Reconstruction of a large pelvic defect by transfer of a quadruplet combination of pedicled flaps from the medial thigh using bilateral muscular gracilis flaps and bilateral vertical posteromedial thigh (vPMT) propeller flaps—A case report

Abstract

The reconstruction of defects of the perianal area and vagina places a high demand on a reconstructive surgeon. Different reconstructive methods include a skin graft, a local skin flap, a musculocutaneous flap, and a pedicled perforator flap. Here, we report the case of a 59‐year‐old female patient with a pelvic defect, who underwent reconstruction with a quadruplet combination of pedicled flaps from the medial thigh, due to an extensive resection of a recurrence of a squamous cell carcinoma of the anus, vulva, and partially the colon. The surgical oncologist performed a rectum amputation, a partial colectomy, a complete hysterectomy, and a resection of the dorso‐lateral vaginal vault in order to achieve tumor‐free margins. The resulting defect measured 14 × 11 cm2 with 8 cm of deep space. The defect was covered and reconstructed by employing a bilateral pedicled gracilis muscle flap rotated about 120° and advanced to fill up the residual spare space in the deep and a bilateral vertical posteromedial thigh (vPMT) using a propeller flap measuring 27 × 10 cm2 rotated 180° in order to reconstruct the vagina and the perianal area. All flaps survived without major post‐operative complications. The donor site morbidity was minimal. The range of motion was not limited over both hip and knee joints. Patient had no problem with urination. Sexual intercourse was not highly considered due to patient's old age. The follow‐up at 6 months showed acceptable cosmetic results with a satisfying contour of the coverage and reconstructed area. The combination of pedicled gracilis muscle flap and vPMT propeller flap may represent a valuable option in such a defect where deep space obliteration and reconstruction of the vagina with perianal contouring are needed.

Combination of four pedicled flaps for multilayer reconstruction of massive pelvic defect: A case report

“…The PMT flap, mostly supplied by the profunda femoris artery perforators (Scaglioni et al, 2015), also showed excellent results in either the perineal or upper thigh region (Scaglioni et al, 2017). In particular, we already used it for a multiple‐flaps reconstruction, in bilateral fashion and in combination the gracilis flaps, for the coverage of a very large perineal and vulvar defect (Wishart et al, 2020).…”

“…The PMT flap, mostly supplied by the profunda femoris artery perforators (Scaglioni et al, 2015), also showed excellent results in either the perineal or upper thigh region (Scaglioni et al, 2017). In particular, we already used it for a multiple-flaps reconstruction, in bilateral fashion and in combination the gracilis flaps, for the coverage of a very large perineal and vulvar defect (Wishart et al, 2020). JP Hong et al already showed with a case series of 16 patients the efficacy of multiple pedicled perforator-based flaps to cover extensive perineal defects, while proposing an interesting algorithmic approach according to anatomical divisions of the perineum (Hong et al, 2017).…”

Reconstruction of a radical total vulvectomy defect with a single split anterolateral thigh perforator flap: A case report and review of the literature

“…However, existing reports of its use for vulvar reconstruction have required using multiple flaps. (Wishart, Fritsche, & Scaglioni, 2019) The PAP flap has been associated with favorable clinical outcomes in vulvar reconstruction, and has been transposed both as an island flap and as a V–Y advancement flap (Chang et al, 2016; Huang et al, 2015). Advantages of the PAP flap include the robust perforator anatomy in the medial thigh region, the ability for primary donor site closure in most cases, and the possibility for preservation of sensation with the internal pudendal nerve (Chen, Scaglioni, & Kuo, 2015).…”

Propeller posteromedial thigh perforator flaps for coverage of extensive perineal defects

“…The operation was performed in the same way as previously described by Scaglioni et al (Chen et al, 2015; Scaglioni et al, 2015; Scaglioni et al, 2018; Wishart et al, 2020a, 2020b) The authors added their own methods in this big frame. The surgery was performed in a lithotomy position under general anesthesia.…”