eMedicine Specialties > Plastic Surgery > Trunk

Perineal Reconstruction

Author: Chet L Nastala, MD, Plastic, Reconstructive, and Microsurgical Associates of South Texas, PA
Contributor Information and Disclosures

Updated: Feb 27, 2009

Introduction

Perineal reconstruction may be divided into genitourinary reconstruction for acquired and congenital deformities and reconstruction for cancer. Reconstruction for congenital deformities is covered under the topic of urogenital reconstruction, while penile and vaginal reconstructions are covered separately in this journal. This article discusses perineal reconstruction related to cancer ablation in both male and female patients.

The plastic surgeon encounters large defects in the perineal region most commonly in male patients following ablation of a recurrent low pelvic tumor. This is observed most often in concert with extensive irradiation of the pelvis. Preoperative consultation with the plastic surgeon is sought most often when the ablative surgeon is not confident that he or she can achieve a closed wound primarily. The oncologic team principally is concerned with separating the pelvic and abdominal cavities, protecting the small bowel from postoperative enteritis problems, preventing postoperative perineal herniation, and obtaining a healed wound primarily. Because this anatomic site is particularly prone to wound healing problems, the cancer surgeon often is concerned with bringing fresh, nonirradiated, vascularized tissue into the region.

Presentation

Perform an overall nutritional assessment, including serum parameters, to determine the patient's suitability for large flap procedure. Assess the degree and nature of the expected perineal wound following cancer ablation; this can be performed most accurately in consultation with the cancer surgeon. In the female patient, this involves anticipated defect of the external genitalia, labia, minora, and majora; the extent of the perineal skin defect; and the extent of total or partial vaginectomy planned. If partial or total perineal proctectomy is performed with the surrounding skin, assess how much skin to remove. If cystectomy is planned or is possible, preoperative involvement of a urologist for planning ileal conduit is essential.

Indications

Perineal reconstruction is indicated when the anticipated defect is large and cannot be enclosed primarily. The following flaps may be considered in the preoperative evaluation of the patient:

  • Gracilis myocutaneous flaps1,2,3,4
  • Rectus abdominis flaps5,6,7,8,9,10
  • Posterior thigh flaps
  • Groin flaps
  • Pudendal fasciocutaneous flaps
  • Gluteal (split) flaps11
  • Rectus femoris flaps
  • Tensor fascia lata flaps
  • Vastus lateralis flaps
  • Perforator flaps
    • Deep inferior epigastric perforator (DIEP) flap12,13
    • Superior gluteal artery perforator (SGAP) flap14
    • Anterolateral thigh (ALT) flap

These flaps represent a partial, though not exhaustive, list of those that should be considered preoperatively. Assess whether stomas are to be created through the remaining rectus muscle and whether sacrifice may be contraindicated. Certain flaps may be favored because of positioning considerations; for example, the split gluteus myocutaneous flap can be performed with the patient in the prone position. If the defect is limited to the perianal region, these flaps are robust and may provide adequate closure. If the defect is anticipated to be superficial only, then a groin flap, pudendal flap, or posterior thigh flap may be preferred.

If significant dead space requires obliteration, a rectus abdominis myocutaneous flap based vertically (VRAM) or horizontally (TRAM) may be indicated. Lower extremity flaps (eg, tensor fascia lata, vastus lateralis, rectus femoris) may be preferred if abdominal or other donor sites are unavailable. In addition, a variety of other flaps are used less commonly but may be indicated in specific instances. These include the internal oblique muscle flap, omentum, medial or anterior thigh flaps, or superficial inferior epigastric artery flap.

The gracilis flap represents the "workhorse" for reconstruction of the perineal and pelvic defect. In 1976, McCraw et al described the original reconstruction with the gracilis myocutaneous flap.2

Relevant Anatomy

The major blood supply to the gracilis myocutaneous or gracilis muscle flap is derived from the medial femoral circumflex artery. This artery enters the muscle approximately 8-10 cm below the inguinal ligament. Additional minor perforators originate proximally from the obturator artery and may supply a short gracilis flap. Occasionally one or two branches from the superficial femoral artery supplying the middle and distal portions of the muscle may be divided.

The nerve supply is the anterior branch of the obturator nerve, located between the adductor longus and magnus muscles. This nerve enters from deep to superficial, 1-2 cm superior to the major vascular pedicle from the medial femoral circumflex. When the adductor longus and magnus are retracted and the pedicle is dissected to the profundus femoris artery, its length ranges from 5-7 cm. This allows for more proximal positioning of the muscle pedicle.

The overlying skin paddle of the medial thigh may be elevated with the muscle. However, exercise care in elevating the skin territory distal on the medial thigh that has poor reliability. The skin island may be relocated more reliably proximally over the proximal two thirds of the muscle. Carefully elevate small musculocutaneous or septal perforators with the surrounding fascia over the sartorius laterally and the adductors medially to capture both the musculocutaneous perforators through the gracilis muscle as well as small septocutaneous perforators that may lie on either side of it.

Contraindications

Entertain the possibility of vascular disease in the lower extremity. Seek clinical assessment for claudication or other symptoms of vascular disease. Thorough examination of the peripheral pulses may indicate vascular disease, which may be a contraindication to gracilis reconstruction.

More on Perineal Reconstruction

Overview: Perineal Reconstruction
Treatment: Perineal Reconstruction
Follow-up: Perineal Reconstruction
Multimedia: Perineal Reconstruction
References
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References

  1. Ducic I, Dayan JH, Attinger CE, Curry P. Complex perineal and groin wound reconstruction using the extended dissection technique of the gracilis flap. Plast Reconstr Surg. Aug 2008;122(2):472-8. [Medline].

  2. McCraw JB, Massey FM, Shanklin KD, Horton CE. Vaginal reconstruction with gracilis myocutaneous flaps. Plast Reconstr Surg. Aug 1976;58(2):176-83. [Medline].

  3. Nastala CL, McCraw JB, McMellin A. Vaginal reconstruction using the gracilis myocutaneous flap. In: Alter G, ed. Reconstructive and Plastic Surgery of the External Genitalia. WB Saunders Co;1998.

  4. Persichetti P, Cogliandro A, Marangi GF, et al. Pelvic and perineal reconstruction following abdominoperineal resection: the role of gracilis flap. Ann Plast Surg. Aug 2007;59(2):168-72. [Medline].

  5. Bell SW, Dehni N, Chaouat M, et al. Primary rectus abdominis myocutaneous flap for repair of perineal and vaginal defects after extended abdominoperineal resection. Br J Surg. Apr 2005;92(4):482-6. [Medline].

  6. Buchel EW, Finical S, Johnson C. Pelvic reconstruction using vertical rectus abdominis musculocutaneous flaps. Ann Plast Surg. Jan 2004;52(1):22-6. [Medline].

  7. Hui K, Zhang F, Pickus E, et al. Modification of the vertical rectus abdominis musculocutaneous (VRAM) flap for functional reconstruction of complex vulvoperineal defects. Ann Plast Surg. Dec 2003;51(6):556-60. [Medline].

  8. Sunesen KG, Buntzen S, Tei T, Lindegaard JC, Norgaard M, Laurberg S. Perineal healing and survival after anal cancer salvage surgery: 10-year experience with primary perineal reconstruction using the vertical rectus abdominis myocutaneous (VRAM) flap. Ann Surg Oncol. Jan 2009;16(1):68-77. [Medline].

  9. Tobin GR, Day TG. Vaginal and pelvic reconstruction with distally based rectus abdominis myocutaneous flaps. Plast Reconstr Surg. Jan 1988;81(1):62-73. [Medline].

  10. Weiwei L, Zhifei L, Ang Z, Lin Z, Dan L, Qiaoqun. Vaginal reconstruction with the muscle-sparing vertical rectus abdominis myocutaneous flap. J Plast Reconstr Aesthet Surg. Oct 18 2008;[Medline].

  11. Gould WL, Montero N, Cukic J, et al. The "split" gluteus maximus musculocutaneous flap. Plast Reconstr Surg. Feb 1994;93(2):330-6. [Medline].

  12. Eo S, Kim D, Jones NF. Microdissection thinning of a pedicled deep inferior epigastric perforator flap for burn scar contracture of the groin: case report. J Reconstr Microsurg. Oct 2005;21(7):447-50; discussion 451-2. [Medline].

  13. Muneuchi G, Ohno M, Shiota A, et al. Deep inferior epigastric perforator (DIEP) flap for vulvar reconstruction after radical vulvectomy: a less invasive and simple procedure utilizing an abdominal incision wound. Ann Plast Surg. Oct 2005;55(4):427-9. [Medline].

  14. Blondeel PN, Van Landuyt K, Hamdi M, Monstrey SJ. Soft tissue reconstruction with the superior gluteal artery perforator flap. Clin Plast Surg. Jul 2003;30(3):371-82. [Medline].

  15. Benito P, De Juan A, Cano M, Elena E. Reconstruction of an extensive perineal defect using two modified V-Y flaps based on perforators from the gluteus maximus muscle. J Plast Reconstr Aesthet Surg. Sep 2008;61(9):e1-4. [Medline].

  16. Di Mauro D, D'Hoore A, Penninckx F, De Wever I, Vergote I, Hierner R. V-Y bilateral gluteus maximus myocutaneous advancement flap in the reconstruction of large perineal defects after resection of pelvic malignancies. Colorectal Dis. Jul 15 2008;[Medline].

  17. Hurwitz DJ, Walton RL. Closure of chronic wounds of the perineal and sacral regions using the gluteal thigh flap. Ann Plast Surg. May 1982;8(5):375-86. [Medline].

  18. Wang X, Qiao Q, Burd A, et al. Perineum reconstruction with pedicled anterolateral thigh fasciocutaneous flap. Ann Plast Surg. Feb 2006;56(2):151-5. [Medline].

  19. Abbott DE, Halverson AL, Wayne JD, Kim JY, Talamonti MS, Dumanian GA. The oblique rectus abdominal myocutaneous flap for complex pelvic wound reconstruction. Dis Colon Rectum. Aug 2008;51(8):1237-41. [Medline].

  20. Nelson RA, Butler CE. Surgical outcomes of VRAM versus thigh flaps for immediate reconstruction of pelvic and perineal cancer resection defects. Plast Reconstr Surg. Jan 2009;123(1):175-83. [Medline].

  21. Nisar PJ, Scott HJ. Myocutaneous flap reconstruction of the pelvis after abdominoperineal excision. Colorectal Dis. Nov 14 2008;[Medline].

  22. Said HK, Bevers M, Butler CE. Reconstruction of the pelvic floor and perineum with human acellular dermal matrix and thigh flaps following pelvic exenteration. Gynecol Oncol. Dec 2007;107(3):578-82. [Medline].

  23. Wang TN, Whetzel T, Mathes SJ, Vasconez LO. A fasciocutaneous flap for vaginal and perineal reconstruction. Plast Reconstr Surg. Jul 1987;80(1):95-103. [Medline].

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Further Reading

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Keywords

perineal reconstruction, genitourinary reconstruction, rectal cancer reconstruction, urogenital reconstruction, perineal defect, pelvic tumor, pelvic irradiation

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Contributor Information and Disclosures

Author

Chet L Nastala, MD, Plastic, Reconstructive, and Microsurgical Associates of South Texas, PA
Disclosure: Nothing to disclose.

Medical Editor

Dennis P Orgill, MD, PhD, Professor of Surgery, Harvard Medical School; Associate Chief of Plastic Surgery, Brigham and Women's Hospital
Dennis P Orgill, MD, PhD is a member of the following medical societies: American Burn Association, American Medical Association, American Society for Reconstructive Microsurgery, Massachusetts Medical Society, and Plastic Surgery Research Council
Disclosure: Kinetic Concepts, Inc. Grant/research funds Principle Investigator; Isologen Corporation Grant/research funds Principle Investigator; Massachusetts Institute of Technology Royalty None; Brigham and Women's Hospital Royalty None; Regenesis Corporation Scientific Advisory Board Consulting; Kinetic Concepts, Inc. Expert Witness None

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Jaime R Garza, MD, DDS, FACS, Consulting Staff, Private Practice
Jaime R Garza, MD, DDS, FACS is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American Cleft Palate/Craniofacial Association, American College of Surgeons, American Medical Association, American Society for Aesthetic Plastic Surgery, American Society of Maxillofacial Surgeons, Texas Medical Association, and Texas Society of Plastic Surgeons
Disclosure: Allergan Honoraria Consulting

CME Editor

Nicolas (Nick) G Slenkovich, MD, Director, Colorado Plastic Surgery Center
Nicolas (Nick) G Slenkovich, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Society of Aesthetic Plastic Surgery, American Society of Plastic Surgeons, and Colorado Medical Society
Disclosure: Nothing to disclose.

Chief Editor

Jorge I de la Torre, MD, FACS, Professor of Surgery and Physical Medicine and Rehabilitation, Residency Program Director, Division of Plastic Surgery, University of Alabama at Birmingham; Director, Center for Advanced Surgical Aesthetics
Jorge I de la Torre, MD, FACS is a member of the following medical societies: American Association of Plastic Surgeons, American Burn Association, American College of Surgeons, American Medical Association, American Society for Laser Medicine and Surgery, American Society for Reconstructive Microsurgery, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, Association for Academic Surgery, and Medical Association of the State of Alabama
Disclosure: Nothing to disclose.

 
 
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