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Background. Sarcoma is a rare malignancy, and more recent management algorithms emphasize a multidisciplinary approach and limb salvage, which has resulted in an increase in overall survival and limb preservation. However, limb salvage has resulted in a higher rate of wound complications. Objective. To compare the complications between immediate and delayed (>three weeks) reconstruction in the multidisciplinary limb salvage sarcoma patient population. Methods. A ten-year retrospective review of patients who underwent sarcoma resection was performed. The outcome of interest was wound complication in the postoperative period based on timing of reconstruction. We defined infection as any infection requiring intravenous antibiotics, partial flap failure as any flap requiring a debridement or revision, hematoma/seroma as any hematoma/seroma requiring drainage, and wound dehiscence as a wound that was not completely intact by three weeks postoperatively. Results. 70 (17 delayed, 53 immediate) patients who underwent sarcoma resection and reconstruction met the inclusion criteria. Delayed reconstruction significantly increased the incidence of postoperative wound infection and wound dehiscence. There was no difference in partial or total flap loss, hematoma, or seroma between the two groups. Discussion and Conclusion. Immediate reconstruction results in decreased wound complications may reduce the morbidity associated with multidisciplinary treatment in the limb salvage sarcoma patient.

Background: The reliability of deep inferior epigastric artery perforator (DIEP) flap reconstruction following abdominal liposuction is controversial. The authors' early cases were technically successful; however, they experienced high partial flap loss and fat necrosis rates. The authors sought to compare DIEP flap outcomes in the setting of prior liposuction after the use of intraoperative indocyanine green angiography compared to when flaps were assessed on clinical grounds alone., Methods: A retrospective review of a consecutive series of DIEP flaps following liposuction at a single institution was performed, comparing those evaluated on clinical grounds alone and those in which indocyanine green angiography was used intraoperatively. Outcomes measured included anastomotic complications, total flap loss, partial flap loss, fat necrosis, and postoperative abdominal wounds., Results: Thirteen DIEP flaps following prior liposuction were performed on 11 patients from July of 2003 through January of 2014. All patients had preoperative imaging with duplex ultrasound or computed tomographic angiography to analyze perforator suitability before surgical exploration. Seven flaps were evaluated intraoperatively on clinical grounds alone. Six flaps were assessed and modified based on indocyanine green angiography. All flaps were successful; however, partial flap loss and fat necrosis rates dropped from 71.4 percent to 0 percent when indocyanine green angiography was used intraoperatively (p = 0.02)., Conclusions: Indocyanine green angiography is an excellent vascular imaging modality for intraoperative use to assess flap perfusion, and improves outcomes in DIEP flaps when harvested after prior abdominal suction lipectomy.

Background: In the last decade, there has been increasing use of contralateral prophylactic mastectomy (CPM) in patients with unilateral breast cancer and ductal carcinoma-in-situ (DCIS) undergoing mastectomy. Although many factors have been proposed to explain this trend, the impact of breast reconstruction on CPM has not been studied., Methods: A retrospective review of patients with unilateral invasive breast cancer or DCIS from Surveillance, Epidemiology, and End Results registry data (2004-2008) was conducted. Characteristics of patients undergoing CPM and reconstruction were evaluated., Results: A total of 102,674 patients diagnosed with DCIS or stage I to III infiltrating breast cancer underwent mastectomy for their primary lesion. Of these, 16,197 patients (16 %) underwent a CPM. A significantly higher proportion of women undergoing CPM had reconstruction performed (46 %) than those patients not undergoing CPM (15 %) (p < 0.001). Of the 20,760 patients (20 %) who underwent reconstruction, 7410 (36 %) had implant reconstruction, 7705 (37 %) tissue reconstruction, and 1941 (9 %) combined tissue/implant reconstruction; there were no data for 3,702 (18 %). There was an increasing trend of patients undergoing reconstruction from 2004 (n = 3390, 16.3 %) to 2008 (n = 5406, 26 %) (p < 0.001). On multivariable analysis, significant variables predicting CPM included age <45 years, stage I disease (odds ratio [OR] 1.44, 95 % confidence interval [CI] 1.35-1.54), lobular histology (OR 1.15, 95 % CI 1.11-1.20), and undergoing breast reconstruction (OR 3.58, 95 % CI 3.41-3.75)., Conclusions: Besides age, undergoing reconstructive surgery is the factor most strongly associated with CPM. This suggests that apart from risk reduction, the availability of and/or patient willingness to undergo breast reconstruction may influence the decision to undergo CPM.

Introduction: The most effective management of a patient with sarcoma is surgical resection. Often the resection is performed, the wound is irradiated, adjuvant chemotherapy is administered, and the wound is closed without plastic surgery consultation. Wound complications, after these treatment protocols, often require plastic surgery involvement and the treatment may require more advanced reconstructive techniques with higher rates of complications than if involvement occurred earlier., Methods: A retrospective review of all patients who underwent sarcoma excision from 2001 to 2011 was performed. Factors such as tumor size, radiation, chemotherapy, delayed reconstruction (>3 weeks), and immediate reconstruction (<3 weeks) were analyzed for their correlation with wound complications or flap loss., Results: A total of 127 patients underwent sarcoma resection. Wound complications occurred in 49 (38%) patients. All 15 delayed reconstructions had a wound complication, whereas only 11 (37%) of immediate reconstructions had a wound complication. Wound complications with tissue excision less than 500 g occurred in 18 (26%) patients and occurred in 31 (54%) patients with excision greater than 500 g. Seventy-two patients underwent radiation with a wound complication rate of 46% compared with 29% for patients who were not radiated. Chemotherapy was used in 35 patients with a wound complication rate of 49%., Conclusions: The most predictive factor of sarcoma complication is whether the procedure was a delayed or immediate reconstruction. The second most predictive factor is the amount of tissue excised, greater than 500 g of tissue excised was associated with significantly higher complication rates. Other aspects of sarcoma treatment that may be correlated with higher incidence of wound complications are radiation and the use of adjuvant chemotherapy. Early plastic surgery involvement can help with preoperative planning and reduce the complication rates in patients with sarcoma resection.

Background: Determining the nature of a breast mass after autologous reconstruction can be difficult., Methods: A retrospective review of all autologous breast reconstructions was performed over 10 years. All postoperative breast masses were identified. Tumor characteristics, adjuvant treatment, timing of the development of the mass, and correlation with radiology were reviewed., Results: A total of 365 flaps were performed on 272 patients [253 deep inferior epigastric perforator (DIEP), 35 superficial inferior epigastric artery (SIEA), 22 muscle-sparing free transverse rectus abdominis myocutaneous (free MS-TRAM), 25 latissimus, and 30 pedicled TRAM]. Breast masses were identified in 66 breasts (18 %). The majority of these were from fat necrosis, occurring in 54 breasts (15 % overall; DIEP 13.4 %, SIEA 5.7 %, free MS-TRAM 15 %, latissimus 0 %, pedicled TRAM 47 %), first identified at a mean of 3 months. Recurrent carcinoma was diagnosed in 13 breasts (3.6 %). Factors associated with the postreconstruction mass representing recurrent carcinoma were later time period after reconstruction (mean 24 months), closer surgical margins, and lymphovascular invasion. Radiographic imaging accurately diagnosed recurrent carcinoma in 11 (92 %) of 12 patients in whom it was utilized and suggested a benign diagnosis in all 16 patients with fat necrosis in whom it was utilized., Conclusions: Breast masses frequently present after autologous reconstruction. Fat necrosis is the most common cause. Recurrent carcinoma can occur in the reconstructed breast and presents later. A higher index of suspicion for recurrence should accompany any mass in which prior lymphovascular invasion was present or if original margins were <1 cm. Radiographic imaging accurately identifies the cause of these masses.

Background: Since the inception and popularization of microsurgery in the 1960s and 1970s, it has been commonly accepted that the outcome of free tissue transfer directly correlates with surgeon experience., Methods: The clinical outcomes of three young microsurgeons at a single institution were retrospectively reviewed. Free flaps performed by these individuals were categorized according to the surgeon's years of practice and analyzed using statistical methods., Results: A total of 410 free flaps were identified. No correlation was found between the surgeon's years of experience and the outcomes measured., Conclusions: There has been increased exposure to microsurgery during plastic surgery training at many programs, and consequently, residents have often already surpassed the learning curve. The imperfect correlation between experience and superior outcomes in medicine serves to suggest that further research in the specific underlying principles of surgical learning is needed to understand the relationship between experience and superior surgical outcomes.

Background: Checkrein ligament release for treatment of proximal interphalangeal joint Dupuytren contractures does not address the shortened arteries or deficient skin. The Digit Widget uses soft-tissue distraction to overcome these issues. This study compares checkrein ligament release after fasciectomy versus preliminary soft-tissue distraction, followed by operative release, for treatment of proximal interphalangeal joint Dupuytren contractures., Methods: The authors compared operative and postoperative characteristics of patients treated with either fasciectomy plus checkrein ligament release or Digit Widget distraction between 2001 and 2008. Seventeen patients (20 digits) underwent ligament release (mean contracture, 55.9 degrees); six of these 20 were reoperations. Thirteen patients (17 digits) underwent distraction (mean contracture, 67.6 degrees); 10 of 17 were reoperations., Results: The 20 digits treated with fasciectomy plus ligament release had an average extension improvement of 31.4 degrees (range, -4 to 70 degrees). Digits treated with distraction had an average extension improvement of 53.4 degrees (range, 30 to 75 degrees) (p<0.001 versus ligament release). Three digits treated with distraction improved to full proximal interphalangeal extension. Initial contractures of 60 degrees or less treated by ligament release (n=12) or distraction (n=7) improved by means of 28.8 degrees and 47.7 degrees, respectively (p=0.048). Contractures greater than 60 degrees treated by ligament release (n=8) or distraction (n=10) improved by means of 35.3 degrees and 57.3 degrees, respectively (p=0.02)., Conclusion: Soft-tissue distraction followed by operative release showed greater correction than Dupuytren fasciectomy plus checkrein ligament release., Clinical Question/level of Evidence: Therapeutic, III.

Introduction: Acellular dermal matrices have been used with increasing frequency in both reconstructive and cosmetic surgery. While many studies have described the safety and morbidity profiles of these materials, little is known about the relative mechanical properties of individual sheets of allograft harvested from distinct donors., Methods: Sixty-two individual sheets of an acellular dermal matrix from distinct lot numbers (signifying different donors of the dermis) were prospectively analyzed before use. Distribution of thickness according to manufacturer specifications in the dry state were as follows: 0.009 inches to 0.013 inches (1 [1.6%]); 0.79 mm to 1.78 mm (3 [4.8%]); 0.79 mm to 2.03 mm (5 [8%]); 0.8 mm to 3.3 mm (1 [1.6%]); 1.8 mm to 3.3 mm (10 [16.1%]) and 28 mm (6 [9.7%]). The size of the matrix was recorded while dry, after hydration and following stretch. The percentage change in surface area was recorded for each lot., Results: The 62 reconstructive cases included breast implant reconstruction (2 [3.2%]); ventral hernia repair (11 [17.7%]); abdominal closure following autologous tissue harvest (6 [9.6%]); autologous breast reconstruction (37 [59.6%]); extremity wound closures (3 [4.8%]) and reinforcement of vertical rectus abdominis muscle closure (3 [4.8%]). The mean percentage change in the size of the acellular dermal matrix to the hydrated state was 58% (36 of 62; thickness 0.06 mm to 3.30 mm); the mean percentage change in size from dry state was 7.14% (range 0% to 18.7%). The mean percentage change in the size of the hydrated matrix to the stretched state was 25.7% (range 0.25% to 70.6%). The variability in elasticity among the individual sheets was significant (P<0.0005)., Conclusion: The acellular dermal matrix displayed highly variable elastic properties among distinct donors. This may be significant in procedures in which symmetry is critical.

Background: The lymphatic drainage patterns of the head and neck (H&N) is complex. Therefore, identification of the sentinel lymph node (SLN) for H&N melanoma can be challenging., Methods: Retrospective review of a prospectively collected melanoma database, from February 1997 through October 2008, identified 137 patients with H&N melanoma. All underwent pre-operative lymphoscintigraphy, and after 2007, patients underwent single photon emission computed tomography combined with computed tomography (SPECT/CT)., Results: The mean number of SLNs per patient was 2.6. An SLN was successfully identified in 97% of patients, and in 9%, the SLN was positive for metastatic disease. The majority of patients (88%) drained to a unilateral level. Bilateral drainage occurred in 10%, with only two patients draining outside of the neck. The majority of patients (58%) had an SLN in level IIa (jugulodigastric lymph nodes). The regional recurrence rate was 4%, which all occurred prior to the use of SPECT/CT., Discussion: Utilization of SPECT/CT and knowledge of common lymphatic drainage patterns in neck lymph node levels can assist the surgeon in properly locating and excising the SLN with minimal morbidity, limiting unnecessary dissections, as well as reducing false negative results., (Copyright © 2011 Wiley-Liss, Inc.)

Perforator flaps are preferable for breast reconstruction after mastectomy in many patients. Preoperative imaging of the perforators and source vessels is desirable to reduce surgeon stress, limit donor and recipient site complications, and minimize operative time and associated costs. Computed tomographic angiography (CTA) has been shown to provide highly accurate representations of vascular anatomy with excellent spatial resolution. A critical review of the currently available literature was performed to identify the benefits of preoperative imaging (specifically CTA) in perforator flap reconstruction., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Insufficient soft-tissue coverage following total knee arthroplasty (TKA) may threaten prosthesis retention or compromise joint function. A retrospective review was conducted of all patients who underwent prophylactic flap reconstruction of the knee prior to TKA or salvage flap reconstruction over a 6-year period. Twenty-three patients underwent prophylactic flap reconstruction. Complications at the time of flap transfer were common (48%), however, all flaps survived. All 23 successfully completed subsequent TKA with no wound complications occurring at the time of TKA. Complications in the salvage group were also frequent (44%) and 3 required above knee amputation. Postoperative range of motion was significantly better in the prophylactic group, as well as when cutaneous flaps were chosen. Prophylactic flap reconstruction of the knee prior to TKA in high-risk patients is an excellent option in this small subset of patients, many of whom would not be offered TKA without addressing the compromised soft-tissue envelope first.

The deep inferior epigastric artery perforator flap is an option for women desiring autologous tissue breast reconstruction. If this reconstruction fails, other autologous tissue flaps, including the gluteal artery perforator and latissimus dorsi flaps, may be used for salvage. The anterolateral thigh (ALT) flap offers adequate tissue volume for breast reconstruction, acceptable fat quality and a long vascular pedicle. Other advantages include obviating the need for intraoperative position changes and harvesting tissue outside of the radiation field. Two cases involving ALT flaps used in the setting of deep inferior epigastric artery perforator failure are presented with favourable results. A review of the anatomy of the ALT flap is included.

Successful dialysis access necessitates superficial arteriovenous fistula (AVF) placement to facilitate identification of anatomical landmarks for safe cannulation. Suction-assisted lipectomy (SAL) may be an alternative to traditional surgical AVF revision procedures for placing fistulas more superficially. Three patients with an average body mass index of 45.2 kg/m(2), with inaccessible AVFs due to obesity, underwent ultrasound-guided SAL of their upper extremities. Successful cannulation was achieved within two weeks. A clinically insignificant hematoma and arm swelling occurred in one patient. SAL provides a safe and effective alternative for salvaging deep AVFs for dialysis access in the upper extremities of obese patients.

Genetic testing for BRCA mutations has led to greater needs for breast reconstruction and prophylactic gynecologic procedures. A retrospective review of all perforator flap breast reconstructions was performed over 5 years. A total of 316 flaps were performed on 232 patients. Nineteen patients had an intraabdominal procedure at the time of their breast reconstruction, including 8 unilateral and 11 bilateral reconstructions (22 flaps). The concomitant procedures incurred an additional mean operative time of 61 minutes. One arterial thrombosis occurred leading to a single flap failure (1/30, 3.3%). No significant differences were noted in complication rates between the combined group and those who did not have a simultaneous procedure (anastomotic complications 3.3% vs. 7.7%; failure rate 3.3% vs. 3.1%; abdominal wound 10.5% vs. 15%; fat necrosis 10% vs. 12.2%). The coordinated effort allowing simultaneous intraabdominal procedures and perforator flap breast reconstruction affords effective reconstruction for those requiring additional procedures without an increase in postoperative complication rates.

Background: Preoperative computed tomography has been used to facilitate deep inferior epigastric artery perforator (DIEAP) flap breast reconstruction. This study identifies the improvements in outcome that this may provide., Methods: A retrospective review of a consecutive series of DIEAP and superficial inferior epigastric artery (SIEA) flap breast reconstructions was performed over 5 years. All patients underwent hand-held Doppler interrogation of the abdomen. Patient demographics, operative times, and postoperative outcomes were compared before and after the routine use of computed tomographic imaging., Results: Two hundred eighty-seven flaps were performed on 213 patients. There were 139 unilateral and 74 bilateral reconstructions, with 168 flaps performed immediately after mastectomy and 119 flaps performed in a delayed setting. One hundred one flaps were performed with computed tomographic imaging, whereas 186 flaps followed hand-held Doppler interrogation alone. Mean follow-up was 24 months. The use of computed tomography had a beneficial impact on operative times (unilateral, 370 versus 459 minutes; bilateral, 515 versus 657 minutes; p < 0.05), number of perforators included (1.5 versus 1.9; p < 0.05), and abdominal bulges (1 percent versus 9.1 percent; p < 0.05). Anastomotic complications (6.9 percent versus 8.1 percent), failure rates (2 percent versus 3.8 percent), fat necrosis (10.9 percent versus 13.4 percent), and abdominal wounds (11.8 percent versus 16.6 percent) were not found to be significantly different. Computed tomography did identify three cases of deep inferior epigastric vessel ligation from previous operations, which compromised these as suitable source vessels., Conclusions: This study suggests that preoperative computed tomography leads to decreased operative times and a reduction in abdominal bulge rates, and may reduce the learning curve in DIEAP breast reconstruction compared with hand-held Doppler evaluation alone.

This study evaluates the efficacy of our protocol using intra-arterial infusion of tissue plasminogen activator (TPA) on free flap salvage following venous thrombosis. A retrospective review was conducted of every free flap performed by a single surgeon since the beginning of his practice. Free flap salvage rates were documented following flap exploration, intra-arterial infusion of TPA, and revision of the venous anastomosis, with or without vein grafting. One hundred twenty-two free tissue transfers were performed from July 2003 through April 2006. Twelve anastomotic complications occurred in 11 flaps (1 arterial thrombosis, 11 venous thromboses). One free muscle flap failed due to arterial thrombosis. All venous thromboses were salvaged using the TPA protocol, although one revision thrombosed on postoperative day 1 and required a second venous revision, leading to its ultimate salvage. We believe that intra-arterial TPA is an effective adjunct in the treatment of microsurgical venous thrombosis and may increase salvage rates following anastomotic complications.

Background: The vascular anatomy of the anterolateral thigh flap has been well studied, but no study has evaluated the effect of the vastus lateralis motor nerve anatomy on anterolateral thigh flap harvest., Methods: A retrospective review was performed of all anterolateral thigh flaps from January of 2003 through December of 2004. Information regarding the motor nerve to the vastus lateralis muscle was recorded, along with its influence on anterolateral thigh flap harvest., Results: Forty-three anterolateral thigh flap procedures were performed over a 2-year period. In three cases (7 percent), the course of the motor nerve to the vastus lateralis resulted in a significant modification in anterolateral thigh flap harvest. In one case, the motor nerve passed between the venae comitantes of the descending branch of the lateral femoral circumflex artery just proximal to the midperforator origin. In two cases, large skin islands were raised with two perforators included in each flap. The motor nerve passed between the two perforators in these cases., Conclusions: Two patterns of vastus lateralis motor nerve anatomy can adversely influence anterolateral thigh flap elevation. One involves the motor nerve passing through the main vascular pedicle. The other occurs when multiple perforators are required to support large flaps with the motor nerve passing between these perforators. In some cases, the course of the nerve may require transection of the nerve, with a subsequent deficit in vastus lateralis function. In similar cases, if the nerve is preserved, the vascular pedicle may require significant modification, which may possibly compromise flap perfusion.

We sought to show how severe soft-tissue injuries of the proximal index finger caused by fourth-degree electrical burns to the hand may be surgically reconstructed. Soft-tissue coverage was provided with a reverse second dorsal metacarpal artery flap in two patients. Both digits were successfully salvaged by use of this reconstructive method. Both donor sites were closed primarily and healed without difficulty. The reverse second dorsal metacarpal artery flap provides well-vascularized tissue without excess bulk and allows near-normal hand function.

Background: The internal mammary and thoracodorsal vessels are the standard recipient sites in microsurgical breast reconstruction. We review our series of venous outflow alternatives when these vessels are inadequate or unusable., Materials and Methods: A retrospective review of all free breast reconstructions was performed from July 2003 through December 2005. Outcomes were measured with regard to re-exploration, flap failure, and fat necrosis, with attention to the timing and side of reconstruction, as well as the presence or absence of radiation therapy., Results: A total of 141 free breast reconstructions were performed during the study period. In seven cases (5%), alternative venous outflow vessels were selected (cephalic or external jugular vein). Nine anastamotic complications occurred, all of which involved the left internal mammary group (statistically significant for venous thrombosis, P = 0.0063) and three flaps failed. All cephalic and external jugular veins remained patent with no flap failures or fat necrosis within this group., Conclusion: The cephalic vein and external jugular vein are excellent alternatives for venous outflow in free breast reconstruction if neither the internal mammary nor thoracodorsal veins are sufficient, especially in left-sided reconstruction., (2007 Wiley-Liss, Inc.)

This study's purpose was to evaluate clinical and surgical outcomes in patients with upper facial melanoma. A sentinel lymph node (SLN) biopsy database review identified 43 patients receiving a diagnosis of upper facial melanoma between February 1997 and April 2005 at Mayo Clinic Arizona in Scottsdale. Patients underwent wide local excision (n = 40) or Mohs excision (n = 3) and SLN biopsy. Nine patients (21%) had positive margins requiring reexcision. SLN mapping identified the SLN in 39 patients (91%) and drainage to bilateral lymph node basins in 8 (21%). The SLN was positive for melanoma in 2 patients (5%). Recurrence in 33 patients with more than 1 year of follow-up (local in 5 [15%] and regional in 1 [3%]) was treated with salvage surgery; 1 patient developed metastatic disease. Two patients (5%) died, one of an unknown cause and the other of metastatic melanoma. We concluded that oncologic surgery can result in good local disease control in patients with upper facial melanoma.

Background: Studies comparing similar and sizable numbers of deep inferior epigastric perforator (DIEP) and pedicled transverse rectus abdominis musculocutaneous (TRAM) flap reconstructions are lacking. The authors hoped to determine whether the DIEP flap has advantages over the pedicled TRAM flap for breast reconstruction., Methods: The authors retrospectively reviewed the records of women undergoing breast reconstruction over a 9-year period at a single institution. Patients were grouped by type of reconstruction: DIEP or pedicled TRAM. Only patients with at least 3 months of postoperative follow-up were studied., Results: A total of 190 women underwent unilateral breast reconstructions (96 DIEP and 94 pedicled TRAM flaps). The patient groups were similar in terms of age, body mass index, preoperative chest wall irradiation and abdominal operations, and cancer stage. The median hospital stay for the DIEP group was shorter than that for the pedicled TRAM group (4 versus 5 days, p < .001). Operative time for the DIEP group (5:53 hours) was longer than that for the pedicled TRAM group (4:46 hours, p < .001). The fat necrosis rates for the pedicled TRAM group were higher (58.5 percent) than those for the DIEP group (17.7 percent, p < .001). Abdominal wall hernias occurred more frequently in pedicled TRAM (16.0 percent) than DIEP patients (1.0 percent, p < .001). Abdominal wall bulge rates were similar for both groups (DIEP 9.4 percent versus pedicled TRAM 14.9 percent)., Conclusions: DIEP flap reconstruction can be performed with lower morbidity rates and shorter hospital stays than pedicled TRAM reconstruction. Specifically, fat necrosis and abdominal wall hernias are less common in DIEP patients than in pedicled TRAM patients, while flap failure and abdominal wall bulging rates are similar in the two patient groups. These data support the DIEP flap as the preferred option over the pedicled TRAM flap for autologous breast reconstruction in postmastectomy patients.

This study compares the outcome of Singapore flap, vertical rectus abdominis musculocutaneous flap (VRAM), and gracilis musculocutaneous flap vaginal reconstruction. A retrospective review of 99 consecutive patients with complete vaginal defects was conducted at the Mayo Clinic from January 1988 to October 2001. All possible complications were determined for each of the 3 reconstructive techniques, along with the effects of radiation and smoking on the respective complication rates. Preoperative and postoperative sexual function and adequacy were compared between each group. Ninety-nine patients ranging in age from 19 to 80 years (mean, 51.6 years) were compared, with a mean follow-up of 28.9 months. Forty-one VRAM, 13 gracilis, and 45 modified Singapore flaps were used for vaginal reconstruction. The majority was due to acquired vaginal defects due to recurrent pelvic malignancy. The overall complication rate was lower following VRAM than either gracilis or Singapore flap reconstructions (13/41, 31.7%; 8/13, 61.5%; and 21/45, 46.7%, respectively). The flap specific complication rate was least in the VRAM group (9/41, 22%; 7/13, 53.8%; and 17/45, 37.8%, respectively). The VRAM had a significant protective effect against the development of postoperative small bowel obstruction. Preoperative sexual activity predicted postoperative activity in 75 of 88 patients (85.2%) and was not affected by the type of reconstruction, although more patients with a Singapore flap required vaginal dilatation to maintain patency. In conclusion, the VRAM has a lower overall and flap-related complication rate compared with either gracilis or Singapore flap reconstruction. It has become our vaginal reconstructive flap of choice.