An Algorithmic Approach to Perineal Reconstruction

Abstract

Summary: Perineal wounds are one of the more challenging plastic surgical defects to reconstruct. Resections in the perineum vary in size and are frequently complicated by radiation, chemotherapy, and contamination. Furthermore, the awkward location and potential need to maintain function of the anus, urethra, and vagina and to allow comfortable sitting all contribute to the complexity of these reconstructions. In light of this complex nature, many options are available for flap coverage. In this paper, we discuss the properties of perineal defects that make each option appropriate.

Gender-specific Anatomical Distribution of Internal Pudendal Artery Perforator: A Radiographic Study for Perineal Reconstruction

“…), and that cannot be repaired with minor local techniques. 3 , 5 , 9 , 13 , 14 , 19 , 22 , 47 – 51 These flaps are considered reliable and effective. In fact, a success (flap survival) rate of over 85% and an 80%–100% rate of patient satisfaction were reported.…”

“… 9 , 19 Altogether, literature and clinical experience strongly support the use of IPA-based flaps in perineal reconstruction. 3 , 5 , 9 , 13 , 14 , 49 – 51 …”

“…Several reconstructive techniques are currently available, including direct wound closure and skin grafts, local or pedicled flaps, and microsurgical free flap reconstruction. 3 , 5 – 11 Pedicled fasciocutaneous flaps have shown to be a less invasive and ideal option to repair moderate perineal defects. 5 , 12 – 14 Possibly, they could also be adopted for smaller defects because direct wound closure, skin grafts, and local flaps have been associated with poor outcomes due to wound dehiscence, scarring, anatomical disruption, and functional restriction.…”

“… 3 , 5 – 11 Pedicled fasciocutaneous flaps have shown to be a less invasive and ideal option to repair moderate perineal defects. 5 , 12 – 14 Possibly, they could also be adopted for smaller defects because direct wound closure, skin grafts, and local flaps have been associated with poor outcomes due to wound dehiscence, scarring, anatomical disruption, and functional restriction. 3 , 5 – 7 , 15 – 18 Among fasciocutaneous flaps, those based on the internal pudendal artery (IPA) system and its branches (eg, perineal artery) have been frequently used and have been associated with optimal outcomes, as they provide an ideal restoration of native tissue structure, limited scarring, function restoration, and retention of sensation.…”

“… 5 , 12 – 14 Possibly, they could also be adopted for smaller defects because direct wound closure, skin grafts, and local flaps have been associated with poor outcomes due to wound dehiscence, scarring, anatomical disruption, and functional restriction. 3 , 5 – 7 , 15 – 18 Among fasciocutaneous flaps, those based on the internal pudendal artery (IPA) system and its branches (eg, perineal artery) have been frequently used and have been associated with optimal outcomes, as they provide an ideal restoration of native tissue structure, limited scarring, function restoration, and retention of sensation. 1 , 4 , 12 , 19 – 29 Examples of IPA perforator flaps (IPAP flaps) include the “Lotus petal” flap (Gluteal-fold flap) and the “Singapore” flap (Pudendal thigh fasciocutaneous flap).…”