Int J Colorectal Dis DOI 10.1007/s00384-015-2402-8

ORIGINAL ARTICLE

Free latissimus dorsi myocutaneous flap for pelvic floor reconstruction following pelvic exenteration Ahmed Hossamedine Abdou 1 & Lei Li 2 & Karl Khatib-Chahidi 1 & Achim Troja 1 & Phillip Looft 1 & Eva Monika Gudewer 2 & Hans-Rudolf Raab 1 & Dalibor Antolovic 1

Accepted: 19 September 2015 # Springer-Verlag Berlin Heidelberg 2015

Abstract Introduction Pelvic floor defects following pelvic exenteration constitute a challenge to the reconstructive surgeon. Whenever the common reconstruction options such as the gluteus maximus myocutaneous flap (GLM) and the vertical rectus abdominis myocutaneous flap (VRAM) are not feasible, free tissue transfer will be the only remaining option. Being one of the most reliable and versatile flaps used for microsurgical reconstruction, the free latissimus dorsi (LD) muscle flap provides an adequate solution to this problem. Patients and methods We describe our experience with 12 consecutive patients who underwent the free transfer of LD free flap for secondary reconstruction of the pelvic floor and perineum following pelvic exenteration for management of locally advanced pelvic malignancies in Klinikum Oldenburg from 2007 to 2014. Results Recurrent cancer of the anal canal was the most common pathology necessitating the performance of pelvic exenteration. Thrombosis of the vascular anastomosis was reported in two cases and ended with total flap loss in one of them. Functional limitations arose in two patients postoperatively. The mean hospital stay was 25 days. Conclusion Free LD myocutaneous flap provides an adequate solution for reconstruction of pelvic defects resulting from

* Ahmed Hossamedine Abdou [email protected] 1

University Department of General and Visceral Surgery, Klinikum Oldenburg, Rahel-Straus-Strasse 10, 26133 Oldenburg, Germany

2

Department of Oral and Maxillofacial Surgery, Klinikum Oldenburg, Rahel-Straus-Strasse 10, 26133 Oldenburg, Germany

radical oncological resections in cases where the use of locoregional flaps, such as the gluteus maximus flap and the vertical rectus abdominis flap, is not feasible because of an extensive defect, disruption of the vascular pedicle, or due to planning for bilateral stomas placement. Keywords Latissimus dorsi . Pelvic exenteration . Secondary reconstruction . Sacrectomy

Introduction Radical pelvic oncological resection in the form of abdominoperineal resection (APR) and pelvic exenteration (PE) is the only way of treatment of recurrent and locally advanced pelvic malignancies [1]. The resulting defect always constitutes a challenge to the reconstructive surgeon. Primary wound closure after radical pelvic surgeries is correlated with a high incidence of wound complications including wound infection and wound dehiscence which is reported to be between 35 and 66 % [1–5]. This may be attributed to the fact that most of the patients with pelvic malignancies received irradiation to the pelvic region prior to surgery, which results in an irreversible tissue damage leading to an increased risk of developing major wound complications [1–6]. Myocutaneous flap reconstruction can achieve a tension free wound closure using healthy, well vascularized, nonirradiated tissues, thus enhancing wound healing and reducing rate of complications [7]. Though a lot of flaps were described for management of such defects, e.g., gracilis flap [8], vertical rectus abdominis muscle flap (VRAM) [9], and gluteus maximus flap [10], the choice of the proper reconstruction method may vary from one case to the other, being affected by several factors such as the type of the performed oncological resection, the

Int J Colorectal Dis

condition of the locoregional tissues and their blood supply, as well as the preference and the experience of the reconstructive surgeon [7]. In many cases of pelvic exenteration, branches of the internal iliac artery such as the superior and the inferior gluteal arteries, which constitute the main blood supply of the gluteus maximus muscle, are divided, sometimes bilaterally, thus eliminating the gluteus maximus myocutaneous flap, inferior gluteal artery perforator flap (IGAP), or superior gluteal artery perforator flap (SGAP) as options for reconstruction [11]. Furthermore, previous abdominal surgeries carry the risk of severing the inferior epigastric vessels. Together with planning for bilateral stomas placement, this makes the VRAM flap no more an optimal reconstruction option in such cases. Pedicled gracilis flap, as previously described in literature, could be utilized for smaller defects but would not be a valid option for reconstruction of such large defects following pelvic exenteration [12]. Whenever the most common reliable locoregional flaps are not available for reconstruction, free tissue transfer would provide an adequate alternative. The free latissimus dorsi (LD) myocutaneous flap is one of the most reliable flaps used in microsurgical reconstruction with the length and caliber of its vascular pedicle (the thoracodorsal artery), in addition to its relatively constant anatomy, making the microsurgical vascular anastomosis technically more feasible [13]. Moreover, the LD flap provides a good volume which is of great advantage in obliterating the large dead space created by pelvic exenteration. Furthermore, the free LD flap can be harvested in combination with the adjacent serratus anterior muscle providing an extra volume of tissues available for reconstruction, which adds another technical advantage to the use of this flap [13–15]. This article describes our center experience with secondary reconstruction of extensive pelvic floor defects following pelvic exenteration using the free LD flap in 12 consecutive patients.

complications. Postoperative pathology reports were reviewed, and tumor staging was reported according to the American Joint Committee on Cancer (AJCC).

Patients and methods

Preparation of the recipient vessels

The data of 12 patients who underwent a secondary pelvic reconstruction after surgical resection of an advanced pelvic malignancy between December 2007 and May 2014 were retrieved from electronic files and retrospectively analyzed. Follow-up lasted until the first of October 2014 or until the patient’s death. Length of hospital stay represented the time from the day of surgery to the day of hospital discharge. Demographic data included the age and sex, previous chemo radiotherapy, and general condition of the patient according to the American Society of Anesthesiologists (ASA) scoring system. Outcome data focused on the operative time, length of postoperative hospital stay, and local and general

The femoral artery and vein were the recipient vessels in all of the patients in this series. The position of the artery was marked by palpating the femoral pulse. A skin incision was made about 2.5 cm below the inguinal ligament and parallel to the vessels, then the artery and the vein were identified, and the smaller branches and tributaries were ligated and divided. The skin incision was extended medially at the upper medial aspect of the thigh to reach the existing pelvic defects, thus creating a track for the vascular pedicle of the flap. To avoid strangulation of the vascular pedicle, the proximal fibers of the adductor longus muscle were routinely partially divided using the monopolar diathermy.

Indication of surgery All the pelvic exenteration patients, operated upon in our center, gets a standard primary multilayer closure of the sacroperineal wound using remnants of the levator ani muscles, subcutaneous tissue, and skin edges bilaterally. In the case series presented in this paper, a secondary reconstruction was planned from the beginning following an extended resection of a pelvic malignancy in toto with partial sacrectomy as well as the tumor-infiltrated medial parts of the gluteus maximus muscles unilaterally or bilaterally, hence creating an extensive deep defect which needed a bulky mass for reconstruction to achieve a proper seal of the pelvic cavity. In all of the patients in this series, the major part of the soft tissue defect was in the depth of the pelvic cavity; the choice of the free LD for reconstruction was made to provide an adequate amount of muscle tissue for reconstruction. Technique of surgery Pelvic exenteration (total pelvic exenteration (TPE) and posterior pelvic exenteration (PPE)) was performed with partial sacrectomy at the level of the third sacral vertebra (S3) in all of the patients in this series. Following the oncological resection, an omental flap was mobilized to seal the abdominal inlet into the pelvic cavity, and a vicryl mesh was sutured to the pelvic outlet to prevent herniation of the intra-abdominal contents into the pelvis. Vacuum dressing was used for wound management and was regularly changed every fifth day until the planned time for reconstruction after the patients had recovered from the first operation and became fit to undergo the free microsurgical tissue transfer surgery.

Int J Colorectal Dis

Flap harvest

Vein graft interposition

The LD flap was harvested in combination with the serratus anterior muscle in four cases where the defects were relatively deep. On setting the flap, the serratus anterior part was used to obliterate the depth of the pelvic defect, and the LD was used to cover the more superficial part. The standard position for flap harvest used in our center is the supine position with a slight elevation of the thorax, which can be achieved by putting a pillow under the middle of the back of the patient. This position allows the work of a second team at the recipient vessels and pelvis simultaneously. The ipsilateral arm was abducted and positioned on an anterosuperiorly-based Mayo stand. The skin incision was made along the posterior axillary fold, which represents the anterior border of the muscle, and was extended inferiorly and medially over the muscle surface. Skin edges of the incision were retracted bilaterally to enable an adequate access to the muscle, and the dissection was continued using the monopolar diathermy. The thoracodorsal artery with its vena comitans were identified and raised within the flap. Afterward, the dissection was continued below the deep surface of the muscle toward the origin of the subscapular artery in the axilla. Perforators coming from the intercostals were clipped or coagulated using the bipolar diathermy according to their caliber. To gain the most possible length and caliber of the vascular pedicle, the flap harvest was based on the subscapular artery and vein, which were identified, ligated, and divided using micro scissors at their junction with the axillary artery and vein, respectively. This also enabled the concomitant harvesting of the serratus anterior muscle part if needed. The muscle fibers were then divided superiorly, medially, and inferiorly using the bipolar scissors to free the flap from its attachments. After harvesting the flap, special care was given to hemostasis. Two suction drains were inserted subcutaneously. The donor site was closed in two layers using vicryl 3/0 sutures for the subcutaneous closure, and the skin was closed using a skin stapler.

This was performed in two patients using a cephalic vein graft to achieve a tension-free microsurgical arterial and venous anastomoses as the pelvic defect extended further posteriorly beyond the reach of the length of the original vascular pedicle.

Preparation of the recipient site and positioning of the flap The perineal defect was carefully deepithelialized using fine curettes, the flap was temporarily stapled to the outlines of the defect, and the vascular pedicle of the flap was laid in the previously prepared track in the upper medial aspect of the thigh. After performing the end-to-side anastomosis between the subscapular vessels and the femoral artery and vein, the temporary staples were removed, and the flap was set in the depth of the pelvic defect. The skin defect was closed primarily using the skin island overlying the flap. The last step of insetting the flap was performed either in the lithotomy or the Jack-knife position according to the extension of the defect, anteriorly or posteriorly, respectively.

Results The series includes seven females and five males with mean age of 58 years, median age was 56 years. Mean follow up time was 13 months. Nine patients received neoadjuvant chemoradiotherapy, one patient received neoadjuvant radiotherapy only, and two patients did not receive any neoadjuvant therapy. The mean dose of irradiation was 51.84 Gy, median 50.4 Gy The most common pathology was recurrent squamous cell carcinoma of the anal canal in five patients, followed by recurrent rectal cancer in three patients, 1ry rectal cancer in two patients, 1ry vulvar cancer in one patient and recurrent cervical cancer in one patient (Fig. 1). TPE was the cause of the defect in half of the patients, and extended PPE was the cause in the other half. Partial sacral resection at the level of the third sacral vertebra was performed in all of the patients. Total flap loss was reported in one patient due to venous pedicle thrombosis. The patient refused any further surgical intervention for treatment of the pelvic defect and was managed conservatively with frequent application of vacuum dressings. On the other hand, the rest of the patients of this group (11 patients) showed a good uptake of the flap, and partial flap loss was not reported (Table 1). Thrombus formation in the venous pedicle with hematoma formation at the anastomosis site with subsequent venous congestion of the flap was reported in two cases; urgent thrombectomy was performed in both of them and was successful in only one, while thrombosis led to the previously mentioned total flap loss in the other case. Functional disabilities arose in two patients in the form of reduced ability of active anterior flexion and abduction of the shoulder. Both patients showed marked improvement under physiotherapy, and both of them were able to perform the routine daily tasks without help 1 year postoperatively. Superficial inguinal wound dehiscence occurred in two patients who received previous irradiation to the inguinal region and was treated conservatively with regular dressings (Table 1). The shortest postoperative hospital stay following reconstruction was 15 days, and the longest was 38 days with a mean of 25 days. The pathological classification was stage III in nine cases, stage IV in two cases, and II in one case (Fig. 2). The operative time ranged from 238 to 477 min with a mean of 372 min.

Int J Colorectal Dis Fig. 1 Type of the pelvic malignancy

6 5 4 recurrent

3

primary

2 1 0 Anal cancer

Eight patients were ASA II, three patients were ASA III, and one ASA IV. Anecdotally, the ASA IV patient had only a minor wound dehiscence at the inguinal region with no gravid systemic complications and was discharged on the 21st postoperative day. Local recurrence was encountered in the 10th postoperative month in only one patient who suffered from vulvar cancer, and the patient died 10 months after diagnosis of the recurrence. Other than that, no other local recurrences had been reported in our series until May 2014. Distant metastases in the liver were diagnosed in two patients, one preoperative and another intraoperative. In the rest of the patients, distant metastases had not been reported until the time of conduction of this study. The two patients died in the 7th and the 16th postoperative months.

Technical data All the flaps were harvested as myocutaneous flaps with a skin island big enough to achieve a tension-free skin closure. Muscle flap size varied between 72 and 325 cm2, and the size of the overlying skin island was always designed in proportion to the perineal skin defect. The largest tissue defect (measured from the external skin defect) was length 20 cm×width 12 cm×depth 20 cm and the smallest was length 5 cm×width 5 cm×depth 15 cm. All the anastomoses

Table 1

Complications of surgery

Complication

Number of patients

Recipient wound dehiscence Donor wound dehiscence Seroma formation at the donor site Superficial wound dehiscence at the anastomosis site (inguinal region) Limitation of shoulder movement Thrombosis of the vascular pedicle Partial necrosis of the flap Total flap loss

0 0 0 2 2 2 0 1

Rectal cancer

Cervical cancer

Vulvar cancer

were performed end-to-side with the femoral vessels. Vein graft interposition was used in two cases for both of the vein and the artery and was successful in only one. Serratus anterior was co-harvested in four patients where the defect needed a larger amount of soft tissue to obliterate its depth.

Discussion Management of the pelvic floor and perineal defects resulting from radical pelvic resections always pose a challenge to the reconstructive surgeon. The choice of the suitable reconstruction option varies greatly according to the size of the defect and the condition of the loco regional tissues regarding the previous tissue irradiation and the presence of intact reliable vascular supply. The extended resection always results in severe distortion of the anatomy of the region, e.g., partial resection of the gluteus maximus muscle, division of some branches of the internal iliac artery, and injury of the inferior epigastric vessels during a previous laparotomy. Furthermore, preoperative radiotherapy results in irreversible damage of the local tissues, which makes a primary closure of such defects often associated with a high risk of wound complications [16–18]. In all of the cases of this group, the performance of a locoregional reconstruction using the commonly used flaps as the gluteus maximus flap and VRAM was not possible due the presence of an extensive defect that was also associated with division of the branches of the internal iliac artery, including the gluteal vessels, bilaterally. Moreover, the presence of bilateral trans-rectus stomas in six patients, as well as the performance of multiple previous laparotomies in the other half, rendered the use of VRAM not preferred. Opposed to Kaartinen et al. who reconstructed a series of 12 patients following TPE using a pedicled transverse myocutaneous gracilis muscle flap [19], we did not take the gracilis muscle flap into consideration for reconstruction of the pelvic defects encountered in our series. Gracilis flap is well-known in literature for being a small cylindrical flap which is not going to fill the enormous depth of the pelvic

Int J Colorectal Dis Fig. 2 AJCC pathological staging of the pelvic malignancies

10 9 8 7 6 5 4 3 2 1 0 Stage II

defect following TPE or PPE with sacrectomy [8] (Fig. 3). It is not mentioned if the patients in the Kaartinen et al. series had sacrectomy as part of the TPE, which may be due to the fact that the most common pathology in their series was cancer of the cervix uteri, hence a more extension of the tumor anteriorly rather than posteriorly with a less incidence of infiltration of the sacral bone. This will lead to the creation of a smaller defect in the depth of the pelvis which can be reconstructed using a smaller muscle mass, hence the myocutaneous gracilis flap with its transverse skin island seems to be beneficial in reconstructing such defects as reported in their series [19]. The lateral or the semilateral decubitus positions are the most common positions for the flap harvest. However, we performed the flap harvest in the supine position of the patient with slight elevation of the thorax which allows the flap harvest with simultaneous preparation of the recipient vessels at the inguinal region by a second team [20]. To the best of our knowledge, this is the largest published series in the English literature describing the microsurgical free LD reconstruction of the pelvic floor following pelvic exenteration. The successful use of the free LD in reconstruction of perineal defects was only described in some case reports as well as small series [21–26]. In the series published by

Fig. 3 Extensive defect following TPE with resection of the external genitalia in a male patient suffering from recurrent anal cancer (Pt. n3)

Stage III

Stage IV

Petrie et al. in 2009, three patients had a successful free LD reconstruction of perineal defects following abdominoperineal resection (APR) of the rectum [23, 27]. Stechl et al. [26] described the free LD in eight patients who underwent pelvic exenteration. Neither total nor partial flap loss was reported. Ages of the patients in this study was higher than ours with a mean age of 68 years met with 58 years in our series. On the other hand, Stechl et al. reported a shorter postoperative hospital stay of 22 days met with 25 days in ours. Nevertheless, we think that the actual impact of reconstructive surgery on the reduction of the postoperative hospital stay of patients undergoing extensive oncological pelvic resections cannot be assessed in cases of secondary reconstruction. It should rather be evaluated in patients undergoing primary reconstruction, e.g., following primary VRAM or gluteus maximus flap reconstruction because of the transitional period between the primary and the secondary. The relatively long intraoperative time in our series (up to 477 min), with a mean of 372 min, can be attributed to the need to change the patient to the prone position after completing the microsurgical anastomosis to finish setting the flap into the most posterior part of the defect in some cases. Contrary to authors who used intraperitoneal vessels as recipients as Petrie et al. [22, 25], who used the stumps of inferior mesenteric vessels following a case of abdominoperineal resection of the rectum, we consider the femoral vessels as a good and reliable source for the microsurgical anastomosis that does not necessitate performing another laparotomy in patients undergoing secondary reconstruction. However, operating upon a previously irradiated inguinal region carries an increased risk of wound dehiscence which was encountered in two patients in our series [17, 18]. Even in cases where the femoral vessels show atherosclerotic changes, alternatives may include the use of vein graft interposition which can provide a means for elongation of the vascular pedicle to bypass the pathological segment at the recipient vessels. On the other hand, it must be taken into consideration that the interpositional vein graft may be

Int J Colorectal Dis

From our experience, we could say that in pelvic exenteration surgery, whenever the locoregional myocutaneous reconstruction is not feasible, a secondary free tissue transfer for adequate soft tissue coverage should be planned as soon as possible to decrease the expected general and local wound complications. Having always been one of the most versatile and reliable flaps used in microsurgical reconstruction, the free LD flap provides a good reconstruction option in these more complex cases [13] (Fig. 5).

Conclusion

Fig. 4 Free LD with a large skin island

associated with a significantly increased risk of flap failure, which happened in one patient in our series, as reported by Miller et al. in their study published in 1993 [27]. Nevertheless, the single flap loss reported in our series should not be attributed only to the use of vein graft interposition, as the patient suffered also from severe atherosclerosis. In spite of the low incidence of donor site-related complications in our series (two patients), the use of free LD flap is not totally without postoperative donor site morbidity, and patients should be informed about the possible functional limitations prior to flap transfer [28]. The co-harvest of the serratus anterior muscle is advantageous, especially in deeper defects, which needed more bulk for their reconstruction (Fig. 4). Free transfer of the LD for reconstruction of postoncologic defects of the pelvis and perineum has not been commonly performed until recently, as locoregional myocutaneous options have always been the first choice [21]. However, the standard use of neoadjuvant radiotherapy as well as the adoption of more extensive resection techniques by the colorectal surgeons in order to achieve an R0 resection resulted in limitations of the use of locoregional flaps in some cases.

Free LD myocutaneous flap provides an adequate and versatile solution for reconstruction of pelvic defects following radical oncologic resections, especially in cases where the use of locoregional flaps as the gluteus maximus flap or the vertical rectus abdominis flap is not feasible.

References 1.

2.

3.

4.

5. 6.

7. 8.

9. 10.

11.

12.

Fig. 5 Immediate intraoperative view after insetting of the flap

Bullard KM, Trudel JL, Baxter NN et al (2005) Primary perineal wound closure after preoperative radiotherapy and abdominoperineal resection has a high incidence of wound failure. Dis Colon Rectum 48:438–443 Christian CK, Kwaan MR, Betensky RA et al (2005) Risk factors for perineal wound complications following abdominoperineal resection. Dis Colon Rectum 48:43–48 Petrelli N, Rosenfield L, Herrera L et al (1986) The morbidity of perineal wounds following abdominoperineal resection for rectal carcinoma. J Surg Oncol 32:138–140 Shibata D, Hyland W, Busse P et al (1999) Immediate reconstruction of the perineal wound with gracilis muscle flaps following abdominoperineal resection and intraoperative radiation therapy for recurrent carcinoma of the rectum. Ann Surg Oncol 6:33–37 Rothenberger DA, Wong WD (1992) Abdominoperineal resection for adenocarcinoma of the low rectum. World J Surg 16:478–485 Wibe A, Eriksen MT, Syse A et al (2005) Effect of hospital caseload on long-term outcome after standardization of rectal cancer surgery at a national level. Br J Surg 92:217–224 Nisar PJ, Scott HJ (2009) Myocutaneous flap reconstruction of pelvis after abdominoperineal excision. Color Dis 11(8):806–816 McCraw JB, Massey FM, Ahanklin KD et al (1976) Vaginal reconstruction with gracilis myocutaneous flaps. Plast Reconstr Surg 58: 176–183 Taylor GI, Corlett R, Boyd JB (1983) The extended deep inferior epigastric flap: a clinical technique. Plastreconstr Surg 72:751–765 Holm T, Ljung A, Häggmark T et al (2007) Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer. Br J Surg 94(2):232–238 Wagstaff MJ, Rozen WM, Whitaker IS et al (2009) Perineal and posterior vaginal wall reconstruction with superior and inferior gluteal artery perforator flaps. Microsurgery 29(8):626–629 Vermaas M, Ferenschild FT, Hofer SO et al (2005) Primary and secondary reconstruction after surgery of the irradiated pelvis using a gracilis muscle flap transposition. Eur J Surg Oncol 31(9):1000–1005

Int J Colorectal Dis 13.

Tomita K, Yano K, Nishibayashi A et al (2013) The role of latissimus dorsi myocutaneous flaps in secondary breast reconstruction after breast-conserving surgery. Eplasty 13, e28 14. Kim YH, Youn SK, Kim JT et al (2011) Treatment of the severely infected frontal sinus with latissimus dorsi myocutaneous free flaps. J Craniofac Surg 22(3):962–966 15. Girod A, Boissonnet H, Jouffroy T et al (2012) Latissimus dorsi free flap reconstruction o f anterior sku ll base d efects. J Craniomaxillofac Surg 40(2):177–179 16. Abdou A, Bruns H, Troja A et al (2015) Plastische Deckung ausgedehnter Defekte nach exenterativen Eingriffen im Becken. Zentralbl Chir 140:214–218 17. Rudolph R, Vande BJ, Schneider JA et al (1988) Slowed growth of cultured fibroblasts from human radiation wounds. Plast Reconstr Surg 82(4):669–677 18. Krueger WW, Goepfert H, Romsdahl M et al (1987) Fibroblast implantation enhances wound healing as indicated by breaking strength determinations. Otolaryngology 86(5): 804–811 19. Kaartinen IS, Vuento MH, Hyoty MK et al (2015) Reconstruction of the pelvic floor and the vagina after total pelvic exenteration using the transverse musculocutaneous gracilis flap. J Plast Reconstr Aesthet Surg 68:93–97 20. Riediger D, Schmelzle R (1986) Modifizierte Anwendung des myokutanenLatissimusdorsi-Lappens zur Defektdeckung im Mund- Kiefer- Gesichtsbereich. Dtsch Z Mund Kiefer Gesichts Chir 10:364–374

21.

22.

23.

24.

25.

26.

27.

28.

Kieran I, Nugent N, Riordain MO et al (2012) Reconstruction of the pelvis and perineum with a free latissimus dorsi myocutaneous flap: a case report. Ann R Coll Surg Eng 94:254–256 Kraybill WG, Reinsch J, Puckett CL et al (1984) Pelvic abscess following preoperative radiation and abdominoperineal resection: management with a free flap. J Surg Oncol 25:18–20 Petrie NC, Chan JK, Chave H et al (2010) The inferior mesenteric vessels as recipients when performing free tissue transfer for pelvic defects following abdomino-perineal resection. A novel technique and review of intra-peritoneal recipient vessel options for microvascular transfer. J Plast Reconstr Aesthet Surg 63:133–140 Lin CT, Chen SG, Chen TM et al (2011) Successful management of osteoradionecrotic precoccygeal defect with the free latissimus dorsi muscle flap: case report and literature review. Microsurgery 6:490–494 Stechl NM, Baumeister S, Grimm K (2011) Microsurgical reconstruction of the pelvic floor after pelvic exenteration. Reduced morbidity and improved quality of life by an interdisciplinary concept. Chirurg 82(7):625–630 Petrie N, Branagan G, McGuiness C et al (2009) Reconstruction of the perineum following anorectal cancer excision. Int J Color Dis 24:97–104 Miller MJ, Schusterman MA, Reece GP et al (1993) Interposition vein grafting in head and neck reconstructive microsurgery. J Reconstr Microsurg 9(3):245–251 Adams WP, Lipschitz AH, Ansari M et al (2004) Functional donor site morbidity following latissimus dorsi muscle flap transfer. Ann Plast Surg 53(1):6–11

Free latissimus dorsi myocutaneous flap for pelvic floor reconstruction following pelvic exenteration.

Pelvic floor defects following pelvic exenteration constitute a challenge to the reconstructive surgeon. Whenever the common reconstruction options su...
1KB Sizes 1 Downloads 16 Views