PERINEAL RECONSTRUCTION

Successful reconstruction is dependent on the restoration of both adequate

form and adequate function

• Perineal reconstruction may be divided into genitourinary reconstruction for:– Acquired and congenital deformities – Reconstruction for cancer• Post AP resection +/- radiotherapy

• Treating primary and recurrent anorectal and other pelvic malignancies often requires extensive resection such as:– pelvic exenteration – abdominoperineal resection, – chemotherapy and radiotherapy.

“Immediate flap reconstruction for large pelvic/perineal defects created by

resection/radiotherapy has been shown to result in fewer wound complications than

primary closure method”

• Buchel EW, Finical S, Johnson C. Pelvic reconstruction using vertical rectus abdominis musculocutaneous flaps. Ann Plast Surg. 2004;52:22–26

• Burke TW, Morris M, Roh MS, Levenback C, Gershenson DM. Perineal reconstruction using single gracilis myocutaneous flaps. Gynecol Oncol. 1995;57:221–225

• Butler CE, Rodriguez-Bigas MA. Pelvic reconstruction after abdominoperineal resection: Is it worthwhile? Ann Surg Oncol. 2005;12:91–94

• Chessin DB, Hartley J, Cohen AM, et al. Rectus flap reconstruction decreases perineal wound complications after pelvic chemoradiation and surgery: A cohort study. Ann Surg Oncol. 2005;12:104–110.

• Butler CE, Güundeslioglu AO, Rodriguez-Bigas MA. Outcomes of immediate VRAM flap reconstruction for irradiated abdominoperineal resection defects. J Am Coll Surg. 2008;206:694–703.

Goals of reconstruction

• Separating the pelvic and abdominal cavities• Protecting the bowel from postoperative

problems• Preventing post-operative perineal herniation• Obtaining a healed wound• Maintaining the adequacy of micturition• Proper evacuation of faecal stream• Aesthetics • Restore sexual function

• Flaps reduce complications by:– Obliterating pelvic dead space– Recruiting healthy well-vascularized tissue into the

region, which has commonly been irradiated and contaminated

– Tension free closure– Interposing flap skin between irradiated perineal

wound edges

What is a Flap?

What is a Flap?

• 16th century Dutch word “flappe”– ….something that hangs broad and loose ,

fastened only by one side..”

What is a Flap?

• A flap is a unit of tissue that may be transferred from a donor to a recipient site while maintaining its blood supply.– Flaps can be characterized by their component parts

• cutaneous, musculocutaneous, osseocutaneous

– Their relationship to the defect • local, regional, or distant

– Nature of the blood supply• random versus axial

– The movement placed on the flap • advancement, pivot, transposition, free, pedicled

Mathes & Nahai 1981Muscle Flap Classification

Angiosome ConceptTaylor & Palmer BJPS 1987

• 3D composite of tissue supplied by an artery & draining vein

Fasciocutaneous flapsCormack & Lamberty (BJPS 1984)

• Type A – multiple perforators in the flap base– no discrete origin– may be combination of direct or indirect

perforators• Type B – pedicle or free flap based on a single

perforator• Type C – multiple segmental perforators from

the same vessel

Which Flap?

• Rectus abdominis flaps• Gracilis myocutaneous flaps• Posterior thigh flaps• Perforator flaps– Superior & Inferior gluteal artery perforator (IGAP,

SGAP)– Anterolateral thigh flaps (ALT)

• Free flap

Rectus Abdominis Flaps

• Types– VRAM (vertical rectus abdominis flap)– ORAM (extended oblique rectus abdominis flap)

• 1st choice for perineal reconstruction due to its:– Reliable vascularity, – Bulk to obliterate dead space– Large skin paddle – Ease of harvest with laparotomy

Anatomy•Type III muscle therefore can be raised on both pedicles

•superior epigastric artery•deep inferior epigastric artery

•Extended oblique rectus abdominis popularised by Taylor, allows for longer skin paddle

Surgical Outcomes of VRAM versus Thigh Flaps for Immediate Reconstruction of Pelvic and Perineal Cancer Resection DefectsPRS Volume 123(1), January 2009, pp 175-183

MD Anderson Group

• Methods: – 133 patients who underwent abdominoperineal resection or

pelvic exenteration for cancer resection • VRAM (n = 114) or• thigh flap (n = 19)

– 19 patients received 21 thigh flaps: » 9 gracilis (bilateral in 2 patients), » 8 anterolateral thigh flaps, » 4 posterior thigh flaps

– Immediate reconstruction of the perineal/pelvic defect were studied.

– Patient, tumor, and treatment characteristics; surgical outcomes; and postoperative donor- and recipient-site complications were compared between the two groups.

:The thigh flap group had a significantly greater incidence of

• major complications (42% vs 15%) • higher rates of donor-site cellulitis (26% vs 6%) • recipient-site complications, including cellulitis

(21% vs 4%)• pelvic abscess (32% vs 6%)• major wound dehiscence (21% vs 5%)

Surgical Outcomes of VRAM versus Thigh Flaps for Immediate Reconstruction of Pelvic and Perineal Cancer Resection DefectsPRS Volume 123(1), January 2009, pp 175-183

MD Anderson Group

• VRAM flaps are associated with fewer complications than thigh flaps when used for immediate reconstruction of abdominoperineal resection and pelvic exenteration defects and do not increase early abdominal wall morbidity.

• VRAM flaps, if available, should be the first choice for immediate reconstruction of perineal/pelvic defects following abdominoperineal resection and pelvic exenteration.

Gracilis myocutaneous flap

• Type II myocutaneous flap• Blood supply – Medial femoral circumflex artery (major)• This artery enters the muscle approximately 8-10 cm

below the inguinal ligament.

– Minor perforators:• Proximally from the obturator artery• Occasionally one or two branches from the superficial

femoral artery supplying the middle and distal portions.

Posterior Thigh Flaps

• This flap includes the inferior portion of the gluteus maximus muscle and encompasses the territory of the posterior thigh,

• Supplied by the descending branch of the inferior gluteal artery

Anterolateral Thigh Flap

• Cormack & Lamberty Type B perforator flap• Pedicle: – Descending branch of the lateral circumflex

femoral artery

Superior Gluteal Artery Perforator Flap(S-GAP)

• The superior gluteal artery and venae arise from the internal iliac system deep in the pelvis.

• They exit posteriorly through the greater sciatic foramen, superior to the piriformis muscle and inferior to the gluteus medius.

• The vessels perforate the gluteus maximus muscle on their way to the fat and skin that overlies them

Post-Operative Care

• NO PRESSURE ON FLAP• Patient positioning• Regular flap checks