Perineal Flap Reconstruction after Oncologic Resection

Abstract

BACKGROUND Surgical treatment of perineal cancers can lead to extensive demolition, which represents a challenge for the reconstructive surgeon. Complications after primary perineal wound closure are common due to local tension, large pelvic dead space after the oncologic resection, a contaminated field, and frequent conjunction with neoadjuvant chemoradiation. 1,2 METHODS Patients who underwent abdominoperineal resections for anorectal or vulvovaginal cancer were retrospectively analyzed. We include all the patients who could not be repaired by direct closure due to excessive skin tension. We assessed the different flaps used, the surgical complications rate, wound healing, or the progression to chronic wounds. RESULTS We identified 20 patients who underwent this procedure in the last 10 years. The flaps used were all fasciocutaneous, either in a random or perforator fashion. Our first choice for defects of the external vulvar region or the perineum area was lotus petal flap (Figs. 1, 2). 3 Fig. 1. Complete vulvar defect: a reconstruction with bilateral lotus petal flap is scheduled. Fig. 2. View showing the result 6 months after surgery. Second, we used vertical deep inferior epigastric artery perforator flap if there was a large dead space to fulfill or a defect involving the vaginal wall. 4 If the deep inferior epigastric artery perforator flap would be too thick or not available according to previous abdominal surgeries, we used the antero-lateral thigh flap. 5 In some other cases where the lotus petal flap was not available due to poor local conditions (radiotherapy damage) and the defect was small, we used local random fasciocutaneous flaps from the gluteal or the medial thigh region. 6 We reported no major complications necessitating intervention, and there were no complete flap necrosis or reconstructive failures. All the cases of partial flap loss (approximately 20%) healed by second intention without important scarring retraction. We assessed no progression to chronic wounds. CONCLUSIONS Reconstruction of the perineal region could be a very challenging procedure. Different flaps could be used according to local conditions and the entity of the resection. For wide defects, prior publications have demonstrated a lower rate of local wound complications and shorter hospital length of stay in patients undergoing immediate flap coverage. 2 Our results are comparable with those of the literature. Moreover, we prefer the use of fasciocutaneous flaps rather than muscle flaps to reduce donor-site morbidity.