Skip to main content

Advertisement

SpringerLink
Log in

MRI of surgical flaps in pelvic reconstructive surgery: a pictorial review of normal and abnormal findings

  • Review
  • Published:
Abdominal Radiology Aims and scope Submit manuscript

Abstract

Surgical flaps are commonly used for pelvic reconstruction in a subgroup of patients with locally advanced or recurrent anorectal and gynecologic malignancies and following complications of pelvic irradiation. Surgical scenarios where flaps may be placed include (but are not limited to) extended or radical abdominal perineal resection (APR) and total pelvic exenteration (PE). Surgical flaps in pelvic reconstruction serve several functions, including reducing dead space and providing structural support, facilitating wound closure and cosmetic appearance, enhancing the postsurgical healing process, protecting anastomoses and helping to prevent adhesions of organs and viscera to adjacent structures and the pelvic side wall. The most commonly used surgical flaps in pelvic reconstruction surgery include the VRAM (Vertical Rectus Abdominis Muscle), MRAM (Modified Rectus Abdominis Myocutaneous flap), gracilis, sartorius and omental flaps. Surgical flaps can be mistaken for recurrent or residual tumor by radiologists who are not familiar with the appearance or surgical methods of flap placement, since flaps may have a mass-like appearance on cross sectional imaging, including CT and MRI. Recurrent neoplasm may be difficult to differentiate from postoperative changes of flap placement and associated postsurgical anatomic distortion. This review article focuses on understanding the nuances of surgically placed pelvic flaps and identifying their normal and abnormal appearances on magnetic resonance imaging (MRI) along a time continuum. Postsurgical complications, including hematoma, postoperative fluid collections, infection, ischemia, and necrosis as well as tumor recurrence on the initial and follow-up magnetic resonance imaging are illustrated and discussed.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9
Fig. 10
Fig. 11
Fig. 12
Fig. 13
Fig. 14
Fig. 15
Fig. 16
Fig. 17
Fig. 18
Fig. 19
Fig. 20
Fig. 21

Similar content being viewed by others

References

  1. Sagebiel TL, Faria SC, Aparna Balachandran, Sacks JM, You YN, Bhosale PR (2011) Pelvic reconstruction with omental and VRAM flaps: anatomy, surgical technique, normal postoperative findings, and complications. Radiographics 31:2005–19. https://doi.org/10.1148/rg.317115112

    Article  PubMed  Google Scholar 

  2. Chessin DB, Hartley J, Cohen AM, Mazumdar M, Cordeiro P, Disa J, Mehrara B, Minsky BD, Paty P, Weiser M, Wong WD, Guillem JG (2005) Rectus Flap Reconstruction Decreases Perineal Wound Complications After Pelvic Chemoradiation and Surgery: A Cohort Study. Ann Surg Oncol 12:104–110. https://doi.org/10.1245/aso.2005.03.100

    Article  PubMed  Google Scholar 

  3. Cibula D, Slama J, Kocian R, Nanka O (2019) Gynecologic Oncology Modified rectus abdominis myoperitoneal flap for pelvic floor reconstruction. Gynecol Oncol 153:463–464. https://doi.org/10.1016/j.ygyno.2019.01.004

    Article  CAS  PubMed  Google Scholar 

  4. Bell SW, Dehni N, Chaouat M, Lifante JC, Parc R, Tiret E (2005) Primary rectus abdominis myocutaneous flap for repair of perineal and vaginal defects after extended abdominoperineal resection. Br J Surg 92:482–486. https://doi.org/10.1002/bjs.4857

    Article  CAS  PubMed  Google Scholar 

  5. CS Jones, J Nowers, NJ Smart, J Coelho AW and ID (2017) Pelvic floor reconstruction with bilateral gracilis flaps following extralevator abdominoperineal excision – a video vignette. Color Dis 19:1120–1121. https://doi.org/10.1111/codi.13933

  6. Spasojevic M, Mariathasan AB, Goscinski M (2018) Vertical Rectus Abdominis Musculocutaneous Flap Repair Improves Perineal Wound Healing after Abdominoperineal Resection for Irradiated Locally Advanced Rectal Cancer. Ann Surg Oncol 25:1357–1365. https://doi.org/10.1245/s10434-018-6363-3

    Article  PubMed  Google Scholar 

  7. Butler CE, Fa CS, Gündeslioglu AÖ, Rodriguez-bigas MA, Fa CS (2008) Outcomes of immediate vertical rectus abdominis myocutaneous flap reconstruction for irradiated abdominoperineal resection defects. J Am Coll Surg 206:694–703. https://doi.org/10.1016/j.jamcollsurg.2007.12.007

    Article  PubMed  Google Scholar 

  8. Benson C, Soisson AP, Carlson J, Culbertson G, Hawley-Bowland C RF (1993) Neovaginal reconstruction with a rectus abdominis myocutaneous flap. Obs Gynecol 81:871–875.

    CAS  Google Scholar 

  9. Lall C, Tirkes TA, Patel AA, Lamba R, Verma S, Jennings SG, Sandrasegaran K (2012) Flaps, Slings, and Other Things: CT After Reconstructive Surgery— Expected Changes and Detection of Complications. Am J Roentgenol 198:W521–W533. https://doi.org/10.2214/ajr.11.7552

    Article  Google Scholar 

  10. Fox MG, Bancroft LW, Peterson JJ, Kransdorf MJ, TerKonda SP, O’Connor MI (2006) MRI Appearance of Myocutaneous Flaps Commonly Used in Orthopedic Reconstructive Surgery. Am J Roentgenol 187:800–806. https://doi.org/10.2214/ajr.05.0484

    Article  Google Scholar 

  11. Sagebiel TL, Faria SC, Balachandran A, Butler CE, Garvey PB, Bhosale PR (2014) Pelvic reconstruction with pedicled thigh flaps: Indications, surgical techniques, and postoperative imaging. Am J Roentgenol 202:593–601. https://doi.org/10.2214/ajr.13.11394

    Article  Google Scholar 

  12. Griffin N, Rabouhans J, Grant LA, Ng RLH, Ross D, Roblin P, George ML (2011) Pelvi-perineal flap reconstruction: normal imaging appearances and post-operative complications on cross-sectional imaging. Insights Imaging 2:215–223. https://doi.org/10.1007/s13244-011-0070-y

    Article  PubMed  PubMed Central  Google Scholar 

  13. Wong JJ, Daly B, Krebs TL, Elias EG, Jacobs SC (1996) Surgical transfer of the sartorius muscle to the groin after lymphadenectomy or debridement: CT findings. Am J Roentgenol 166:109–112. https://doi.org/10.2214/ajr.166.1.8571857

    Article  CAS  Google Scholar 

  14. Collins D, Hogan AM, Shea DO, Winter DC (2009) The Omentum : Anatomical, Metabolic, and Surgical Aspects. 1138–1146. https://doi.org/10.1007/s11605-009-0855-1

    Article  Google Scholar 

  15. Chu Y, Allen RJ (2017) Greater Omental Lymph Node Flap for Upper Limb Lymphedema with Lymph Nodes–depleted Patient. Plast Reconstr Surg Glob Open. https://doi.org/10.1097/gox.0000000000001288

    Article  PubMed  PubMed Central  Google Scholar 

  16. Lall C, Bura V, Lee TK, Bhosale P, Faria SC, Choi J-I, Wang ZJ (2018) Diffusion-weighted imaging in hemorrhagic abdominal and pelvic lesions: restricted diffusion can mimic malignancy. Abdom Radiol 43:1772–1784. https://doi.org/10.1007/s00261-017-1366-2

    Article  Google Scholar 

  17. Burkholz KJ, Roberts CC, Lidner TK (2007) Posttraumatic Pseudolipoma (Fat Necrosis) Mimicking Atypical Lipoma or Liposarcoma on MRI. Radiol Case Reports 2:56–60. https://doi.org/10.2484/rcr.v2i2.98

    Article  Google Scholar 

  18. Gabrysz-Forget F, Tabet P, Rahal A, Bissada E, Christopoulos A, Ayad T (2019) Free versus pedicled flaps for reconstruction of head and neck cancer defects : a systematic review. J Otolaryngol - Head Neck Surg 48:1–31. https://doi.org/10.1186/s40463-019-0334-y

    Article  Google Scholar 

Download references

Acknowledgements

The authors offer their special thanks to Christopher M. Brown (chmbrown@gmail.com, medical illustrator) for the excellent illustrations created to enhance the quality of this article.

Funding

There is no funding associated with this manuscript.

Author information

Authors and Affiliations

  1. Department of Radiology, County Clinical Emergency Hospital, Cluj, 3-5 Clinicilor, Cluj County, 400000, Cluj-Napoca, Romania

    Vlad Bura & Roxana Maria Pintican

  2. Albany Medical College, New York, 553 Mercer St., Albany, NY, 12208, USA

    Parth Visrodia

  3. University of Texas MD Anderson Cancer Center, 1515 Holocombe Boulevard, Unit 1473, Houston, TX, 77030-4008, USA

    Priya Bhosale & Silvana C. Faria

  4. Division of Women’s Imaging, Department of Radiology, College of Medicine-Jacksonville, University of Florida, 4nd Floor, Tower II, 580 West 8th Street, C90, Jacksonville, FL, 32209, USA

    Smita Sharma

  5. Division of Abdominal and Body Imaging, Department of Radiology, College of Medicine-Jacksonville, University of Florida, 2nd Floor, Clinical Center, 655 West 8th Street, C90, Jacksonville, FL, 32209, USA

    Dheeraj Reddy Gopireddy & Chandana Lall

Authors
  1. Vlad Bura
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Parth Visrodia
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Priya Bhosale
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Silvana C. Faria
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Roxana Maria Pintican
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Smita Sharma
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Dheeraj Reddy Gopireddy
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Chandana Lall
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Vlad Bura.

Ethics declarations

Conflict of interest

All authors declare that they have no conflicts of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the Ethical Standards of the Institutional and/or National Research Committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. For this type of study, formal consent is not required.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Bura, V., Visrodia, P., Bhosale, P. et al. MRI of surgical flaps in pelvic reconstructive surgery: a pictorial review of normal and abnormal findings. Abdom Radiol 45, 3307–3320 (2020). https://doi.org/10.1007/s00261-019-02211-z

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00261-019-02211-z

Keywords

Search

Navigation