made in the field of breast reconstruction, especially since general surgeons, patients, and the community as a whole have become more knowledgeable and accepting. This has provided an impetus for plastic surgeons to develop better techniques, many of which are reviewed here. In general, less time now elapses between ablative and reconstructive surgery, and frequently reconstruction follows immediately. Procedures requiring fewer steps with less donor and recipient site morbidity are favored for both the mound and nipple areolar reconstruction. There is a definite trend toward submuscular implantation to minimize the negative effects of capsular contracture. With a deficiency of skin or muscle, the trend is toward using musculocutaneous flaps primarily, latissimus dorsi, and more recently the rectus abdominis flap. Occasionally, microvascular flap reconstruction is indicated for extensive chest wall defects, e.g., postirradiation injury. Reconstructed breasts are not capable of nourishment, frequently are not erogenous , and most often are not as pleasing to the eye as the contralateral breast. Yet reconstruction has, in the majority of cases, improved the quality of life for those women who have developed breast cancer and offered hope to those women in a high-risk category for developing breast cancer. To those ends, the search for the perfect breast reconstruction will continue.