The Versatile ORAM Flap: A Microsurgeon's Pedicled Flap for Perineal Reconstruction Compared with Reported VRAM Outcomes

Abstract

Abstract Background Abdominoperineal resection (APR) and pelvic exenteration create large, frequently irradiated three-dimensional defects with expectedly high complication rates. The oblique rectus abdominis myocutaneous (ORAM) flap offers an articulated skin paddle with variable thickness and the potential for muscle-sparing harvest. We report our experience using ORAM flaps for pelvic, perineal, and vaginal reconstruction following oncologic resection and compare our results with pooled vertical rectus abdominis muscle (VRAM) flap outcomes derived from the published literature. Methods We conducted a retrospective review of consecutive patients undergoing ORAM flap reconstruction after APR or pelvic exenteration (July 2016–September 2025). Demographics, oncologic treatments, operative details, and outcomes were abstracted and compared with pooled VRAM reference rates extracted from large published series and systematic reviews. Our primary outcomes were flap survival, recipient and donor site complications, and reoperation. Subgroup analysis examined risk factors for complications and whether vaginal reconstruction was performed. Results A total of 26 patients underwent ORAM reconstruction. The cohort was predominantly female (73%) with a mean age of 58.2 years and body mass index of 27.5 kg/m 2 . Ninety-two percent of patients received neoadjuvant radiation. Most reconstructions used pedicled ORAM flaps (96%), whereas in one case a free ORAM flap was used. Median follow-up was 3.2 months. Complete flap loss occurred in one patient (4%) and partial necrosis in two patients (8%). Recipient site delayed healing occurred in 35% and donor site delayed healing in 31%. Compared with pooled VRAM controls, ORAM outcomes did not differ significantly for complete flap loss (3.8 vs. 1.8–2.3%, p  = 0.38), perineal wound morbidity (34.6 vs. 22.5–27%, p  = 0.22), reoperation (15.4 vs. 10.1%, p  = 0.33), or perineal hernia (0 vs. 0.2%, p  = 1.00). Donor site delayed healing was numerically higher than the pooled VRAM estimate (30.8 vs. 15–17%) but not statistically different in comparison ( p  = 0.10). In 18 patients requiring vaginal reconstruction, the thinner distal skin paddle enabled creation of a neovaginal vault with favorable early functionality. Conclusion The ORAM flap provides a reliable and versatile flap for reconstruction of large pelvic defects after cancer extirpation. The articulated design with proximal soft tissue bulk for filling dead space and thinner distal skin for lining facilitates simultaneous pelvic, perineal, and vaginal reconstruction. Careful attention to perforator number and preoperative risk modification may further optimize outcomes.