Plastic and Reconstructive Surgery in the Treatment of Oncological Perineal and Genital Defects
Identifieur interne : 000514 ( Pmc/Corpus ); précédent : 000513; suivant : 000515Plastic and Reconstructive Surgery in the Treatment of Oncological Perineal and Genital Defects
Auteurs : Rebekka Brodbeck ; Raymund E. Horch ; Andreas Arkudas ; Justus P. BeierSource :
- Frontiers in Oncology [ 2234-943X ] ; 2015.
Abstract
Defects of the perineum may result from ablative procedures of different malignancies. The evolution of more radical excisional surgery techniques resulted in an increase in large defects of the perineum. The perineogenital region
Url:
DOI: 10.3389/fonc.2015.00212
PubMed: 26500887
PubMed Central: 4597132
Links to Exploration step
PMC:4597132Le document en format XML
<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Plastic and Reconstructive Surgery in the Treatment of Oncological Perineal and Genital Defects</title><author><name sortKey="Brodbeck, Rebekka" sort="Brodbeck, Rebekka" uniqKey="Brodbeck R" first="Rebekka" last="Brodbeck">Rebekka Brodbeck</name><affiliation><nlm:aff id="aff1"><institution>Department of Plastic and Hand Surgery, University Hospital of Erlangen, Friedrich-Alexander-University Erlangen-Nuernberg</institution>,<addr-line>Erlangen</addr-line>,<country>Germany</country></nlm:aff></affiliation></author><author><name sortKey="Horch, Raymund E" sort="Horch, Raymund E" uniqKey="Horch R" first="Raymund E." last="Horch">Raymund E. Horch</name><affiliation><nlm:aff id="aff1"><institution>Department of Plastic and Hand Surgery, University Hospital of Erlangen, Friedrich-Alexander-University Erlangen-Nuernberg</institution>,<addr-line>Erlangen</addr-line>,<country>Germany</country></nlm:aff></affiliation></author><author><name sortKey="Arkudas, Andreas" sort="Arkudas, Andreas" uniqKey="Arkudas A" first="Andreas" last="Arkudas">Andreas Arkudas</name><affiliation><nlm:aff id="aff1"><institution>Department of Plastic and Hand Surgery, University Hospital of Erlangen, Friedrich-Alexander-University Erlangen-Nuernberg</institution>,<addr-line>Erlangen</addr-line>,<country>Germany</country></nlm:aff></affiliation></author><author><name sortKey="Beier, Justus P" sort="Beier, Justus P" uniqKey="Beier J" first="Justus P." last="Beier">Justus P. Beier</name><affiliation><nlm:aff id="aff1"><institution>Department of Plastic and Hand Surgery, University Hospital of Erlangen, Friedrich-Alexander-University Erlangen-Nuernberg</institution>,<addr-line>Erlangen</addr-line>,<country>Germany</country></nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">26500887</idno><idno type="pmc">4597132</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4597132</idno><idno type="RBID">PMC:4597132</idno><idno type="doi">10.3389/fonc.2015.00212</idno><date when="2015">2015</date><idno type="wicri:Area/Pmc/Corpus">000514</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000514</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Plastic and Reconstructive Surgery in the Treatment of Oncological Perineal and Genital Defects</title><author><name sortKey="Brodbeck, Rebekka" sort="Brodbeck, Rebekka" uniqKey="Brodbeck R" first="Rebekka" last="Brodbeck">Rebekka Brodbeck</name><affiliation><nlm:aff id="aff1"><institution>Department of Plastic and Hand Surgery, University Hospital of Erlangen, Friedrich-Alexander-University Erlangen-Nuernberg</institution>,<addr-line>Erlangen</addr-line>,<country>Germany</country></nlm:aff></affiliation></author><author><name sortKey="Horch, Raymund E" sort="Horch, Raymund E" uniqKey="Horch R" first="Raymund E." last="Horch">Raymund E. Horch</name><affiliation><nlm:aff id="aff1"><institution>Department of Plastic and Hand Surgery, University Hospital of Erlangen, Friedrich-Alexander-University Erlangen-Nuernberg</institution>,<addr-line>Erlangen</addr-line>,<country>Germany</country></nlm:aff></affiliation></author><author><name sortKey="Arkudas, Andreas" sort="Arkudas, Andreas" uniqKey="Arkudas A" first="Andreas" last="Arkudas">Andreas Arkudas</name><affiliation><nlm:aff id="aff1"><institution>Department of Plastic and Hand Surgery, University Hospital of Erlangen, Friedrich-Alexander-University Erlangen-Nuernberg</institution>,<addr-line>Erlangen</addr-line>,<country>Germany</country></nlm:aff></affiliation></author><author><name sortKey="Beier, Justus P" sort="Beier, Justus P" uniqKey="Beier J" first="Justus P." last="Beier">Justus P. Beier</name><affiliation><nlm:aff id="aff1"><institution>Department of Plastic and Hand Surgery, University Hospital of Erlangen, Friedrich-Alexander-University Erlangen-Nuernberg</institution>,<addr-line>Erlangen</addr-line>,<country>Germany</country></nlm:aff></affiliation></author></analytic><series><title level="j">Frontiers in Oncology</title><idno type="eISSN">2234-943X</idno><imprint><date when="2015">2015</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p>Defects of the perineum may result from ablative procedures of different malignancies. The evolution of more radical excisional surgery techniques resulted in an increase in large defects of the perineum. The perineogenital region <italic>per se</italic> has many different functions for urination, bowel evacuation, sexuality, and reproduction. Up-to-date individual and interdisciplinary surgical treatment concepts are necessary to provide optimum oncological as well as quality of life outcome. Not only the reconstructive method but also the timing of the reconstruction is crucial. In cases of postresectional exposition of e.g., pelvic or femoral vessels or intrapelvic and intra-abdominal organs, simultaneous flap procedure is mandatory. In particular, the reconstructive armamentarium of the plastic surgeon should include not only pedicled flaps but also free microsurgical flaps so that no compromise in terms of the extent of the oncological resection has to be accepted. For intra-abdominally and/or pelvic tumors of the rectum, the anus, or the female reproductive system, which were resected through an abdominally and a sacrally surgical access, simultaneous vertical rectus abdominis myocutaneous (VRAM) flap reconstruction is recommendable. In terms of soft tissue sarcoma of the pelvic/caudal abdomen/proximal thigh region, two-stage reconstructions are possible. This review focuses on the treatment of perineum, genitals, and pelvic floor defects after resection of malignant tumors, giving a distinct overview of the different types of defects faced in this region and describing a number of reconstructive techniques, especially VRAM flap and pedicled flaps like antero-lateral thigh flap or free flaps. Finally, this review outlines some considerations concerning timing of the different operative steps.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Winterton, Ris" uniqKey="Winterton R">RIS Winterton</name></author><author><name sortKey="Lambe, Gf" uniqKey="Lambe G">GF Lambe</name></author><author><name sortKey="Ekwobi, C" uniqKey="Ekwobi C">C Ekwobi</name></author><author><name sortKey="Oudit, D" uniqKey="Oudit D">D Oudit</name></author><author><name sortKey="Mowatt, D" uniqKey="Mowatt D">D Mowatt</name></author><author><name sortKey="Murphy, Jv" uniqKey="Murphy J">JV Murphy</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kolehmainen, M" uniqKey="Kolehmainen M">M Kolehmainen</name></author><author><name sortKey="Suominen, S" uniqKey="Suominen S">S Suominen</name></author><author><name sortKey="Tukiainen, E" uniqKey="Tukiainen E">E Tukiainen</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Beier, Jp" uniqKey="Beier J">JP Beier</name></author><author><name sortKey="Croner, Rs" uniqKey="Croner R">RS Croner</name></author><author><name sortKey="Lang, W" uniqKey="Lang W">W Lang</name></author><author><name sortKey="Arkudas, A" uniqKey="Arkudas A">A Arkudas</name></author><author><name sortKey="Schmitz, M" uniqKey="Schmitz M">M Schmitz</name></author><author><name sortKey="Gohl, J" uniqKey="Gohl J">J Göhl</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Chessin, B" uniqKey="Chessin B">B Chessin</name></author><author><name sortKey="Hartley, J" uniqKey="Hartley J">J Hartley</name></author><author><name sortKey="Cohen, Am" uniqKey="Cohen A">AM Cohen</name></author><author><name sortKey="Mazumdar, M" uniqKey="Mazumdar M">M Mazumdar</name></author><author><name sortKey="Cordeiro, P" uniqKey="Cordeiro P">P Cordeiro</name></author><author><name sortKey="Disa, J" uniqKey="Disa J">J Disa</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Nielsen, Mb" uniqKey="Nielsen M">MB Nielsen</name></author><author><name sortKey="Rasmussen, Pc" uniqKey="Rasmussen P">PC Rasmussen</name></author><author><name sortKey="Lindegaard, Jc" uniqKey="Lindegaard J">JC Lindegaard</name></author><author><name sortKey="Laurberg, S" uniqKey="Laurberg S">S Laurberg</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Emmertsen, Kj" uniqKey="Emmertsen K">KJ Emmertsen</name></author><author><name sortKey="Laurberg, S" uniqKey="Laurberg S">S Laurberg</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Christensen, Hk" uniqKey="Christensen H">HK Christensen</name></author><author><name sortKey="Nerstr M, P" uniqKey="Nerstr M P">P Nerstrøm</name></author><author><name sortKey="Tei, T" uniqKey="Tei T">T Tei</name></author><author><name sortKey="Laurberg, S" uniqKey="Laurberg S">S Laurberg</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Horch, Re" uniqKey="Horch R">RE Horch</name></author><author><name sortKey="Hohenberger, W" uniqKey="Hohenberger W">W Hohenberger</name></author><author><name sortKey="Eweida, A" uniqKey="Eweida A">A Eweida</name></author><author><name sortKey="Kneser, U" uniqKey="Kneser U">U Kneser</name></author><author><name sortKey="Weber, K" uniqKey="Weber K">K Weber</name></author><author><name sortKey="Arkudas, A" uniqKey="Arkudas A">A Arkudas</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Sauer, R" uniqKey="Sauer R">R Sauer</name></author><author><name sortKey="Becker, H" uniqKey="Becker H">H Becker</name></author><author><name sortKey="Hohenberger, W" uniqKey="Hohenberger W">W Hohenberger</name></author><author><name sortKey="Rodel, C" uniqKey="Rodel C">C Rödel</name></author><author><name sortKey="Wittekind, C" uniqKey="Wittekind C">C Wittekind</name></author><author><name sortKey="Fietkau, R" uniqKey="Fietkau R">R Fietkau</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Ferrand, F" uniqKey="Ferrand F">F Ferrand</name></author><author><name sortKey="Malka, D" uniqKey="Malka D">D Malka</name></author><author><name sortKey="Bourredjem, A" uniqKey="Bourredjem A">A Bourredjem</name></author><author><name sortKey="Allonier, C" uniqKey="Allonier C">C Allonier</name></author><author><name sortKey="Bouche, O" uniqKey="Bouche O">O Bouché</name></author><author><name sortKey="Louafi, S" uniqKey="Louafi S">S Louafi</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Ghurani, Gb" uniqKey="Ghurani G">GB Ghurani</name></author><author><name sortKey="Penalver, Ma" uniqKey="Penalver M">MA Penalver</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Sourrouille, I" uniqKey="Sourrouille I">I Sourrouille</name></author><author><name sortKey="Vilcot, L" uniqKey="Vilcot L">L Vilcot</name></author><author><name sortKey="Honore, C" uniqKey="Honore C">C Honoré</name></author><author><name sortKey="Coppola, S" uniqKey="Coppola S">S Coppola</name></author><author><name sortKey="Terrier, P" uniqKey="Terrier P">P Terrier</name></author><author><name sortKey="Le Cesne, A" uniqKey="Le Cesne A">A Le Cesne</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Das Gupta, K" uniqKey="Das Gupta K">K Das Gupta</name></author><author><name sortKey="Busch, K" uniqKey="Busch K">K Busch</name></author><author><name sortKey="Kall, S" uniqKey="Kall S">S Kall</name></author><author><name sortKey="Vogt, Pm" uniqKey="Vogt P">PM Vogt</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Korlof, B" uniqKey="Korlof B">B Körlof</name></author><author><name sortKey="Nylen, B" uniqKey="Nylen B">B Nylén</name></author><author><name sortKey="Tillinger, Kg" uniqKey="Tillinger K">KG Tillinger</name></author><author><name sortKey="Tjernberg, B" uniqKey="Tjernberg B">B Tjernberg</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Wong, S" uniqKey="Wong S">S Wong</name></author><author><name sortKey="Garvey, P" uniqKey="Garvey P">P Garvey</name></author><author><name sortKey="Skibber, J" uniqKey="Skibber J">J Skibber</name></author><author><name sortKey="Yu, P" uniqKey="Yu P">P Yu</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Onaitis, Mw" uniqKey="Onaitis M">MW Onaitis</name></author><author><name sortKey="Noone, Rb" uniqKey="Noone R">RB Noone</name></author><author><name sortKey="Hartwig, M" uniqKey="Hartwig M">M Hartwig</name></author><author><name sortKey="Hurwitz, H" uniqKey="Hurwitz H">H Hurwitz</name></author><author><name sortKey="Morse, M" uniqKey="Morse M">M Morse</name></author><author><name sortKey="Jowell, P" uniqKey="Jowell P">P Jowell</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Gerard, Jp" uniqKey="Gerard J">JP Gerard</name></author><author><name sortKey="Romestaing, P" uniqKey="Romestaing P">P Romestaing</name></author><author><name sortKey="Chapet, O" uniqKey="Chapet O">O Chapet</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Croner, Rs" uniqKey="Croner R">RS Croner</name></author><author><name sortKey="Merkel, S" uniqKey="Merkel S">S Merkel</name></author><author><name sortKey="Papadopoulos, T" uniqKey="Papadopoulos T">T Papadopoulos</name></author><author><name sortKey="Schellerer, V" uniqKey="Schellerer V">V Schellerer</name></author><author><name sortKey="Hohenberger, W" uniqKey="Hohenberger W">W Hohenberger</name></author><author><name sortKey="Goehl, J" uniqKey="Goehl J">J Goehl</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Jain, Ak" uniqKey="Jain A">AK Jain</name></author><author><name sortKey="Defranzo, Aj" uniqKey="Defranzo A">AJ DeFranzo</name></author><author><name sortKey="Marks, Mw" uniqKey="Marks M">MW Marks</name></author><author><name sortKey="Loggie, Bw" uniqKey="Loggie B">BW Loggie</name></author><author><name sortKey="Lentz, S" uniqKey="Lentz S">S Lentz</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Horch, Re" uniqKey="Horch R">RE Horch</name></author><author><name sortKey="Gitsch, G" uniqKey="Gitsch G">G Gitsch</name></author><author><name sortKey="Schultze Seemann, W" uniqKey="Schultze Seemann W">W Schultze-Seemann</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Horch, Re" uniqKey="Horch R">RE Horch</name></author><author><name sortKey="Ulrich, K" uniqKey="Ulrich K">K Ulrich</name></author><author><name sortKey="Weber, K" uniqKey="Weber K">K Weber</name></author><author><name sortKey="Hohenberger, W" uniqKey="Hohenberger W">W Hohenberger</name></author><author><name sortKey="Dragu, A" uniqKey="Dragu A">A Dragu</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Nelson, Ra" uniqKey="Nelson R">RA Nelson</name></author><author><name sortKey="Butler, Ce" uniqKey="Butler C">CE Butler</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Horch, Re" uniqKey="Horch R">RE Horch</name></author><author><name sortKey="Beier, Jp" uniqKey="Beier J">JP Beier</name></author><author><name sortKey="Kneser, U" uniqKey="Kneser U">U Kneser</name></author><author><name sortKey="Arkudas, A" uniqKey="Arkudas A">A Arkudas</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Sun, D" uniqKey="Sun D">D Sun</name></author><author><name sortKey="Yang, Y" uniqKey="Yang Y">Y Yang</name></author><author><name sortKey="Wei, Z" uniqKey="Wei Z">Z Wei</name></author><author><name sortKey="Xu, Y" uniqKey="Xu Y">Y Xu</name></author><author><name sortKey="Zhang, X" uniqKey="Zhang X">X Zhang</name></author><author><name sortKey="Hong, B" uniqKey="Hong B">B Hong</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Howell, Am" uniqKey="Howell A">AM Howell</name></author><author><name sortKey="Jarral, Oa" uniqKey="Jarral O">OA Jarral</name></author><author><name sortKey="Faiz, O" uniqKey="Faiz O">O Faiz</name></author><author><name sortKey="Ziprin, P" uniqKey="Ziprin P">P Ziprin</name></author><author><name sortKey="Darzi, A" uniqKey="Darzi A">A Darzi</name></author><author><name sortKey="Zacharakis, E" uniqKey="Zacharakis E">E Zacharakis</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Tei, Tm" uniqKey="Tei T">TM Tei</name></author><author><name sortKey="Stolzenburg, T" uniqKey="Stolzenburg T">T Stolzenburg</name></author><author><name sortKey="Buntzen, S" uniqKey="Buntzen S">S Buntzen</name></author><author><name sortKey="Laurberg, S" uniqKey="Laurberg S">S Laurberg</name></author><author><name sortKey="Kjeldsen, H" uniqKey="Kjeldsen H">H Kjeldsen</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Foster, Jd" uniqKey="Foster J">JD Foster</name></author><author><name sortKey="Pathak, S" uniqKey="Pathak S">S Pathak</name></author><author><name sortKey="Smart, Nj" uniqKey="Smart N">NJ Smart</name></author><author><name sortKey="Branagan, G" uniqKey="Branagan G">G Branagan</name></author><author><name sortKey="Longman, Rj" uniqKey="Longman R">RJ Longman</name></author><author><name sortKey="Thomas, Mg" uniqKey="Thomas M">MG Thomas</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Jensen, Kk" uniqKey="Jensen K">KK Jensen</name></author><author><name sortKey="Rashid, L" uniqKey="Rashid L">L Rashid</name></author><author><name sortKey="Pilsgaard, B" uniqKey="Pilsgaard B">B Pilsgaard</name></author><author><name sortKey="M Ller, P" uniqKey="M Ller P">P Møller</name></author><author><name sortKey="Wille J Rgensen, P" uniqKey="Wille J Rgensen P">P Wille-Jørgensen</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Anthony, Jp" uniqKey="Anthony J">JP Anthony</name></author><author><name sortKey="Mathes, Sj" uniqKey="Mathes S">SJ Mathes</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Huang, Jj" uniqKey="Huang J">JJ Huang</name></author><author><name sortKey="Chang, Nj" uniqKey="Chang N">NJ Chang</name></author><author><name sortKey="Chou, Hh" uniqKey="Chou H">HH Chou</name></author><author><name sortKey="Wu, Cw" uniqKey="Wu C">CW Wu</name></author><author><name sortKey="Abdelrahman, M" uniqKey="Abdelrahman M">M Abdelrahman</name></author><author><name sortKey="Chen, Hy" uniqKey="Chen H">HY Chen</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="De Haas, Wg" uniqKey="De Haas W">WG de Haas</name></author><author><name sortKey="Miller, Mj" uniqKey="Miller M">MJ Miller</name></author><author><name sortKey="Temple, Wj" uniqKey="Temple W">WJ Temple</name></author><author><name sortKey="Kroll, Ss" uniqKey="Kroll S">SS Kroll</name></author><author><name sortKey="Schusterman, Ma" uniqKey="Schusterman M">MA Schusterman</name></author><author><name sortKey="Reece, Gp" uniqKey="Reece G">GP Reece</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Campbell, Ca" uniqKey="Campbell C">CA Campbell</name></author><author><name sortKey="Butler, Ce" uniqKey="Butler C">CE Butler</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Ho, K" uniqKey="Ho K">K Ho</name></author><author><name sortKey="Warrier, S" uniqKey="Warrier S">S Warrier</name></author><author><name sortKey="Solomon, Mj" uniqKey="Solomon M">MJ Solomon</name></author><author><name sortKey="Lee, K" uniqKey="Lee K">K Lee</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Zhao, Jc" uniqKey="Zhao J">JC Zhao</name></author><author><name sortKey="Xian, Cj" uniqKey="Xian C">CJ Xian</name></author><author><name sortKey="Yu, Ja" uniqKey="Yu J">JA Yu</name></author><author><name sortKey="Shi, K" uniqKey="Shi K">K Shi</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Steinau, Hu" uniqKey="Steinau H">HU Steinau</name></author><author><name sortKey="Steinstr Sser, L" uniqKey="Steinstr Sser L">L Steinsträsser</name></author><author><name sortKey="Hauser, J" uniqKey="Hauser J">J Hauser</name></author><author><name sortKey="Tilkorn, D" uniqKey="Tilkorn D">D Tilkorn</name></author><author><name sortKey="Stricker, I" uniqKey="Stricker I">I Stricker</name></author><author><name sortKey="Daigeler, A" uniqKey="Daigeler A">A Daigeler</name></author></analytic></biblStruct><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Von Mehren, M" uniqKey="Von Mehren M">M von Mehren</name></author><author><name sortKey="Benjamin, Rs" uniqKey="Benjamin R">RS Benjamin</name></author><author><name sortKey="Bui, Mm" uniqKey="Bui M">MM Bui</name></author><author><name sortKey="Casper, Es" uniqKey="Casper E">ES Casper</name></author><author><name sortKey="Conrad, Eu" uniqKey="Conrad E">EU Conrad</name></author><author><name sortKey="Delaney, Tf" uniqKey="Delaney T">TF DeLaney</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Bonvalot, S" uniqKey="Bonvalot S">S Bonvalot</name></author><author><name sortKey="Rivoire, M" uniqKey="Rivoire M">M Rivoire</name></author><author><name sortKey="Castaing, M" uniqKey="Castaing M">M Castaing</name></author><author><name sortKey="Stoeckle, E" uniqKey="Stoeckle E">E Stoeckle</name></author><author><name sortKey="Le Cesne, A" uniqKey="Le Cesne A">A Le Cesne</name></author><author><name sortKey="Blay, Jy" uniqKey="Blay J">JY Blay</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Darouiche, O" uniqKey="Darouiche O">O Darouiche</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Gravvanis, Ai" uniqKey="Gravvanis A">AI Gravvanis</name></author><author><name sortKey="Tsoutsos, Da" uniqKey="Tsoutsos D">DA Tsoutsos</name></author><author><name sortKey="Karakitsos, D" uniqKey="Karakitsos D">D Karakitsos</name></author><author><name sortKey="Panayotou, P" uniqKey="Panayotou P">P Panayotou</name></author><author><name sortKey="Iconomou, T" uniqKey="Iconomou T">T Iconomou</name></author><author><name sortKey="Zografos, G" uniqKey="Zografos G">G Zografos</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Hennessey, Db" uniqKey="Hennessey D">DB Hennessey</name></author><author><name sortKey="Bolton, E" uniqKey="Bolton E">E Bolton</name></author><author><name sortKey="Thomas, Az" uniqKey="Thomas A">AZ Thomas</name></author><author><name sortKey="Lynch, Th" uniqKey="Lynch T">TH Lynch</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Ludolph, I" uniqKey="Ludolph I">I Ludolph</name></author><author><name sortKey="Apel, H" uniqKey="Apel H">H Apel</name></author><author><name sortKey="Horch, Re" uniqKey="Horch R">RE Horch</name></author><author><name sortKey="Beier, Jp" uniqKey="Beier J">JP Beier</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Fujioka, M" uniqKey="Fujioka M">M Fujioka</name></author><author><name sortKey="Hayashida, K" uniqKey="Hayashida K">K Hayashida</name></author><author><name sortKey="Morooka, S" uniqKey="Morooka S">S Morooka</name></author><author><name sortKey="Saijo, H" uniqKey="Saijo H">H Saijo</name></author><author><name sortKey="Nonaka, T" uniqKey="Nonaka T">T Nonaka</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Wee, Jt" uniqKey="Wee J">JT Wee</name></author><author><name sortKey="Joseph, Vt" uniqKey="Joseph V">VT Joseph</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Mcgregor, Ia" uniqKey="Mcgregor I">IA McGregor</name></author><author><name sortKey="Jackson, It" uniqKey="Jackson I">IT Jackson</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Waterhouse, N" uniqKey="Waterhouse N">N Waterhouse</name></author><author><name sortKey="Healy, C" uniqKey="Healy C">C Healy</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Ay, A" uniqKey="Ay A">A Ay</name></author><author><name sortKey="Aytekin, O" uniqKey="Aytekin O">O Aytekin</name></author><author><name sortKey="Aytekin, A" uniqKey="Aytekin A">A Aytekin</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Becker, Dw" uniqKey="Becker D">DW Becker</name></author><author><name sortKey="Massey, Fm" uniqKey="Massey F">FM Massey</name></author><author><name sortKey="Mccraw, Jb" uniqKey="Mccraw J">JB McCraw</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Schmidt, Vj" uniqKey="Schmidt V">VJ Schmidt</name></author><author><name sortKey="Horch, Re" uniqKey="Horch R">RE Horch</name></author><author><name sortKey="Dragu, A" uniqKey="Dragu A">A Dragu</name></author><author><name sortKey="Weber, K" uniqKey="Weber K">K Weber</name></author><author><name sortKey="Gohl, J" uniqKey="Gohl J">J Göhl</name></author><author><name sortKey="Mehlhorn, G" uniqKey="Mehlhorn G">G Mehlhorn</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Galandiuk, S" uniqKey="Galandiuk S">S Galandiuk</name></author><author><name sortKey="Jorden, J" uniqKey="Jorden J">J Jorden</name></author><author><name sortKey="Mahid, S" uniqKey="Mahid S">S Mahid</name></author><author><name sortKey="Mccafferty, Mh" uniqKey="Mccafferty M">MH McCafferty</name></author><author><name sortKey="Tobin, G" uniqKey="Tobin G">G Tobin</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Hung, Sj" uniqKey="Hung S">SJ Hung</name></author><author><name sortKey="Chen, Hc" uniqKey="Chen H">HC Chen</name></author><author><name sortKey="Wei, Fc" uniqKey="Wei F">FC Wei</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Taeger, Cd" uniqKey="Taeger C">CD Taeger</name></author><author><name sortKey="Arkudas, A" uniqKey="Arkudas A">A Arkudas</name></author><author><name sortKey="Beier, Jp" uniqKey="Beier J">JP Beier</name></author><author><name sortKey="Horch, Re" uniqKey="Horch R">RE Horch</name></author></analytic></biblStruct></listBibl></div1></back></TEI><pmc article-type="review-article"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">Front Oncol</journal-id><journal-id journal-id-type="iso-abbrev">Front Oncol</journal-id><journal-id journal-id-type="publisher-id">Front. Oncol.</journal-id><journal-title-group><journal-title>Frontiers in Oncology</journal-title></journal-title-group><issn pub-type="epub">2234-943X</issn><publisher><publisher-name>Frontiers Media S.A.</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">26500887</article-id><article-id pub-id-type="pmc">4597132</article-id><article-id pub-id-type="doi">10.3389/fonc.2015.00212</article-id><article-categories><subj-group subj-group-type="heading"><subject>Oncology</subject><subj-group><subject>Review</subject></subj-group></subj-group></article-categories><title-group><article-title>Plastic and Reconstructive Surgery in the Treatment of Oncological Perineal and Genital Defects</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Brodbeck</surname><given-names>Rebekka</given-names></name><xref ref-type="aff" rid="aff1"><sup>1</sup></xref><uri xlink:type="simple" xlink:href="http://frontiersin.org/people/u/277789"></uri></contrib><contrib contrib-type="author"><name><surname>Horch</surname><given-names>Raymund E.</given-names></name><xref ref-type="aff" rid="aff1"><sup>1</sup></xref><uri xlink:type="simple" xlink:href="http://frontiersin.org/people/u/275798"></uri></contrib><contrib contrib-type="author"><name><surname>Arkudas</surname><given-names>Andreas</given-names></name><xref ref-type="aff" rid="aff1"><sup>1</sup></xref><uri xlink:type="simple" xlink:href="http://frontiersin.org/people/u/133615"></uri></contrib><contrib contrib-type="author"><name><surname>Beier</surname><given-names>Justus P.</given-names></name><xref ref-type="aff" rid="aff1"><sup>1</sup></xref><xref ref-type="corresp" rid="cor1">*</xref><uri xlink:type="simple" xlink:href="http://frontiersin.org/people/u/227750"></uri></contrib></contrib-group><aff id="aff1"><sup>1</sup><institution>Department of Plastic and Hand Surgery, University Hospital of Erlangen, Friedrich-Alexander-University Erlangen-Nuernberg</institution>,<addr-line>Erlangen</addr-line>,<country>Germany</country></aff><author-notes><fn fn-type="edited-by"><p>Edited by: Björn Behr, Ruhr University Bochum, Germany</p></fn><fn fn-type="edited-by"><p>Reviewed by: Ziv Radisavljevic, Brigham and Women’s Hospital, USA; Paul Willemsen, ZNA, Belgium</p></fn><corresp content-type="corresp" id="cor1">*Correspondence: Justus P. Beier, Department of Plastic and Hand Surgery, University Hospital of Erlangen, Friedrich-Alexander-University Erlangen-Nuernberg, Erlangen, Germany, <email>justus.beier@uk-erlangen.de</email></corresp><fn fn-type="other" id="fn001"><p>Specialty section: This article was submitted to Surgical Oncology, a section of the journal Frontiers in Oncology</p></fn></author-notes><pub-date pub-type="epub"><day>08</day><month>10</month><year>2015</year></pub-date><pub-date pub-type="collection"><year>2015</year></pub-date><volume>5</volume><elocation-id>212</elocation-id><history><date date-type="received"><day>18</day><month>6</month><year>2015</year></date><date date-type="accepted"><day>17</day><month>9</month><year>2015</year></date></history><permissions><copyright-statement>Copyright © 2015 Brodbeck, Horch, Arkudas and Beier.</copyright-statement><copyright-year>2015</copyright-year><copyright-holder>Brodbeck, Horch, Arkudas and Beier</copyright-holder><license xlink:href="http://creativecommons.org/licenses/by/4.0/"><license-p>This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.</license-p></license></permissions><abstract><p>Defects of the perineum may result from ablative procedures of different malignancies. The evolution of more radical excisional surgery techniques resulted in an increase in large defects of the perineum. The perineogenital region <italic>per se</italic> has many different functions for urination, bowel evacuation, sexuality, and reproduction. Up-to-date individual and interdisciplinary surgical treatment concepts are necessary to provide optimum oncological as well as quality of life outcome. Not only the reconstructive method but also the timing of the reconstruction is crucial. In cases of postresectional exposition of e.g., pelvic or femoral vessels or intrapelvic and intra-abdominal organs, simultaneous flap procedure is mandatory. In particular, the reconstructive armamentarium of the plastic surgeon should include not only pedicled flaps but also free microsurgical flaps so that no compromise in terms of the extent of the oncological resection has to be accepted. For intra-abdominally and/or pelvic tumors of the rectum, the anus, or the female reproductive system, which were resected through an abdominally and a sacrally surgical access, simultaneous vertical rectus abdominis myocutaneous (VRAM) flap reconstruction is recommendable. In terms of soft tissue sarcoma of the pelvic/caudal abdomen/proximal thigh region, two-stage reconstructions are possible. This review focuses on the treatment of perineum, genitals, and pelvic floor defects after resection of malignant tumors, giving a distinct overview of the different types of defects faced in this region and describing a number of reconstructive techniques, especially VRAM flap and pedicled flaps like antero-lateral thigh flap or free flaps. Finally, this review outlines some considerations concerning timing of the different operative steps.</p></abstract><kwd-group><kwd>interdisciplinary surgery</kwd><kwd>exenteration</kwd><kwd>VRAM flap</kwd><kwd>perineal reconstruction</kwd><kwd>microsurgical free flap</kwd></kwd-group><counts><fig-count count="4"></fig-count><table-count count="2"></table-count><equation-count count="0"></equation-count><ref-count count="52"></ref-count><page-count count="8"></page-count><word-count count="5301"></word-count></counts></article-meta></front><body><sec sec-type="intro" id="S1"><title>Introduction</title><p>Defects of the perineum usually result from ablative procedures of different malignancies, such as gynecological (cervix, vagina, endometrial), urological (urinary bladder, prostate), and colorectal (anal and rectal carcinoma) tumors. The evolution of more radical excisional surgery techniques resulted in an increase in large defects of the perineum (<xref rid="B1" ref-type="bibr">1</xref>). The perineogenital region <italic>per se</italic> has many different functions for urination, bowel evacuation, sexuality, and reproduction (<xref rid="B2" ref-type="bibr">2</xref>), so extensive resection in this region results often in functional deficits.</p><p>Pelvic surgery is characterized by a complex anatomy, involvement of different organs and microbial environment of this region. Plastic-reconstructive measures like simultaneously used skin grafts, pedicled, or free flaps avoid different complications or reduce their incidence, such as chronic wound healing disorders and chronic secretion of intrapelvic or peritoneal wound cavities (<xref rid="B3" ref-type="bibr">3</xref>, <xref rid="B4" ref-type="bibr">4</xref>). For locally advanced primary or recurrent rectal cancer invading the urine bladder or prostate, pelvic exenteration is often the only treatment, with is potentially curative (<xref rid="B5" ref-type="bibr">5</xref>–<xref rid="B7" ref-type="bibr">7</xref>). Radical surgery completely resects all malignant disease, often including the complete or at least large parts of pelvic viscera, vessels, muscles, ligaments, or pelvic bone. In modern concepts of advanced oncological surgery, survival is not the only consideration; quality of life has to be taken into account (<xref rid="B8" ref-type="bibr">8</xref>). Up-to-date individual and interdisciplinary surgical treatment concepts are necessary to provide optimum oncological as well as quality of life outcome (<xref rid="B3" ref-type="bibr">3</xref>, <xref rid="B9" ref-type="bibr">9</xref>).</p><p>This review focuses on the treatment of perineum, genitals, and pelvic floor defects after resection of malignant tumors, giving a distinct overview of the different types of defects faced in this region and describing a number of reconstructive techniques. Finally, this review outlines some considerations concerning timing of the different operative steps.</p><p>Literature about pelvic reconstruction in particular is very rare and review articles or larger case series are absent, hence only case reports have been published. There is only scarce literature with sufficient evidence on this topic, apart from some single case reports and a few case series, this will be critically discussed in the following review.</p></sec><sec id="S2"><title>Pelvic Region: Extra- and Intrapelvic Tumors</title><p>In the pelvic and the inguinal/proximal femoral region, there are essentially two various tumor entities to discuss. Their anatomical localization and extension require very different treatment concepts. In course of this, both initial multidisciplinary team approach and form of reconstructive measures have been adapted to it (<xref rid="B3" ref-type="bibr">3</xref>, <xref rid="B8" ref-type="bibr">8</xref>). On the one hand, there are mainly intra-abdominal and pelvic tumors, which are mostly low rectal carcinomas and deep infiltrating anal carcinomas (<xref rid="B10" ref-type="bibr">10</xref>), as well as far advanced gynecological tumors [e.g., vulval cancer (<xref rid="B11" ref-type="bibr">11</xref>) or cervix cancer (<xref rid="B3" ref-type="bibr">3</xref>)]. On the other hand, there are soft tissue sarcomas of the pelvis, the caudal abdomen, and the proximal femoral region (<xref rid="B12" ref-type="bibr">12</xref>).</p><p>Despite this, there are many other indications, like congenital defects, infections, trauma, lymphedema, and other uncommon problems, e.g., transsexuality (<xref rid="B2" ref-type="bibr">2</xref>) requiring reconstructive surgery in the pelvic region, which are not subject of this review.</p><p>Different reconstruction methods are available for the above-mentioned malignancies. An overview of the most common pedicled (Table <xref ref-type="table" rid="T1">1</xref>) and free flaps (Table <xref ref-type="table" rid="T2">2</xref>) for reconstruction of the perigenital region is shown in Tables <xref ref-type="table" rid="T1">1</xref> and <xref ref-type="table" rid="T2">2</xref>.</p><table-wrap id="T1" position="float"><label>Table 1</label><caption><p><bold>The most useful pedicled flaps for defect reconstruction of the pelvic region [modification of Beier et al. (<xref rid="B3" ref-type="bibr">3</xref>) and Das Gupta et al. (<xref rid="B13" ref-type="bibr">13</xref>)]</bold>.</p></caption><table frame="hsides" rules="groups"><thead><tr><th valign="top" align="left" rowspan="1" colspan="1">Pedicled flaps</th><th valign="top" align="left" rowspan="1" colspan="1">Vascular supply</th><th valign="top" align="left" rowspan="1" colspan="1">Region of defect reconstruction</th></tr></thead><tbody><tr><td valign="top" align="left" rowspan="1" colspan="1">Gluteus muscle flap</td><td valign="top" align="left" rowspan="1" colspan="1">Superior gluteal artery/inferior gluteal artery</td><td valign="top" align="left" rowspan="1" colspan="1">Sacral</td></tr><tr><td valign="top" align="left" rowspan="1" colspan="1">SGAP/IGAP flap</td><td valign="top" align="left" rowspan="1" colspan="1">Superior/inferior gluteal artery perforator</td><td valign="top" align="left" rowspan="1" colspan="1">Sacral</td></tr><tr><td valign="top" align="left" rowspan="1" colspan="1">TRAM flap</td><td valign="top" align="left" rowspan="1" colspan="1">Inferior epigastric artery</td><td valign="top" align="left" rowspan="1" colspan="1">Pelvic floor</td></tr><tr><td valign="top" align="left" rowspan="1" colspan="1">VRAM flap</td><td valign="top" align="left" rowspan="1" colspan="1">Inferior epigastric artery</td><td valign="top" align="left" rowspan="1" colspan="1">Pelvic floor</td></tr><tr><td valign="top" align="left" rowspan="1" colspan="1">Groin flap</td><td valign="top" align="left" rowspan="1" colspan="1">Medial circumflex femoral artery/superficial circumflex iliac artery</td><td valign="top" align="left" rowspan="1" colspan="1">Perineal</td></tr><tr><td valign="top" align="left" rowspan="1" colspan="1">SCIP flap</td><td valign="top" align="left" rowspan="1" colspan="1">Superficial circumflex iliac artery perforator</td><td valign="top" align="left" rowspan="1" colspan="1">Inguinal</td></tr><tr><td valign="top" align="left" rowspan="1" colspan="1">Gracilis muscle flap</td><td valign="top" align="left" rowspan="1" colspan="1">Medial circumflex femoral artery</td><td valign="top" align="left" rowspan="1" colspan="1">Perineal</td></tr><tr><td valign="top" align="left" rowspan="1" colspan="1">Pudendal flap</td><td valign="top" align="left" rowspan="1" colspan="1">External pudendal artery</td><td valign="top" align="left" rowspan="1" colspan="1">Perineal</td></tr><tr><td valign="top" align="left" rowspan="1" colspan="1">Tensor fascie latae flap</td><td valign="top" align="left" rowspan="1" colspan="1">Lateral circumflex femoral artery</td><td valign="top" align="left" rowspan="1" colspan="1">Perineal</td></tr><tr><td valign="top" align="left" rowspan="1" colspan="1">Rectus femoris muscle flap</td><td valign="top" align="left" rowspan="1" colspan="1">Lateral circumflex femoral artery</td><td valign="top" align="left" rowspan="1" colspan="1">Ischial</td></tr><tr><td valign="top" align="left" rowspan="1" colspan="1">Vastus lateralis muscle flap</td><td valign="top" align="left" rowspan="1" colspan="1">Lateral circumflex femoral artery</td><td valign="top" align="left" rowspan="1" colspan="1">Ischial/Perineal</td></tr></tbody></table><table-wrap-foot><p><italic>SGAP, superior gluteal artery perforator; IGAP, inferior gluteal artery perforator; TRAM, transversal rectus abdominis myocutaneous flap; VRAM, vertical rectus abdominis myocutaneous flap; SCIP, superficial circumflex iliac artery perforator</italic>.</p></table-wrap-foot></table-wrap><table-wrap id="T2" position="float"><label>Table 2</label><caption><p><bold>The most useful microsurgical free flaps for defect reconstruction of the pelvic region [modification of Beier et al. (<xref rid="B3" ref-type="bibr">3</xref>) and Das Gupta et al. (<xref rid="B13" ref-type="bibr">13</xref>)]</bold>.</p></caption><table frame="hsides" rules="groups"><thead><tr><th valign="top" align="left" rowspan="1" colspan="1">Vascular system</th><th valign="top" align="left" rowspan="1" colspan="1">Microsurgical free flaps</th></tr></thead><tbody><tr><td valign="top" align="left" rowspan="1" colspan="1">Subscapularis artery</td><td valign="top" align="left" rowspan="1" colspan="1">Latissimus dorsi muscle flap (thoracodorsal artery)<break></break>Scapular/Parascapular flap (circumflex scapula artery)<break></break>Serratus anterior muscle flap (serratus branch of thoracodorsal artery)<break></break>Combinations</td></tr><tr><td valign="top" align="left" rowspan="1" colspan="1">Inferior epigastric artery</td><td valign="top" align="left" rowspan="1" colspan="1">Vertical rectus abdominis myocutaneous (VRAM) flap<break></break>expanded VRAM<break></break>Transversal rectus abdominis myocutaneous (TRAM) flap or deep inferior epigastric perforator (DIEP) flap</td></tr><tr><td valign="top" align="left" rowspan="1" colspan="1">Lateral circumflex femoral artery</td><td valign="top" align="left" rowspan="1" colspan="1">Antero-lateral thigh (ALT) flap (descending branch)<break></break>Tensor fascie latae (TFL) flap (ascending branch)<break></break>Combinations with rectus femoral muscle, lateral vastus muscle, etc.</td></tr></tbody></table></table-wrap><p>In most of the cases, primary closure of perineal defects is not possible. Skin grafts are suboptimal in the perigenital area due high bacterial load in this region, frequently leading to graft loss, prolonged healing resulting in unsatisfactory scar quality and contractures that may affect urination or coitus (<xref rid="B14" ref-type="bibr">14</xref>). Over the past decades, flap reconstruction has replaced these techniques in the vast majority of cases. An ideal flap should provide soft-tissue volume to close dead space in pelvis and the skin island should replace resected perineal skin (<xref rid="B15" ref-type="bibr">15</xref>). These flaps will be described and discussed in detail for the two different groups of malignancies in the pelvic regions in the following paragraph.</p></sec><sec id="S3"><title>Plastic-Reconstructive Measures of Rectal and Anal Carcinomas</title><p>Modern treatment of rectal and anal carcinomas includes a multimodal therapy concept. Preoperative neoadjuvant radio-chemotherapy has become standard treatment for rectal cancer and has been shown to downstage tumors (<xref rid="B15" ref-type="bibr">15</xref>, <xref rid="B16" ref-type="bibr">16</xref>), before radical aggressive surgery is applied to achieve a lasting cure (<xref rid="B8" ref-type="bibr">8</xref>, <xref rid="B17" ref-type="bibr">17</xref>). Despite the concept that multidisciplinary team approach is identically for both entities, the surgical therapy concept itself is very different, associated with the plastic-reconstructive possibilities (<xref rid="B3" ref-type="bibr">3</xref>).</p><p>For intra-abdominal and/or pelvic tumors of the rectum, the anus or the female reproductive system, which were resected through an abdominal and a perineal surgical access (<xref rid="B18" ref-type="bibr">18</xref>), simultaneous flap reconstruction is recommendable. The goal is not only a perineal and/or sacral defect reconstruction but also an intrapelvic sealing, as well as a vaginal partial reconstruction if necessary; both is facilitated by the vertical rectus abdominis myocutaneous (VRAM) flap (Figure <xref ref-type="fig" rid="F1">1</xref>) (<xref rid="B8" ref-type="bibr">8</xref>, <xref rid="B13" ref-type="bibr">13</xref>, <xref rid="B19" ref-type="bibr">19</xref>). To achieve an oncological safe situation, aggressive surgery must be implemented and performing pelvic exenteration with “en bloc” resection of multiple pelvic structures is necessary (<xref rid="B8" ref-type="bibr">8</xref>, <xref rid="B9" ref-type="bibr">9</xref>, <xref rid="B18" ref-type="bibr">18</xref>). After abdominoperineal extirpation, often a large intrapelvic cavity remains, perineal wound complications including wound dehiscence and longtime of secretion occur, even according to radiotherapy. Studies have shown that the VRAM flap is a reliable and safe method for pelvic reconstruction in patients with advanced disease requiring pelvic exenteration and radiation, with relatively low rate of donor and recipient site complications (<xref rid="B20" ref-type="bibr">20</xref>–<xref rid="B22" ref-type="bibr">22</xref>).</p><fig id="F1" position="float"><label>Figure 1</label><caption><p><bold>Defect reconstruction after resection of a rectal carcinoma using VRAM flap illustrated by intraoperative photographs and schematic drawings of the surgical technique</bold>. <bold>(A)</bold> Preoperative marking for VRAM-flap procedure with the planned skin paddle and location of the ostomy performed on the day before surgery. Black arrow marks the flap pedicle. <bold>(B)</bold> The operation involves a two-part procedure with an anterior abdominal dissection first, which is followed by a second step with perineal tumor excision (black arrow) in prone position. We first ensure the viability of the deep inferior epigastric vessels before we proceed with the flap raising. The design of the flap and the size of the skin paddle are then planned according to the prospective perineal and pelvic defect. The skin island is placed vertically over the rectus muscle. The rectus muscle is dissected cranially from the costal arch. In the prone phase, tumor excision (black arrow) had been completed <bold>(C)</bold>. The flap (black asterisk) is then flipped and rotated at 180° into the pelvic cavity so that the skin paddle closes the defect <bold>(D)</bold>. Intraoperative view with VRAM flap (black asterisk) inserted to reconstruct perineal defect <bold>(E)</bold>.</p></caption><graphic xlink:href="fonc-05-00212-g001"></graphic></fig><p>During the last years, important advances in generation of vascularized tissue engineering have been achieved (<xref rid="B23" ref-type="bibr">23</xref>). However, until today flap surgery still remains the gold standard for plastic-reconstructive treatment of oncological defects (<xref rid="B24" ref-type="bibr">24</xref>). The immediately/simultaneously used transpelvic VRAM flap has several advantages: first of all, the VRAM flap is a very safe and robust flap and relatively easy to technical perform, when necessary plastic-reconstructive expertise exists. Furthermore, the vascular supply of the deep inferior epigastric vessel is constant. Using the VRAM flap as a transpelvic flap not only allows reconstruction of perineal and perigenital skin defects, but also enables obliteration of the sacral cavity (<xref rid="B22" ref-type="bibr">22</xref>, <xref rid="B25" ref-type="bibr">25</xref>, <xref rid="B26" ref-type="bibr">26</xref>). Principally, alloplastic and biological matrices have also been used to avoid a herniation of the small bowel, but these techniques are correlated with a significant risk for foreign body reaction, and are prone to infections and formation of chronic fistula, especially if non-absorbable matrices have been used in a radiated field (<xref rid="B27" ref-type="bibr">27</xref>, <xref rid="B28" ref-type="bibr">28</xref>). Furthermore, a vascularized muscle flap can reliably fill dead space in the pelvis and can even help to cure local infection (<xref rid="B29" ref-type="bibr">29</xref>).</p><p>Vertical rectus abdominis myocutaneous flap can also be used for reconstruction of the vagina, when part of the vagina are infiltrated by the tumor and need to be excised. Therefore, the unilateral caudally pedicled VRAM flap can reconstruct half of circumference of the vagina (<xref rid="B8" ref-type="bibr">8</xref>). Moreover, vaginal fistula development can be avoided, because of the sealing effect and the well-vascularized tissue over the sutured vaginal stump (<xref rid="B30" ref-type="bibr">30</xref>).</p><p>A situation after multiple abdominal surgeries represents a major challenge for VRAM flap implementation. On the one hand, the deep inferior epigastric vascular supply may not be available anymore; on the other hand, significant scarring complicates the preparation. Careful preparation and experience of the surgeon permit the implementation of a VRAM flap even in these cases; furthermore, assessment of the deep inferior epigastric vessels through computer angiography is recommended.</p><p>Vertical rectus abdominis myocutaneous flaps can also be desepithelialized, which allows to obliterate larger dead space volumes and adjustment of the skin paddle to smaller skin defects, no bulky perineal skin surface and a shorter suture line is achieved. Vascularized dermis at the wound base seems to be associated with a rapidly healing, even in an irradiated field (<xref rid="B31" ref-type="bibr">31</xref>, <xref rid="B32" ref-type="bibr">32</xref>).</p><p>The most common defects of tumors in this region are caused by rectal and anal carcinomas. In addition, excision of other tumors necessitates a resection of the neighboring skin-/soft tissue, which requires a reconstruction during the same operation. This includes, e.g., extensive gynecological and bladder carcinomas. In case of resection of pelvic bone, VRAM flap can be transferred anteriorly to the symphysis instead of the transpelvic course (<xref rid="B33" ref-type="bibr">33</xref>). Two-stage reconstruction has some disadvantages in such cases. Secondary reopening of the abdomen carries a lot of risks, like discrete intestinal loops that are easily being injured during dissection, e.g., interim negative wound pressure therapy is a possible option, but carries the risk for chronic fistulas through the continuous negative pressure (<xref rid="B34" ref-type="bibr">34</xref>), hence single-stage reconstruction is strongly recommended under these circumstances.</p><p>Summarizing, we suggest that VRAM flap is a particularly suitable method for pelvic reconstruction in patients with advanced colorectal cancer disease requiring pelvic exenteration (<xref rid="B20" ref-type="bibr">20</xref>–<xref rid="B22" ref-type="bibr">22</xref>).</p></sec><sec id="S4"><title>Plastic-Surgical Measures of Sarcomas of the Pelvic Region</title><p>In terms of soft tissue sarcoma of the pelvic/caudal abdomen/proximal thigh region, two-stage reconstruction is possible. Until the final histopathological results, negative wound pressure therapy can be used after tumor resection. Additional resections can be performed until histopathological R0-margins are achieved. Nevertheless simultaneous tumor resection and defect reconstruction can be useful (<xref rid="B35" ref-type="bibr">35</xref>).</p><p>In general, perineal soft tissue tumors are rare, so optimizing their management and outcome of treatment are still subject to investigation (<xref rid="B12" ref-type="bibr">12</xref>). General guidelines have been published, although the histological types are very variable and the locations mostly very complex and various (<xref rid="B36" ref-type="bibr">36</xref>, <xref rid="B37" ref-type="bibr">37</xref>). Soft tissue sarcoma requires individual treatments, because optimal local control prevents deaths, related to local progression (<xref rid="B38" ref-type="bibr">38</xref>). The soft tissue sarcoma tumor size is often very large, because these tumors grow often without symptoms in the ischioanal fossa (<xref rid="B12" ref-type="bibr">12</xref>). In case of chemo- or radiosensitive subtypes, neoadjuvant radio-chemotherapy should be discussed (<xref rid="B36" ref-type="bibr">36</xref>).</p><p>Treatment of arrosion hemorrhage and exposed osteosynthesis implants are urgent indications of simultaneous reconstructions (<xref rid="B39" ref-type="bibr">39</xref>). Another indication for simultaneous defect reconstruction is exposition of vulnerable structure like nerves or vessels, e.g., negative wound pressure therapy (possibly using an additional silicon membrane beneath the sponge for protection of underlying structures) may be applied in between, since harm of nerves by negative pressure therapy has not been reported so far. Nevertheless, the risk especially for infection of expanded defects even after radio-chemotherapy is very high; therefore, simultaneous defect reconstruction is recommended.</p><p>However, timing of reconstruction is very challenging. To achieve a long-lasting cure, thorough examination of the patient and his local findings, as well as the radiologic findings, has to be evaluated in a multidisciplinary approach. No compromise in terms of the extent of the oncological resection has to be accepted, and the extent of the defect decides the treatment regime as a simultaneous vs. a two-stage defect reconstruction (<xref rid="B3" ref-type="bibr">3</xref>).</p><p>As an example for two-stage defect reconstruction and using a pedicled antero-lateral thigh (ALT) flap, Figure <xref ref-type="fig" rid="F2">2</xref> shows the case of a patient with dermatofibrosarcoma protuberans at the left groin. Negative wound pressure therapy was applied until the histopathological R0-result was confirmed. For defect reconstruction (Figure <xref ref-type="fig" rid="F2">2</xref>A), a caudally pedicled ALT flap was used (Figures <xref ref-type="fig" rid="F2">2</xref>B,C).</p><fig id="F2" position="float"><label>Figure 2</label><caption><p><bold>Defect reconstruction at groin after resection of a dermatofibrosarcoma protuberans using caudal pedicled ALT flap</bold>. <bold>(A)</bold> Extent of groin defect after resection (black asterisk) of a dermatofibrosarcoma protuberans. <bold>(B)</bold> Intraoperative view after dissection of ALT flap and rotation into the groin defect. For typical manner of harvesting ALT flap, ALT perforator is localized between the central to lower third of the ALT flap area after skin incision and initial preparation. White arrow shows the ALT perforator. <bold>(C)</bold> Intraoperative view at the end of the operation with ALT flap (black asterisk) and skin graft at donor site to reconstruct groin defect.</p></caption><graphic xlink:href="fonc-05-00212-g002"></graphic></fig><p>All in all, in cases of reconstructions after sarcoma resection in the pelvic region, we recommend a two-stage reconstruction where possible, i.e., when no vulnerable structures are exposed after tumor resection. Many factors like size and character of the defect have to receive attention, but often a pedicled flap like ALT flap or VRAM flap could be used (<xref rid="B3" ref-type="bibr">3</xref>, <xref rid="B40" ref-type="bibr">40</xref>).</p></sec><sec id="S5"><title>Combined Intra- and Extrapelvic Defects</title><p>Combined intrapelvic organ defects (e.g., chronic bladder fistulas) and concurrent abdominal skin defects (e.g., with abdominal skin fistulas and/or unstable scars or skin grafts) are very challenging. In particular, due to side effects of radiotherapy, skin grafts are prone to complications. Most times the defect may initially underestimated and skin grafts are applied, which need to be replaced during the further course by vascularized tissue/flaps.</p><p>As an example for such postoperative complication, a vesico-cutaneous fistula of the caudal rectus abdominis muscle after sarcoma resection and radiotherapy may result, which is very difficult to treat (<xref rid="B41" ref-type="bibr">41</xref>). For treatment of this rare entity, microsurgical free flap transplantation can become necessary, especially to avoid an additional weakening of the abdominal wall using the contralateral rectus abdominal muscle. A combined bipedicular latissimus dorsi/anterior serrate flap is capable of covering the intrapelvic defect (bladder vault using the part of serratus flap) as well as the abdominal wall defect cranial to the symphysis (using the part of latissimus dorsi flap) (<xref rid="B42" ref-type="bibr">42</xref>).</p><p>Reconstruction of combined intra- and extrapelvic defects is always very challenging. The literature describes no patent remedy, so we suggest for treatment of this rare entity microsurgical free flap transplantation (<xref rid="B42" ref-type="bibr">42</xref>, <xref rid="B43" ref-type="bibr">43</xref>).</p></sec><sec id="S6"><title>Secondary Treatment of Perigenital Defects</title><p>Sometimes patients present themselves, secondary or after complications have occured, like recurrent abscending or phlegmonous infections of the pelvis, persistent severe secretion out of chronic sacral cavities or fistulas in prostate/vaginal/urine bladder region. Treatment of such sequelae is technically very challenging and connected to a severe risk profile. A reopening of the abdominal access for VRAM flap is difficult, because of a high risk for injury of adherent small intestine or fibrosis as well as stenosis of the pelvic entry. Another problem is loss of both inferior epigastric vessels. In these cases, other pedicled regional flaps should be used for defect reconstruction (<xref rid="B15" ref-type="bibr">15</xref>).</p><p>To cover posterior defects, gluteal flaps are useful (<xref rid="B1" ref-type="bibr">1</xref>); for ventral defects, pudendal flaps (<xref rid="B44" ref-type="bibr">44</xref>) and groin flaps (<xref rid="B45" ref-type="bibr">45</xref>) should be mentioned. Similarly, the use of lateral vastus muscle flap (<xref rid="B46" ref-type="bibr">46</xref>) and ALT flap (<xref rid="B15" ref-type="bibr">15</xref>) for defect reconstruction after pelvic exenteration has been described. Myocutaneous gluteal flaps are mainly used as rotation – or as VY advancement – flaps (<xref rid="B47" ref-type="bibr">47</xref>), while the gracilis muscle flap is mainly used as proximally pedicled muscle flap (<xref rid="B48" ref-type="bibr">48</xref>). Complications result most from chronic lymphfistulas or lymphedema at femoral or groin region. Gluteal perforator flaps (SGAP and IGAP) do not affect the motor function and minimize the donor-side morbidity (<xref rid="B49" ref-type="bibr">49</xref>), thus, offering a technically more advanced solution with relatively low donor site morbidity.</p><p>A successful defect reconstruction including in particular a sufficient filling of presacral cavity requires an acceptable intrapelvic access using pedicled gluteal muscle flaps. Sometimes sacral or coccygeal bone has been resected (<xref rid="B50" ref-type="bibr">50</xref>).</p><p>Secondary sealing itself is very challenging, if chronic sacral cavities or recurrent pelvic infections are being observed. An access to and sufficient filling of presacral dead space is difficult to achieve in a secondary perineal approach. In such cases, sufficient three-dimensional defect reconstruction often is not possible without microsurgical free flaps. These could be anastomosed to local blood vessels, like gluteal vessels (<xref rid="B51" ref-type="bibr">51</xref>), femoral vessels, or iliac vessels after an arterio-venous loop (Figure <xref ref-type="fig" rid="F3">3</xref>).</p><fig id="F3" position="float"><label>Figure 3</label><caption><p><bold>Perineal defect reconstruction after resection of a chronic sacral cavity with fistulas using a microsurgical free “buried” latissimus dorsi flap and an arterio-venous loop</bold>. In history, after radio-chemotherapy a rectal carcinoma had been resected. <bold>(A)</bold> Preoperative presentation of chronic sacral fistula (black arrow). <bold>(B)</bold> Situs after dissection of the arterio-venous loop (black arrow). <bold>(C)</bold> Intraoperative view at anastomosed latissimus dorsi flap (black asterisk) at the loop (black arrow). <bold>(D)</bold> MR-Angiography with microsurgical free “buried” latissimus dorsi flap (black asterisk) inserted to reconstruct perineal defect and imaging of the consistent arterio-venous loop (white arrow). <bold>(E)</bold> Result 1 month postoperatively.</p></caption><graphic xlink:href="fonc-05-00212-g003"></graphic></fig><p>After radiation, wound healing disorders are more frequent, therefore skin grafts are often not useful for defect reconstruction in such cases. Primary treatment with pedicled or microsurgical free flaps can be appropriate (<xref rid="B52" ref-type="bibr">52</xref>).</p></sec><sec id="S7"><title>Conclusion</title><p>The evolution of more radical excisional surgery techniques resulted in an increase in large defects of the perineum. In most of the cases, primary closure of perineal defects is not possible. Skin grafts are suboptimal in the perigenital area. For intra-abdominally and/or pelvic tumors of the rectum, the anus or the female reproductive system, which were resected through an abdominally and a sacrally surgical access, simultaneous VRAM flap reconstruction is recommendable. We suggest the VRAM flap as a particularly suitable method for pelvic reconstruction in patients with advanced colorectal cancer disease requiring pelvic exenteration. In terms of soft tissue sarcoma of the pelvic/caudal abdomen/proximal thigh region, two-stage reconstructions are possible. Many factors, like size and character of the defect have to be considered, but often a pedicled flap, like ALT flap could be used in cases of sarcoma resection. Secondary sealing itself is very challenging, if chronic sacral cavities or recurrent pelvic infections are being observed. In such cases, sufficient three-dimensional defect reconstruction often is not possible without microsurgical free flaps (Figure <xref ref-type="fig" rid="F4">4</xref>).</p><fig id="F4" position="float"><label>Figure 4</label><caption><p><bold>Schematic drawing of the surgical technique for perineal defect reconstruction, with schematic drawing of VRAM flap (black asterisk), ALT flap (red asterisk) and microsurgical free latissimus dorsi flap and an arterio-venous loop (hash)</bold>.</p></caption><graphic xlink:href="fonc-05-00212-g004"></graphic></fig></sec><sec id="S8"><title>Conflict of Interest Statement</title><p>The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.</p></sec></body><back><ref-list><title>References</title><ref id="B1"><label>1</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Winterton</surname><given-names>RIS</given-names></name><name><surname>Lambe</surname><given-names>GF</given-names></name><name><surname>Ekwobi</surname><given-names>C</given-names></name><name><surname>Oudit</surname><given-names>D</given-names></name><name><surname>Mowatt</surname><given-names>D</given-names></name><name><surname>Murphy</surname><given-names>JV</given-names></name><etal></etal></person-group><article-title>Gluteal fold flaps for perineal reconstruction</article-title>. <source>J Plast Reconstr Aesthet Surg</source> (<year>2013</year>) <volume>66</volume>:<fpage>397</fpage>–<lpage>405</lpage>.<pub-id pub-id-type="doi">10.1016/j.bjps.2012.09.026</pub-id><pub-id pub-id-type="pmid">23098585</pub-id></mixed-citation></ref><ref id="B2"><label>2</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Kolehmainen</surname><given-names>M</given-names></name><name><surname>Suominen</surname><given-names>S</given-names></name><name><surname>Tukiainen</surname><given-names>E</given-names></name></person-group>. <article-title>Pelvic, perineal and genital reconstructions</article-title>. <source>Scand J Surg</source> (<year>2013</year>) <volume>102</volume>:<fpage>25</fpage>–<lpage>31</lpage>.<pub-id pub-id-type="doi">10.1177/145749691310200106</pub-id><pub-id pub-id-type="pmid">23628633</pub-id></mixed-citation></ref><ref id="B3"><label>3</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Beier</surname><given-names>JP</given-names></name><name><surname>Croner</surname><given-names>RS</given-names></name><name><surname>Lang</surname><given-names>W</given-names></name><name><surname>Arkudas</surname><given-names>A</given-names></name><name><surname>Schmitz</surname><given-names>M</given-names></name><name><surname>Göhl</surname><given-names>J</given-names></name></person-group><article-title>Komplikationsvermeidung in der onkologischen Chirurgie der Becken-/Leistenregion</article-title>. <source>Der Chirurg</source> (<year>2015</year>) <volume>86</volume>:<fpage>242</fpage>–<lpage>50</lpage>.<pub-id pub-id-type="doi">10.1007/s00104-014-2835-6</pub-id></mixed-citation></ref><ref id="B4"><label>4</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Chessin</surname><given-names>B</given-names></name><name><surname>Hartley</surname><given-names>J</given-names></name><name><surname>Cohen</surname><given-names>AM</given-names></name><name><surname>Mazumdar</surname><given-names>M</given-names></name><name><surname>Cordeiro</surname><given-names>P</given-names></name><name><surname>Disa</surname><given-names>J</given-names></name><etal></etal></person-group><article-title>Rectus flap reconstruction decreases perineal wound complications after pelvic chemoradiation and surgery: a cohort study</article-title>. <source>Ann Surg Oncol</source> (<year>2005</year>) <volume>12</volume>:<fpage>104</fpage>–<lpage>10</lpage>.<pub-id pub-id-type="doi">10.1245/ASO.2005.03.100</pub-id><pub-id pub-id-type="pmid">15827789</pub-id></mixed-citation></ref><ref id="B5"><label>5</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Nielsen</surname><given-names>MB</given-names></name><name><surname>Rasmussen</surname><given-names>PC</given-names></name><name><surname>Lindegaard</surname><given-names>JC</given-names></name><name><surname>Laurberg</surname><given-names>S</given-names></name></person-group>. <article-title>A 10-year experience of total pelvic exenteration for primary advanced and locally recurrent rectal cancer based on a prospective database</article-title>. <source>Colorectal Dis</source> (<year>2012</year>) <volume>14</volume>:<fpage>1076</fpage>–<lpage>83</lpage>.<pub-id pub-id-type="doi">10.1111/j.1463-1318.2011.02893.x</pub-id><pub-id pub-id-type="pmid">22107085</pub-id></mixed-citation></ref><ref id="B6"><label>6</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Emmertsen</surname><given-names>KJ</given-names></name><name><surname>Laurberg</surname><given-names>S</given-names></name></person-group><article-title>Low anterior resection syndrome score</article-title>. <source>Ann Surg</source> (<year>2012</year>) <volume>255</volume>:<fpage>922</fpage>–<lpage>8</lpage>.<pub-id pub-id-type="doi">10.1097/SLA.0b013e31824f1c21</pub-id><pub-id pub-id-type="pmid">22504191</pub-id></mixed-citation></ref><ref id="B7"><label>7</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Christensen</surname><given-names>HK</given-names></name><name><surname>Nerstrøm</surname><given-names>P</given-names></name><name><surname>Tei</surname><given-names>T</given-names></name><name><surname>Laurberg</surname><given-names>S</given-names></name></person-group>. <article-title>Perineal repair after extralevator abdominoperineal excision for low rectal cancer</article-title>. <source>Dis Colon Rectum</source> (<year>2011</year>) <volume>54</volume>:<fpage>711</fpage>–<lpage>7</lpage>.<pub-id pub-id-type="doi">10.1007/DCR.0b013e3182163c89</pub-id><pub-id pub-id-type="pmid">21552056</pub-id></mixed-citation></ref><ref id="B8"><label>8</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Horch</surname><given-names>RE</given-names></name><name><surname>Hohenberger</surname><given-names>W</given-names></name><name><surname>Eweida</surname><given-names>A</given-names></name><name><surname>Kneser</surname><given-names>U</given-names></name><name><surname>Weber</surname><given-names>K</given-names></name><name><surname>Arkudas</surname><given-names>A</given-names></name><etal></etal></person-group><article-title>A hundred patients with vertical rectus abdominis myocutaneous (VRAM) flap for pelvic reconstruction after total pelvic exenteration</article-title>. <source>Int J Colorectal Dis</source> (<year>2014</year>) <volume>29</volume>:<fpage>813</fpage>–<lpage>23</lpage>.<pub-id pub-id-type="doi">10.1007/s00384-014-1868-0</pub-id><pub-id pub-id-type="pmid">24752738</pub-id></mixed-citation></ref><ref id="B9"><label>9</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Sauer</surname><given-names>R</given-names></name><name><surname>Becker</surname><given-names>H</given-names></name><name><surname>Hohenberger</surname><given-names>W</given-names></name><name><surname>Rödel</surname><given-names>C</given-names></name><name><surname>Wittekind</surname><given-names>C</given-names></name><name><surname>Fietkau</surname><given-names>R</given-names></name><etal></etal></person-group><article-title>Preoperative versus postoperative chemoradiotherapy for rectal cancer</article-title>. <source>N Engl J Med</source> (<year>2004</year>) <volume>351</volume>:<fpage>1731</fpage>–<lpage>40</lpage>.<pub-id pub-id-type="doi">10.1056/NEJMoa040694</pub-id><pub-id pub-id-type="pmid">15496622</pub-id></mixed-citation></ref><ref id="B10"><label>10</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Ferrand</surname><given-names>F</given-names></name><name><surname>Malka</surname><given-names>D</given-names></name><name><surname>Bourredjem</surname><given-names>A</given-names></name><name><surname>Allonier</surname><given-names>C</given-names></name><name><surname>Bouché</surname><given-names>O</given-names></name><name><surname>Louafi</surname><given-names>S</given-names></name></person-group>. <article-title>Impact of primary tumour resection on survival of patients with colorectal cancer and synchronous metastases treated by chemotherapy: results from the multicenter, randomised trial Fédération Francophone de Cancérologie Digestive 9601</article-title>. <source>Eur J Cancer</source> (<year>2013</year>) <volume>49</volume>:<fpage>90</fpage>–<lpage>7</lpage>.<pub-id pub-id-type="doi">10.1016/j.ejca.2012.07.006</pub-id><pub-id pub-id-type="pmid">22926014</pub-id></mixed-citation></ref><ref id="B11"><label>11</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Ghurani</surname><given-names>GB</given-names></name><name><surname>Penalver</surname><given-names>MA</given-names></name></person-group>. <article-title>An update on vulvar cancer</article-title>. <source>Am J Obstet Gynecol</source> (<year>2001</year>) <volume>185</volume>:<fpage>294</fpage>–<lpage>9</lpage>.<pub-id pub-id-type="doi">10.1067/mob.2001.117401</pub-id><pub-id pub-id-type="pmid">11518882</pub-id></mixed-citation></ref><ref id="B12"><label>12</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Sourrouille</surname><given-names>I</given-names></name><name><surname>Vilcot</surname><given-names>L</given-names></name><name><surname>Honoré</surname><given-names>C</given-names></name><name><surname>Coppola</surname><given-names>S</given-names></name><name><surname>Terrier</surname><given-names>P</given-names></name><name><surname>Le Cesne</surname><given-names>A</given-names></name></person-group>. <article-title>Algorithm for the surgical management of mesenchymal tumors of the perineum in adults</article-title>. <source>Dis Colon Rectum</source> (<year>2015</year>) <volume>58</volume>:<fpage>304</fpage>–<lpage>13</lpage>.<pub-id pub-id-type="doi">10.1097/DCR.0000000000000272</pub-id><pub-id pub-id-type="pmid">25664708</pub-id></mixed-citation></ref><ref id="B13"><label>13</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Das Gupta</surname><given-names>K</given-names></name><name><surname>Busch</surname><given-names>K</given-names></name><name><surname>Kall</surname><given-names>S</given-names></name><name><surname>Vogt</surname><given-names>PM</given-names></name></person-group><article-title>Plastisch-rekonstruktive Therapie bei postonkologischen Defekten im Bereich der Beckenregion</article-title>. <source>Der Chirurg</source> (<year>2004</year>) <volume>75</volume>:<fpage>1135</fpage>–<lpage>44</lpage>.<pub-id pub-id-type="doi">10.1007/s00104-004-0964-z</pub-id></mixed-citation></ref><ref id="B14"><label>14</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Körlof</surname><given-names>B</given-names></name><name><surname>Nylén</surname><given-names>B</given-names></name><name><surname>Tillinger</surname><given-names>KG</given-names></name><name><surname>Tjernberg</surname><given-names>B</given-names></name></person-group>. <article-title>Different methods of reconstruction after vulvectomies for cancer of the vulva</article-title>. <source>Acta Obstet Gynecol Scand</source> (<year>1975</year>) <volume>54</volume>:<fpage>411</fpage>–<lpage>5</lpage>.<pub-id pub-id-type="doi">10.3109/00016347509157103</pub-id><pub-id pub-id-type="pmid">1106112</pub-id></mixed-citation></ref><ref id="B15"><label>15</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Wong</surname><given-names>S</given-names></name><name><surname>Garvey</surname><given-names>P</given-names></name><name><surname>Skibber</surname><given-names>J</given-names></name><name><surname>Yu</surname><given-names>P</given-names></name></person-group>. <article-title>Reconstruction of pelvic exenteration defects with anterolateral thigh-vastus lateralis muscle flaps</article-title>. <source>Plast Reconstr Surg</source> (<year>2009</year>) <volume>124</volume>:<fpage>1177</fpage>–<lpage>85</lpage>.<pub-id pub-id-type="doi">10.1097/PRS.0b013e3181b5a40f</pub-id><pub-id pub-id-type="pmid">19935301</pub-id></mixed-citation></ref><ref id="B16"><label>16</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Onaitis</surname><given-names>MW</given-names></name><name><surname>Noone</surname><given-names>RB</given-names></name><name><surname>Hartwig</surname><given-names>M</given-names></name><name><surname>Hurwitz</surname><given-names>H</given-names></name><name><surname>Morse</surname><given-names>M</given-names></name><name><surname>Jowell</surname><given-names>P</given-names></name><etal></etal></person-group><article-title>Neoadjuvant chemoradiation for rectal cancer: analysis of clinical outcomes from a 13-year institutional experience</article-title>. <source>Ann Surg</source> (<year>2001</year>) <volume>233</volume>:<fpage>778</fpage>–<lpage>85</lpage>.<pub-id pub-id-type="doi">10.1097/00000658-200106000-00007</pub-id><pub-id pub-id-type="pmid">11371736</pub-id></mixed-citation></ref><ref id="B17"><label>17</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Gerard</surname><given-names>JP</given-names></name><name><surname>Romestaing</surname><given-names>P</given-names></name><name><surname>Chapet</surname><given-names>O</given-names></name></person-group>. <article-title>Radiotherapy alone in the curative treatment of rectal carcinoma</article-title>. <source>Lancet Oncol</source> (<year>2003</year>) <volume>4</volume>:<fpage>158</fpage>–<lpage>66</lpage>.<pub-id pub-id-type="doi">10.1016/S1470-2045(03)01020-9</pub-id><pub-id pub-id-type="pmid">12623361</pub-id></mixed-citation></ref><ref id="B18"><label>18</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Croner</surname><given-names>RS</given-names></name><name><surname>Merkel</surname><given-names>S</given-names></name><name><surname>Papadopoulos</surname><given-names>T</given-names></name><name><surname>Schellerer</surname><given-names>V</given-names></name><name><surname>Hohenberger</surname><given-names>W</given-names></name><name><surname>Goehl</surname><given-names>J</given-names></name></person-group>. <article-title>Multivisceral resection for colon carcinoma</article-title>. <source>Dis Colon Rectum</source> (<year>2009</year>) <volume>52</volume>:<fpage>1381</fpage>–<lpage>6</lpage>.<pub-id pub-id-type="doi">10.1007/DCR.0b013e3181ab580b</pub-id><pub-id pub-id-type="pmid">19617748</pub-id></mixed-citation></ref><ref id="B19"><label>19</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Jain</surname><given-names>AK</given-names></name><name><surname>DeFranzo</surname><given-names>AJ</given-names></name><name><surname>Marks</surname><given-names>MW</given-names></name><name><surname>Loggie</surname><given-names>BW</given-names></name><name><surname>Lentz</surname><given-names>S</given-names></name></person-group>. <article-title>Reconstruction of pelvic exenterative wounds with transpelvic rectus abdominis flaps: a case series</article-title>. <source>Ann Plast Surg</source> (<year>1997</year>) <volume>38</volume>:<fpage>115</fpage>–<lpage>22</lpage>.<pub-id pub-id-type="doi">10.1097/00000637-199702000-00004</pub-id><pub-id pub-id-type="pmid">9043579</pub-id></mixed-citation></ref><ref id="B20"><label>20</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Horch</surname><given-names>RE</given-names></name><name><surname>Gitsch</surname><given-names>G</given-names></name><name><surname>Schultze-Seemann</surname><given-names>W</given-names></name></person-group>. <article-title>Bilateral pedicled myocutaneous vertical rectus abdominus muscle flaps to close vesicovaginal and pouch-vaginal fistulas with simultaneous vaginal and perineal reconstruction in irradiated pelvic wounds</article-title>. <source>Urology</source> (<year>2002</year>) <volume>60</volume>:<fpage>502</fpage>–<lpage>7</lpage>.<pub-id pub-id-type="doi">10.1016/S0090-4295(02)01823-X</pub-id><pub-id pub-id-type="pmid">12350497</pub-id></mixed-citation></ref><ref id="B21"><label>21</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Horch</surname><given-names>RE</given-names></name><name><surname>Ulrich</surname><given-names>K</given-names></name><name><surname>Weber</surname><given-names>K</given-names></name><name><surname>Hohenberger</surname><given-names>W</given-names></name><name><surname>Dragu</surname><given-names>A</given-names></name></person-group><article-title>The transpelvic vertical rectus abdominis flap: one interdisciplinary approach to reduce postoperative complications after surgery for rectal cancer</article-title>. <source>Ann Surg</source> (<year>2013</year>) <volume>257</volume>:<fpage>e16</fpage><pub-id pub-id-type="doi">10.1097/SLA.0b013e31828cbe3a</pub-id><pub-id pub-id-type="pmid">23665972</pub-id></mixed-citation></ref><ref id="B22"><label>22</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Nelson</surname><given-names>RA</given-names></name><name><surname>Butler</surname><given-names>CE</given-names></name></person-group>. <article-title>Surgical outcomes of VRAM versus thigh flaps for immediate reconstruction of pelvic and perineal cancer resection defects</article-title>. <source>Plast Reconstr Surg</source> (<year>2009</year>) <volume>123</volume>:<fpage>175</fpage>–<lpage>83</lpage>.<pub-id pub-id-type="doi">10.1097/PRS.0b013e3181904df7</pub-id><pub-id pub-id-type="pmid">19116551</pub-id></mixed-citation></ref><ref id="B23"><label>23</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Horch</surname><given-names>RE</given-names></name><name><surname>Beier</surname><given-names>JP</given-names></name><name><surname>Kneser</surname><given-names>U</given-names></name><name><surname>Arkudas</surname><given-names>A</given-names></name></person-group>. <article-title>Successful human long-term application of in situ bone tissue engineering</article-title>. <source>J Cell Mol Med</source> (<year>2014</year>) <volume>18</volume>:<fpage>1478</fpage>–<lpage>85</lpage>.<pub-id pub-id-type="doi">10.1111/jcmm.12296</pub-id><pub-id pub-id-type="pmid">24801710</pub-id></mixed-citation></ref><ref id="B24"><label>24</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Sun</surname><given-names>D</given-names></name><name><surname>Yang</surname><given-names>Y</given-names></name><name><surname>Wei</surname><given-names>Z</given-names></name><name><surname>Xu</surname><given-names>Y</given-names></name><name><surname>Zhang</surname><given-names>X</given-names></name><name><surname>Hong</surname><given-names>B</given-names></name></person-group>. <article-title>Engineering of pre-vascularized urethral patch with muscle flaps and hypoxia-activated hUCMSCs improves its therapeutic outcome</article-title>. <source>J Cell Mol Med</source> (<year>2014</year>) <volume>18</volume>:<fpage>434</fpage>–<lpage>43</lpage>.<pub-id pub-id-type="doi">10.1111/jcmm.12157</pub-id><pub-id pub-id-type="pmid">24460735</pub-id></mixed-citation></ref><ref id="B25"><label>25</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Howell</surname><given-names>AM</given-names></name><name><surname>Jarral</surname><given-names>OA</given-names></name><name><surname>Faiz</surname><given-names>O</given-names></name><name><surname>Ziprin</surname><given-names>P</given-names></name><name><surname>Darzi</surname><given-names>A</given-names></name><name><surname>Zacharakis</surname><given-names>E</given-names></name></person-group>. <article-title>How should perineal wounds be closed following abdominoperineal resection in patients post radiotherapy – primary closure or flap repair? Best evidence topic (BET)</article-title>. <source>Int J Surg</source> (<year>2013</year>) <volume>11</volume>:<fpage>514</fpage>–<lpage>7</lpage>.<pub-id pub-id-type="doi">10.1016/j.ijsu.2013.05.004</pub-id><pub-id pub-id-type="pmid">23707627</pub-id></mixed-citation></ref><ref id="B26"><label>26</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Tei</surname><given-names>TM</given-names></name><name><surname>Stolzenburg</surname><given-names>T</given-names></name><name><surname>Buntzen</surname><given-names>S</given-names></name><name><surname>Laurberg</surname><given-names>S</given-names></name><name><surname>Kjeldsen</surname><given-names>H</given-names></name></person-group>. <article-title>Use of transpelvic rectus abdominis musculocutaneous flap for anal cancer salvage surgery</article-title>. <source>Br J Surg</source> (<year>2003</year>) <volume>90</volume>:<fpage>575</fpage>–<lpage>80</lpage>.<pub-id pub-id-type="doi">10.1002/bjs.4073</pub-id><pub-id pub-id-type="pmid">12734865</pub-id></mixed-citation></ref><ref id="B27"><label>27</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Foster</surname><given-names>JD</given-names></name><name><surname>Pathak</surname><given-names>S</given-names></name><name><surname>Smart</surname><given-names>NJ</given-names></name><name><surname>Branagan</surname><given-names>G</given-names></name><name><surname>Longman</surname><given-names>RJ</given-names></name><name><surname>Thomas</surname><given-names>MG</given-names></name><etal></etal></person-group><article-title>Reconstruction of the perineum following extralevator abdominoperineal excision for carcinoma of the lower rectum: a systematic review</article-title>. <source>Colorectal Dis</source> (<year>2012</year>) <volume>14</volume>:<fpage>1052</fpage>–<lpage>9</lpage>.<pub-id pub-id-type="doi">10.1111/j.1463-1318.2012.03169.x</pub-id><pub-id pub-id-type="pmid">22762519</pub-id></mixed-citation></ref><ref id="B28"><label>28</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Jensen</surname><given-names>KK</given-names></name><name><surname>Rashid</surname><given-names>L</given-names></name><name><surname>Pilsgaard</surname><given-names>B</given-names></name><name><surname>Møller</surname><given-names>P</given-names></name><name><surname>Wille-Jørgensen</surname><given-names>P</given-names></name></person-group>. <article-title>Pelvic floor reconstruction with a biological mesh after extralevator abdominoperineal excision leads to few perineal hernias and acceptable wound complication rates with minor movement limitations: single-centre experience including clinical examination and interview</article-title>. <source>Colorectal Dis</source> (<year>2014</year>) <volume>16</volume>:<fpage>192</fpage>–<lpage>7</lpage>.<pub-id pub-id-type="doi">10.1111/codi.12492</pub-id><pub-id pub-id-type="pmid">24251666</pub-id></mixed-citation></ref><ref id="B29"><label>29</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Anthony</surname><given-names>JP</given-names></name><name><surname>Mathes</surname><given-names>SJ</given-names></name></person-group>. <article-title>The recalcitrant perineal wound after rectal extirpation. Applications of muscle flap closure</article-title>. <source>Arch Surg</source> (<year>1990</year>) <volume>125</volume>:<fpage>1371</fpage>–<lpage>6</lpage>.<pub-id pub-id-type="doi">10.1001/archsurg.1990.01410220155022</pub-id><pub-id pub-id-type="pmid">2222178</pub-id></mixed-citation></ref><ref id="B30"><label>30</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Huang</surname><given-names>JJ</given-names></name><name><surname>Chang</surname><given-names>NJ</given-names></name><name><surname>Chou</surname><given-names>HH</given-names></name><name><surname>Wu</surname><given-names>CW</given-names></name><name><surname>Abdelrahman</surname><given-names>M</given-names></name><name><surname>Chen</surname><given-names>HY</given-names></name></person-group>. <article-title>Pedicle perforator flaps for vulvar reconstruction–new generation of less invasive vulvar reconstruction with favorable results</article-title>. <source>Gynecol Oncol</source> (<year>2015</year>) <volume>137</volume>:<fpage>66</fpage>–<lpage>72</lpage>.<pub-id pub-id-type="doi">10.1016/j.ygyno.2015.01.526</pub-id><pub-id pub-id-type="pmid">25596518</pub-id></mixed-citation></ref><ref id="B31"><label>31</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>de Haas</surname><given-names>WG</given-names></name><name><surname>Miller</surname><given-names>MJ</given-names></name><name><surname>Temple</surname><given-names>WJ</given-names></name><name><surname>Kroll</surname><given-names>SS</given-names></name><name><surname>Schusterman</surname><given-names>MA</given-names></name><name><surname>Reece</surname><given-names>GP</given-names></name><etal></etal></person-group><article-title>Perineal wound closure with the rectus abdominis musculocutaneous flap after tumor ablation</article-title>. <source>Ann Surg Oncol</source> (<year>1995</year>) <volume>2</volume>:<fpage>400</fpage>–<lpage>6</lpage>.<pub-id pub-id-type="doi">10.1007/BF02306372</pub-id><pub-id pub-id-type="pmid">7496834</pub-id></mixed-citation></ref><ref id="B32"><label>32</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Campbell</surname><given-names>CA</given-names></name><name><surname>Butler</surname><given-names>CE</given-names></name></person-group>. <article-title>Use of adjuvant techniques improves surgical outcomes of complex vertical rectus abdominis myocutaneous flap reconstructions of pelvic cancer defects</article-title>. <source>Plast Reconstr Surg</source> (<year>2011</year>) <volume>128</volume>:<fpage>447</fpage>–<lpage>58</lpage>.<pub-id pub-id-type="doi">10.1097/PRS.0b013e31821e6fd2</pub-id><pub-id pub-id-type="pmid">21788836</pub-id></mixed-citation></ref><ref id="B33"><label>33</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Ho</surname><given-names>K</given-names></name><name><surname>Warrier</surname><given-names>S</given-names></name><name><surname>Solomon</surname><given-names>MJ</given-names></name><name><surname>Lee</surname><given-names>K</given-names></name></person-group>. <article-title>A prepelvic tunnel for the rectus abdominis myocutaneous flap in perineal reconstruction</article-title>. <source>J Plast Reconstr Aesthet Surg</source> (<year>2006</year>) <volume>59</volume>:<fpage>1415</fpage>–<lpage>9</lpage>.<pub-id pub-id-type="doi">10.1016/j.bjps.2006.01.050</pub-id><pub-id pub-id-type="pmid">17113532</pub-id></mixed-citation></ref><ref id="B34"><label>34</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Zhao</surname><given-names>JC</given-names></name><name><surname>Xian</surname><given-names>CJ</given-names></name><name><surname>Yu</surname><given-names>JA</given-names></name><name><surname>Shi</surname><given-names>K</given-names></name></person-group>. <article-title>Reconstruction of infected and denuded scrotum and penis by combined application of negative pressure wound therapy and split-thickness skin grafting</article-title>. <source>Int Wound J</source> (<year>2013</year>) <volume>10</volume>:<fpage>407</fpage>–<lpage>10</lpage>.<pub-id pub-id-type="doi">10.1111/j.1742-481X.2012.00997.x</pub-id><pub-id pub-id-type="pmid">22672131</pub-id></mixed-citation></ref><ref id="B35"><label>35</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Steinau</surname><given-names>HU</given-names></name><name><surname>Steinsträsser</surname><given-names>L</given-names></name><name><surname>Hauser</surname><given-names>J</given-names></name><name><surname>Tilkorn</surname><given-names>D</given-names></name><name><surname>Stricker</surname><given-names>I</given-names></name><name><surname>Daigeler</surname><given-names>A</given-names></name></person-group><article-title>Bösartige Weichgewebsgeschwülste: Resektion und plastische Wiederherstellung</article-title>. <source>Der Chirurg; Zeitschrift für alle Gebiete der operativen Medizen</source> (<year>2012</year>) <volume>83</volume>:<fpage>673</fpage>–<lpage>84</lpage>.<pub-id pub-id-type="doi">10.1007/s00104-011-2241-2</pub-id></mixed-citation></ref><ref id="B36"><label>36</label><mixed-citation publication-type="journal"><collab>The ESMO/European Sarcoma Network Working Group</collab>. <article-title>Soft tissue and visceral sarcomas: ESMO clinical practice guidelines for diagnosis, treatment and follow-up</article-title>. <source>Ann Oncol</source> (<year>2014</year>) <volume>25</volume>(<issue>Suppl 3</issue>):<fpage>102</fpage>–<lpage>12</lpage>.<pub-id pub-id-type="doi">10.1093/annonc/mdu254</pub-id></mixed-citation></ref><ref id="B37"><label>37</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>von Mehren</surname><given-names>M</given-names></name><name><surname>Benjamin</surname><given-names>RS</given-names></name><name><surname>Bui</surname><given-names>MM</given-names></name><name><surname>Casper</surname><given-names>ES</given-names></name><name><surname>Conrad</surname><given-names>EU</given-names></name><name><surname>DeLaney</surname><given-names>TF</given-names></name><etal></etal></person-group><article-title>Soft tissue sarcoma, version 2.2012: featured updates to the NCCN guidelines</article-title>. <source>J Natl Compr Canc Netw</source> (<year>2012</year>) <volume>10</volume>:<fpage>951</fpage>–<lpage>60</lpage>.<pub-id pub-id-type="pmid">22878820</pub-id></mixed-citation></ref><ref id="B38"><label>38</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Bonvalot</surname><given-names>S</given-names></name><name><surname>Rivoire</surname><given-names>M</given-names></name><name><surname>Castaing</surname><given-names>M</given-names></name><name><surname>Stoeckle</surname><given-names>E</given-names></name><name><surname>Le Cesne</surname><given-names>A</given-names></name><name><surname>Blay</surname><given-names>JY</given-names></name></person-group>. <article-title>Primary retroperitoneal sarcomas: a multivariate analysis of surgical factors associated with local control</article-title>. <source>J Clin Oncol</source> (<year>2009</year>) <volume>27</volume>:<fpage>31</fpage>–<lpage>7</lpage>.<pub-id pub-id-type="doi">10.1200/JCO.2008.18.0802</pub-id><pub-id pub-id-type="pmid">19047280</pub-id></mixed-citation></ref><ref id="B39"><label>39</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Darouiche</surname><given-names>O</given-names></name></person-group><article-title>Treatment of infections associated with surgical implants</article-title>. <source>N Engl J Med</source> (<year>2004</year>) <volume>350</volume>:<fpage>1422</fpage>–<lpage>9</lpage>.<pub-id pub-id-type="doi">10.1056/NEJMra035415</pub-id><pub-id pub-id-type="pmid">15070792</pub-id></mixed-citation></ref><ref id="B40"><label>40</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Gravvanis</surname><given-names>AI</given-names></name><name><surname>Tsoutsos</surname><given-names>DA</given-names></name><name><surname>Karakitsos</surname><given-names>D</given-names></name><name><surname>Panayotou</surname><given-names>P</given-names></name><name><surname>Iconomou</surname><given-names>T</given-names></name><name><surname>Zografos</surname><given-names>G</given-names></name><etal></etal></person-group><article-title>Application of the pedicled anterolateral thigh flap to defects from the pelvis to the knee</article-title>. <source>Microsurgery</source> (<year>2006</year>) <volume>26</volume>:<fpage>432</fpage>–<lpage>8</lpage>.<pub-id pub-id-type="doi">10.1002/micr.20267</pub-id><pub-id pub-id-type="pmid">16924632</pub-id></mixed-citation></ref><ref id="B41"><label>41</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Hennessey</surname><given-names>DB</given-names></name><name><surname>Bolton</surname><given-names>E</given-names></name><name><surname>Thomas</surname><given-names>AZ</given-names></name><name><surname>Lynch</surname><given-names>TH</given-names></name></person-group>. <article-title>Vesicocutaneous fistula following adjuvant radiotherapy for prostate cancer</article-title>. <source>BMJ Case Rep</source> (<year>2013</year>) <volume>2013</volume><pub-id pub-id-type="doi">10.1136/bcr-2013-008986</pub-id><pub-id pub-id-type="pmid">23625668</pub-id></mixed-citation></ref><ref id="B42"><label>42</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Ludolph</surname><given-names>I</given-names></name><name><surname>Apel</surname><given-names>H</given-names></name><name><surname>Horch</surname><given-names>RE</given-names></name><name><surname>Beier</surname><given-names>JP</given-names></name></person-group>. <article-title>Treatment of a chronic vesicocutaneous fistula and abdominal wall defect after resection of a soft tissue sarcoma using a bipedicled latissimus dorsi and serratus anterior free flap</article-title>. <source>Int J Urol</source> (<year>2014</year>) <volume>21</volume>:<fpage>1178</fpage>–<lpage>80</lpage>.<pub-id pub-id-type="doi">10.1111/iju.12545</pub-id><pub-id pub-id-type="pmid">25040066</pub-id></mixed-citation></ref><ref id="B43"><label>43</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Fujioka</surname><given-names>M</given-names></name><name><surname>Hayashida</surname><given-names>K</given-names></name><name><surname>Morooka</surname><given-names>S</given-names></name><name><surname>Saijo</surname><given-names>H</given-names></name><name><surname>Nonaka</surname><given-names>T</given-names></name></person-group>. <article-title>Combined serratus anterior and latissimus dorsi myocutaneous flap for obliteration of an irradiated pelvic exenteration defect and simultaneous site for colostomy revision</article-title>. <source>World J Surg Oncol</source> (<year>2014</year>) <volume>12</volume>:<fpage>319</fpage>.<pub-id pub-id-type="doi">10.1186/1477-7819-12-319</pub-id><pub-id pub-id-type="pmid">25335529</pub-id></mixed-citation></ref><ref id="B44"><label>44</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Wee</surname><given-names>JT</given-names></name><name><surname>Joseph</surname><given-names>VT</given-names></name></person-group>. <article-title>A new technique of vaginal reconstruction using neurovascular pudendal-thigh flaps: a preliminary report</article-title>. <source>Plast Reconstr Surg</source> (<year>1989</year>) <volume>83</volume>:<fpage>701</fpage>–<lpage>9</lpage>.<pub-id pub-id-type="doi">10.1097/00006534-198904000-00018</pub-id><pub-id pub-id-type="pmid">2648427</pub-id></mixed-citation></ref><ref id="B45"><label>45</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>McGregor</surname><given-names>IA</given-names></name><name><surname>Jackson</surname><given-names>IT</given-names></name></person-group><article-title>The groin flap</article-title>. <source>Br J Plast Surg</source> (<year>1972</year>) <volume>25</volume>:<fpage>3</fpage>–<lpage>16</lpage>.<pub-id pub-id-type="doi">10.1016/S0007-1226(72)80097-3</pub-id><pub-id pub-id-type="pmid">4550433</pub-id></mixed-citation></ref><ref id="B46"><label>46</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Waterhouse</surname><given-names>N</given-names></name><name><surname>Healy</surname><given-names>C</given-names></name></person-group>. <article-title>Vastus lateralis myocutaneous flap for reconstruction of defects around the groin and pelvis</article-title>. <source>Br J Surg</source> (<year>1990</year>) <volume>77</volume>:<fpage>1275</fpage>–<lpage>7</lpage>.<pub-id pub-id-type="doi">10.1002/bjs.1800771125</pub-id><pub-id pub-id-type="pmid">2253010</pub-id></mixed-citation></ref><ref id="B47"><label>47</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Ay</surname><given-names>A</given-names></name><name><surname>Aytekin</surname><given-names>O</given-names></name><name><surname>Aytekin</surname><given-names>A</given-names></name></person-group>. <article-title>Interdigitating fasciocutaneous gluteal V-Y advancement flaps for reconstruction of sacral defects</article-title>. <source>Ann Plast Surg</source> (<year>2003</year>) <volume>50</volume>:<fpage>636</fpage>–<lpage>8</lpage>.<pub-id pub-id-type="doi">10.1097/01.SAP.0000054241.94281.D2</pub-id><pub-id pub-id-type="pmid">12783019</pub-id></mixed-citation></ref><ref id="B48"><label>48</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Becker</surname><given-names>DW</given-names></name><name><surname>Massey</surname><given-names>FM</given-names></name><name><surname>McCraw</surname><given-names>JB</given-names></name></person-group>. <article-title>Musculocutaneous flaps in reconstructive pelvic surgery</article-title>. <source>Obstet Gynecol</source> (<year>1979</year>) <volume>54</volume>:<fpage>178</fpage>–<lpage>83</lpage>.<pub-id pub-id-type="pmid">379721</pub-id></mixed-citation></ref><ref id="B49"><label>49</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Schmidt</surname><given-names>VJ</given-names></name><name><surname>Horch</surname><given-names>RE</given-names></name><name><surname>Dragu</surname><given-names>A</given-names></name><name><surname>Weber</surname><given-names>K</given-names></name><name><surname>Göhl</surname><given-names>J</given-names></name><name><surname>Mehlhorn</surname><given-names>G</given-names></name><etal></etal></person-group><article-title>Perineal and vaginal wall reconstruction using a combined inferior gluteal and pudendal artery perforator flap: a case report</article-title>. <source>J Plast Reconstr Aesthet Surg</source> (<year>2012</year>) <volume>65</volume>:<fpage>1734</fpage>–<lpage>7</lpage>.<pub-id pub-id-type="doi">10.1016/j.bjps.2012.04.055</pub-id><pub-id pub-id-type="pmid">22652285</pub-id></mixed-citation></ref><ref id="B50"><label>50</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Galandiuk</surname><given-names>S</given-names></name><name><surname>Jorden</surname><given-names>J</given-names></name><name><surname>Mahid</surname><given-names>S</given-names></name><name><surname>McCafferty</surname><given-names>MH</given-names></name><name><surname>Tobin</surname><given-names>G</given-names></name></person-group>. <article-title>The use of tissue flaps as an adjunct to pelvic surgery</article-title>. <source>Am J Surg</source> (<year>2005</year>) <volume>190</volume>:<fpage>186</fpage>–<lpage>90</lpage>.<pub-id pub-id-type="doi">10.1016/j.amjsurg.2005.05.009</pub-id><pub-id pub-id-type="pmid">16023428</pub-id></mixed-citation></ref><ref id="B51"><label>51</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Hung</surname><given-names>SJ</given-names></name><name><surname>Chen</surname><given-names>HC</given-names></name><name><surname>Wei</surname><given-names>FC</given-names></name></person-group>. <article-title>Free flaps for reconstruction of the lower back and sacral area</article-title>. <source>Microsurgery</source> (<year>2000</year>) <volume>20</volume>:<fpage>72</fpage>–<lpage>6</lpage>.<pub-id pub-id-type="doi">10.1002/(SICI)1098-2752(2000)20:2<72</pub-id><pub-id pub-id-type="pmid">10702740</pub-id></mixed-citation></ref><ref id="B52"><label>52</label><mixed-citation publication-type="journal"><person-group person-group-type="author"><name><surname>Taeger</surname><given-names>CD</given-names></name><name><surname>Arkudas</surname><given-names>A</given-names></name><name><surname>Beier</surname><given-names>JP</given-names></name><name><surname>Horch</surname><given-names>RE</given-names></name></person-group>. <article-title>Emergency arterio-venous loop for free-flap defect reconstruction of the lower thigh with a post-irradiated and heavily infected wound</article-title>. <source>Int Wound J</source> (<year>2015</year>) <volume>12</volume>:<fpage>598</fpage>–<lpage>600</lpage>.<pub-id pub-id-type="doi">10.1111/iwj.12278</pub-id><pub-id pub-id-type="pmid">24725637</pub-id></mixed-citation></ref></ref-list></back></pmc></record>Pour manipuler ce document sous Unix (Dilib)
EXPLOR_STEP=$WICRI_ROOT/Wicri/Sante/explor/LymphedemaV1/Data/Pmc/Corpus
HfdSelect -h $EXPLOR_STEP/biblio.hfd -nk 000514 | SxmlIndent | more
Ou
HfdSelect -h $EXPLOR_AREA/Data/Pmc/Corpus/biblio.hfd -nk 000514 | SxmlIndent | more
Pour mettre un lien sur cette page dans le réseau Wicri
{{Explor lien
|wiki= Wicri/Sante
|area= LymphedemaV1
|flux= Pmc
|étape= Corpus
|type= RBID
|clé= PMC:4597132
|texte= Plastic and Reconstructive Surgery in the Treatment of Oncological Perineal and Genital Defects
}}
Pour générer des pages wiki
HfdIndexSelect -h $EXPLOR_AREA/Data/Pmc/Corpus/RBID.i -Sk "pubmed:26500887" \
| HfdSelect -Kh $EXPLOR_AREA/Data/Pmc/Corpus/biblio.hfd \
| NlmPubMed2Wicri -a LymphedemaV1
| This area was generated with Dilib version V0.6.31. |  |