Vertical rectus abdominis flap (VRAM) for perineal reconstruction following pelvic surgery: A systematic review

Published:November 08, 2020DOI:



      The vertical rectus abdominis myocutaneous (VRAM) flap is an established technique employed to reconstruct pelvic and perineal defects not amenable to primary closure. The aim of this study was to systematically review the morbidity of VRAM flap reconstruction following exenterative pelvic surgery.

      Materials and methods

      A systematic literature search was conducted by using Medline, EMBASE, and Cochrane databases. Abstracts of all studies published from inception to November 2019 were identified. Search terms used included ‘vertical rectus abdominis myocutaneous’, ‘vertical rectus abdominis musculocutaneous’ and ‘VRAM’. Only studies that described outcomes when a VRAM flap was used during exenterative pelvic surgery were included; case reports were excluded. The primary outcome measure was VRAM flap morbidity. Secondary outcome measures included donor site morbidity and hospital length of stay.


      Sixty-five studies with a total of 1827 patients were identified and included. Perineal reconstruction was most commonly performed following abdominal perineal excision of the rectum (APER) (n = 636 and 34.8%). Median patient age at surgery ranged from 38 to 78 years. Mean perineal flap morbidity was 27%, with a complete flap loss rate of 1.8% and a perineal hernia rate of 0.2%. Mean donor site morbidity was 15%, with an abdominal dehiscence rate of 5.5% and an incisional hernia rate of 3.3%.


      While overall morbidity after VRAM flap reconstruction in pelvic visceral surgery is high; the risk of major complications remains low. These data are important when counselling patients for surgery.


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        • Mathes S.J.
        • Bostwick 3rd, J.
        A rectus abdominis myocutaneous flap to reconstruct abdominal wall defects.
        Br J Plast Surg. 1977; 30: 282-283
        • Shukla H.S.
        • Hughes L.E.
        The rectus abdominis flap for perineal wounds.
        Ann R Coll Surg Engl. 1984; 66: 337-339
        • Abott D.E.
        • Halversn A.L.
        • Wayne J.D.
        • et al.
        The oblique rectus abdominal myocutaneous flap for complex pelvic wound reconstruction.
        Dis Colon Rectum. 2008; 51: 1237-1241
        • McAllister E.
        • Wells K.
        • Chaet M.
        • Norman J.
        • Cruse W.
        Perineal reconstruction after surgical extirpation of pelvic malignancies using the transpelvic transverse rectus abdominal myocutaneous flap.
        Ann Surg Oncol. 1994; 1: 164-168
        • Stein M.J.
        • Karir A.
        • Ramji M.
        • et al.
        Surgical outcomes of VRAM versus gracilis flaps for the reconstruction of pelvic defects following oncologic resection.
        J Plast Reconstr Aesthet Surg. 2019; 72: 565-571
        • Nelson R.A.
        • Butler C.E.
        Surgical outcomes of VRAM versus thigh flaps for immediate reconstruction of pelvic and perineal cancer resection defects.
        Plast Reconstr Surg. 2009; 123: 175-183
        • Nisar P.J.
        • Scott H.J.
        Myocutaneous flap reconstruction of the pelvis after abdominoperineal excision.
        Colorectal Dis. 2009; 11: 806-816
        • Butt H.Z.
        • Salem M.K.
        • Vijaynagar B.
        • Chaudhri S.
        • Singh B.
        Perineal reconstruction after extra-levator abdominoperineal excision (eLAPE): a systematic review.
        Int J Colorectal Dis. 2013; 28: 1459-1468
        • Wilson T.R.
        • Welbourn H.
        • Stanley P.
        • Hartley J.E.
        The success of rectus and gracilis muscle flaps in the treatment of chronic pelvic sepsis and persistent perineal sinus: a systematic review.
        Colorectal Dis. 2014; 16: 751-759
        • Howell A.M.
        • Jarral O.A.
        • Faiz O.
        • Ziprin P.
        • Darzi A.
        • Zacharakis E.
        How should perineal wounds be closed following abdominoperineal resection in patients post radiotherapy–primary closure or flap repair? Best evidence topic (BET).
        Int J Surg. 2013; 11: 514-517
        • Moher D.
        • Shamseer L.
        • Clarke M.
        • et al.
        Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) 2015 statement.
        Syst Rev. 2015; 4: 1
        • Shea B.J.
        • Reeves B.C.
        • Wells G.
        • et al.
        AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both.
        BMJ. 2017; 358: j4008
      1. Radwan R.W., Harries R.L., Drew P., Evans M.D. Vertical rectus abdominis myocutaneous flap (VRAM) for perineal reconstruction following pelvic surgery: a systematic review. PROSPERO 2019 CRD42019141319 Available from:

      2. Wells G.A.S.B., O'Connell D., Peterson J., Welch V., Losos M., Tugwell P. The Newcastle-Ottawa scale (NOS) for assessing the quality of non-randomised studies in meta-analyses 2012.

        • Jadad A.R.
        • Moore R.A.
        • Carroll D.
        • et al.
        Assessing the quality of reports of randomized clinical trials: is blinding necessary?.
        Control Clin Trials. 1996; 17 (PMID 8721797): 1-12
        • Chaudhry A.
        • Oliver J.D.
        • Vyas K.S.
        • et al.
        Comparison of outcomes in oncoplastic pelvic reconstruction with VRAM versus omental flaps: a large cohort analysis.
        J Reconstr Microsurg. 2019; 35: 425-429
        • Chokshi R.J.
        • Kuhrt M.P.
        • Arrese D.
        • Martin Jr., E.W.
        Reconstruction of total pelvic exenteration defects with rectus abdominus myocutaneous flaps versus primary closure.
        Am J Surg. 2013; 205: 64-70
        • Mortensen A.R.
        • Grossmann I.
        • Rosenkilde M.
        • Wara P.
        • Laurberg S.
        • Christensen P.
        Double-blind randomized controlled trial of collagen mesh for the prevention of abdominal incisional hernia in patients having a vertical rectus abdominis myocutaneus flap during surgery for advanced pelvic malignancy.
        Colorectal Dis. 2017; 19: 491-500
        • Touny A.
        • Othman H.
        • Maamoon S.
        • Ramzy S.
        • Elmarakby H.
        Perineal reconstruction using pedicled vertical rectus abdominis myocutaneous flap (VRAM).
        J Surg Oncol. 2014; 110: 752-757
        • Foster J.D.
        • Tou S.
        • Curtis N.J.
        • et al.
        Closure of the perineal defect after abdominoperineal excision for rectal adenocarcinoma – ACPGBI position statement.
        Colorectal Dis. 2018; 20: 5-23
        • Radwan R.W.
        • Codd R.J.
        • Wright M.
        • et al.
        Quality-of-life outcomes following pelvic exenteration for primary rectal cancer.
        Br J Surg. 2015; 102: 1574-1580
        • Musters G.D.
        • Buskens C.J.
        • Bemelman W.A.
        • Tanis P.J.
        Perineal wound healing after abdominoperineal resection for rectal cancer: a systematic review and meta-analysis.
        Dis Colon Rectum. 2014; 57: 1129-1139
        • Bullard K.M.
        • Trudel J.L.
        • Baxter N.N.
        • Rothenberger D.A.
        Primary perineal wound closure after preoperative radiotherapy and abdominoperineal resection has a high incidence of wound failure.
        Dis Colon Rectum. 2005; 48: 438-443
        • Warbrick-Smith J.
        • Drew P.J.
        Post-operative care of VRAM flaps for perineal reconstruction: results of a UK practice survey and literature review.
        J Plast Reconstr Aesthet Surg. 2018; 71: 271-273