RECONSTRUCTION OF A COMPLEX PELVIC PERINEAL DEFECT WITH PEDICLED ANTEROLATERAL THIGH FLAP COMBINED WITH BILATERAL LOTUS PETAL FLAP: A CASE REPORT FEDERICO CONTEDINI, M.D.,1 LUCA NEGOSANTI, M.D.,1* VALENTINA PINTO, M.D.,1 CARLO MARIA ORANGES, M.D.,1 ROSSELLA SGARZANI, Ph.D.,1 FERDINANDO LECCE, M.D.,2 BRUNO COLA, M.D.,2 and RICCARDO CIPRIANI, M.D.1
Reconstructing extensive perineal defects represents a challenge, and reconstructive choice requires a careful physical assessment of previous radiotherapy, pre-existing scars, the presence of stomas, and the availability of donor sites. We report a case of a patient affected by an anal carcinoma who underwent a pelvic exenteration and bilateral inguinal iliac obturator lymph node dissection. We performed a pedicled anterolateral thigh flap (ALT) combined with bilateral lotus petal flaps (LPF) to reconstruct the pelvic–perineal area. The result was good, and no major post-operative complications were reported. Bilateral LPF, combined with a pedicled ALT, may represent a C 2014 Wiley Periodicals, Inc. Microsurgery 35:154– valid option in pelvic–perineal reconstruction following a wide oncological resection. V 157, 2015.
Reconstructing
extensive pelvic defects represents a challenge in reconstructive surgery, and various surgical options have been proposed. The choice of the flap for complex pelvic defects involving different anatomical structures requires a careful physical assessment for previous incisions, the presence of stomas, and the availability of potential donor sites. Wide defects, with a large pelvic dead space to fill, require a bulky flap or a combination of multiple flaps. The following techniques were described to reconstruct the pelvic and perineal region,1,2 including pedicled flaps, such as the vertical rectus abdominis muscle (VRAM) flap, the tensor fascia lata flap and gluteal flaps, and free flaps.3–5 We report the case of a patient affected by a squamous cell carcinoma of the rectum and the anal canal, reconstructed using a combination of an anterolateral thigh flap (ALT) and bilateral lotus petal flaps (LPF). CASE REPORT
A 63-year-old woman affected by a deep involving squamous cell carcinoma of the rectum and anal canal, complicated by a rectum–vaginalis fistula, underwent pelvic exenteration and bilateral inguinal iliac obturator lymph node dissection. General surgeons performed the resection of the urethra, bladder, uterus, annessi, vagina, rectum, and anal canal and performed an ileal-colostomy on the left side
1 Division of Plastic Surgery, S.Orsola-Malpighi University Hospital, Bologna, Italia 2 Division of Surgery, S.Orsola-Malpighi University Hospital, Bologna, Italia *Correspondence to: Luca Negosanti, M.D., Division of Plastic Surgery, S.Orsola-Malpighi University Hospital, Via Massarenti 9, 40138, Bologna, Italy. E-mail: [email protected] Received 18 April 2014; Revision accepted 16 July 2014; Accepted 18 July 2014 Published online 2 August 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22304
Ó 2014 Wiley Periodicals, Inc.
of the abdominal wall. In the same surgical step, a urologist performed a urinary diversion in the right iliac fossa. To reconstruct the pelvic–perineal defect (Fig. 1), we performed a pedicled ALT flap combined with a bilateral LPF. The pedicled ALT6–8 flap was harvested to fill the wide pelvic dead space and to prevent the adhesion of the bowel to the residual pelvic wall; a double LPF was used to cover the external perineal defect. Doppler was not used to identify the perforators. The first incision was performed on the medial side of the flap, down to the fascia and over the rectus femoris muscle. Then, a subfascial dissection was performed toward the lateral side, and two different musculo-cutaneous perforators were identified in the septum between the rectus femoris and the vastus lateralis muscles. For a longer pedicle, we selected the distal perforator vessel. The achieved flap size was 22 3 12 cm, and the pedicle length was 16 cm (Fig. 2A). The flap was de-epithelized and tunneled below the rectus femoralis and sartorious muscles (Fig. 2B) and then tunneled in a subcutaneous inguinal plane to reach the pelvic area (Fig. 2C), filling the dead space (Fig. 2D). Tunneling the flap under the muscular plane helped avoid the kinking of the pedicle. To monitor the flap vitality, we left a small sentinel skin island on the upper pole of the flap (Fig. 2D). The flap was fixed into the inner part of the defect, and two drains were positioned to reduce the dead space. The donor site closure required a skin graft harvested from the flap itself during its de-epithelization. We used a double LPF9,10 for the external vulvar defect. It was designed on the network of the internal pudendal artery perforator vessels and localized near the midline of the perineum area (Fig. 3). The first incision was performed on one side of the flap down to the fascia; the perforator vessels entering the flap base were carefully preserved during the dissection. The pedicled flaps were raised, including the fascia, and transposed to
Local Perforator Flaps in Perineal Reconstruction
Figure 1. Perineal defect after pelvic exenteration.
cover the buried ALT flap. Medial suture reconstructs an ideal boundary at which to obtain a shape similar to a vulva. LPF were sutured superiorly to the monitoring skin island of the ALT flap (Fig. 4). One drain for the side was inserted, and primary closure was performed in the donor sites of the LPF. The drains were removed after 3 days, and the sutures were removed after 15 days. Complete mobilization of the patient began 7 days after surgery, with a gradual recovery of deambulation. No major post-operative complications such as necrosis, hematoma, or infection were reported and no donor site morbidity resulted. A definitive histological examination confirmed a complete tumor resection. The patient was disease-free after 3 years of follow up, without functional impairment and without a deficit in the knee extensor mechanism at the ALT donor site. The residual scars were excellent and not visible (Fig. 5). Sexual restoration was not obtained with this procedure because of the presence of the ALT flap under the LPF. DISCUSSION
Reconstructive strategies for pelvic–perineal defects consequent to oncosurgical resections include local skin flaps or skin grafts and different pedicled flaps such as rectus abdominis, rectus femoris, tensor fascia lata,
155
gracilis, sartorius, groin, and deep inferior epigastric perforator.1,11,12 Free flaps have been described for wide and complex defects; however, they require microsurgical techniques and experience. The goals of pelvic and perineal reconstruction are to provide durable cutaneous coverage, ensure containment of the peritoneal contents, prevent herniation, and avoid dead spaces. The use of local skin flaps for extensive defects is limited because of their poor availability. Additionally, skin grafts are not indicated for extensive resections because of the risk of wide dead space and frequent urinary and fecal contamination, which cause maceration and breakdown. The VRAM flap is a good alternative because it provides well-vascularized tissues with adequate dimension to reconstruct even large and deep pelvic and perineal defects. Occasionally, as in this case, the presence of laparotomies or stomas on the abdominal wall impairs vascularization and impedes flap harvesting. The major disadvantage of this type of surgery is the cosmetic outcome because of the difficulty of tailoring the flap to reconstruct the vaginal shape. Another well-described historical disadvantage is the risk of a secondary abdominal wall hernia after the removal of the rectus muscle. Gluteal flaps, as described in the reconstruction of pelvic and vaginal wall defects,13,14 are not indicated in cases of extensive lack of tissue involving the perineal region. Pelvic exenteration and bilateral inguinal iliac obturator lymph node dissection compromise the local vascular supply for the use of many regional flaps. In our case, a median laparotomy and the presence of an ileal–colostomy and urinary diversion limited the harvesting of pedicled flaps from the abdominal area. Since its description, ALT flap joints have frequently been used for soft tissue reconstruction because of their safe and long vascular pedicle, wide arc of rotation, availability and simple dissection, and harvesting technique.1 ALT has successfully been used as a free flap in head and neck reconstruction and in lower and upper extremities. Despite the objective advantages of its utilization, few reports in the literature describe a pedicled ALT flap for pelvic and perineal defects. The pivot point of the pedicled ALT flap is approximately 2 cm below the inguinal ligament, corresponding to the origin of the lateral circumflex artery. LPF combined with a pedicled ALT in the reconstruction of pelvic and perineal region was not reported in literature. The results that we reported with LPF, combined with a pedicled ALT, were satisfactory both aesthetically and functionally. The association of these two flaps may represent a valid option in immediate and onestage pelvic–perineal reconstruction following a wide oncological resection. Microsurgery DOI 10.1002/micr
156
Contedini et al.
Figure 2. The ALT flap was harvested and transposed to the perineum. (A) The ALT was based on the distal perforator for a longer pedicle; (B) The flap was disepithelized and tunneled below the rectus femoralis and sartorious muscles; (C) The flap was tunneled in a subcutaneous inguinal plane to reach the pelvic area; (D) A skin island was left to monitor the flap vitality.
Figure 3. Bilateral lotus petal flap planning.
This procedure allows the filling of any post resection pelvic dead space and properly covering the perineal area with local tissues. Microsurgery DOI 10.1002/micr
Figure 4. The result at the end of surgery. The ALT flap was inset to fill the perineal volume defect and a monitoring skin paddle was left outside.
Local Perforator Flaps in Perineal Reconstruction
Figure 5. Results at 1 year. The flaps were fully healed with good quality scars that were slightly visible and hidden in the gluteal fold.
A combination of these pedicled flaps may provide good results aesthetically and functionally, with minimal donor site morbidity in pelvic–perineal reconstruction following a wide oncological resection.
REFERENCES 1. H€ockel M, Dornh€ ofer N. Vulvovaginal reconstruction for neoplastic disease. Lancet Oncol 2008;9:559–568. € uz S, Noyan 2. Kulahci Y, Sever C, Evinc R, Uygur F, S¸ahin C, Oks€ N, Duman H, Y€ uksel F. Versatile use of rectus abdominis muscle and musculocutaneous flaps for soft-tissue reconstruction: Our clinical experiences in 25 cases. Eur J Plast Surg 2011;34:437–444.
157
3. Garvey PB, Clemens MW, Rhines LD, Sacks JM. Vertical rectus abdominis musculocutaneous flow-through flap to a free fibula flap for total sacrectomy reconstruction. Microsurgery 2013;33:32–38. 4. Lin CT, Chen SG, Chen TM, Dai NT, Fu JP, Chang SC. Successful management of osteoradionecrotic precoccygeal defect with the free latissimus dorsi muscle flap: Case report and literature review. Microsurgery 2011;31:490–494. 5. Phan TQ, Spilker G, Theodorou P, Gossmann A, Heiss M, Weinand C. Combined latissimus dorsi and serratus anterior flaps for pelvic reconstruction. Microsurgery 2011;31:529–534. 6. Friji MT, Suri MP, Shankhdhar VK, Ahmad QG, Yadav PS. Pedicled anterolateral thigh flap: A versatile flap for difficult regional soft tissue reconstruction. Ann Plast Surg 2010;64:458–461. 7. Lannon DA, Ross GL, Addison PD, Novak CB, Lipa JE, Neligan PC. Versatility of the proximally pedicled anterolateral thigh flap and its use in complex abdominal and pelvic reconstruction. Plast Reconstr Surg 2011;127:677–688. 8. Maxhimer JB, Hui-Chou HG, Rodriguez ED. Clinical applications of the pedicled anterolateral thigh flap in complex abdominal-pelvic reconstruction. Ann Plast Surg 2011;66:285–291. 9. Yii NW, Niranjan NS. Lotus petal flaps in vulvo-vaginal reconstruction. Br J Plast Surg 1996;49:547–554. 10. Argenta PA, Lindsay R, Aldridge RB, Siddiqui N, Burton K, Telfer JR. Vulvar reconstruction using the “lotus petal” fascio-cutaneous flap. Gynecol Oncol 2013;131:726. 11. Nisar PJ, Scott HJ. Myocutaneous flap reconstruction of the pelvis after abdominoperineal excision. Colorectal Dis 2009;11:806–816. 12. Morton KE, Davies D, Dewhurst J. The use of the fasciocutaneous flap in vaginal reconstruction. Br J Obstet Gynaecol 1986;93:970– 973. 13. Ayestaray B, Proske YM. Perineal and posterior vaginal wall reconstruction with a superior gluteal artery dual perforator-pedicled propeller flap. Microsurgery 2015;35:64–67. 14. Kuo P-J, Chew K-Y, Kuo Y-R, Lin P-Y. Comparison of outcomes of pressure sore reconstructions among perforator flaps, perforatorbased rotation fasciocutaneous flaps, and musculocutaneous flaps. Microsurgery 2014;34:547–553.
Microsurgery DOI 10.1002/micr
Reconstructing extensive perineal defects represents a challenge, and reconstructive choice requires a careful physical assessment of previous radiotherapy, pre-existing scars, the presence of stomas, and the availability of donor sites. We report a case of a patient affected by an anal carcinoma who underwent a pelvic exenteration and bilateral inguinal iliac obturator lymph node dissection. We performed a pedicled anterolateral thigh flap (ALT) combined with bilateral lotus petal flaps (LPF) to reconstruct the pelvic–perineal area. The result was good, and no major post-operative complications were reported. Bilateral LPF, combined with a pedicled ALT, may represent a C 2014 Wiley Periodicals, Inc. Microsurgery 35:154– valid option in pelvic–perineal reconstruction following a wide oncological resection. V 157, 2015.
Reconstructing
extensive pelvic defects represents a challenge in reconstructive surgery, and various surgical options have been proposed. The choice of the flap for complex pelvic defects involving different anatomical structures requires a careful physical assessment for previous incisions, the presence of stomas, and the availability of potential donor sites. Wide defects, with a large pelvic dead space to fill, require a bulky flap or a combination of multiple flaps. The following techniques were described to reconstruct the pelvic and perineal region,1,2 including pedicled flaps, such as the vertical rectus abdominis muscle (VRAM) flap, the tensor fascia lata flap and gluteal flaps, and free flaps.3–5 We report the case of a patient affected by a squamous cell carcinoma of the rectum and the anal canal, reconstructed using a combination of an anterolateral thigh flap (ALT) and bilateral lotus petal flaps (LPF). CASE REPORT
A 63-year-old woman affected by a deep involving squamous cell carcinoma of the rectum and anal canal, complicated by a rectum–vaginalis fistula, underwent pelvic exenteration and bilateral inguinal iliac obturator lymph node dissection. General surgeons performed the resection of the urethra, bladder, uterus, annessi, vagina, rectum, and anal canal and performed an ileal-colostomy on the left side
1 Division of Plastic Surgery, S.Orsola-Malpighi University Hospital, Bologna, Italia 2 Division of Surgery, S.Orsola-Malpighi University Hospital, Bologna, Italia *Correspondence to: Luca Negosanti, M.D., Division of Plastic Surgery, S.Orsola-Malpighi University Hospital, Via Massarenti 9, 40138, Bologna, Italy. E-mail: [email protected] Received 18 April 2014; Revision accepted 16 July 2014; Accepted 18 July 2014 Published online 2 August 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22304
Ó 2014 Wiley Periodicals, Inc.
of the abdominal wall. In the same surgical step, a urologist performed a urinary diversion in the right iliac fossa. To reconstruct the pelvic–perineal defect (Fig. 1), we performed a pedicled ALT flap combined with a bilateral LPF. The pedicled ALT6–8 flap was harvested to fill the wide pelvic dead space and to prevent the adhesion of the bowel to the residual pelvic wall; a double LPF was used to cover the external perineal defect. Doppler was not used to identify the perforators. The first incision was performed on the medial side of the flap, down to the fascia and over the rectus femoris muscle. Then, a subfascial dissection was performed toward the lateral side, and two different musculo-cutaneous perforators were identified in the septum between the rectus femoris and the vastus lateralis muscles. For a longer pedicle, we selected the distal perforator vessel. The achieved flap size was 22 3 12 cm, and the pedicle length was 16 cm (Fig. 2A). The flap was de-epithelized and tunneled below the rectus femoralis and sartorious muscles (Fig. 2B) and then tunneled in a subcutaneous inguinal plane to reach the pelvic area (Fig. 2C), filling the dead space (Fig. 2D). Tunneling the flap under the muscular plane helped avoid the kinking of the pedicle. To monitor the flap vitality, we left a small sentinel skin island on the upper pole of the flap (Fig. 2D). The flap was fixed into the inner part of the defect, and two drains were positioned to reduce the dead space. The donor site closure required a skin graft harvested from the flap itself during its de-epithelization. We used a double LPF9,10 for the external vulvar defect. It was designed on the network of the internal pudendal artery perforator vessels and localized near the midline of the perineum area (Fig. 3). The first incision was performed on one side of the flap down to the fascia; the perforator vessels entering the flap base were carefully preserved during the dissection. The pedicled flaps were raised, including the fascia, and transposed to
Local Perforator Flaps in Perineal Reconstruction
Figure 1. Perineal defect after pelvic exenteration.
cover the buried ALT flap. Medial suture reconstructs an ideal boundary at which to obtain a shape similar to a vulva. LPF were sutured superiorly to the monitoring skin island of the ALT flap (Fig. 4). One drain for the side was inserted, and primary closure was performed in the donor sites of the LPF. The drains were removed after 3 days, and the sutures were removed after 15 days. Complete mobilization of the patient began 7 days after surgery, with a gradual recovery of deambulation. No major post-operative complications such as necrosis, hematoma, or infection were reported and no donor site morbidity resulted. A definitive histological examination confirmed a complete tumor resection. The patient was disease-free after 3 years of follow up, without functional impairment and without a deficit in the knee extensor mechanism at the ALT donor site. The residual scars were excellent and not visible (Fig. 5). Sexual restoration was not obtained with this procedure because of the presence of the ALT flap under the LPF. DISCUSSION
Reconstructive strategies for pelvic–perineal defects consequent to oncosurgical resections include local skin flaps or skin grafts and different pedicled flaps such as rectus abdominis, rectus femoris, tensor fascia lata,
155
gracilis, sartorius, groin, and deep inferior epigastric perforator.1,11,12 Free flaps have been described for wide and complex defects; however, they require microsurgical techniques and experience. The goals of pelvic and perineal reconstruction are to provide durable cutaneous coverage, ensure containment of the peritoneal contents, prevent herniation, and avoid dead spaces. The use of local skin flaps for extensive defects is limited because of their poor availability. Additionally, skin grafts are not indicated for extensive resections because of the risk of wide dead space and frequent urinary and fecal contamination, which cause maceration and breakdown. The VRAM flap is a good alternative because it provides well-vascularized tissues with adequate dimension to reconstruct even large and deep pelvic and perineal defects. Occasionally, as in this case, the presence of laparotomies or stomas on the abdominal wall impairs vascularization and impedes flap harvesting. The major disadvantage of this type of surgery is the cosmetic outcome because of the difficulty of tailoring the flap to reconstruct the vaginal shape. Another well-described historical disadvantage is the risk of a secondary abdominal wall hernia after the removal of the rectus muscle. Gluteal flaps, as described in the reconstruction of pelvic and vaginal wall defects,13,14 are not indicated in cases of extensive lack of tissue involving the perineal region. Pelvic exenteration and bilateral inguinal iliac obturator lymph node dissection compromise the local vascular supply for the use of many regional flaps. In our case, a median laparotomy and the presence of an ileal–colostomy and urinary diversion limited the harvesting of pedicled flaps from the abdominal area. Since its description, ALT flap joints have frequently been used for soft tissue reconstruction because of their safe and long vascular pedicle, wide arc of rotation, availability and simple dissection, and harvesting technique.1 ALT has successfully been used as a free flap in head and neck reconstruction and in lower and upper extremities. Despite the objective advantages of its utilization, few reports in the literature describe a pedicled ALT flap for pelvic and perineal defects. The pivot point of the pedicled ALT flap is approximately 2 cm below the inguinal ligament, corresponding to the origin of the lateral circumflex artery. LPF combined with a pedicled ALT in the reconstruction of pelvic and perineal region was not reported in literature. The results that we reported with LPF, combined with a pedicled ALT, were satisfactory both aesthetically and functionally. The association of these two flaps may represent a valid option in immediate and onestage pelvic–perineal reconstruction following a wide oncological resection. Microsurgery DOI 10.1002/micr
156
Contedini et al.
Figure 2. The ALT flap was harvested and transposed to the perineum. (A) The ALT was based on the distal perforator for a longer pedicle; (B) The flap was disepithelized and tunneled below the rectus femoralis and sartorious muscles; (C) The flap was tunneled in a subcutaneous inguinal plane to reach the pelvic area; (D) A skin island was left to monitor the flap vitality.
Figure 3. Bilateral lotus petal flap planning.
This procedure allows the filling of any post resection pelvic dead space and properly covering the perineal area with local tissues. Microsurgery DOI 10.1002/micr
Figure 4. The result at the end of surgery. The ALT flap was inset to fill the perineal volume defect and a monitoring skin paddle was left outside.
Local Perforator Flaps in Perineal Reconstruction
Figure 5. Results at 1 year. The flaps were fully healed with good quality scars that were slightly visible and hidden in the gluteal fold.
A combination of these pedicled flaps may provide good results aesthetically and functionally, with minimal donor site morbidity in pelvic–perineal reconstruction following a wide oncological resection.
REFERENCES 1. H€ockel M, Dornh€ ofer N. Vulvovaginal reconstruction for neoplastic disease. Lancet Oncol 2008;9:559–568. € uz S, Noyan 2. Kulahci Y, Sever C, Evinc R, Uygur F, S¸ahin C, Oks€ N, Duman H, Y€ uksel F. Versatile use of rectus abdominis muscle and musculocutaneous flaps for soft-tissue reconstruction: Our clinical experiences in 25 cases. Eur J Plast Surg 2011;34:437–444.
157
3. Garvey PB, Clemens MW, Rhines LD, Sacks JM. Vertical rectus abdominis musculocutaneous flow-through flap to a free fibula flap for total sacrectomy reconstruction. Microsurgery 2013;33:32–38. 4. Lin CT, Chen SG, Chen TM, Dai NT, Fu JP, Chang SC. Successful management of osteoradionecrotic precoccygeal defect with the free latissimus dorsi muscle flap: Case report and literature review. Microsurgery 2011;31:490–494. 5. Phan TQ, Spilker G, Theodorou P, Gossmann A, Heiss M, Weinand C. Combined latissimus dorsi and serratus anterior flaps for pelvic reconstruction. Microsurgery 2011;31:529–534. 6. Friji MT, Suri MP, Shankhdhar VK, Ahmad QG, Yadav PS. Pedicled anterolateral thigh flap: A versatile flap for difficult regional soft tissue reconstruction. Ann Plast Surg 2010;64:458–461. 7. Lannon DA, Ross GL, Addison PD, Novak CB, Lipa JE, Neligan PC. Versatility of the proximally pedicled anterolateral thigh flap and its use in complex abdominal and pelvic reconstruction. Plast Reconstr Surg 2011;127:677–688. 8. Maxhimer JB, Hui-Chou HG, Rodriguez ED. Clinical applications of the pedicled anterolateral thigh flap in complex abdominal-pelvic reconstruction. Ann Plast Surg 2011;66:285–291. 9. Yii NW, Niranjan NS. Lotus petal flaps in vulvo-vaginal reconstruction. Br J Plast Surg 1996;49:547–554. 10. Argenta PA, Lindsay R, Aldridge RB, Siddiqui N, Burton K, Telfer JR. Vulvar reconstruction using the “lotus petal” fascio-cutaneous flap. Gynecol Oncol 2013;131:726. 11. Nisar PJ, Scott HJ. Myocutaneous flap reconstruction of the pelvis after abdominoperineal excision. Colorectal Dis 2009;11:806–816. 12. Morton KE, Davies D, Dewhurst J. The use of the fasciocutaneous flap in vaginal reconstruction. Br J Obstet Gynaecol 1986;93:970– 973. 13. Ayestaray B, Proske YM. Perineal and posterior vaginal wall reconstruction with a superior gluteal artery dual perforator-pedicled propeller flap. Microsurgery 2015;35:64–67. 14. Kuo P-J, Chew K-Y, Kuo Y-R, Lin P-Y. Comparison of outcomes of pressure sore reconstructions among perforator flaps, perforatorbased rotation fasciocutaneous flaps, and musculocutaneous flaps. Microsurgery 2014;34:547–553.
Microsurgery DOI 10.1002/micr
