Perineal Reconstruction Using The Internal Pudendal ...



Title: Perineal Reconstruction Using The Internal Pudendal Arterial System

Authors: Yoshihiro Kimata, MD, Yuzaburo Namba, MD; Tetsuya Tsutsui, MD; Eijiro Tokuyama, MD and Narushi Sugiyama, MD.

Purpose: To reconstruct large, deep defects of the perineal area, a pedicled gracilis musculocutaneous flap, or a pedicled rectus abdominis musculocutaneous flap is commonly used. However in using the gracilis musculocutaneous flap, limited mobility of the flap due to location of the pedicle and, the bulkiness of the skin portion can be disadvantageous. In using the distally based rectus abdominis musculocutaneous flap, harvesting the muscle and bulkiness of the flap are also a problem.

In 1996, Yii and Niranjan reported useful local flaps for perineal defects reconstruction. In 1997, Knol and Hage also reported the same kind of flaps called an infragluteal skin flap. To reconstruct the large perineal defects easily and safely, we have modified their operative procedures and used local skin flaps nourished by the internal pudendal arterial system.

Materials: From 1996 through 2003, we transferred skin flaps nourished by the internal pudendal arterial system in 11 patients. Reconstruction was performed for large perineal defects in 5 women, for rectovaginal fistulas in 5 women, and for a large, deep defect of the anal skin and rectal mucosa in 1 man with perianal Pager disease.

Methods: In female patients, the vaginal orifice, anus, and ischial tuberosity are marked before surgery. Within this triangle are many skin perforators derived from the internal pudendal arterial system. We design a flap whose medial part contains perforators. The flap is elevated from lateral to medial and includes the skin, subcutaneous tissue, and superficial fascia. This flap can be elevated in only 15 to 20 minutes. For large perineal defects, bilateral flaps are designed and elevated.

In 1 of the 10 female, the defect involved the anterior half of the anal skin and mucosa. To reconstruct this defect, we designed the bi-lobed flap on the right side. And the anterior lobe of this flap was designed to include the labium minus and vestibule mucosa for reconstruction of the anus. Vascularized labium minus and vestibule mucosa were transferred into the defect of anus. At the same time, the skin flap on the left side was elevated to cover the left part of the defect.

In the male patient, the wide excision was performed that involves the anal skin, rectum mucosa and part of the internal anal sphincter. For this patient, a scrotal flap (12 x 12 cm) nourished by the posterior scrotal artery derived from pudendal arterial system was designed and rolled into a tube to create rectal mucosa to be inserted into the defect. The donor site was closed primarily.

Results: The maximum size of transferred flaps was 15 x 15 cm. All flaps survived completely without postoperative complications. In two patients in whom the anal skin and mucosa were reconstructed, no contracture developed present around the new anus.

Conclusions: Flaps utilizing the internal pudendal arterial system represent a versatile alternative to the various other flaps available for perineal and perianal reconstruction. Such flaps are easy to elevate, are sensate, and have good circulation and a wide skin territory. It is also a sensate flap. Furthermore, we developed this flap to meet indications for reconstruction around the anus. The disadvantages are; there can be a mismatch of skin texture and color when applied inside the vagina or in the labial region. It can be bulging around the pedicle’s hinge point and cause discomfort and pain during position, which would usually disappear 6 months postoperatively.

References

1. Yii,N.W., and Niranjan, N.S. Lotus petal flaps in vulvovaginal reconstruction. Br. J. Plast. Surg. 49:547-554,1996.

2. Knol, A.A.C., and Hage, J.J. The infragluteal skin flap: A new option for reconstruction in the perineogenital area. Plast, and Reconstr. Surg. 99:1954-1959,1997.

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