Reconstructive

Home , Mons pubis, Rectus abdominis muscle, Vulva

RECONSTRUCTIVE

An Algorithmic Anatomical Subunit Approach to Pelvic Wound Reconstruction

Alexander F. Mericli, M.D. Background: Prior radiation therapy, pelvic dead space, and a dependent loca- Justin P. Martin, M.D. tion contribute to perineal dehiscence rates as high as 66 percent after primary Chris A. Campbell, M.D. closure of pelvic wounds. Various regional flaps have been described to recon- Charlottesville, Va. struct pelvic defects, but an algorithmic pairing of individual flaps to specific anatomical regions has not been described. Methods: A retrospective review of a prospectively maintained database was performed to identify consecutive pelvic reconstructions from 2010 to 2013 with at least 6 months’ follow-up. Pelvic defects and resulting flaps were described cpt by anatomical subunits involved: anterolateral thigh flap for mons, gracilis flap for labia majora and introitus, vertical rectus abdominis myocutaneous flap for vagina and/or perineal raphe, and gluteus musculocutaneous flap for isolated perianal defects. Results: Twenty-seven women and three men underwent consecutive pelvic reconstruction with a mean age of 60 years (range, 26 to 83 years) and a mean body mass index of 28 kg/m2 (range, 17 to 40 kg/m2). Twenty-one patients (70 percent) had prior radiation therapy. In total, 45 flaps were performed according to the subunit principle. Three patients had a minor dehiscence (<5 cm), one patient had a major dehiscence, and one required reoperation for abscess. There were two partial flap losses necessitating débridement and readvancement of the flap. Twenty-five percent of female patients were sexually active after vaginal reconstruction. Conclusions: The pelvic subunit principle provides an effective algorithm for choosing the ideal pedicled flap for each region involved in acquired pelvic defects. This algorithm is based on individual attributes that make each flap most appropriate for each subunit. Complications were minimal and patient satisfaction with appearance and function was excellent. (Plast. Reconstr. Surg. 137: 1004, 2016.)

cquired pelvic defects present complex cases have failed preoperative chemotherapy reconstructive challenges because of the and radiation therapy, the latter of which further combination of significant pelvic dead contributes to the inhospitable environment for A 12 space, the need for perineal soft-tissue resurfac- postoperative wound healing. Other causes of ing, and the shear forces associated with the acquired pelvic defects include locally advanced dependent pelvis. Wound healing in this region cancers of the genitalia or perineal skin, lichen has historically been poor, with dehiscence rates sclerosus, or necrotizing soft-tissue infections. All up to 66 percent and wounds persisting for a of these factors, both alone and in combination, median 167 days in the absence of soft-tissue explain the frequent failure of primary perineal reconstruction.1–11 wound closure and emphasize the importance of Acquired defects with significant pelvic dead durable and reliable soft-tissue reconstruction. space are most commonly the product of abdomi- To achieve primary wound healing and restore noperineal resections or pelvic exenterations for urogenital and anorectal function, the location of the treatment of colorectal, gynecologic, and the defect and the presence of pelvic dead space urologic malignancies. The majority of these should dictate the flap(s) selected. Individual flaps have been compared to one another for From the Department of Plastic Surgery, University of Virginia Health System. Received for publication June 4, 2015; accepted November Disclosure: The authors have no financial interest 9, 2015. to declare in relation to the content of this article. No Copyright © 2016 by the American Society of Plastic Surgeons external funding was received. DOI: 10.1097/01.prs.0000479973.45051.b6

complication rates but without consideration of abdominis myocutaneous donor site (Table 2). the numerous defect patterns and multiple flap Three patients had a minor dehiscence (<5 cm), options. Successful reconstruction of the pelvis one patient had a major dehiscence, and one mandates an organized algorithmic approach, required reoperation for abscess; there were which can best be achieved by using the principle two partial flap losses necessitating débridement of anatomical subunits. and readvancement of the flap. The vertical rectus abdominis myocutaneous flap had a 31 - per PATIENTS AND METHODS cent complication rate, whereas the gracilis flap was associated with a 20 percent complication A retrospective review of a prospectively main- rate. There was a 19 percent complication rate tained database was performed to identify con- among patients with prior radiation therapy and a secutive pelvic reconstructions from 2010 to 2013 33 percent complication rate among those with with at least 6 months’ follow-up. All cases were no history of radiation therapy. None of the com- performed by the senior author (C.A.C.) at a sin- plication rate comparisons reached significance. gle institution. Twenty-four female patients required partial Charts were reviewed for preoperative and or total vaginal resection and reconstruction. Six- postoperative details, and complications were teen of those patients (67 percent) reported being recorded. Minor and major wound dehiscence was sexually active preoperatively and six patients defined as less than 5 cm and greater than 5 cm, (25 percent) reported sexual function after respectively. Infection was defined as any type of reconstruction by 6 months. All patients reported wound-related complication requiring treatment normal urinary function except one male patient with antibiotics. requiring a double-strain protocol to completely Pelvic defects and flaps were paired by evalu- empty the bladder after partial sacrectomy, one ating the anatomical subunits involved and the female patient with detrusor weakness after corresponding flap characteristics (Table 1 and abdominoperineal resection, and another female Fig. 1). Complications were compared between patient requiring revision surgery to externalize flap types and between patients with and with- her urethra after total perineal reconstruction. out radiation therapy. Sexual and urinary function were measured by postoperative survey after Mons Pubis 6 months of recovery. A detailed algorithmic flow diagram is provided to demonstrate the clinical Methods of mons and vulvar reconstruction factors considered during flap selection (Fig. 2). have evolved from split-thickness skin grafting to various regional flap options. Most small anterior perineal defects (<20 cm2) can be closed primarily RESULTS or with the use of local cutaneous flaps.13 However, The results are summarized in Table 2. Twenty- medium size defects (20 to 60 cm2) or defects with seven women and three men underwent consecu- previous radiation exposure will require the use tive pelvic reconstruction, with a mean age of of regional fasciocutaneous or musculocutaneous 60 years and a mean body mass index of 28 kg/m2. flaps.14–17 Twenty-one patients (70 percent) had prior radia- The anterolateral thigh flap has been described tion therapy. Although not included in the subunit for mons and vulvar reconstruction and provides the principle, our case series also includes 12 exter- appropriate surface area, soft-tissue thickness, and nal oblique flaps, performed as component sepa- pedicle reach to be the ideal flap for mons recon- rations to facilitate closure of the vertical rectus struction.18 The pedicle length ranges from 16 to

Table 1. Regional Flaps for Pelvic Reconstruction* Defect Flap of Choice Pedicle Technical Citation Mons ALT flap Descending branch of lateral femoral Neligan and Lannon, 2010 circumflex vessels Vulva/labia Gracilis Medial femoral circumflex vessels Burke et al., 1995 Vagina VRAM Deep inferior epigastric vessels Campbell and Butler, 2011 Gracilis Medial femoral circumflex vessels Cordiero et al., 2002 Perianal Gluteal fasciocutaneous flap Inferior gluteal artery Arnold et al., 2012 ALT, anterolateral thigh; VRAM, vertical rectus abdominis myocutaneous. *The table notes the flap of choice for each subunit, that flap’s blood supply, and an article that clearly describes the technical approach for each particular flap.

Fig. 1. Diagrammatic representation of the anatomical subunit algorithm for reconstruction of pelvic defects. The anterolateral thigh (ALT) flap is preferentially used to reconstruct defects in the region of the mons pubis; the vertical rectus abdominis myocutaneous (VRAM) flap is used for vaginal canal reconstruction, the perineal raphe, and larger defects including the perianal space; the gracilis flap is used for reconstruction of the labia majora; and the gluteal fasciocutaneous flap is best used for isolated defects of the posterior perineum.

Fig. 2. Algorithm decision tree for reconstruction of pelvic defects. VRAM, vertical rectus abdominis myocutaneous.

19 cm, easily reaching the perineum and inferior thin fasciocutaneous or bulkier musculocutaneous abdominal wall when directed deep to the rectus flap, it can be sensate if harvested with the lateral femoris and sartorius muscles.19 The anterolateral femoral cutaneous nerve, and its skin paddle can thigh is incredibly versatile; it can be designed as a be as large as 20 × 30 cm and can be fenestrated or

1006 Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. Volume 137, Number 3 • Pelvic Wound Reconstruction ( Continued ) Complications ration requiring dressing changes loss requiring dressing changes ration; healed withhealed ration; dressing changes abscess and 5-cm skin edge separation separation, healed with dressing changes 3-cm skin edge sepa - edge skin 3-cm None None Partial skin graft 3-cm skin edge sepa - None Abdominal wound None 1-cm wound None None None None Reconstruction fasciocutaneous flap flaps fasciocutaneous V-Y turnover flap rotation advancement flap fasciocutaneous flap fasciocutaneous flaps musculocutaneous flaps musculocutaneous flaps fasciocutaneous flap Gracilis musculocutaneous flap 1. Fascia-sparing VRAM 2. Component separation 1. Extended fascia-sparing VRAM 2. Component separation back 3. Transverse 4. Bilateral gluteal 2. Right fasciocutaneous gluteal 3. Left gluteal V-Y 4. Full-thickness skin graft 1. Left gluteus maximus muscle 1. Gracilis musculocutaneous flap 2. Omental flap Bilateral V-Y gluteal Bilateral V-Y 1. Fascia-sparing VRAM 2. Component separation 3. Omental flap 1. Fascia-sparing VRAM 2. Component separation 1. Fascia-sparing VRAM 2. Component separation Pedicled ALT flap Pedicled ALT Bilateral gracilis Bilateral gracilis 1. Right gracilis muscle flap 2. Left pudendal artery

Surgery Extirpative sacrectomy (S3/4 level) excision of involved skin and subcutaneous tissue, partial excision of cutaneous recurrence of involved tissue, including the symphysis pubis, anterior bladder, vagina, anterior vulva, and mons pubis resection of posterior vaginal wall, uterus, cervix, ovaries bilateral labia and vaginal canal APR TPE APR, wide local D é bridement TPE Prior APR; wide local APR; en bloc resection LAR, small bowel APR, en bloc resection En bloc mons resection En bloc resection of TPE None

Defect Location posterior vaginal wall vaginal wall perineum and overlying sacrum perineum and overlying sacrum and vulva perineum and perineal body canal, vulva perineum and posterior vaginal wall posterior vaginal wall majora and vaginal canal and rectovaginal septum Perineum and Posterior Posterior Posterior Vaginal canal Vaginal Posterior Mons, vaginal Posterior Perineum and Mons Bilateral labia Vaginal canal Vaginal Perineal body No No Yes No No No No No No No No No Yes Active Smoker

No Yes Yes No Yes Yes Yes Yes No Yes Yes Yes No XRT Prior obesity Comorbidities COPD, HTN None COPD DM, HTN, HTN HTN, PVD None Obesity None None HTN HTN None ) 2 BMI 32 35 23 34 25.8 19.8 19.5 31 17 27 25 28 31 (kg/m Diagnosis fistula cancer hidradenitis fasciitis cancer rectal cancer cancer fistula Rectovaginal Cervical SCCA; Necrotizing Cervical Recurrent SCCA Rectal cancer Rectal cancer SCCA SCCA Bladder Rectovaginal

58 42 47 79 57 79 73 77 70 83 51 59 26 (yr) Patient Data Patient Age at Surgery Table 2. Table Patient 1 2 3 4 5 6 7 8 9 10 11 12 13

1007 Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. Plastic and Reconstructive Surgery • March 2016 Complications 11 cm None None None None None Wound separation, Wound None None None None None Partial flap loss None None Partial flap loss None None Reconstruction fasciocutaneous flaps musculocutaneous flaps fasciocutaneous flaps advancement flaps (V-Y) advancement flaps (V-Y) flaps Bilateral V-Y gluteal Bilateral V-Y 3. Bilateral V-Y gluteal 3. Bilateral V-Y 1. Right pedicled ALT 1. Right pedicled ALT 2. Bilateral gracilis Right fascia-sparing VRAM Bilateral gluteus myocutaneous 1. Fascia-sparing VRAM 2. Component separation 1. Fascia-sparing VRAM 2. Component separation Fascia-sparing VRAM 2. Omental flap 1. Bilateral gluteus myocutaneous Pedicled ALT Gracilis myocutaneous flap Fascia-sparing VRAM Fascia-sparing VRAM Bilateral gluteal advancement Fascia-sparing VRAM Fascia-sparing VRAM 1. Fascia-sparing VRAM 2. Component separation 1. Fascia-sparing VRAM 2. Component separation Surgery Extirpative excision, multiple d é bridements, therapy VAC vaginal canal vulva, rectum, anus, posterior vagina, and sigmoid colon sacrectomy resection vulvectomy of sarcoma wall of vagina circumferential anterior vagina wall of vagina None Wide local Anterior wall of the Perineal proctectomy TPE TPE En bloc resection of APR and partial Mons and labia Labia TPE Total radical Total Wide local excision APR with posterior Vulvectomy with Vulvectomy APR with TPE APR with posterior Defect Location perineum labia majora, posterior perineum perineum labia/vulva vulva vulva perineum perineum Posterior Mons, bilateral Vaginal canal Vaginal Pelvis Pelvis Pelvis Pelvis Posterior Mons, right Right labia and Pelvis Perineum and Gluteus Pelvis Vulva and vagina Vulva Pelvis and Pelvis and No No No No Yes No No Yes No No No No No No No No No Active Smoker

Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes No No Yes Yes No No XRT Prior

HTN, asthma, asthma, HTN, cervical/ vaginal cancer asthma, CAD, OSA dyslipidemia Comorbidities HTN, DM None None None COPD None None DM CAD, MI, HTN, MI, DM, HTN HTN, DM HTN, HTN, DM None None None ) 2 25 27 32 31 33 28 28 25 24 40 28 27 23 29 27 28 25 BMI (kg/m Diagnosis hernia carcinoma cancer fasciitis carcinoma cancer Perineal Hidradenitis SCCA Rectal cancer Clear cell Cervical Vaginal SCCA Vaginal Rectal cancer Necrotizing Vulvar SCCA Vulvar Rectal Hidradenitis DFSP Anal cancer Bladder Rectal cancer Rectal cancer

60 36 72 48 56 78 38 57 62 47 61 65 64 67 72 41 66 (yr) ) ( Continued Age at Surgery 14 (removal exenteration pelvic total TPE, resection; abdominoperineal APR, hypertension; HTN, pulmonarydisease; obstructive chronic COPD, therapy; radiation squamous SCCA, XRT, myocutaneous; index; mass body BMI, abdominis rectus vertical VRAM, conduit); ileal and ileostomy ureters; distal bilateral colon, rectosigmoid ovary, and tube left vagina, cervix, uterus, bladder, of MI, coronaryarterydisease; CAD, closure; vacuum-assisted VAC, thigh; anterolateral ALT, resection; anterior low LAR, disease; vascular peripheral PVD, mellitus; diabetes DM, carcinoma; cell dermatofibrosarcoma protuberans. myocardial infarction; OSA, obstructive sleep apnea; DFSP, 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Table 2. Table Patient

split depending on the reconstructive need.19 The disease). These defects usually result in missing fascia lata can be harvested as a component of the skin and subcutaneous tissue; bone and deeper flap for greater strength, a feature that may be nec- structures are rarely exposed. essary in cases involving full-thickness defects of the If the wound is not irradiated and is relatively inferior abdominal wall. Moreover, it is relatively small, a nonmeshed split-thickness skin graft is a tolerant of fecal contamination and maceration— good reconstructive option, providing acceptable an important requirement in perineal reconstruc- cosmesis and replacing the thinner soft tissue near tion.20 Given these many beneficial attributes, we the introitus.21 A skin graft is an especially prudent consider the anterolateral thigh flap our first-line option if the risk of local recurrence is high. The option for soft-tissue reconstruction in the region suprapubic area, within the pubic hairline, is an of the mons. excellent donor site for vulvar and labial recon- Case 1 struction; this location eliminates the need for a separate donor site, and the scar is hidden within An 83-year-old woman with a history of recur- 21 rent squamous cell carcinoma of the anterior the hair-bearing skin. vulva presented after a right hemivulvectomy that If the vulva and labia have been irradiated or if was closed primarily followed by adjuvant radia- there are plans for external beam radiation ther- tion therapy. Two years after the completion of apy, the risk of skin graft loss is sufficiently high her radiation therapy, she developed a necrotizing to preclude its use for reconstruction. In addi- soft-tissue infection within the irradiated tissues of tion, many local flap options such as the puden- the mons that was resected, leaving an oblique 15 dal flap are frequently included in the irradiation × 10-cm defect (Fig. 3) with exposed pubis at the field, preventing this method of reconstruction. wound base. To reconstruct this defect, a right ped- In these situations, a regional fasciocutaneous or icled anterolateral thigh flap was designed, includ- musculocutaneous flap is an excellent alterna- ing a portion of the vastus lateralis muscle. The flap tive. In situations where the entire unilateral or was passed under the rectus femoris and sartorius bilateral labia majora are resected, we prefer to use the gracilis flap, unilateral or bilateral, respec- muscles and delivered to the defect by means of 22–24 a subcutaneous tunnel. She did not develop any tively. Although the skin paddle is relatively complications and proceeded to completely heal small, it is adequate for resurfacing the labia and her donor- and recipient-site wounds. Six months vulva. The short arc of rotation is a frequently after surgery, she was fully healed and ambulatory, cited limitation of the gracilis flap; however, it is having achieved her preoperative level of function. easily rotated to the vulvar region. Case 2 Vulva and Labia A 51-year-old woman presented with a history Defects of the vulva and labia are typically of recurrent squamous cell carcinoma of the labia secondary to skin cancer excisions or similar con- majora. She had a history of radiation therapy to ditions (Bowen disease, extramammary Paget the area from her initial disease. The recurrence

Fig. 3. Mons defect after resection of irradiated skin because of necrotizing soft-tissue infection in the setting of prior right hemivulvectomy because of squamous cell carcinoma. Mons reconstruction with a right pedicled anterolateral thigh flap. The surface area of the skin paddle can adequately cover large defects of the mons and the pedicle can be passed beneath the rectus femoris and sartorius muscles to easily reach the anterior pelvis.

involved the bilateral labia requiring an en bloc used to reconstruct the vagina must also provide resection of the bilateral labia majora, distal ure- adequate vascularized tissue to obliterate pelvic thra and vaginal canal, and mons pubis. Because dead space, allow healing of perineal wounds, and of her irradiation history, skin grafting and local prevent herniation of intraabdominal contents.24 tissue reconstruction were contraindicated; there- Another unique aspect of vaginal reconstruc- fore, bilateral gracilis musculocutaneous flaps tion is that the creation of a neovagina is not only were used to provide a functional and anatomi- necessary to prevent postoperative wound-related cal reconstruction of the labia and vulvar surface complications but also important for the psycho- (Fig. 4). The most superior element of the defect logical well-being of many women, particularly was able to be closed primarily. The patient went those who wish to remain sexually active.25 There- on to fully heal her wounds, achieving a functional fore, women undergoing pelvic surgery in which and stable reconstruction. part of or the entire vagina must be resected often request a functional vaginal reconstruction. Vagina and Perineal Raphe The most commonly used flap options for The surgical management of vaginal defects vaginal reconstruction include the rectus abdomi- presents the plastic surgeon with multiple recon- nis and gracilis musculocutaneous flaps, and the structive challenges. In addition to necessitating internal pudendal and posterior thigh fasciocu- the creation of a cylindrical structure that must be taneous flaps. Other less frequently used options of adequate size to permit sexual intercourse, flaps include the omental flap with a skin graft, which requires postoperative stent dilation to prevent stenosis; and a tensor fasciae latae flap, which is plagued by lack of pedicle length and an undesir- able donor-site scar.23,26 A useful algorithm for partial and total vaginal reconstruction was proposed by Cordeiro et al., in which reconstructive flap options are determined by the anatomical location of the vaginal defect.27 This algorithm has proven to be reliable and useful in our approach to vaginal defects. Often, vaginectomy defects communicate with the intrapelvic and intraabdominal space as in rectal carcinoma resections. In this instance, flap reconstruction serves a dual purpose: to obliterate dead space and prevent herniation and to provide the patient with a functional neovagina. Bulky flaps provide the appropriate soft-tissue fullness and skin to reconstruct the vagina and perineal raphe. In addition, in our experience, we have found the pedicled omental flap to be useful to close the pelvic inlet to prevent inferior displace- ment of the intraabdominal viscera. The omental flap can be combined with an additional regional flap to provide muscle for further dead space obliteration and a skin paddle for either external or vaginal canal reconstruction, depending on the defect type.28 Campbell and Butler demonstrated a decreased perineal dehiscence rate, a decreased fluid accumulation rate, and a lower rate of reop- Fig. 4. Defect involving the bilateral labia majora, distal urethra, eration when omental and vertical rectus abdomi- distal vagina canal, and mons pubis after resection of recurrent nis myocutaneous flaps were used in combination squamous cell carcinoma of the labia in an irradiated field. The for pelvic/perineal reconstruction compared defect was reconstructed with bilateral gracilis musculocutane- to when the vertical rectus abdominis myocuta- ous flaps to reconstruct the distal vaginal canal and labia majora. neous flap was used alone.29 They theorize that The vascular pedicles of the gracilis area are safely outside of the the increase in vascularity and soft-tissue volume irradiated field from prior treatment. could be attributable to the improved outcomes.

Vertical rectus abdominis myocutaneous flaps abdominoperineal resection with an en bloc resec- are our preferred first option for the more com- tion of the posterior vaginal wall with immediate mon posterior or circumferential vaginal defects reconstruction using a vertical rectus abdominis to obliterate potential space, prevent pelvic her- myocutaneous flap to recreate the perineum and nias, and provide the appropriate soft-tissue posterior vaginal wall, and to provide vascularized surface area for a functional vaginal reconstruc- tissue to the irradiated pelvis and perineum to tion.29,30 When bilateral ostomies are present assist with postoperative wound healing (Fig. 5). preoperatively, bilateral gracilis musculocutane- The proximal portion of the flap that is visible ous flaps with or without omentum are a second forms the posterior vaginal wall, whereas the distal 23,24 option within the subunit principle. portion of the flap is deepithelialized and buried Cases 3 and 4 under the irradiated skin flaps to improve wound We present two patients who both required healing and obliterate dead space. vaginal reconstruction, each of a different nature The second vaginal reconstruction patient is and requiring flaps from different locations. The a 59-year-old woman with locally advanced, recur- first vaginal reconstruction patient is a 70-year- rent urothelial cancer of the bladder status after old woman with a history of obstructing rectal chemotherapy and pelvic irradiation. She under- cancer after diverting colostomy, chemotherapy, went a full pelvic exenteration. Immediate vagi- and pelvic irradiation. She then underwent an nal and perineal reconstruction was performed

Fig. 5. Vaginal, perineal raphe, and perianal defect reconstructed with vertical rectus abdominis myocutaneous flap. The proximal skin paddle is used for the posterior vaginal wall. The distal skin paddle is deepithelialized and buried underneath irradiated perineal skin flaps to bolster the repair and obliterate potential space.

with bilateral pedicled gracilis musculocutaneous Rectus abdominis flaps are useful when this defect flaps, which were approximated en face by their is paired with a vaginal defect or extended rectus- skin paddles extracorporeally and rotated into the based flaps are required for larger defects involv- perineal defect to create the neovagina (Fig. 6). ing the coccyx and sacrum.31,32 This patient had an abundance of subcutaneous Fasciocutaneous gluteal-based flaps are well adipose tissue in her thighs, which provided for a suited for perianal defects. These flaps may be bulky flap that filled the pelvis with vascularized, based on perforators of the gluteal artery with nonirradiated tissue. or without a muscle cuff.33,34 Bilateral gluteal Both patients have progressed to fully heal artery perforator fasciocutaneous flaps provide their wounds without any complications. Both ample tissue for reconstruction of large posterior patients possess a functional vagina without com- perineum defects, and preserve the gluteal cleft plaint of donor-site morbidity. and spare the gluteus muscle, thus minimizing donor-site morbidity.35 When the pelvic inlet is Perianal Defects wide and/or the pelvic dead space is quite large, Posterior perineal defects limited to the peri- the addition of the omentum can be a useful anal skin can be reconstructed with rectus abdom- adjunct for pelvic management. inis musculocutaneous flaps, thigh-based flaps, or Case 5 buttock flaps. Thigh-based flaps have been shown A 32-year-old physically active man presented to have higher donor- and recipient-site complica- with recurrent rectal cancer invading the coccyx tion rates than flaps harvested from the trunk.30 after chemotherapy and pelvic irradiation. He wanted to spare his rectus muscles because of his workout regimen, and the colorectal surgeons anticipated a small cutaneous defect limited to the perianal skin. In the absence of a vertical rectus abdominis muscle, an omental flap was based off the right gastroepiploic pedicle and brought along the paracolic gutter and sutured to the presacral fascia above the level of the coccygectomy (Fig. 7). Bilateral gluteus V-Y advancement flaps were used to reconstruct the perianal defect (Fig. 7). He healed without incident and resumed all physical activity without limitation.

Total Perineal Reconstruction The anatomical subunit concept can easily be used for the reconstruction of extensive defects that affect multiple pelvic anatomical subunits. The flaps discussed in this article are each based on separate and distinct pedicles, thereby permit- ting the use of multiple flaps in a single patient, if necessary. Case 6 A 38-year-old woman presented with a history of Crohn disease and extensive perineal hidradenitis (Fig. 8). Her hidradenitis had failed conservative management consisting of oral and topical antibiotics and conservative drainage and débridement. Her function was severely limited as a result of her condition, preventing her from engaging in sexual relations, impairing her mobil- Fig. 6. Total vaginal reconstruction with bilateral gracilis flaps ity, and causing debilitating pain. Because of the in a patient with bilateral ostomies preoperatively. To obliterate large surface area involved and severe nature of pelvic dead space, the distal portions of the gracilis are sutured the disease, the excision and reconstruction were to the presacral fascia. approached in a staged fashion. First, a radical

Fig. 7. Isolated perianal defect after abdominoperineal resec- Fig. 8. Total perineal reconstruction in a patient with diffuse tion and coccygectomy for recurrent rectal carcinoma in a perineal hidradenitis. The mons pubis region was reconstructed young male patient. Omental flap is used to obliterate pelvic with a pedicled right anterolateral thigh fasciocutaneous flap. dead space after coccygectomy (above). Bilateral gluteus fascio- The labia majora were recreated with bilateral pedicled graci- cutaneous advancement flaps were used to reconstruct the iso- lis myocutaneous flaps, and the posterior perineum was resur- lated perianal defect. The scar pattern recapitulates the gluteal faced with bilateral inferior gluteal artery advancement flaps. cleft and crease while providing appropriate soft-tissue volume for the reconstruction (below). initial reconstruction and consisted of scar revision, flap liposuction, and advancement of the excision of the hidradenitis was performed, result- mons anterolateral thigh flap (Fig. 8). At the ing in soft-tissue defects of the mons, bilateral conclusion of her reconstruction, the patient was labia majora, and posterior perineum; the labia able to engage in sexual intercourse, her mobility minora were spared. A wound vacuum-assisted and pain were improved, and she had no signs of closure device was then applied to encourage the recurrent disease. ingrowth of healthy granulation tissue. Regional flaps were planned to provide soft and durable coverage. Reconstruction was then performed DISCUSSION according to the anatomical subunit principle. We believe the algorithm presented above The mons pubis region was reconstructed with provides a thoughtful, organized approach for a pedicled right anterolateral thigh flap. The the treatment of a variety of pelvic and perineal labia majora were recreated with bilateral ped- defects. Similar to certain theories of facial and icled gracilis musculocutaneous flaps, and the nasal reconstruction, the complex three-dimen- posterior perineum was resurfaced with bilateral sional surface of the perineum lends itself to a inferior gluteal artery perforator flaps. Six weeks reconstructive approach based on the anatomical after her initial reconstruction, externalization subunit principle. Each flap included in the algo- of the urethra was performed by reorienting the rithm recruits tissue from a distinct anatomical gracilis skin paddles through the use of Z-plasties. area and relies on a separate blood supply, per- The final stage was performed 12 weeks after her mitting use of multiple different flaps in extensive

defects involving multiple subunits. Following microsurgically anastomosed to either an interpo- such a plan will provide for a reliable, functional sition vein graft, a pelvic vessel in closer proximity reconstruction and, perhaps most importantly, a to the defect, or to a saphenous vein loop to the healed wound. femoral arterial system.40–42 Each defect location is paired with its flap of Because of pedicle length limitations, the grac- choice based on specific anatomical attributes, ilis flap was most commonly used for reconstruc- aesthetic considerations, and functional implica- tion of the adjacent labia majora, which require tions. The pedicled anterolateral thigh flap can only a 90-degree rotation. More anterior or pos- easily reach the inferior abdomen and mons, and terior reconstructions were typically achieved its soft-tissue characteristics mimic the pliable, soft with an anterolateral thigh flap or vertical rectus tissue typical of the region. The gracilis flap can abdominis myocutaneous flap, respectively. The be rotated to reconstruct the vulva and anterior anterolateral thigh flap was passed deep to the vaginal canal. The skin paddles can be designed rectus femoris and sartorius muscles to effectively so that the incision lines are located on the typi- increase pedicle length when reaching the mons. cal anatomical boundaries of the vulvar subunits. The gracilis myocutaneous flap was also used as The vertical rectus abdominis myocutaneous flap a second option for total vaginal reconstruction is the workhorse for vaginal and perineal raphe as described previously, but this should be evalu- reconstruction. It is well outside the zone of irra- ated on a case-by-case basis because of the more diation and its bulk can easily obliterate the pelvic proximal location of the vaginal canal to be recon- dead space. If functional vaginal reconstruction structed relative to pedicle location and the need is needed, the soft, pliable skin paddle can be for a 180-degree rotation of the skin paddles.7 shaped into a neovaginal canal. If resurfacing is Taking longer skin paddles to reach the presacral not required, the flap can be deepithelialized and space and using physical examination and indo- placed within the pelvic inlet to obliterate dead cyanine green laser angiography to evaluate flap space. If additional soft-tissue volume is required, viability after rotation are important when per- the vertical rectus abdominis muscle can be har- forming total vaginal reconstruction with gracilis vested as an extended flap, reaching to the midax- flaps. illary line. Gluteus-based flaps are well suited for There are several technical maneuvers to min- reconstruction of the posterior pelvis. They can imize donor-site morbidity from flap harvest in be designed with or without muscle, depending these complicated reconstructions. A fascia-spar- on the ambulatory status of the patient and the ing technique was used for vertical rectus abdomi- need for volume. The flaps are easily advanced nis myocutaneous flap harvest, and we frequently into the defect, and the gluteal cleft can be repro- performed a component separation to assist in duced when bilateral flaps are used. An omental abdominal wall closure and minimize donor-site flap should be included in the reconstruction morbidity.29 In elevating the anterolateral thigh when additional dead space needs to be filled or flap, we carefully protected the lateral femoral when small bowel is visualized slipping into the cutaneous nerve to minimize postoperative neu- false pelvis during inset of the abdomen- or thigh- ropathy or neuroma formation and microsurgi- based flap. This is typically more common in cally repaired motor nerve fascicles when possible female patients and after total pelvic exenteration for the remaining vastus lateralis muscle. The glu- compared with low anterior or abdominoperineal teus advancement flaps were elevated as fasciocu- resection. taneous flaps to spare the function of the gluteus Occasionally, microsurgical techniques are muscle, especially the lower half of the muscle necessary for pelvic reconstruction. In the obese belly in all ambulatory patients.35 patient where all skin paddles are too thick to Postoperative activity modification is very facilitate pedicled flap reconstruction of the important for the success of pelvic soft-tissue vagina, one option is either a free jejunum flap reconstruction. The patient is restricted to the or a supercharged jejunum flap pedicled on the supine and lateral recumbent positions changed fourth vascular arcade and supercharged to the every 2 hours in a low-pressure bed when not second arcade.36–39 Microsurgical techniques ambulating. Ambulation is permitted on postop- also come into play when a thigh-based flap or erative day 1; however, the patient must logroll to abdominally based flap cannot be reliably inset stand from the supine position. The patient is not into the defect because of inadequate pedicle permitted to sit upright greater than 30 degrees length or too much tension on the pedicle. In this for 3 weeks, after which a graduated sitting pro- situation, the pedicle can be transected and then tocol is initiated until full activity is permitted

at 6 weeks after surgery. A physical therapist is restoration of function, namely, the ability to consulted to teach the patient how to safely tran- engage in sexual intercourse and to minimize sition from the supine to the standing position. urinary incontinence. Our series showed that If there are areas of delayed wound healing, the 25 percent of female patients engaged in sexual restriction from sitting may be increased until it intercourse after 6 months of recovery from par- is certain that the wound is not increasing in size. tial or total vaginal resection and reconstruction, Complete pelvic rest is required for a minimum which is similar to other reported values; Crosby of 6 weeks. et al. showed that 22 percent of patients were sex- In this series, there was no statistically sig- ually active after partial vaginal reconstruction.44 nificant difference in flap complication rates Similar to Crosby and colleagues, we believe the with regard to irradiation history (19 per- most notable predictor of postreconstruction sex- cent complication rate with irradiation versus ual intercourse is the presence of prereconstruc- 33 percent without). If the patient has been tion sexual intercourse and patient age. Flaps irradiated, we do not use flaps that include tis- for vaginal reconstruction should be designed to sue from the irradiation field. This commonly reproduce appropriate dimensions on average excludes pudendal flaps. The selection of flaps of 10 cm of vaginal circumference and 10 cm of within the anatomical subunit model permits the vaginal length.12 Contracture of the reconstructed addition of nonirradiated tissue into the surgical vagina occurs most commonly along flap suture field for reconstruction. Sometimes, the lower lines. This is seen more commonly when the abdominal wall has been irradiated, and this may introitus requires reconstruction with multiple preclude use of the vertical rectus abdominis flaps than in the posterior vagina alone (as seen muscle. Often, these cases also involve a mons in our total perineal reconstruction case in this resection that will require an anterolateral thigh series). An adult medium vaginal dilator with a flap outside the field of irradiation. The timing water-based lubricant can be used after adjacent of reconstruction after irradiation is based on tissue transfer for cases where scars between flaps planned oncologic resection of the tumor bed. contract, creating stenosis. After traditional long-course neoadjuvant chem- Rates of urinary dysfunction after pelvic resec- oirradiation for rectal cancer, surgical resection tion and irradiation for colon cancer vary widely and consequently reconstruction typically follow in the literature, from 30 to 77 percent.45 Our 8 to 12 later weeks in most cases.43 series, by comparison, shows only 10 percent of In addition, there were no significant differ- patients with major urologic complaints after vari- ences in overall complication rates between flap ous forms of pelvic resection. One complaint was types, with vertical rectus abdominis myocutane- structural after multiple flaps (anterolateral thigh ous flaps associated with an overall 31 percent and two gracilis flaps) contracted to cover the complication rate and gracilis flaps with a 20 urethra, another after a standard abdominoperi- percent overall complication rate. Gluteus flaps neal resection, and the third after partial sacrec- were associated with only small draining sites at tomy producing difficulty with voiding. All other the new gluteal cleft remedied with wound care. patients who maintained their bladder and lower The subunit principle makes flap comparisons urinary tract eventually regained urinary conti- difficult, as different flaps were used for different nence. Our lower urologic dysfunction rate may defects. For example, vertical rectus abdominis be the result of diversity in our patient popula- myocutaneous flaps were used for the posterior tion or a decreased sensitivity in our clinic survey vagina and perineal raphe where weight-bearing compared with validated models used in studies and shear forces are greatest and with defects with designed exclusively for postoperative function significant dead space, whereas the introitus and after cancer treatment. mons, reconstructed by thigh-based flaps, were Although each flap presented in this study has not in the wound-bearing area, with minimal been described thoroughly in the literature, our dead space. Gluteus flaps were used in this series subunit approach is novel, simplifying a typically for isolated perineal defects only, with less dead very challenging reconstruction. The study is lim- space and with omental flaps when available. In ited in that it is a case series with a small hetero- the literature, vertical rectus abdominis myocuta- geneous group of patients. However, the wide age neous flaps have outperformed thigh-based flaps range and diverse cause of defects demonstrate in defects of similar size.30 that this algorithmic approach can be successfully In addition to providing a healed wound, a used to treat a variety of patients in an array of secondary goal of pelvic reconstruction is the clinical scenarios.

CONCLUSIONS CODING PERSPECTIVE Reconstruction of the pelvis and perineum is Coding information provided by Dr. challenging, and optimal results require a thought- cpt Raymund Janevicius is intended to ful, organized approach. The pelvic subunit prin- provide coding guidance. ciple provides an effective algorithm for choosing the ideal pedicled flap for each region involved in 14000 Adjacent tissue transfer, trunk; defect acquired pelvic defects, including total pelvic cov- ≤10 cm2 erage. In using this algorithmic approach, we are 14001 Adjacent tissue transfer, trunk; defect able to demonstrate a minimal complication rate 10.1 to 30.0 cm2 for a variety of defects in a complex and challeng- 14301 Adjacent tissue transfer, any area; de- ing group of patients. fect 30.1 to 60.0 cm2 14302 Adjacent tissue transfer, any area; each 2 Christopher A. Campbell, M.D. additional 30.0 cm , or part thereof Department of Plastic Surgery 15734 Muscle, myocutaneous, or fasciocuta- University of Virginia Health System neous flap; trunk P.O. Box 800376 15738 Muscle, myocutaneous, or fasciocuta- Charlottesville, Va. 22908 neous flap; lower extremity [email protected] 49904 Omental flap Acknowledgment • If a local flap is used for reconstruction, the adjacent tissue transfer codes, The authors thank Anita Impagliazzo, M.A., for 14XXX, are used and are reported by the her work in creating Figure 1. size of the total defect. • The vertical rectus abdominis musculocu- references taneous and gluteal flaps are trunk flaps. 1. Turza Campbell K, Hedrick TL. Perineal wound healing Each flap is reported with code 15734. complications in patients undergoing abdominoperineal • Use the lower extremity flap code, 15738, resection and pelvic exenteration. Paper presented at: to report each anterolateral thigh and Southeastern Surgical Congress Annual Meeting; February gracilis flap. 11–14, 2012; Birmingham, Ala. • Each flap is reported separately, even 2. Butler CE, Gündeslioglu AO, Rodriguez-Bigas MA. Outcomes of immediate vertical rectus abdominis myocuta- though used for the same defect. Thus, a neous flap reconstruction for irradiated abdominoperineal defect reconstructed with a right antero- resection defects. J Am Coll Surg. 2008;206:694–703. lateral thigh flap, bilateral gracilis myocu- 3. Goldberg GL, Sukumvanich P, Einstein MH, Smith HO, taneous flaps, and bilateral V-Y gluteal fas- Anderson PS, Fields AL. Total pelvic exenteration: The Albert ciocutaneous flaps is reported as follows: Einstein College of Medicine/Montefiore Medical Center Experience (1987 to 2003). Gynecol Oncol. 2006;101:261–268. 4. McAllister E, Wells K, Chaet M, Norman J, Cruse W. Perineal 15378 Right anterolateral thigh flap reconstruction after surgical extirpation of pelvic malignan- 15738-59 Right gracilis myocutaneous flap cies using the transpelvic transverse rectus abdominal myo- 15738-59 Left gracilis myocutaneous flap cutaneous flap.Ann Surg Oncol. 1994;1:164–168. 15734-51 Right V-Y gluteal fasciocutaneous flap 5. Yeh KA, Hoffman JP, Kusiak JE, Litwin S, Sigurdson ER, 15734-59 Left V-Y gluteal fasciocutaneous flap Eisenberg BL. Reconstruction with myocutaneous flaps following resection of locally recurrent rectal cancer. Am Surg. 1995;61:581–589. • Although “bilateral” flaps are performed, 6. Touran T, Frost DB, O’Connell TX. Sacral resection: Operative the bilateral modifier, 50, is not used, as technique and outcome. Arch Surg. 1990;125:911–913. codes 15734 and 15738 are not codes that 7. McCraw JB, Massey FM, Shanklin KD, Horton CE. Vaginal payers, including Medicare, recognize as reconstruction with gracilis myocutaneous flaps. Plast bilateral. Use modifier 59 in these cases. Reconstr Surg. 1976;58:176–183. 8. Shibata D, Hyland W, Busse P, et al. Immediate reconstruc- • Some payers attempt to bundle all mus- tion of the perineal wound with gracilis muscle flaps fol- cle flaps together and allow for only one lowing abdominoperineal resection and intraoperative muscle/fascial flap code per defect. This radiation therapy for recurrent carcinoma of the rectum. is incorrect coding, and does not follow Ann Surg Oncol. 1999;6:33–37. American Medical Association Current 9. Guarner F, Malagelada JR. Role of bacteria in experimental colitis. Best Pract Res Clin Gastroenterol. 2003;17:793–804. Procedural Terminology rules. Each mus- 10. Larson EL, McGinley KJ, Foglia AR, Talbot GH, Leyden JJ. cle/fascial flap should be listed separately. Composition and antimicrobic resistance of skin flora in hos- pitalized and healthy adults. J Clin Microbiol. 1986;23:604–608.

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