Immediate Flap Reconstruction of Perineal Resection Defects

Primary closure of irradiated perineal wounds after pelvic surgery has been reported to result in complications in 25 to 60% of patients. To minimize wound-related morbidity, nonirradiated, well-vascularized flap tissue is placed into the defect to facilitate wound healing, reduce dead space, and lessen suture line tension. Meticulous preoperative planning of the reconstructive technique, placement of incisions, cognizance of postoperative stomas, and minimization of donor-site morbidity are crucial for a successful reconstruction. These authors analyzed the experience at the University of Texas M.D. Anderson Cancer Center using this approach, and evaluated outcomes, risks, and benefits. Surgical techniques that improved outcome and reduced complications were described.

All consecutive patients over a 3-year period (5/1/2001 to 4/30/2004) who underwent oncologic resection resulting in a perineal defect and who had flap reconstruction were retrospectively analyzed. Surgical indications, defect characteristics, reconstructive technique, surgical outcome, and donor and recipient site complications were evaluated.

Eighty-three patients were included in the study (61 females, 22 males; mean age: 60.8 years; age range: 45–72 years). The mean follow-up was 14.4 months (range: 3 to 36 months). Flap reconstruction was performed immediately after oncologic resection in 78 patients and for salvage of a failed primary closure in 5 patients. Indications were curative resection in 72 patients and palliation in 11 patients. Primary tumors originated from the rectum (44), vagina or vulva (18), anus (12), penis (7), and colon (2). Preoperative radiation therapy was used in 64 patients, including 4 who received both external beam and intraoperative radiotherapy. Pedicled flaps were used for reconstruction in 82 patients, including VRAM (60), gracilis muscle (11), anterolateral thigh (6), posterior thigh (4), and omentum (1) flaps. A free latissimus dorsi muscle flap with vein grafts was used in 1 patient. Overall, complications occurred in 18 patients. Recipient-site complications occurred in 11 patients and included complete flap failure (1), partial flap loss (2), and wound dehiscence (8). Donor-site complications occurred in 7 patients, including wound dehiscence (3), hematoma (1), seroma (2), and abdominal bulge (1).

Immediate flap reconstruction of perineal wounds provides well-vascularized tissue to a compromised wound bed and can be performed with a relatively low rate of postoperative complications.