Gluteal Flaps Revisited: Technical Modifications for Perineal Wound Reconstruction
Paige L. Myers, MD, Serena Day, Peter Krasniak, Ronald P. Bossert, MD.
University of Rochester Medical Center, Rochester, NY, USA.
Background: Adbominoperineal resection (APR) is the gold standard treatment for anorectal malignancies. Traditionally, this has been performed via a laparotomy incision for colonic mobilization and a perineal approach for extirpation of low rectal and anal carcinomas. The laparotomy approach allows for harvest of the rectus abdominis muscle for dead space obliteration and perineal reconstruction. However, with the increasing number of robotic-assisted laparoscopic APRs being performed, a large abdominal donor site with high morbidity is less than ideal. We describe a method of advancing bilateral fasciocutaneous gluteal flaps into the pelvic cavity to reconstruct the perineum. This entails modification of previously described gluteal-based reconstruction methods. This operation is performed easily and rapidly in the prone position without muscle harvest. The patient is spared a large anterior deficit but reaps the benefits of a robust reconstruction without functional impairment at the donor site.
Methods: A retrospective chart review was performed from July 1, 2012 to February 8, 2017 of our institution's electronic record database. All patients who underwent bilateral V-Y gluteal fasciocutaneous flaps for perineal defects were included. The operative technique entails an approach in the prone jack-knife position. Perforating vessels off the inferior gluteal artery system (IGAPs) were identified with Doppler probe. Large fasciocutaneous flaps were designed around these perforators and advanced medially into the defect. One flap was selected for de-epithelialization of the leading 2/3rds of the flap. The trailing edge of this segment was incised through the superficial fascial system. This trailing edge is then sutured to the contralateral levator complex, thus securing the majority of the flap directly into the pelvis. A flap raised in similar fashion from the contralateral side is advanced medially to the remaining flap segment. Closure was performed over closed suction drains with one drain placed directly into the pelvis. This was initially bolstered with resorbable mesh, which was later abandoned with significantly lower complication rates. Patient demographics and co-morbidities along with adjunctive therapies were investigated. Outcomes and complications were analyzed.
Results: Twenty patients (33 total flaps) were identified who underwent bilateral fasciocutaneous V-Y flap reconstruction for perineal defects, largely secondary to APR. The average age was 58 years and 12 patients were male (60%). Ten patients experienced complications (50%) with 4 patients developing an SSI (20%), 8 patients experienced minor dehiscence (40%) 0 patients developed a seroma and only 2 patients required re-operation (10%). These complication rates markedly improved when an absorbable mesh sling was no longer placed in the pelvis (66.7% vs 25%). The average length of stay was 14 days (+/- 10 days), median 9 days. These results are comparable to other methods of perineal reconstruction. All dehiscences were less than 3cm and healed with conservative management.
Conclusions: This modified technique of bilateral fasciocutaneous gluteal V-Y advancement flaps for perineal wound control is a safe and effective method of reconstructing perineal defects which does not create functional donor site impairment. An overall complication rate of 25% was achieved when total autologous reconstruction was utilized through further technical refinement.
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