Perineal wound reconstruction remains a complex undertaking owing to the awkward and contoured location, with the need to obliterate dead space while maintaining anus, urethra and vagina function.1 Perineal wounds may result from trauma or oncological resections, and defects varies in size and composition. Furthermore, reconstruction is made more challenging by radiotherapy, chemotherapy, and contamination. The VRAM flap has been the traditional workhorse for perineum reconstruction but has the disadvantage of abdominal wall weakness and excess tissue bulk.
We present a case series of local perforator flaps utilized in moderate and large perineum soft tissue reconstruction.
24 patients were included in this series from a single centre and patient demographics, operative, and post-operative details were recorded. Perineum defects were a consequence of abdominoperineal resection, vulval cancer resection, hidradenitis suppurativa excision, or Fournier’s gangrene. 12 patients received adjuvant radiotherapy to the local primary cancer prior to reconstruction.
A total of 25 local perforator flaps were raised based on the internal pudendal, inferior gluteal, and/or posterior labial arteries. A hand-held doppler was used to identify the perforators pre-operatively, and the flap was designed around the perforators to meet the reconstruction requirements. All donor sites were closed primarily. The average operative duration was 120mins, and patients were discharged around post-operative day six. Two patients had wound dehiscence, one of whom was found to have a positive oncological margin at the site of dehiscence. There were no cases of coverage failure, including patients who received radiotherapy at the local region prior to surgery.
We described a series of local perforator flaps to provide thin and pliable soft tissue and are sufficiently robust as a single-stage procedure with minimal donor site morbidity. Local perforator flaps should be considered in the perineum wound reconstructive algorithm, even in patients who had previously received local radiotherapy.