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BACKGROUND
Sacral and perineal defects are often managed with standard loco-regional options. However, in extensive defects, in the setting of prior radiation, reconstruction may require unconventional techniques. We present three illustrative cases of such defects which were treated with different approaches to achieve successful closure.
METHODS
Three consecutive cases of extensive perineal and/or sacral defects, requiring unique reconstruction techniques, were reviewed. In all of these cases, a simple regional flap was inadequate to address the complex characteristics of the defect.
RESULTS
Case 1: A 45 year-old female with a remote history of a desmoid tumor overlying the sacrum was initially managed with surgical resection and adjuvant radiation therapy. She subsequently presented with a non-healing sacral wound (10 x 14cm). Local tissue limitations, as a consequence of radiation, and specific anatomic considerations precluded the use of local flaps. This patient successfully underwent latissimus dorsi myocutaneous free flap reconstruction utilizing greater saphenous vein grafts to the descending branch of the lateral circumflex femoral vessels.
Case 2: A 34 year-old female presented with extensive, necrotizing, infected recurrent anal squamous cell carcinoma, following initial treatment with chemo-radiation therapy. This patient required abdominoperineal resection (APR) and coccygectomy. The anticipated soft tissue defect measured 30 x 21cm (excluding the surface area requirement for posterior wall vaginal reconstruction). This large, complex defect was successfully reconstructed in a staged fashion. At the first stage, the vertical rectus abdominis musculocutaneous (VRAM) flap skin territory was augmented with a delay procedure; at which time, bilateral costal margin tissue expanders were placed. At the time of tumor extirpation, the extended VRAM flap was transposed to resurface the perineum, bilateral gluteal soft tissue defects, and a limited posterior wall neo-vagina. A contralateral components separation was performed to facilitate fascial closure.
Case 3: A 64 year-old male presented with recurrent, necrotizing anal squamous cell carcinoma involving the perineum and gluteal region, following initial management with chemo-radiation therapy. This patient required an APR and partial sacrectomy, resulting with a soft tissue defect measuring 20 x 25cm. He successfully underwent single stage reconstruction using a large VRAM flap in combination with bilateral gluteal V-Y advancement flaps. Advancement of the gluteal flaps was facilitated by partial resection of the ischial tuberosities. An omentum flap was used to further obliterate the pelvic dead space, and the pelvic floor was reinforced with an acellular dermal matrix sling.
CONCLUSIONS
Most large sacral and perineal defects are routinely managed using standard loco-regional flap options. In circumstances when these defects are extraordinarily large and/or local tissues are compromised by prior surgery, radiation, and/or infection, standard flap options are not adequate. Strategies illustrated here include modification of standard flaps, utilization of multiple flaps, assessment of distant donor sites, unique preparation of recipient vessels, and adjuvant procedures, all of which may be applied to these difficult cases. Careful consideration of reconstruction requirements, thoughtful surgical planning, and specialized postoperative management allow for successful treatment of patients with unusually challenging sacral and perineal defects.