Reconstruction of Perineal Defects: A Comparison of the Myocutaneous Gracilis and the Gluteal Fold Flap in Interdisciplinary Anorectal Tumor Resection

Abstract

Introduction:Resection of anorectal malignancies may result in extensive perineal/pelvic defects that require an interdisciplinary surgical approach involving reconstructive surgery. The myocutaneous gracilis flap (MGF) and the gluteal fold flap (GFF) are common options for defect coverage in this area. Here we report our experience with the MGF/GFF and compare the outcome regarding clinical key parameters. Methods: In a retrospective chart review, we collected data from the Department of Plastic Surgery of the University of Freiburg from December 2008-18 focusing on epidemiological, oncological, and therapy-related data including comorbidities (ASA Classification) and peri-/postoperative complications (Clavien-Dindo-System). Results: Twenty-nine patients were included with a mean follow-up of 17 months. Of the cases, 19 (65.5%) presented with recurrent disease, 21 (72.4%) received radiochemotherapy preoperatively, 2 (6.9%) received chemotherapy alone. Microscopic tumor free margins were achieved in 25 cases (86.2%). 17 patients (7 men, 10 women, rectal adenocarcinoma n = 11; anal squamous cell carcinoma n = 6; mean age 58.5 ± 10.68, mean BMI 23.1, mean ASA score 2.8) received a MGF (unilateral n = 10; bilateral n = 7). Twelve patients (7 men, 5 women, rectal adenocarcinoma n = 7; anal squamous cell carcinoma n = 4, proctodeal gland carcinoma n = 1, mean age 66.2 ± 9.2, mean BMI 23.6, mean ASA score 2.6) received coverage with a GFF (unilateral n = 4; bilateral n = 8). Mean operation time of coverage was 105 ± 9 min for unilateral and 163 ± 11 for bilateral MGFs, 70 ± 13 min for unilateral and 107 ± 14 for bilateral GFFs. Complications affected 62%. There was no significant difference in the complication rate between the MGF-and GFF-group. Complications were mainly wound healing disorders that did not extend the hospital stay. No flap loss and no complication that lead to long-lasting disability was documented (both groups). Pain-free sitting took more time in the GFF-group due to the location of the donor site. Conclusion: MG-flaps and GF-flaps prove to be reliable and robust techniques for perineal/pelvic reconstruction. Though flap elevation is significantly faster for GF-flaps, Thiele et al. Gracilis/Gluteal Fold for Perineal Coverage preoperative planning and intraoperative Doppler confirmation are advisable. With comparable complication rates, we suggest a decision-making based on distribution of adipose tissue for dead space obliteration, intraoperative patient positioning, and perforator vessel quality/distribution.

Redefining the Reconstructive Ladder in Vulvoperineal Reconstruction: The Role of Pedicled Perforator Flaps

“…The design of perforator-based flap is versatile and not affected The incidence of poor wound healing that requires debridement in perforator flaps and myocutaneous flaps are 22.4 and 25%, respectively, in our series which is comparable results from the results of myocutaneous flaps in literatures. 17,[23][24][25] In comparison to myocutaneous flaps, thinner perforator flaps present a better choice for some of the defects. The use of perforator flaps also preserves adjacent myocutaneous flaps for future usage if cancer recurrence happens with larger defects that require soft tissue obliterations.…”

Lotus petal flap and vertical rectus abdominis myocutaneous flap in vulvoperineal reconstruction: a systematic review of differences in complications

“…Two studies reported that no general complications occurred [14,28]. Complications reported in other studies were urinary tract infection (1.3%), deep venous thrombosis (1.3%) and cerebrovascular incident (1.3%) (details in Appendix III).…”

“…All but three of these studies are case series [14][15][16][17][18][19][20][21][22][23][24][25][26]. Only Negosanti et al [27], Confalonieri et al [18] and Thiele et al [28] reported a case control study in which a reconstruction with LP flaps was compared with other flaps. About half of the studies (56.3%) were small studies (<20 patients), the largest was that of Confalonieri et al which included 106 patients [14,18,[20][21][22]24,[26][27][28].…”

“…Only Negosanti et al [27], Confalonieri et al [18] and Thiele et al [28] reported a case control study in which a reconstruction with LP flaps was compared with other flaps. About half of the studies (56.3%) were small studies (<20 patients), the largest was that of Confalonieri et al which included 106 patients [14,18,[20][21][22]24,[26][27][28]. In 62.5% of the studies, only females were included [14,15,[17][18][19]21,23,[25][26][27].…”

Perineal healing following salvage surgery for anal cancer

“…High rates of perineal complications in anal cancer surgery have previously been reported [5,6] with improved results after the introduction of perineal reconstruction using musculocutaneous flaps [7,8]. Various flaps have been used but consensus on the optimal flap is lacking [9–11].…”