Phẫu Thuật Tạo Hình Grabb & Smith’s (Bản Cập Nhật – Kevin C. Chung)

ATL, anterolateral thigh flap; STSG, split-thickness skin graft.
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Other Reconstructive Options
Tissue Expansion
Tissue expansion is another modality available, although infrequently used, to aid with lower extremity
reconstruction. It is typically used for skin resurfacing, coverage of wounds, removal of benign defects,
and repair of contour abnormalities as it provides local tissue with appropriate skin match and similar
quality. It is difficult to use in the acute setting and is more suitable for chronic conditions. The expanded
tissue has a good blood supply from essentially being delayed, which can contribute to successful
reconstruction. It is best to expand tissue transversely from the defect, as the tissue moves better in that
plane. Large, crescent-shaped expanders work best. They can be placed near the edge of a wound or with
an endoscope to limit incisions. Expanders do have high infection rates (up to 30%). The more distal they
are placed, the more common the complications and are infrequently successful below the knee, making
the lower leg a relative contraindication to their use. 1,8,31
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Negative-Pressure Wound Therapy
The first commercially available negative pressure wound therapy device, or the wound vacuum-assisted
closure (VAC), was available in 1996 (KCI, San Antonio, TX) and has transformed the practice of wound
care. 30 The VAC uses an open-cell polymer foam in the wound bed, which is sealed and placed under
negative pressure. In doing so, it promotes granulation tissue formation on a cellular level and increases
blood flow, while grossly contracting the wound and decreasing bacterial contamination. 1,8,30
The wound VAC is most useful as a temporizing measure before definitive closure and is not meant to be
used as a definitive reconstruction. 8 It can safely be placed on soft tissue, bone, and tendon and produce
adequate granulation tissue to take a skin graft or even achieve secondary healing in some cases 30 and
will increase the survival of random pattern flaps. 8
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Dermal Regeneration Templates
A dermal regeneration template is a form of artificial skin (Integra, Life Sciences, Plainsboro, NJ) that can
be used for the treatment of wounds. Integra is a layered product that is made up of bovine type I
collagen with glycosaminoglycans that is covered with a silicone layer. The collagen matrix allows
dermal regeneration, whereas the silicone is a temporary protective barrier. It is an immediate off-the-
shelf product that can be used to close wounds and is particularly useful in patients who do not have
adequate local donor tissue. Currently, Integra is most commonly used for burn wounds, but it can also
be used for vascular ulcers, for wounds from lesion excision, and for tendon and bone exposure. It is
placed on the wound bed and left in place for three or more weeks. Then, the silicone barrier is removed
and a thin skin graft is placed over the Integra. 32,33
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Other Problems
Chronic Osteomyelitis
Chronic osteomyelitis is most commonly caused by retained necrotic bone, infected bone, ischemic tissue,
dead space, and inadequate soft-tissue coverage. Treatment of chronic wounds and osteomyelitis require
conversion to an acute wound again. This is best approached by thinking of the infected or necrotic area
as a tumor and removing it in entirety, until healthy, viable tissue with punctate bleeding has been
reached. Bacteria require eradication with antibiotics, typically those that cover Staphylococcus species, as
those are most common. If present, hardware can harbor bacteria and should be removed. If the fracture
is still not repaired and requires fixation, an external fixator is appropriate. 1,9
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Persistent Nonunion
Bony nonunions are more common in the foot because of the tenuous vascular supply of the talus and
navicular bones. Some avascular necrosis is caused by trauma, whereas others are from damage from
open approaches during fixation. Typically, this problem can be treated with arthrodesis. In patients who
have had multiple revisions, infection, or significant osteonecrosis, vascularized bone flap is used. Large
bone gaps require free fibula or free iliac crest. Smaller defects benefit from medial femoral condyle free
flaps. 18 This flap is ideal because it contains a vascularized periosteum and cancellous bone and can be
utilized to fix many different persistent nonunions. The donor site at the distal femur is well tolerated and
does not cause any instability; the patient can be weight-bearing on the donor site immediately. 34
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Salvage of Below-Knee Amputation Stumps
Another important aspect of lower extremity reconstruction is salvage of amputation stumps. Patients are
much more likely to use a prosthesis if they have a below-knee amputation versus an above-knee
amputation. However, sometimes the trauma that cause the amputation creates a wound that is not
amenable to primary closure without either shortening the stump, revising the amputation, or doing a
free flap for coverage. About 14 cm of length is necessary to support a prosthesis for a below-knee
amputation. If done during the inciting event, free flap with spare parts can be performed to preserve
length, otherwise, traditional free flaps can be performed to make the amputation remnant amenable for a
prosthesis 1,4,9
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Avascular Necrosis of the Femoral Head
Avascular necrosis of the femoral head is a progressive condition that initially affects patients between
the ages of 20 and 50 years and is caused by alcohol consumption, steroids, trauma, and Perthes disease.
It starts with osteonecrosis, which leads to cartilage destruction and secondary degenerative changes.
Typically, this condition would be managed with total arthroplasty, but in this age group, it is fraught
with a high rate of complications and a high rate of revisions. It can also be treated with core
decompression, but this does not provide structural support. A good solution in this patient population is
to use a vascularized free fibula graft. It requires core decompression of the dead sequestrum to create
space for the fibula. The fibula is placed in this cored-out tunnel in the femoral head and brings both
support and revascularization. Younger patients have a better outcome with free fibula grafting, although
20% of this patient population will still require a total joint replacement later in life. 1,35,36
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Reconstruction of Peroneal Nerve Injuries
The common peroneal nerve is the most frequent nerve injury of the lower extremity, as it can be injured
with penetrating trauma, fractures, knee dislocations, ankle sprains, or iatrogenically during a knee
surgery. Traction injuries recover spontaneously, but patients who suffer irreversible damage benefit
from surgical treatment, otherwise these patients are committed to wearing a foot drop brace. Treatment
options include nerve grafting and tendon transfer. Nerve grafting has shown favorable results,
particularly in small nerve gaps. Tendon transfer should be reserved for those who failed nerve recovery
or repair. A posterior tibialis tendon to anterior tibial tendon transfer is the standard tendon transfer to
treat foot drop. Garozzo et al had favorable results when combining nerve repair with grafting in a one-
stage procedure, discussing that they felt tendon imbalance was part of the reason for poor recovery after
nerve grafting alone. 37-39
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Oncologic Reconstruction
In cases of oncologic extirpation, extremity reconstruction can prevent an amputation. Most cases are
caused by bony sarcomas, and removal of a large segment of bone requires a vascularized reconstruction,
particularly in instances where the patient has been radiated. Most bony defects are amenable to
reconstruction with a free fibula. However, the femur and tibia require strength, which can be
accomplished with a double-barreled fibula or a fibula placed in an allograft (Capanna technique). 1,9
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Aesthetics of the Lower Extremity
Although the ultimate goal of lower extremity reconstruction is to create a functional result, appearance
should not be ignored. The most important aspect of attaining an aesthetic result is proper flap choice.
Muscle flaps covered by skin grafts tend to have a less aesthetic result. Over time, they remain bulky and
frequently require revision for contouring. If a muscle flap is required, attention to inset and
postoperative management can improve results. First, choosing a flap of appropriate dimensions for the
defect can make the initial aesthetic result better. Then, insetting the flap with horizontal mattress sutures
promotes a smoother junction between the flap and the native skin. Postoperative care with compression
with an ACE wrap or compression sock can aid in shrinking the flap to fit the defect. If fasciocutaneous
flaps are used, thinner flaps are better. This can be achieved by choosing a flap that is thinner to begin
with (depending on the patient’s body habitus), thinning the flap around the perforator intraoperatively,
or performing revisions to thin the flap secondarily. Bulky flaps are not just an anesthetic problem in the
lower extremity, those located distally can prevent proper footwear fit. If the cosmetic result after the
initial reconstruction is poor, a revised reconstruction with a fasciocutaneous free flap may provide a
better result. 40-42
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Postoperative Management
Postoperative patient management is dictated by the reconstruction performed. For all free flaps,
standard clinical free flap monitoring, including internal and/or external Doppler signal, color, capillary
refill, and temperature are performed hourly by the nursing staff for the first 48 hours, then every 2 hours
for the next 48 hours, and then every 4 hours for the remaining hospitalization. If the patient has a buried
flap, an internal Doppler device is used.
All patients are initially on bed rest with the affected extremity elevated for 2 to 3 weeks. It is important
to off-load pressure on the reconstruction, usually this can be achieved with positioning and splinting,
but sometimes it requires an external fixator. Most acute reconstructions are prone to venous and
lymphatic insufficiency early on. It is important to keep the extremity elevated and not dependent. After
2 to 3 weeks, a dangle protocol is started to give the reconstruction a gradual accommodation period. The
patient is non-weight-bearing on that extremity until cleared by the orthopedic service.
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Conclusion
Lower extremity reconstruction is a challenging area of surgery that requires consideration of a patient’s
occupation, other injuries, and comorbidities before a reconstructive plan is initiated. The best results are
attributed to proper flap choice and timing, although the ability to incorporate microsurgery has
significantly advanced orthoplastic extremity reconstruction.
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Questions
1. A 27-year-old man had a previous fracture of the foot. He has been repaired operatively with open
reduction internal fixation and bone grafting and has a nonunion of the talonavicular joint. What is
the best option for treatment of this foot wound?
a. Repeat bone grafting
b. Vascularized fibular graft
c. Medial geniculate artery flap
d. Iliac crest osteocutaneous flap
2. An 88-year-old man with advanced heart failure has a chronic wound on his posterior heel with
exposed tendon lacking paratenon. Which of the following is the best option for this patient?
a. Split-thickness skin graft
b. Reverse sural artery flap
c. ALT flap
d. Tissue expansion
3. Which is not true of the rule of thirds for lower extremity reconstruction?
a. Gastrocnemius is a good option for proximal third defects
b. Reverse soleus is a good option for middle third defects
c. Soleus is a good option for middle third defects
d. Free flaps are good options for distal third defects
4. A 65-year-old man just underwent an aortobifemoral bypass procedure. It was complicated by a
ruptured pseudoaneurysm at the femoral anastomosis, and the patient now has an open wound with
exposed graft. Which of the following is true?
a. The wound should be treated with a wound VAC until it granulates.
b. A sartorius flap should be placed over the exposed vessels.
c. Treatment for this patient’s condition will require repeated laparotomy.
d. A skin graft should be adequate to obtain coverage.
5. Which half of the gastrocnemius flap is a better option for most knee wounds and why?
a. Medial because its blood supply is more robust.
b. Lateral because the flap is larger with better reach.
c. Medial because there is no risk of peroneal nerve injury.
d. Lateral because the pedicle location is more consistent.
1. Answer: c. Having failed primary reconstructive options with hardware and bone grafting, likely
from poor vascular supply, this patient needs a vascularized reconstruction, preferably a
vascularized corticocancellous bone flap. Bone grafting did not correct his problem in the past.
Although plausible, a vascularized fibular graft is essentially a cortical bone graft and is larger than
necessary and more difficult to inset into the desired location. An iliac crest osteocutaneous flap
creates a significant donor defect to the lateral abdominal wall.
2. Answer: b. This elderly patient with significant comorbidities is not a candidate for a free flap or
any other prolonged operation, so an ALT flap is not an option for him. Exposed tendon lacking
paratenon will not have good graft take, so a split-thickness skin graft is not an option. Tissue
expansion in the distal lower extremity has a very high complication and failure rate and is therefore
not advisable. Reverse sural artery flap is a good option in this patient as it can be harvested quickly
and will provide stable coverage. If flap viability is a concern, a delay procedure could be performed.
Although not an answer choice, Integra and then skin grafting later would also be a possibility in this
scenario.
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3. Answer: b. Reconstructing the leg can be thought of as a rule of thirds, with gastrocnemius being
the classic option for the proximal third. Soleus for the middle third, and free flap for the distal third.
Reverse soleus is indicated for distal third but is less ideal than a free flap since it is more prone to
necrosis.
4. Answer: b. Exposed vascular structures should be covered with vascularized tissue, and a
sartorius flap would fulfill this purpose. A wound VAC should not be placed directly onto
vasculature. The wound is located at the distal part of the groin and should not require laparotomy
for management. A skin graft would be inadequate to cover exposed vessels and would not take over
a vascular prosthesis.
5. Answer: c. The peroneal nerve is at risk for injury if the lateral head of the gastrocnemius is used,
and therefore the medial head is preferable.
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References
Griffin, JR, Thornton, JF. Lower extremity reconstruction. Sel Read Plast Surg. 2009;11(R1):1-59.
Olson, SA, Glasgow, RR. Acute compartment syndrome in lower extremity musculoskeletal trauma. J Am Acad Orthop Surg. 2005;13(7):436-
444.
Gustilo, RB, Mendoza, RM, Williams, DN. Problems in the management of type III (severe) open fractures: a new classification of type III
open fractures. J Trauma. 1984;24(8):742-746.This is the article that introduced the most widely used classification system for open extremity
fractures. This is important for plastic surgeons, as it is needed to help salvage and reconstruct the extremities on patients who have type IIIB and IIIC
injuries.
Soltanian, H, Garcia, R, Hollenbeck, ST. Current concepts in lower extremity reconstruction. Plast Reconstr Surg. 2015;136(6):815e-829e.
Byrd, HS, Spicer, TE, Cierney, G 3rd. Management of open tibial fracture. Plast Reconstr Surg. 1985;76(5):719-730.Classic article regarding
classifying and treating open tibial fractures. Of particular note, this was written by plastic surgeons, so it more clearly defines which types of injuries
can be treated with local flaps, versus those that require distant tissue transfer.
Hollenbeck, ST, Toranto, TJ, Taylor, BJ, et al. Perineal and lower extremity reconstruction. Plast Reconstr Surg. 2011;128(5):551e-563e.
Pasquale, MD, Frykberg, ER, Tinkoff, GH; ACS Committee on Trauma ; Ad Hoc Committee on Outcomes . Management of complex
extremity trauma. Bull Am Coll Surg. 2006;91(6):36-38.
Ong, YS, Levin, LS. Lower limb salvage in trauma. Plast Reconstr Surg. 2010;125(2):582-588.
Levin, LS, Heitmann, C. Lower extremity reconstruction. Semin Plast Surg. 2003;17(1):069-082.
Lachica, RD. Evidence-based medicine: management of acute lower extremity trauma. Plast Reconstr Surg. 2017;139(1):287e-301e.
Godina, M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg. 1986;78(3):285-292.Landmark article
discussing the timing of treating lower extremity fractures with free flaps. The author broke patients into three groups—early, delayed, and late—and
then assessed infections, flap failure rates, number of anesthetics, hospitalization time, and time to healing. This article is what led to more common
treatment of open fracture with free flaps in the acute period.
Ducic, I, Attinger, CE. Foot and ankle reconstruction: pedicled muscle flaps versus free flaps and the role of diabetes. Plast Reconstr Surg.
2011;128(1):173-180.
Suh, HS, Oh, TS, Lee, HS, et al. A new approach for reconstruction of diabetic foot wounds using the angiosome and supermicrosurgery
concept. Plast Reconstr Surg. 2016;138(4):702e-709e.
Higgins, TF, Klatt, JB, Beals, TC. Lower extremity assessment project (LEAP) – the best available evidence on limb-threatening lower
extremity trauma. Orthop Clin North Am. 2010;41(2):233-239.The LEAP project is a landmark randomized, prospective trial performed at 8 trauma
centers, developed to determine who would benefit from salvage versus who would benefit from primary amputation. While they were unable to make
this determination, they did find that patient’s ability to function afterward was more because of their functional ability before trauma, regarding their
social, economic, and personality disadvantages. Whether treated with salvage or amputation, this patient population had equivalent 2-year outcomes.
Bosse, MJ, MacKenzie, EJ, Kellam, JF, et al. An analysis of outcomes of reconstruction or amputation after leg-threatening injuries. N Engl J
Med. 2002;347(24):1924-1931.
Steiert, AE, Gohritz, A, Schreiber, TC, et al. Delayed flap coverage of open extremity fractures after previous vacuum-assisted closure (VAC)
therapy – worse or worth it? J Plast Reconstr Aesthet Surg. 2009;62(5):675-683.
Wong, TM, Lau, TW, Li, X, Fang, C, Yeung, K, Leung, F. Masquelet technique for treatment of posttraumatic bone defects. Sci World J.
2014;2014:1-6.
Haddock, NT, Wapner, K, Levin, LS. Vascular bone transfer options in the foot and ankle: a retrospective review and update on strategies.
Plast Reconstr Surg. 2013;132(3):685-693.
Ronga, M, Ferraro, S, Fagetti, A, Cherubino, M, Valdatta, L, Cherubino, P. Masquelet technique for the treatment of a severe acute tibial bone
loss. Injury. 2014;45(suppl 6):S111-S1115.
Wagels, M, Rowe, D, Senewiratne, S, Theile, DR. History of lower limb reconstruction after trauma. AZN J Surg. 2013;83(5):348-353.
Hollenbeck, ST, Woo, S, Ong, S, Fitch, RD, Erdmann, D, Levin, LS. The combined use of the Ilizarov method and microsurgical techniques
for limb salvage. Ann Plast Surg. 2009;62(5):486-491.
Rozbruch, SR, Weitzman, A, Watson, JT, Freudigman, O, Katz, HV, Ilizarov, S. Simultaneous treatment of tibial bone and soft-tissue defects
with the Ilizarov method. J Orthop Trauma. 2006;20(3):197-205.
Weiland, AJ, Moore, JR, Daniel, RK. Vascularized bone autografts. Experience with 41 cases. Clin Orthop Relat Res. 1983;174:87-95.
Gottlieb, LJ, Krieger, LM. From the reconstructive ladder to the reconstructive elevator. Plast Reconstr Surg. 1994;93(7):1503-1504.
Parrett, BM, Talbot, SG, Pribaz, JJ, Lee, BT. A review of local and regional flaps for distal leg reconstruction. J Reconstr Microsurg.
2009;25(7):445-455.Good review article about options for reconstruction of the lower extremity.
Behan, FC. The Keystone Design Perforator Island Flap in reconstructive surgery. ANZ J Surg. 2003;73(3):112-120.
D’Arpa, S, Toia, F, Pirrello, R, et al. Propeller flaps: a review of indications and results. Biomed Res Int. 2014;2014:1-7.
Morrison, WA, Crabb, DM, O’Brien, MB, Jenkins, A. The instep of the foot as a fasciocutaneous island and as a free flap for heel defects. Plast
Reconstr Surg. 1983;72(1):56-63.
Agarwal, P, Raza, H. Cross-leg flap: its role in limb salvage. Indian J Orthop. 2008;42(4):439-443.
Colen, DL, Colen, LB, Levin, LS, Kovach, SJ. Godina’s principles in the twenty-first century and the evolution of lower extremity trauma
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reconstruction. J Reconstr Microsurg. 2018;34(8):563-571.
Manders, EK, Oaks, TE, Au, VK, et al. Soft tissue expansion in the lower extremities. Plast Reconstr Surg. 1988;81(2):208-219.
Prystowsky, JH, Nowygrod, R, Marboe, CC, et al. Artificial skin (Integra Dermal regeneration template) for closure of lower extremity
wounds. Vasc Surg. 2000;34(6):557-567.
Lee, LF, Porch, JV, Spenler, W, Garner, WL. Integra in lower extremity reconstruction after burn injury. Plast Reconstr Surg. 2008;121(4):1256-
1262.
Rodriguez-Vegas, JM, Delgado-Serrano, PJ. Corticoperiosteal flap in the treatment of nonunions and small bone gaps: technical details and
expanding possibilities. J Plast Reconstr Aesthet Surg. 2011;64(4):515-527.
Urbaniak, JR, Coogan, PG, Gunneson, EB, Nunley, JA. Treatment of osteonecrosis of the femoral head with free vascularized fibular grafting:
a long-term follow-up study of one hundred and three hips. J Bone Joint Surg Am. 1995;77(5):681-694.
Kawate, KYH, Sugimoto, K, Ono, H, et al. Indications for free vascularized fibular grafting for the treatment of osteonecrosis of the femoral
head. BMC Musculoskelet Disord. 2007;78:1-8.
Garozzo, D, Ferraresi, S, Buffatti, P. Surgical treatment of common peroneal nerve injuries: indications and results: a series of 62 cases. J
Neurosurg Sci. 2004;48(3):105-112.
Vigasio, A, Marcoccio, I, Patelli, A, et al. New tendon transfer for correction of drop-foot in common peroneal nerve palsy. Clin Orthop Relat
Res. 2008;466(6):1454-1466.
Sedel, L, Nizard, RS. Nerve grafting for traction injuries of the common peroneal nerve: a report of 17 cases. J Bone Joint Surg Br.
1993;75B:772-774.
Marek, CA, Pu, LQ. Refinements of free tissue transfer for optimal outcome in lower extremity reconstruction. Ann Plast Surg. 2004;52(3):270-
275.
Ohjimi, H, Taniguchi, Y, Kawano, K, et al. A comparison of thinning and conventional free-flap transfers to the lower extremity. Plast
Reconstr Surg. 2000;105(2):558-566.
Jeon, BJ, Lim, SY, Pyon, JK, et al. Secondary extremity reconstruction with free perforator flaps for aesthetic purposes. J Plast Reconstr Aesthet
Surg. 2011;64(11):1483-1489.
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C H A P T E R 9 7
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Perineal Reconstruction
Julie E. Park
Key Points
Perineal reconstruction may be required because of burns, infection, trauma, hidradenitis
suppurative, or cancer.
Reconstructive options can vary according to location of acquired defect.
Reconstructive options include local, regional, and free flap reconstruction.
Indications for specific reconstructive choice varies according to location and depth of acquired
defect.
Support of pelvic contents and obliteration of any dead space is essential in perineal reconstruction.
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Anatomy
The perineal region spans the pubic symphysis and the coccyx in the anteroposterior dimension and the
ischial tuberosities in the transverse dimension. It is divided into anterior and posterior triangles by a
hypothetical transverse line between the ischial tuberosities. The anterior triangle contains the urogenital
structures, which include the vulva and vagina in females and the scrotum and penis in males. The
posterior triangle includes the anorectal structures. The superior border of the perineum is the pelvic
floor, which consists of the levator ani and coccygeus muscles (Figure 97.1). The pelvic floor, also referred
to as the pelvic diaphragm, supports and separates the pelvic cavity from the perineum. The perineum
refers to the area between the anus and vagina or scrotum. It has a superficial and deep fascial layer. The
deep fascia is contiguous to Colles fascia. 1 The specifics of the anatomy of perineal structures are
delineated in Table 97.1.
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FIGURE 97.1 Structure of the female (A) and male (B) perineum. C. Cross section of penis.
TABLE 97.1
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Anatomy and Neurovascular Pedicles of Structures of the Perineum 1,49
Vulva
Vagina
Penis
Scrotum
Anatomy
External aspect of female
genitalia
Labia majora
Bilateral,
hair-
bearing
skin
folds
that fuse to form
anterior/posterior
commissures
Labia minora
Bilateral folds within
labia
majora,
superiorly
forms
clitoral frenulum and
hood
Flanks
vestibule,
which houses urethra
and introitus
Muscular tube that
connects vestibule to
the uterus
Inferior to urethra
Introitus—opening
Approximate
dimensions:
Diameter 2.6–
3.25 cm
Length
Anterior
wall
6 cm
Posterior
wall
7.5 cm
Radix—root
Corpus—body
Dorsal:
two
corpora
cavernosa
Ventral:
corpus
spongiosum
Glans penis—tip
Urethra
passes
through
corpus
spongiosum,
meatus at tip of
glans penis
Sack with two separate
pockets that contain the
testes,
epididymis,
ductus deferens
Protect
testes,
help
maintain
temperature
of 35°C
Thin skin over dartos
and cremaster muscles
Vasculature
Internal pudendal artery
Internal pudendal vein and
vaginal venous plexus
Uterine and vaginal
arteries, branches of
internal iliac
Vaginal
venous
plexus
Dorsal penile artery
Deep artery of the
penis
Both branches of
internal
pudendal
artery
Dorsal
veins
of
penis
Anterior scrotal artery,
branch of deep external
pudendal artery
Posterior scrotal artery,
branch
of
internal
pudendal artery
Testicular veins
Innervation
Anterior—branches
of
ilioinguinal (T12-L1) and
genitofemoral (L1-2) nerves
Posterior—internal
pudendal nerve (S2-4)
Pudendal nerve
Sympathetic
and
parasympathetic
nerves
of
pelvic
plexus
Dorsal
nerve
of
penis
Posterior scrotal nerves
Anterior scrotal nerves
Genital
branch
of
genitofemoral nerve
Perineal
branch
of
posterior
femoral
cutaneous nerve
The perineum plays important roles in micturition, defecation, sexual activity, and body image, all of
which need to be considered when planning reconstructive goals. Functional requirements include
obliteration of any dead space, prevention of pelvic prolapse, and possible reconstruction of genitalia.
The challenges of reconstructing the perineum consider dependent pressure during postoperative
recovery, bacterial contamination from urogenital and perianal areas, and the propensity for radiation
therapy to be used when oncologic resection is necessary.
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Considerations by Etiology
There are multiple scenarios in which the perineum requires reconstruction. Benign disease processes
include burns, infection (such as Fournier’s gangrene), trauma, and hidradenitis suppurativa. Oncologic
resections include Paget disease; carcinomas of the vulva/vagina, penis, and/or scrotum; and anorectal
cancer. Reconstruction of congenital defects is beyond the scope of this chapter while gender affirmation
procedures are discussed in detail in Chapter 100.
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Burns
The American Burn Association considers any perineal burn as a major injury and criteria for burn center
referral. 2-4 Isolated perineal burns are unusual as the area is relatively protected by the thighs and
abdomen. Perineal burns are typically part more extensive burns of trunk and lower extremity. 4 Adult
etiology is typically due to flame, whereas pediatric etiology is usually due to scald burns from spills or
immersion. 2,4 A third reason for perineal burns is the military cause. 3 The incidence of perineal burns
ranges anywhere from 1.7% to 13% in adults and 1% in children. 4,5 Across adult, pediatric, and military
cohorts, there is an increased male to female ratio. 3-5 The presence of a perineal burn is an independent
risk factor for an increase in morbidity and mortality, although this is not from injuries to the urogenital
structures, but is thought to be related to increased bacteremia and/or relationship to more extensive
injuries. 2,3,5
The presence of perineal burns is associated with increased hospital acquired infections and urinary tract
infections. 2,5 Increased infection risks can convert partial-thickness burns to deeper tissue injury and can
interfere with skin graft take. 4 There is consensus that urinary catherization should be limited to
resuscitation as much as possible, with some advocating its use to help hygiene and comfort. 2,4,5 Long-
term catheterization risks infection and urethral stenosis. There is debate regarding the superiority of
suprapubic versus urethral catheters. 2,4,5
As with any other burn, the depth of the burn will determine need for excision and grafting. Unlike burns
on other areas of the body, genitalia burns are typically not treated with early excision. The exception to
this is the presence of extensive, deep necrotic tissue. Conservative treatment with topical antimicrobials
and wound care is recommended. Most partial-thickness wounds heal by epithelialization. Perineal
wounds heal well with secondary intention after eschar excision. If the perineal burn is part of more
extensive burns, the other areas of burns have priority for skin grafts from available donor sites. Larger
wounds may require excision and grafting to prevent deformities. Full-thickness injuries to genitalia may
require full-thickness skin graft to prevent contracture and care must be taken with bolster dressings to
secure the grafts. Internal vaginal burns can benefit from vaginal stents to help prevent stenosis. 2,4,5
Contracture of perineum can restrict the range of motion of hip and adversely affect micturition,
defecation, and sexual activity. There are additional psychosocial complications of burns to genitalia that
span loss of self-esteem and libido. 4
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Infections
Necrotizing soft tissues of the perineum is often referred to as Fournier gangrene. It can involve the skin,
subcutaneous tissue, fascia, and muscle. Mortality rates range between 10% and 40%. There is a male
predominance. The most common comorbidity is diabetes mellitus, 6 and other risk factors include the
following 7 :
Recent surgery to perineal structures
Malignancy
Alcoholism
Morbid obesity
Immunocompromise
The mainstay of treatment is prompt surgical debridement, broad spectrum IV antibiotics, and
resuscitation. Surgical debridement should aggressively target any infected, ischemic, and/or necrotic
tissues. Second look operations are often necessary. Antibiotic therapy should cover gram positive, gram
negative, and anaerobic bacteria and then be adjusted to the antibiotic sensitivities as speciation of
cultures return. Ideally, blood cultures should be drawn prior to antibiotic initiation. Common
microorganisms involved in Fournier gangrene include the following 7-9 :
Polymicrobial
Escherichia coli
Staphylococcus aureus
Streptococcus species
Enterobacter
Pseudomonas aeruginosa
Bacteroides
Proteus species
Clostridia species
Klebsiella
Corynebacteria
Acinetobacter baumannii
There are conflicting reports on the benefits and cost-effectiveness of hyperbaric oxygen therapy. 7,8 Some
patients may require urinary and/or fecal diversion. 7,8 Negative pressure wound dressings are helpful in
controlling the wound once the infection is adequately debrided and treated. 7
Orchiectomy should be performed only if the testicle itself is not viable. 8,9 In the event of total scrotal
involvement and debridement, protection of the testicles from desiccation can be performed by
placement in subcutaneous thigh pockets. However, as a long-term reconstruction, this is not well
tolerated in younger patients and may decrease fertility owing to the increased temperature of the thigh
pockets. 9 Testicular dressings should be designed to keep the testicle from desiccation and allow for
granulation tissue to form. After granulation tissue is present, scrotal reconstruction can be performed
with split-thickness skin grafts or thigh flaps.
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Trauma
Perineal injuries from military trauma are typically involved in other traumas of the lower extremity
and/or abdomen and pelvis and can be caused by blast injuries such as given by improvised explosive
devices 10,11 or combat-related burns. 3 Military improvised explosive device injuries are further
complicated by bacteria and soil particles that can be driven deep into the involved tissues. 10,11 In the
civilian population, perineal trauma can be from straddle injuries, motor vehicle accidents, and
anogenital penetration due to either accidental falls or sexual assault. 12,13
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Hidradenitis Suppurativa
Hidradenitis suppurativa presents as painful, recurrent nodules that progress to abscesses and
malodorous, draining sinus tracts, which eventually lead to considerable fibrosis. Typically located in the
axilla and/or groin, it can present in any area of the body with apocrine glands, such as the neck, breast,
pannus, genito-anal region, and thighs. French surgeon Alfred Velpeau first described the clinical
presentation of hidradenitis in 1839. However, it was another French surgeon, Aristide Verneuil, who
linked the process to skin-bearing apocrine glands in 1857. 14,15 This gave rise to the term Hidradenitis
Suppurativa, meaning suppurative sweat gland, and engendered its eponym Verneuil disease.
Hidradenitis suppurativa was once believed to be a disease arising from inflammation of apocrine glands
with subsequent bacterial superinfection. 14,16,17 However, it is now understood to be a disease process of
the terminal hair follicle, or the infundibulum. 18-20 A perifollicular lymphocytic infiltration results in
inflammation, which prompts hyperkeratosis of the epithelium of the infundibulum. The resulting
occlusion causes dilation of the follicle bulb and cyst formation. Eventually, the cyst ruptures, releasing
keratin debris and other follicular contents, such as bacteria, into the dermis, resulting in an acute
neutrophilic inflammatory response that progresses to a granulomatous stage with the presence of
foreign body giant cells. If the inflammatory response is extensive, abscess formation occurs, creating
further destruction of other follicles as well as apocrine and eccrine glands. Sinus tracts and fistulas form
between ruptured follicles and the surface of the skin. 18,20,21 In reality, hidradenitis suppurativa is a
misnomer based on historic clinical observations. Advances in understanding the pathophysiology of
hidradenitis suppurativa has given rise to the term acne inversa. 14,15,22
The incidence of hidradenitis is around 1%. There is a 3:1 female to male predominance and tends to
manifest in the second or third decade. There may be a hormonal component associated with it, noting a
decrease in severity after menopause. It is also associated with obesity, diabetes mellitus, metabolic
syndrome, and nicotine use as well as other inflammatory disease processes, such as inflammatory bowel
disease, pyoderma gangrenosum, arthritis, and poly cystic ovarian disease. 19,23 There are two commonly
accepted scales describing the level of severity of hidradenitis, the Hurley Scale and the modified
Sartorius Scale. These grade according to severity, location, and degree of scaring. The process can result
in considerable physical and psychosocial disability.
A Cochran review of literature published up to 2015 found a paucity of high level evidence regarding the
efficacy of definitive therapies for hidradenitis. 23 However, treatment modalities and algorithms have
been suggested based on clinical practice, often graded to levels of classification or severity of disease.
Patient-focused life style modulations include smoking secession, weight loss, and avoidance of
compression and friction in intertriginous areas. Intralesional triamcinolone has been described to
decrease erythema, induration, pain, and lesion size in flare-ups, but long-term efficacy has not been
established. Antibiotic therapies include topical treatments such as clindamycin gel and oral therapies
such as tetracycline, ampicillin, ciprofloxacin, and rifampicin. Most advocate treatments ranging from 2 to
6 weeks. Chronic suppressive therapy may result in resistance. Though staphyloccocus species are
predominant in many of the acute abscess, chronic lesions often are polymicrobial, in which anaerobic
bacteria predominate. 20
Antibiotic therapies do not treat the underlying problem, which is an abnormal inflammatory response.
Several monoclonal antibody antiinflammatory therapies have been studied. Adalimumab, which targets
and blocks TNF-α, is approved by the US Food and Drug Administration for treatment of hidradenitis. 21
There have been several studies on laser therapy using either carbon dioxide (CO2), 1064-nm
neodymium-doped yttrium aluminum garnet (Nd:YAG), or Intense Pulse Light. Though improvement
was noted, recurrence can still occur. 19
Surgical excision is the only method at present to definitively treat the scars and sinus tracts of chronic
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hidradenitis. However, new areas of hidradenitis may still occur adjacent to the treated areas. Incision
and drainage can relieve pain from fluctuant abscesses but should be avoided in firm, solid nodules that
are not purulent. Repeated incision and drainage procedures can also add to the scar burden. Local
excision procedure such as unroofing sinus tract or tangential excision may spare skin but are subject to
higher recurrence rates compared to wide excision. These wounds are left to heal by secondary intention.
Wide excision has a lower recurrence rate, but to resect the entire affected areas, large wounds can result.
The smaller wounds can be closed primarily. Larger wounds can be covered with split-thickness skin
grafting. Rotational flaps have been described to cover larger wounds. Care should be taken in designing
flaps to minimize moving affected tissue into the wound.
Another option for treating these large wounds is healing by secondary intention. Unlike many other
patients requiring perineal reconstruction, hidradenitis patients are uniquely accustomed to painful,
malodorous drainage that requires assiduous dressing changes. Therefore, they are often willing to accept
open, clean wounds that require dressing changes and, while still painful, are not malodorous and
draining. 24 If hidradenitis is left to fester as chronic wound, over time, squamous cell carcinoma can arise
in it, also known as a Marjolin ulcer. 25-28
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Oncologic Causes
Perineal reconstruction for oncologic defects has challenges specific to the nature of the cancer patient.
Fibrosis from neoadjuvant radiation therapy can compromise local tissues available for reconstruction.
The need to start adjuvant radiation therapy can limit the available time for postoperative healing as well
as create the need for more durable coverage. Adjuvant radiation therapy can also cause stenosis of the
perineal structures, such as the vagina. The need for creating stomas must be taken into consideration
when planning flaps and possible rectus muscle harvest.
Cancer patients may also present with baseline nutritional deficits from either cancer cachexia and/or
neoadjuvant chemotherapy. 1 Preoperative anemia may present via chronic blood loss from, for example,
colon cancer, or from neoadjuvant chemotherapy. Optimization of nutrition and anemia may be limited
owing to need for resecting the cancer. All of these things can adversely affect postoperative healing.
Given the challenges of perineal reconstruction in oncologic patients, combination of closure with flaps
decreases major wound complications compared to primary closure. 29,30
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Vulva and Labia
Malignancies of the vulva constitute 1% of female malignancies and 5% genital cancers. 1,31 Ninety-five
percent of the cancers are squamous cell carcinoma (Bowen and Paget disease 32 ), with melanoma,
sarcoma, and basalioma comprising the remainder. 1 In younger patients, human papilloma virus is the
leading cause of cancer, whereas in older patients, lichen sclerosus is often the culprit. Surgical excision is
the first line of therapy and bilateral lymph node dissection is often warranted. Oncologic defects tend to
be limited to skin and subcutaneous tissue. The reconstructive goals are tailored reestablishment of
genitalia, body image, sexual health, and micturition. 1
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Vagina
Vaginal defects can result from primary vaginal malignancy, such as sarcoma. More often, acquired
defects are due to colorectal, gynecologic, or urologic malignancies as part of abdominal perineal
resections or pelvic exenterations. The anterior wall of the vagina is close to the urethra and bladder; the
lateral wall is close to the pelvic muscles; whereas the posterior wall abuts the rectum. Defects involving
the posterior wall need to maintain the separation of the rectum from the vagina. Oncologic resections of
various areas of the vagina can include nearby structures and add to the complexities of reconstruction.
33,34 The resections can be partial or complete and have been classified according to location and extent. 33
Cordeiro et al. described a classification of full-thickness vaginal defects from oncologic resection that is
based on extent of resection and location after simplifying the vagina to a model of a cylinder that is
closed superiorly (Table 97.2). Type I defects are partial, noncircumferential vaginal defects. This is
further subdivided into type IA for anterior and lateral wall defects and type IB for posterior wall defects.
Type II defects are circumferential defects and are subclassified as type IIA for the upper one-to two-
thirds and type IIB for total vaginectomies. 33
TABLE 97.2
Classification of Vaginal Defects From Oncologic Resection 33,34
Defect
Associated Oncologic Resection
Type I
Partial, noncircumferential
IA
Anterior or lateral wall defects
Bladder cancer
Primary vaginal malignancies
IB
Posterior wall defect
Advanced colorectal cancer—abdominal perineal resection
Type II
Circumferential
IIA
Upper one-third to two-thirds
Uterine or cervical cancers
IIB
Total vaginectomies
Pelvic exenterations
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Scrotum and Penis
Most scrotal tumor resections are due to squamous cell carcinoma, Paget disease or human papilloma
virus–related processes. Oncologic defects of the penis can be either partial or complete and are typically
related to lichen sclerosus, carcinoma in situ, carcinoma of the penis, and neuroendocrine tumors. 1
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Reconstruction According to Anatomy
The major goals of perineal reconstruction include a tension-free closure with well-vascularized tissue to
restore or preserve sexual function, body image, micturition, and defecation. The pelvic cavity must be
supported and any dead space must be obliterated in this noncompressible space. Tissue that matches the
thickness of the reconstructed region and minimal donor site morbidity are other considerations. 1,34,35
Multiple algorithms exist regarding the choices in perineal reconstruction, depending on the size and
location of the defect. 31-37 Other factors that affect reconstruction choice include the presence or need for
radiation therapy, need for pelvic support, and presence of a dead space. 35 Because the pelvis is generally
noncompressible, inadequate obliteration of dead space with well-vascularized tissue can lead to
collections, infection, and dehiscence. If the flap chosen for reconstruction lacks adequate volume, an
omental flap can be added to obliterate pelvic dead space.
Patient-specific factors include amount of skin laxity, obesity, and other medical comorbidities that may
restrict the extent of surgery the patient can tolerate. In obese patients, myocutaneous flaps such as the
gracilis or rectus abdominus myocutaneous flaps may be converted to muscle flaps with skin grafting. In
cancer patients, the potential for ostomy creation needs to be considered when planning abdominal-based
flaps. Furthermore, pedicles such as the deep inferior epigastric artery may have been ligated in the
cancer extirpation.
The perineum is rich in anastomosing vessels and perforators perfusing the region. There are multiple
local, fasciocutaneous, island, perforator, and myocutaneous flaps that can be considered. Small defects
can be closed primarily or with local undermining. However, it is important that this can be achieved
without distortion of the perineum, especially the urethra. Defects in which primary closure would cause
perineal distortion or dehiscence require closure going up the reconstructive ladder. Perforator and
muscle-sparing techniques have been applied to traditional myocutaneous flaps and advancement flaps
to minimize donor site morbidity, improve arc of rotation, and provide thinner, better matching tissues.
37-42 The next section will discuss perineal reconstruction based on anatomic region. The flaps available for
reconstruction by anatomy are summarized in Table 97.3. Because of the numerous flaps available to
reconstruct the perineal region, the details of each flap are noted in Table 97.4, which also includes a
citation in which specific, technical methods for harvesting the flap can be found.
TABLE 97.3
Flaps for Reconstruction by Anatomy
Vulva
Vagina
IA
Vagina IB
Vagina IIA
Vagina IIB
Perineum
Scrotum
Penis
Pudendal thigh
(Singapore)
Pudendal
thigh
VRAM
Tubed VRAM
Rolled
TRAM
RAM
SCIP
Radial
forearm
free flap
Lotus petal
ORAM
Tubed V-DIEP
Rolled
DIEP
VY advancement of gracilis,
gluteal, or perineal perforator
+/− omental flap
ALT
Pedicled
ALT
Gluteal fold
rotational
V-DIEP
Tubed ORAM
Rolled
ORAM/ms
ORAM
Bilateral gluteal fold rotational
Internal
pudendal
perforator
Gracilis- rotational
or VY
advancement
ms
ORAM/VRAM
Tubed ms
ORAM/VRAM
Bilateral
gracilis
Internal pudendal perforator
ALT
Perineal artery perforator
Perineal artery
perforator
Internal pudendal
perforator
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ALT, anterior lateral thigh; DIEP, deep inferior epigastric perforator; ms, muscle-sparing; ORAM, oblique rectus abdominus myocutaneous;
SCIP, superficial circumflex iliac perforator; TRAM, transverse rectus abdominus myocutaneous; V-DIEP, vertical deep inferior epigastric
perforator; VRAM, vertical rectus abdominus myocutaneous.
TABLE 97.4
Flaps Used to Reconstruct the Perineum
Flap
Type
Vasculature
Defect
Benefits
Limitations
Details on
Harvest
Pudendal
thigh flap
(Singapore
flap)
Rotational island
flap
Posterior
labial artery
Vulva
Vagina
Thin skin
Erogenous
sensation
Pedicle
could
be
resected in defect or in
field of radiation
Needs additional flap if
significant pelvic dead
space
Monstrey
et al. 50
Lotus petal
flap
Rotational
perforator flap
Perineal and
internal
pudendal
artery
Vulva
Partial
vagina
Thin skin
Similar
skin
quality
Donor site well
concealed
Perforators to Inner and
intermediate petals may
be resected in defect or
in field of neoadjuvant
radiation
Yii &
Niranjan 51
Gluteal fold
flap
Rotational flap
Lowest petal of
the lotus petal flap
Internal
pudendal
artery
Vulva
Vagina
Perineum
Donor site well
concealed
Usually
not
in
field of radiation
therapy for vulvar
cancers
Potential
kinking
of
pedicle when rotated
for inset
Donor
site
sensitive
when sitting
Hashimoto

 et al. 52
Gluteal VY
advancement
flap
Advancement flap
Internal
pudendal
artery
perforators
Vulva
Partial
vagina
Thin skin
Similar
skin
quality
Well-concealed
donor site
Avoids potential
kinking of pedicle
because
not
rotated
Donor
site
sensitive
when sitting
Lee et al. 53
Anterior
lateral thigh
flap
Rotational
perforator flap
Descending
branch of
LCA
Vulva
Scrotum
Penis
Out of field of
radiation therapy
May
include
muscle if needed
Can be sensate
Depending on patient
BMI, tissue may be
bulky
Sensation innervated by
lateral
femoral
cutaneous
nerve
and
not erogenous
Lin et al. 45
Xu & Watt
47
Superficial
circumflex
iliac
perforator flap
Rotational
perforator flap
SCIA
Scrotum
Thin,
durable
tissue
Requires knowledge of
perforator dissection
Han et al.
44
Gracilis flap
Rotational
myocutaneous
flap
Medial
femoral
circumflex
artery
Vagina
Perineum
Out of field of
radiation therapy
Skin
paddle
can
be
unreliable
in
obese
patients
Pusic &
Mehrara 34
Rectus
abdominus
myocutaneous
(RAM) flaps
Rotational
myocutaneous
flap
DIEA
Vagina
Perineum
VRAM
Rotational
myocutaneous
DIEA
Vagina
Perineum
Pusic &
Mehrara 34
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flap
TRAM
Rotational
myocutaneous
flap
DIEA
Vagina
Perineum
Rolled for total
vaginal
reconstruction
Can
have
thick
subcutaneous layer
Pusic &
Mehrara 34
ORAM
Rotational
myocutaneous
flap
Perforator/muscle-
sparing rotational
flap
DIEA
Vagina
Perineum
Thinner
subcutaneous
tissue
More rectus and
fascia preserved
Pedicle
of
pure
perforator
dissection
delicate and can be
inadvertently
avulsed;
medial muscle-sparing
strip
of
rectus
is
protective
Lee &
Dumanian
43
Vertical
DIEP/muscle-
sparing
Perforator/muscle-
sparing rotational
flap
DIEA
Vagina
Perineum
More rectus and
fascia preserved
Pedicle
of
pure
perforator
dissection
delicate and can be
inadvertently
avulsed;
medial muscle-sparing
strip
of
rectus
is
protective
Wang et al.
54
Internal
pudendal
perforator
flaps
Rotational,
propeller, or VY
advancement flaps
Perforators of
the internal
pudendal
artery
Vulva
Scrotum
Perineum
Free
style–based
perforator
flap
design based on
defect and near by
perforators found
by Doppler.
Requires understanding
of
perforator
flap
dissection
Hong et al.
37
Perineal artery
Perforator
Flaps
Rotational,
propeller, or VY
advancement flaps
Perforators of
the perineal
artery branch
of pudendal
artery
Vulva
Perineum
Free
style–based
perforator
flap
design based on
defect and near by
perforators found
by Doppler.
Flaps could be affected
by
neoadjuvant
radiation therapy
Requires understanding
of
perforator
flap
dissection
Kim et al.
39
Radial
Forearm flap
Free flap
Radial artery
Penis
Thin
Sensate
Urethra
reconstruction
Donor site visible
Requires microsurgery
Gottlieb 46
DIEA, deep inferior epigastric artery; DIEP, deep inferior epigastric perforator; LCA, lateral circumflex artery; ORAM, oblique rectus
abdominus myocutaneous; SCIA, superficial circumflex iliac artery; TRAM, transverse rectus abdominus myocutaneous; VRAM, vertical
rectus abdominus myocutaneous.
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Vulvar Reconstruction
Applying the subunit principle, the vulva can be divided into three zones. The upper-third spans the
mons to the labia, the middle third consists of the labia minora and majora, and the lower third involves
the vaginal introitus and perineum. 1
Upper-third defects that are small (<20 cm) can often be closed primarily or with local flaps such as
rhomboid and advancement flaps. Defect of patients who have not had radiation therapy and/or will not
require radiation therapy, can often be reconstructed with a split-thickness skin graft. Defects larger than
20 cm or those that have been or will be radiated can be reconstructed with a pedicled anterolateral thigh
flap. Middle-third defects can be reconstructed with Singapore flaps or lotus petal flaps if the field has not
been radiated. Gracilis myocutaneous flaps or gluteal fold flaps are options if the field was previously
irradiated or the pudendal perforators were ligated during the resection. Lower-third defects are well
covered by gluteal fold flaps or VY-advancement based off of the internal pudendal artery perforators. 1
In the case of defect that crosses midline, bilateral flaps are recommended rather than crossing the
midline with the reconstruction because this can lead to perfusion problems or distortion of the various
orifices.
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Vaginal Reconstruction
Partial-thickness defects may be amenable to split-thickness skin grafts or buccal mucosal grafts. Small
defects may be closed primarily. Type IA flaps are most often addressed with the pudendal thigh flaps,
also known as the Singapore flap. Type IB flaps are most typically reconstructed with rectus abdominus
myocutaneous flap. The skin paddle can be oriented in a vertical or oblique manner depending on patient
body habitus and size required for reconstruction. These flaps bring in well-vascularized tissue that can
obliterate dead space as well as reconstruct the vagina. Perforator and muscle-sparing techniques reduce
donor site morbidity by limiting the amount of rectus facia and muscle that are harvested. 40,41,43 This can
spare rectus function, especially if multiple ostomies are necessary.
For type IIA reconstruction, a rolled transverse rectus abdominus myocutaneous is often used. For type
IIB, option for total vaginal reconstruction is bilateral gracilis myocutaneous flaps, which would provide
adequate tissue for obliteration of dead space as well as vaginal reconstruction. This is also a good choice
if multiple ostomies are necessary.
In obese patients, in whom a myocutaneous flap would be too thick, or those with multiple medical
comorbidities, a rectus abdominis or gracilis muscle flap paired with a split thickness skin graft may
suffice. Vaginal stents to bolster the skin graft with or without negative pressure dressings can be useful
in this area where prevention of shear is difficult. 5,34 In general, for total vaginal reconstruction, an inner
diameter of about 4 cm is desired. In the rolled transverse rectus abdominus myocutaneous flap, this
would translate to a flap width of about 12 to 15 cm depending on subcutaneous thickness. 34
Postoperative vaginal dilators help to prevent stenosis.
There are multifactorial physical and psychological barriers in the return to penile-vaginal penetrative
sexual activity after reconstruction. These range from absence of pleasure, dyspareunia, dryness,
discharge, lack of partner to body image concerns about reconstruction and/or ostomies. 34 Postoperative
penile-vaginal penetrative sex is approximately 50%, and it is most correlated with preoperative activity.
Those who were not sexually active prior to surgery did not become sexually active after surgery.
Therefore, in this population, vaginal reconstruction may not be necessary. It is important to have a direct
conversation about sexual activity and expectations prior to surgery to aid in the surgical planning as
well as patients’ psychological well being. Postoperative counseling with a psychologist may be
beneficial. 34
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Perineal Reconstruction
Perineal defects typically occur after abdominal perineal resections for advanced colorectal cancers. In
women, the vagina is often involved and the reconstruction is discussed in the previous section. In men,
perineal reconstruction can be necessary without concurrent genital reconstruction. The same principles
of obliteration of dead space and well-vascularized tissue in the setting of radiation therapy are
applicable. In addition to rectus abdominus myocutaneous flaps, reconstructive options include bilateral
gluteal fold flaps and bilateral VY advancement flaps based on the gracilis, perineal, or internal pudendal
perforators. 36,39 The presence of radiation may preclude flaps based on perineal perforators.
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Scrotal Reconstruction
Many smaller defects can be closed after local tissue mobilization; larger defects can be reconstructed
with split-thickness skin grafts with or without local tissue mobilization. In the event of previous
irradiation or need for adjuvant radiation therapy, local flaps, such as pedicled pudendal thigh flaps are
possible. Other flaps that have been described include anterior lateral thigh flaps and superficial
circumflex iliac perforator flaps. 1,44,45
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Penile Reconstruction
Partial defects of the glans and/or distal corporectomy can be reconstructed with a split thickness skin
graft. Partial or complete penectomy can be performed with phalloplasty techniques used for gender
affirmation surgery (see Chapter 100). Basic principles include a tube within a tube design to reconstruct
the urethra with the penis in a single flap. The radial forearm free flap provides thin, sensate tissue that
allows for both urethral and penile reconstruction. 46 Rotational anterior lateral thigh flaps have also been
described, but these can be bulky depending on the thickness of the patient’s subcutaneous fat and more
subject to urethral complications and revisions. 47 For total penile reconstruction, not in the setting of
active oncologic therapy, new frontiers include composite tissue allotransplantation. 48
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Postoperative Protocols
Although there are many postoperative protocols reported according to surgeon and institutional
practices, several common themes exist. Suture line care to avoid maceration and to minimize bacterial
contamination from urinary or fecal sources helps prevent dehiscence. Urinary catherization may be
necessary depending on the location of the defect reconstructed. Avoidance of dependent pressure on the
reconstruction can be tailored according to the location of the specific defect and flap by positioning the
patient prone, supine, or lateral decubitus positioning. If the reconstruction crosses the ischial tuberosity,
hip flexion and sitting are avoided in the immediate postoperative stage. Ambulation is important to
avoid venous thromboembolic (VTE) events. However, some prefer to delay ambulation for several days.
Most agree to avoid sitting and transition from a log roll to standing. Physical therapy is a useful adjunct
to help patients remain mobile within their restrictions. In the event of restrictions in mobility, VTE
prophylaxis is important. When sitting is allowed, it is introduced initially in limited periods followed
with assessment of the flap for any hyperemia or compromise and gradually increased in frequency if the
clinical examination remains stable.
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Questions
1. What is the neurovascular pedicle for the Singapore flap?
a. Deep inferior epigastric artery and lateral femoral cutaneous nerve
b. Posterior labial artery and posterior cutaneous nerve of the thigh
c. Inferior perineal artery and middle cluneal nerve
d. Superficial circumflex iliac artery and iliohypogastric nerve
2. Which of the following best describes the etiology of hidradenitis?
a. It is a dysfunction of eccrine glands of the skin, which cause cyst formation and abscesses.
b. It is a dysfunction of apocrine glands of the skin, giving rise to bacterial superinfection and
abscess formation.
c. It is an abnormal neutrophilic infiltration of the follicular bulb, causing destruction of hair
follicles and creating draining sinus tracts.
d. It is an abnormal lymphocytic infiltration of the follicular infundibulum, creating a keratin
plug and rupture of the follicular bulb.
3. A 14-year-old girl sustained deep second-degree scald burns on her bilateral inner thighs and labia
from instant noodle soup that tipped over while she was holding it in her lap. She was admitted to a
burn unit and on day 2 was taken to the operating room for excision of her bilateral inner thigh
burns. Which of the following best describes the management for the second-
 degree burns of the
labia while she is in the operating room?
a. Full-thickness excision, covering with allograft, followed by autograft in 5 days
b. Tangential excision, covering with allograft, followed by autograft in 5 days
c. Mechanical debridement, leaving open to air
d. Mechanical debridement, covering with silver sulfadiazine
4. A 62-year-old female with a T4N1M1 rectal adenocarcinoma was treated with neoadjuvant
chemotherapy and 50 Gy of neoadjuvant radiation therapy. She was sexually active until her
radiation therapy. An abdominoperineal resection with posterior vaginal wall resection and
lymphadenectomy is planned. Which of the following is the most appropriate flap for
reconstruction?
a. Pudendal thigh flap
b. Vertical rectus abdominus myocutaneous flap
c. Perineal perforator VY advancement flap
d. Right gluteal fold flap
5. A 58-year-old man had bilateral internal pudendal artery perforator VY advancement flaps to
reconstruct the perineal defect after abdominoperineal resection. Which of the following
postoperative activities should he avoid on postoperative day 7?
a. Ambulation
b. Standing
c. Sitting
d. Laying supine
1. Answer: b. The Singapore flap is pudendal thigh flap. It receives its perfusion from the posterior
labial artery and derives sensory innervation from the perineal branches of the posterior cutaneous
nerve of thigh. The flaps are useful for vulvar or vaginal reconstruction because they are easily
rotated into position and can provide sensate reconstruction that could be erogenous. Caution should
be used if previous radiation therapy to the perineum has occurred, as the pedicle for this flap is
often in the field of treatment.
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2. Answer: d. Hidradenitis occurs as a dysfunction immune response. A perifollicular lymphocytic
infiltration of the terminal shaft gives rise to overproduction of keratin in the epithelium, creating a
keratin plug. The increased pressure forms a cyst in the bulb, which eventually ruptures, spilling
keratin and bacteria into the dermis. This robust neutrophilic immune response over time becomes
granulomatous with foreign body giant cells. Abscess formation causes further destruction of other
follicles; sinus tract formation and dense fibrosis are common.
3. Answer: d. Unlike burns in other areas of the body, burns of the perineal region are not treated
with early excision and grafting. They are initially treated conservatively with cleaning fibrinous
exudate and topical antimicrobial drugs. They often heal primarily with this treatment.
4. Answer: b. Although a pudendal thigh flap (Singapore flap) could provide a sensate flap for
partial vaginal reconstruction, its pedicle is likely in the zone of radiation therapy and it would
provide insufficient tissue to obliterate pelvic dead space and support the pelvic floor. Perineal
perforator VY advancement flaps would not provide adequate reconstruction for vaginal
reconstruction. A unilateral gluteal fold flap would not provide enough volume for pelvic floor
support and reconstruction of the vagina. A vertical rectus abdominus myocutaneous flap would
provide well-vascularized tissue to prevent prolapse of pelvic contents, obliterate dead space, and
reconstruct the vagina and the perineum in this radiated field.
5. Answer: c. The sitting position will put pressure on internal pudendal artery VY advancement
flaps from the ischium and tension from the hip flexion. This could lead to flap compromise and/or
suture line dehiscence. Ambulation is important for pulmonary toilet and prevention of VTE disease.
Standing and laying supine should not put pressure on the flap.
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References
Weichman, KE, Matros, E, Disa, JJ. Reconstruction of peripelvic oncologic defects. Plast Reconstr Surg. 2017;140(4):601e-612e.A good overview of
reconstruction of acquired perineal defects in the setting of oncologic resection. Reviews anatomy and outlines methods to harvest various flaps.
Abel, NJ, Klaassen, Z, Mansour, EH, et al. Clinical outcome analysis of male and female genital burn injuries: a 15-year experience at a level-1
burn center. Int J Urol. 2012;19(4):351-358.
Clemens, MS, Janak, JC, Rizzo, JA, et al. Burns to the genitalia, perineum, and buttocks increase the risk of death among U.S. service
members sustaining combat-related burns in Iraq and Afghanistan. Burns. 2017;43(5):1120-1128.
Weiler-Mithoff, EM, Hassall, ME, Burd, DA. Burns of the female genitalia and perineum. Burns. 1996;22(5):390-395.
Harpole, BG, Wibbenmeyer, LA, Erickson, BA. Genital burns in the national burn repository: incidence, etiology, and impact on morbidity
and mortality. Urology. 2014;83(2):298-302.
Demir, CY, Yuzkat, N, Ozsular, Y, et al. Fournier gangrene: association of mortality with the complete blood count parameters. Plast Reconstr
Surg. 2018;142(1):68e-75e.
Ferretti, M, Saji, AA, Phillips, J. Fournier’s gangrene: a review and outcome comparison from 2009 to 2016. Adv Wound Care. 2017;6(9):289-
295.
Eke, N. Fournier’s gangrene: a review of 1726 cases. Br J Surg. 2000;87(6):718-728.
Bhatnagar, AM, Mohite, PN, Suthar, M. Fournier’s gangrene: a review of 110 cases for aetiology, predisposing conditions, microorganisms,
and modalities for coverage of necrosed scrotum with bare testes. N Z Med J. 2008;121(1275):46-56.
Jacobs, N, Rourke, K, Rutherford, J, et al. Lower limb injuries caused by improvised explosive devices: proposed “Bastion classification” and
prospective validation. Injury. 2014;45(9):1422-1428.
Smith, S, Devine, M, Taddeo, J, McAlister, VC. Injury profile suffered by targets of antipersonnel improvised explosive devices: prospective
cohort study. BMJ Open. 2017;7(7):e014697.
Jones, JG, Worthington, T. Genital and anal injuries requiring surgical repair in females less than 21 years of age. J Pediatr Adolesc Gynecol.
2008;21(4):207-211.
Csorba, R, Engel, JB, Wieg, C. Surgical repair of an impalement genital injury from an inline skating accident in a 7-year-old prepubertal girl:
a case report. J Pediatr Adolesc Gynecol. 2017;30(1):e11-e13.
Boer, J, Weltevreden, EF. Hidradenitis suppurativa or acne inversa: a clinicopathological study of early lesions. Br J Dermatol. 1996;135(5):721-
725.
Dessinioti, C, Katsambas, A, Antoniou, C. Hidradenitis suppurrativa (acne inversa) as a systemic disease. Clin Dermatol. 2014;32(3):397-408.
Elwood, ET, Bolitho, DG. Negative-pressure dressings in the treatment of hidradenitis suppurativa. Ann Plast Surg. 2001;46(1):49-51.
Shelley, WB. The pathogenesis of hidradenitis suppurativa in man: experimental and histologic observations. AMA Arch Dermatol.
1955;72(6):562.
Prens, E, Deckers, I. Pathophysiology of hidradenitis suppurativa: an update. J Am Acad Dermatol. 2015;73(5 suppl 1):S8-S11.
Gulliver, W, Zouboulis, CC, Prens, E, et al. Evidence-based approach to the treatment of hidradenitis suppurativa/acne inversa, based on the
European guidelines for hidradenitis suppurativa. Rev Endocr Metab Disord. 2016;17(3):343-351.
Guet-Revillet, H, Jais, J-P, Ungeheuer, M-N, et al. The microbiological landscape of anaerobic infections in hidradenitis suppurativa: a
prospective metagenomic study. Clin Infect Dis. 2017;65(2):282-291.
Saunte, DML, Jemec, GBE. Hidradenitis suppurativa: advances in diagnosis and treatment. JAMA. 2017;318(20):2019-2032.
Sellheyer, K, Krahl, D. “Hidradenitis suppurativa” is acne inversa! An appeal to (finally) abandon a misnomer. Int J Dermatol. 2005;44(7):535-
540.
Ingram, JR, Woo, P-N, Chua, SL, et al. Interventions for hidradenitis suppurativa. Cochrane Database Syst Rev. 2015;(10):CD010081.
Humphries, LS, Kueberuwa, E, Beederman, M, Gottlieb, LJ. Wide excision and healing by secondary intent for the surgical treatment of
hidradenitis suppurativa: a single-center experience. J Plast Reconstr Aesthetic Surg. 2016;69(4):554-566. doi:10.1016/j.bjps.2015.12.004.
Maclean, GM, Coleman, DJ. Three fatal cases of squamous cell carcinoma arising in chronic perineal hidradenitis suppurativa. Ann R Coll
Surg Engl. 2007;89(7):709-712.
Altunay, IK, Gökdemir, G, Kurt, A, Kayaoglu, S. Hidradenitis suppurativa and squamous cell carcinoma. Dermatol Surg. 2002;28(1):88-90.
Lin, MT, Breiner, M, Fredricks, S. Marjolin’s ulcer occurring in hidradenitis suppurativa. Plast Reconstr Surg. 1999;103(5):1541-1543.
Gur, E, Neligan, PC, Shafir, R, et al. Squamous cell carcinoma in perineal inflammatory disease. Ann Plast Surg. 1997;38(6):653-657.
Devulapalli, C, Jia Wei, AT, DiBiagio, JR, et al. Primary versus flap closure of perineal defects following oncologic resection: a systematic
review and meta-analysis. Plast Reconstr Surg. 2016;137(5):1602-1613.A meta-analysis of primary versus flap closure for perineal defects in cancer
patients. It shows a decrease in major wound complications in flap closure compared with primary closure without increase in hernia rate, unplanned
reoperations, or length of hospital stay.
Crosby, MA, Hanasono, MM, Feng, L, Butler, CE. Outcomes of partial vaginal reconstruction with pedicled flaps following oncologic
resection. Plast Reconstr Surg. 2011;127(2):663-669.
Tan, B-K, Kang, GC-W, Tay, EH, Por, YC. Subunit principle of vulvar reconstruction: algorithm and outcomes. Arch Plast Surg.
2014;41(4):379-386.
Mericli, AF, Martin, JP, Campbell, CA. An algorithmic anatomical subunit approach to pelvic wound reconstruction. Plast Reconstr Surg.
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2016;137(3):1004-1017.
Cordeiro, PG, Pusic, AL, Disa, JJ. A classification system and reconstructive algorithm for acquired vaginal defects. Plast Reconstr Surg.
2002;110(4):1058-1065.Present the classification for vaginal defects from oncologic resections based on location and extent. Uses the classification to
propose an algorithm for flap reconstruction.
Pusic, AL, Mehrara, BJ. Vaginal reconstruction: an algorithm approach to defect classification and flap reconstruction. J Surg Oncol.
2006;94(6):515-521.Presents algorithm for flap reconstruction of acquired vaginal defects based on the Cordeiro classification and describes the
technical details of flap harvest.
Gentileschi, S, Servillo, M, Garganese, G, et al. Surgical therapy of vulvar cancer: how to choose the correct reconstruction? J Gynecol Oncol.
2016;27(6).
John, HE, Jessop, ZM, Di Candia, M, et al. An algorithmic approach to perineal reconstruction after cancer resection: experience from two
international centers. Ann Plast Surg. 2013;71(1):96-102.
Hong, JP, Kim, CG, Suh, HS, et al. Perineal reconstruction with multiple perforator flaps based on anatomical divisions. Microsurgery.
2017;37(5):394-401.
Sinna, R, Qassemyar, Q, Benhaim, T, et al. Perforator flaps: a new option in perineal reconstruction. J Plast Reconstr Aesthet Surg.
2010;63(11):e766-e774.
Kim, JT, Ho, SYM, Hwang, JH, Lee, JH. Perineal perforator-based island flaps: the next frontier in perineal reconstruction. Plast Reconstr Surg.
2014;133(5):683e-
 687e.
Abbott, DE, Halverson, AL, Wayne, JD, et al. The oblique rectus abdominal myocutaneous flap for complex pelvic wound reconstruction. Dis
Colon Rectum. 2008;51(8):1237-1241.
Combs, PD, Sousa, JD, Louie, O, et al. Comparison of vertical and oblique rectus abdominis myocutaneous flaps for pelvic, perineal, and
groin reconstruction. Plast Reconstr Surg. 2014;134(2):315-323.
Huang, J-J, Chang, N-J, Chou, H-H, et al. Pedicle perforator flaps for vulvar reconstruction–new generation of less invasive vulvar
reconstruction with favorable results. Gynecol Oncol. 2015;137(1):66-72.
Lee, MJ, Dumanian, GA. The oblique rectus abdominis musculocutaneous flap: revisited clinical applications. Plast Reconstr Surg.
2004;114(2):367-373.
Han, HH, Lee, JH, Kim, SM, et al. Scrotal reconstruction using a superficial circumflex iliac artery perforator flap following Fournier’s
gangrene. Int Wound 

J. 2014;13(5):996-999.
Lin, C-T, Chang, S-C, Chen, S-G, Tzeng, Y-S. Reconstruction of perineoscrotal defects in Fournier’s gangrene with pedicle anterolateral thigh
perforator flap. ANZ J Surg. 2016;86(12):1052-1055.
Gottlieb, LJ. Radial forearm. Clin Plast Surg. 2018;45(3):391-398.Describes the technical details in phalloplasty using a radial forearm free flap.
Xu, KY, Watt, AJ. The pedicled anterolateral thigh phalloplasty. Clin Plast Surg. 2018;45(3):399-406.
Tuffaha, SH, Cooney, DS, Sopko, NA, et al. Penile transplantation: an emerging option for genitourinary reconstruction. Transpl Int.
2017;30(5):441-450.
Clerico, C, Lari, A, Mojallal, A, Boucher, F. Anatomy and aesthetics of the labia minora: the ideal vulva? Aesthetic Plast Surg. 2017;41(3):714-
719.
Monstrey, S, Blondeel, P, Van Landuyt, K, et al. The versatility of the pudendal thigh fasciocutaneous flap used as an island flap. Plast
Reconstr Surg. 2001;107(3):719-725.
Yii, NW, Niranjan, NS. Lotus petal flaps in vulvo-vaginal reconstruction. Br J Plast Surg. 1996;49(8):547-554.
Hashimoto, I, Nakanishi, H, Nagae, H, et al. The gluteal-fold flap for vulvar and buttock reconstruction: anatomic study and adjustment of
flap volume. Plast Reconstr Surg. 2001;108(7):1998-2005.
Lee, JH, Shin, JW, Kim, SW, et al. Modified gluteal fold V-Y advancement flap for vulvovaginal reconstruction: Ann Plast Surg.
2013;71(5):571-574.
Wang, X, Qiao, Q, Burd, A, et al. A new technique of vaginal reconstruction with the deep inferior epigastric perforator flap: a preliminary
report. Plast Reconstr Surg. 2007;119(6):1785-1790.
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C H A P T E R 9 8
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Diagnosis and Treatment of Lymphedema
Oluseyi Aliu and Jill P. Stone, and Ming-Huei Cheng
Key Points
Overweight/obesity (BMI >25), skin infections, axillary or pelvic node dissection, radiation, and
genetic predisposition are known risk factors for secondary lymphedema.
Patients should be counseled that there is no cure for primary and secondary lymphedema. Hence,
nonsurgical and surgical treatments focus on symptom improvement and arresting disease
progression.
Prevention is the most effective intervention for lymphedema. Hence, at-risk patients should be
closely monitored for any changes in limb volume to identify subclinical edema and implement early
interventions.
The first-line treatment for lymphedema is compressive decongestive therapy, which consists of skin
care, manual lymphatic drainage, and compression therapy.
Lymphovenous anastomosis is indicated in the early stages of lymphedema with patent lymphatic
vessels identified on indocyanine green lymphography. In this procedure, lymphatic fluid is
bypassed into peripheral subdermal venules.
Vascularized lymph node transfer is thought to restore physiologic lymphatic drainage either by
reconstituting lymphatic channels or by soaking up excess lymphatic fluid and facilitating egress into
the peripheral venous circulation.
The lymphatic system has three vital functions: support of the immune system, gastrointestinal lipid
absorption, and fluid balance. Functionally, to accomplish fluid balance, the lymphatic system is
structurally composed of a unidirectional circulatory network responsible for reabsorption and return of
approximately 90% of interstitial capillary ultrafiltrate to the circulatory system. 1 Lymphedema is the
result of derangements in fluid balance. Lymphedema is a chronic, progressive, and debilitating disease
characterized by abnormal accumulation of protein-rich interstitial fluid resulting in swelling,
inflammation, and irreversible tissue changes typically affecting the limbs 1,2 (Figure 98.1). The underlying
mechanism is a drainage dysfunction due to a malformed or disrupted lymphatic system causing an
insufficiency in reabsorption of ultrafiltrate and transport back to the circulatory system. 1
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FIGURE 98.1 A patient with lymphedema of the left lower extremity.
Lymphedema profoundly impacts patient physical function, psychosocial well-being, and quality of life.
3-6 Lymphedema patients perform worse on objective tests of limb function and demonstrate greater
functional impairment in recreational activities and tasks of daily living. 4-6 Psychosocial morbidity
includes depressive symptoms such as helpless and hopelessness, poor body image, and social isolation
to avoid scrutiny. 5,6 Finally, the economic burden of care is profound both to the patient and healthcare
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system as patients are typically afflicted with recurrent infections, open wounds, chronic pain and often
require long-term intensive treatment for this chronic, progressive condition. 7,8 Current treatment options
are largely palliative with the primary goals of providing symptom relief and preventing disease
progression.
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