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Gender-Specific Anatomical Distribution of Internal Pudendal Artery Perforator: a Radiographic Study for Perineal Reconstruction

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Gender-Specific Anatomical Distribution of Internal Pudendal Artery Perforator: a Radiographic Study for Perineal Reconstruction University of Massachusetts Medical School eScholarship@UMMS Open Access Publications by UMMS Authors 2020-10-29 Gender-specific Anatomical Distribution of Internal Pudendal Artery Perforator: A Radiographic Study for Perineal Reconstruction Regina Sonda Padova University Hospital Et al. Let us know how access to this document benefits ou.y Follow this and additional works at: https://escholarship.umassmed.edu/oapubs Part of the Plastic Surgery Commons, Surgery Commons, Surgical Procedures, Operative Commons, and the Urogenital System Commons Repository Citation Sonda R, Monticelli A, Dalla Venezia E, Giraudo C, Giatsidis G, Bassetto F, Macchi V, Tiengo C. (2020). Gender-specific Anatomical Distribution of Internal Pudendal Artery Perforator: A Radiographic Study for Perineal Reconstruction. Open Access Publications by UMMS Authors. https://doi.org/10.1097/ GOX.0000000000003177. Retrieved from https://escholarship.umassmed.edu/oapubs/4434 Creative Commons License This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 4.0 License. This material is brought to you by eScholarship@UMMS. It has been accepted for inclusion in Open Access Publications by UMMS Authors by an authorized administrator of eScholarship@UMMS. For more information, please contact [email protected]. ORIGINAL ARTICLE Reconstructive Gender-specific Anatomical Distribution of Internal Pudendal Artery Perforator: A Radiographic Study for Perineal Reconstruction Regina Sonda, MD* Andrea Monticelli, MD* Background: Cancer, trauma, infection, or radiation can cause perineal defects. Erica Dalla Venezia, MD* Fasciocutaneous flaps based on perforator vessels (PV) from the internal puden- Chiara Giraudo, MD† dal artery (IPA) provide an ideal reconstructive option for moderate defects. We Giorgio Giatsidis, MD, PhD‡ hypothesized that, due to gender differences in the pelvic–perineal region, the Franco Bassetto, MD* anatomical distribution of PV differs between genders. Veronica Macchi, MD§ Methods: Computed tomography angiographies from male and female patients Cesare Tiengo, MD* without pelvic–perineal pathologies were retrospectively analyzed to study the vas- cular anatomy of the IPA. The number, size, type, and distribution of PV were recorded and compared between genders. Four anatomical regions were defined to describe the distribution of PV on each perineal side: anterior (A), anterior- central (AC), central-posterior (CP), and posterior (P). Results: A total of 63 computed tomography angiographies were analyzed (men, 31; women, 32). Each IPA provides 2 ± 1 PV and 5 ± 2 terminal (cutaneous) branches: in both genders, 85% of PV are septocutaneous (15% musculocutane- ous). In women, 70.5% of PV are located in AC, 28.2% in CP, 1.2% in A, and 0% in P: average diameter of the PV is 2.4 ± 0.3 mm. In men, 53.7% of PV are located in CP, 43.1% in AC, 3.3% in A, and 0% in P: average diameter of the PV is 2.8 ± 0.5 mm. Gender-specific differences in anatomical distribution of PV are signifi- cant (P < 0.001). Conclusions: Number, size, and type of terminal branches of PV of the IPA are con- sistent between genders, but their distribution is different, with women having an anterior predominance. Knowledge of gender-specific anatomy can guide preoper- ative planning and intraoperative dissection in flap-based perineal reconstruction (Plast Reconstr Surg Glob Open 2020;8:e3177; doi: 10.1097/GOX.0000000000003177; Published online 29 October 2020.) INTRODUCTION Although each of the conditions mentioned above has The perineum is an anatomically and functionally a relatively low incidence, collectively they represent a complex region. Several conditions, ranging from cancer common surgical scenario. Cancer is the most frequent to trauma or pressure injuries,1 infection, radiation, con- cause of perineal defects, directly (colorectal adenocarci- genital to gender-affirming surgery, can lead to the need noma, anal squamous cell carcinoma, vulvar and vaginal for perineal reconstruction and function restoration. squamous cell carcinoma, or Paget’s disease) or indirectly (radiation therapy for pelvic tumors). For example, over From the *Clinic of Plastic Reconstructive and Aesthetic Surgery, 6000 vulvar cancers are diagnosed every year in the United Padova University Hospital, Padova, Italy; †Clinic of Radiology, States (0.7% of all cancers in women and 6% of all can- Department of Medicine, Padova University Hospital, Padova, cers affecting the female reproductive system). Other Italy; ‡Division of Plastic Surgery, University of Massachusetts conditions, such as Fournier’s gangrene, are more rare Medical School, Worcester, Mass.; and §Institute of Human (incidence, 1.6 per 100,000 men in the United States) but Anatomy, University of Padova, Padova, Italy. associated with a high morbidity and mortality (7.5% fatal- ity rate).2 Received for publication July 6, 2020; accepted August 18, 2020. The variety and severity of these conditions, as well as their Copyright © 2020 The Authors. Published by Wolters Kluwer Health, impact on patients’ function (including sexual) and quality Inc. on behalf of The American Society of Plastic Surgeons. This of life, highlight the importance of proper defect reconstruc- is an open-access article distributed under the terms of the Creative tion and function restoration. Proper perineal reconstruction Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in Disclosure: The authors have no financial interest to declare any way or used commercially without permission from the journal. in relation to the content of this article. DOI: 10.1097/GOX.0000000000003177 www.PRSGlobalOpen.com 1 PRS Global Open • 2020 has been associated with high patient satisfaction,3,4 although Imaging Analysis preinjury function and quality of life are not fully recovered. CTAs of the abdominal-pelvic area were analyzed by Several reconstructive techniques are currently avail- Horos (Open Source Software, Horosproject.org, v 3.3) to able, including direct wound closure and skin grafts, local investigate the vascular system of the IPA bilaterally. The fol- or pedicled flaps, and microsurgical free flap reconstruc- lowing parameters were assessed: presence of the IPA, the tion.3,5–11 Pedicled fasciocutaneous flaps have shown to be diameter of the IPA at the inlet of the lesser sciatic foramen a less invasive and ideal option to repair moderate perineal (pudendal canal), the number of perforator vessels branch- defects.5,12–14 Possibly, they could also be adopted for smaller ing from each IPA, their type/course (musculocutaneous defects because direct wound closure, skin grafts, and local or septocutaneous), the location of their origin, reported flaps have been associated with poor outcomes due to wound in percentage, and their diameter (ie, both at the origin dehiscence, scarring, anatomical disruption, and functional and where they pierce the pudendal canal) (Fig. 1A). restriction.3,5–7,15–18 Among fasciocutaneous flaps, those Any anatomical variation of that regional vascular sys- based on the internal pudendal artery (IPA) system and its tem was also recorded. The localization of the vessels was branches (eg, perineal artery) have been frequently used and defined using the Cartesian system, considering the anus have been associated with optimal outcomes, as they provide as the origin point (point 0.0).35 The distance of each per- an ideal restoration of native tissue structure, limited scar- forator vessel from the anus was calculated on each main ring, function restoration, and retention of sensation.1,4,12,19–29 axis (ie, x and y): all data were normalized then adapted Examples of IPA perforator flaps (IPAP flaps) include the to a 50th percentile pelvis (constant interischial distance) “Lotus petal” flap (Gluteal-fold flap) and the “Singapore” and expressed as percentage of the distance between the flap (Pudendal thigh fasciocutaneous flap).19,20,22,30–34 anus and each ischial tuberosity (Table 1). To account for Despite the extensive use of flaps based on the IPA sys- variations in patient positioning, the interischial line was tem, only limited studies have investigated and described used to create a standardized Cartesian plane, imagining its vascular anatomy in detail.20,35–37 Most of these studies patients placed in a horizontal supine position. have been based on few cadaveric dissection and have only reported the branching structure of the system, without Identification of Distribution Areas information on its anatomical localization and distribu- To provide a more surgically relevant anatomical knowl- tion.36,37 A more accurate knowledge of the anatomical edge, we segmented the distribution areas of the perforator localization and distribution36,37 of the perforator vessels vessels of the IPA in 4 separate regions on each side, iden- branching from the IPA can guide preoperative planning, tified by easily recognizable and standardized anatomical facilitate safer intraoperative identification, and allow more landmarks. The following landmarks were established: the extended dissection of larger flaps based on this system. In ischial tuberosities (laterally), the midline (medially), the addition, it can help expand the use of free-style perforator anus (posteriorly), and the proximal origin of the urethra 12 flaps based on the IPA system in perineal reconstructions. (bladder outlet; anteriorly).
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