Perineal reconstruction after pelvic resection for cancer often requires flaps to close defects and reduce complications. The rectus abdominis flap has fewer complications than thigh flaps for immediate reconstruction after abdominoperineal resection or pelvic exenteration due to its reliable vascularity and bulk. Gracilis, posterior thigh, and anterolateral thigh flaps are also options but have higher rates of complications compared to the rectus flap. Proper postoperative care including avoiding pressure on the flap is important for successful reconstruction.

2. PERINEAL RECONSTRUCTION
Successful reconstruction is dependent
on the restoration of both adequate
form and adequate function

3. • Perineal reconstruction may be divided into
genitourinary reconstruction for:
– Acquired and congenital deformities
– Reconstruction for cancer
• Post AP resection +/- radiotherapy

4. • Treating primary and recurrent anorectal and
other pelvic malignancies often requires
extensive resection such as:
– pelvic exenteration
– abdominoperinealresection,
– chemotherapy and radiotherapy.

5. “Immediate flap reconstruction for large
pelvic/perineal defects created by
resection/radiotherapy has been shown to
result in fewer wound complications than
primary closure method”
• Buchel EW, Finical S, Johnson C. Pelvic reconstruction using vertical rectus
abdominismusculocutaneous flaps. Ann Plast Surg. 2004;52:22–26
• Burke TW, Morris M, Roh MS, Levenback C, Gershenson DM. Perineal reconstruction using single
gracilismyocutaneous flaps. GynecolOncol. 1995;57:221–225
• Butler CE, Rodriguez-Bigas MA. Pelvic reconstruction after abdominoperineal resection: Is it
worthwhile? Ann SurgOncol. 2005;12:91–94
• Chessin DB, Hartley J, Cohen AM, et al. Rectus flap reconstruction decreases perineal wound
complications after pelvic chemoradiation and surgery: A cohort study. Ann SurgOncol.
2005;12:104–110.
• Butler CE, Güundeslioglu AO, Rodriguez-Bigas MA. Outcomes of immediate VRAM flap
reconstruction for irradiated abdominoperineal resection defects. J Am Coll Surg. 2008;206:694–
703.

6. Goals of reconstruction
• Separating the pelvic and abdominal cavities
• Protecting the bowel from postoperative
problems
• Preventing post-operative perinealherniation
• Obtaining a healed wound
• Maintaining the adequacy of micturition
• Proper evacuation of faecalstream
• Aesthetics
• Restore sexual function

7. • Flaps reduce complications by:
– Obliterating pelvic dead space
– Recruiting healthy well-vascularized tissue into the
region, which has commonly been irradiated and
contaminated
– Tension free closure
– Interposing flap skin between irradiated perineal
wound edges

8. What is a Flap?

9. What is a Flap?
• 16th century Dutch word “flappe”
– ….something that hangs broad and loose ,
fastened only by one side..”

10. What is a Flap?
• A flap is a unit of tissue that may be transferred from a
donor to a recipient site while maintaining its blood
supply.
– Flaps can be characterized by their component parts
• cutaneous, musculocutaneous, osseocutaneous
– Their relationship to the defect
• local, regional, or distant
– Nature of the blood supply
• random versus axial
– The movement placed on the flap
• advancement, pivot, transposition, free, pedicled

11. Mathes&Nahai 1981
Muscle Flap Classification

12. Angiosome Concept
Taylor & Palmer BJPS 1987
• 3D composite of tissue
supplied by an artery &
draining vein

13. Fasciocutaneous flaps
Cormack &Lamberty (BJPS 1984)
• Type A – multiple perforators in the flap base
– no discrete origin
– may be combination of direct or indirect
perforators
• Type B – pedicle or free flap based on a single
perforator
• Type C – multiple segmental perforators from
the same vessel

14. Which Flap?
• Rectus abdominis flaps
• Gracilismyocutaneousflaps
• Posterior thigh flaps
• Perforator flaps
– Superior & Inferior gluteal artery perforator (IGAP,
SGAP)
– Anterolateral thigh flaps (ALT)
• Free flap

15. Rectus Abdominis Flaps
• Types
– VRAM (vertical rectus abdominis flap)
– ORAM (extended oblique rectus abdominis flap)
• 1st choice for perineal reconstruction due to
its:
– Reliable vascularity,
– Bulk to obliterate dead space
– Large skin paddle
– Ease of harvest with laparotomy

16. Anatomy
•Type III muscle therefore can be
raised on both pedicles
•superior epigastric artery
•deep inferior epigastric
artery
•Extended oblique rectus
abdominispopularised by
Taylor, allows for longer skin
paddle

18. Surgical Outcomes of VRAM versus Thigh Flaps for Immediate Reconstruction of Pelvic
and Perineal Cancer Resection Defects
PRS Volume 123(1), January 2009, pp 175-183
MD Anderson Group
• Methods:
– 133 patients who underwent abdominoperineal resection or
pelvic exenteration for cancer resection
• VRAM (n = 114) or
• thigh flap (n = 19)
– 19 patients received 21 thigh flaps:
» 9 gracilis (bilateral in 2 patients),
» 8 anterolateral thigh flaps,
» 4 posterior thigh flaps
– Immediate reconstruction of the perineal/pelvic
defect were studied.
– Patient, tumor, and treatment characteristics; surgical
outcomes; and postoperative donor- and recipient-
site complications were compared between the two
groups.

19. :
The thigh flap group had a significantly
greater incidence of
• major complications (42%vs 15%)
• higher rates of donor-site cellulitis (26% vs
6%)
• recipient-site complications, including cellulitis
(21% vs 4%)
• pelvic abscess (32% vs6%)
• major wound dehiscence (21% vs 5%)

21. Surgical Outcomes of VRAM versus Thigh Flaps for Immediate Reconstruction
of Pelvic and Perineal Cancer Resection Defects
PRS Volume 123(1), January 2009, pp 175-183
MD Anderson Group
• VRAM flaps are associated with fewer
complications than thigh flaps when used for
immediate reconstruction of abdominoperineal
resection and pelvic exenteration defects and do
not increase early abdominal wall morbidity.
• VRAM flaps, if available, should be the first choice
for immediate reconstruction of perineal/pelvic
defects following abdominoperineal resection
and pelvic exenteration.

28. Gracilismyocutaneous flap
• Type II myocutaneous flap
• Blood supply
– Medial femoral circumflex artery (major)
• This artery enters the muscle approximately 8-10 cm
below the inguinal ligament.
– Minor perforators:
• Proximally from the obturator artery
• Occasionally one or two branches from the superficial
femoral artery supplying the middle and distal portions.

32. Posterior Thigh Flaps
• This flap includes the inferior portion of the
gluteus maximus muscle and encompasses
the territory of the posterior thigh,
• Supplied by the descending branch of the
inferior gluteal artery

34. Anterolateral Thigh Flap
• Cormack &Lamberty Type B perforator flap
• Pedicle:
– Descending branch of the lateral circumflex
femoral artery

42. Superior Gluteal Artery Perforator Flap
(S-GAP)
• The superior gluteal artery and venae arise
from the internal iliac system deep in the
pelvis.
• They exit posteriorly through the greater
sciatic foramen, superior to the piriformis
muscle and inferior to the gluteus medius.
• The vessels perforate the gluteus maximus
muscle on their way to the fat and skin that
overlies them

54. Post-Operative Care
• NO PRESSURE ON FLAP
• Patient positioning
• Regular flap checks