Outcomes of the Composite Anterolateral Thigh Flap for Perineal Reconstruction After Postoncological Abdominoperineal Resection

Abstract

BACKGROUND:The vertical rectus abdominis flap is considered the gold standard in perineal reconstruction after oncological abdominoperineal resection; however, it has a nonnegligible donor site morbidity. The anterolateral thigh flap offers reliable soft tissue coverage. OBJECTIVE:The aim was to analyze long-term outcomes of composite anterolateral thigh-vastus lateralis flaps in oncological abdominoperineal resections. DESIGN:We conducted a retrospective cohort analysis of a prospectively maintained database. SETTINGS:This study was conducted in the Lausanne University Hospital. Annually, approximately 10 oncological abdomioperineal resections are performed. Literature reports 7% to 20% of patients undergoing abdominoperineal resection require flap reconstruction; in our institution, approximately 2 patients with large defects after abdominoperineal resections required reconstruction.PATIENTS: Twenty-nine pedicled anterolateral thighvastus lateralis flaps in 27 consecutive patients (mean age 63 years +/-11.2, 23 with radiochemotherapy) after abdominoperineal resection to cover large defects (median 190 cm 2 , 48-600 cm 2 ) were analyzed. INTERVENTION:Pedicled composite anterolateral thighvastus lateralis flaps were performed after oncological abdominoperineal resection. MAIN OUTCOME MEASURES:Descriptive statistical analysis was conducted. Short-and long-term outcomes were analyzed, univariate and multivariate analyses were performed. Median follow-up was 16 months (12-48 months).RESULTS: Flap-related postoperative complications occurred in 16 flaps; flap-survival was 100%. Multivariate logistic analysis identified initial defect size as predictive for complications. Patients with larger defects (≥ 190 cm 2 ) had higher complication rates (p = 0.006). Long-term analysis revealed 3 chronic fistulae, 2 tumor recurrences, 1 flap dysesthesia, and one perineal acne inversa.LIMITATIONS: Limitations include retrospective analysis, selection bias, and lacking a control group. Sample size limits statistical power. CONCLUSIONS:The pedicled anterolateral thighvastus lateralis flap offers reliable, stable tissue with low morbidity and good long-term outcomes. Complications compared favorably with current literature describing perineal reconstructions with rectus abdominis flaps. The composite anterolateral thigh flap is a valid alternative without the setback of abdominal donor site morbidity.

Quality of life and sexual health after perineal reconstruction in Fournier gangrene using pedicled anterolateral thigh flaps

“…Unlike skin grafts, the ALT offers stable skin allowing much better pliability required to reconstruct a complex three-dimensional anatomical region. Furthermore, its versatility in its ability to include several different tissue types (i.e., muscle, fascia lata) can be a clear advantage in complex reconstructions, such as scrotal reconstruction, penile suspensory ligamentoplasty or filling deep perineal dead space ( 16 , 21 ).…”

“…Surgical outcomes were defined as described in previous series characterizing perineal reconstructions by ALT-VL flap ( 16 ). We recorded flap related complications, defined as “major” in case of total or partial flap loss, major wound dehiscence at donor or recipient site involving more than a third of the incision length and persistent perineal dead space requiring additional reconstructive surgical procedures during follow-up.…”

“…Markings identifying ALT-perforators by pencil Doppler are performed prior to the reconstruction; patients are placed in lithotomy position in order to access both the thigh and the perineum. Dissection of the ALT perforator flap was converted, when needed to composite ALT-VL flap as described in previous publications ( 14 , 16 ). This technique allows for a tailored harvest of both coverage, (skin), bulk, (muscle) and eventually tensile component such as fascia lata, allowing reconstruction of the penile suspensory ligament ( 21 ).…”

“…Once elevated, the flap passes through a subcutaneous tunnel under the sartorius and rectus femoris muscles until reaching the perineum: this leads to a gain of 5 to 8 centimeters and avoids tension on the pedicle ( 16 ). Flap inset was performed in layers with deep sutures of the fascia using Vyril 2-0, inverted subcuticular sutures using Vycril 2-0 and Prolene 3-0 suture to the skin.…”

“…Harvested muscle has no significant functional impact at long term ( 15 ). This ductility made this flap the preferred choice for complex perineal reconstruction in patients who underwent abdomino-perineal resection for oncologic reasons in our institution ( 16 ).…”