PRAS3334_proof ■ 31 July 2012 ■ 1/6 + MODEL Journal of Plastic, Reconstructive & Aesthetic Surgery (2012) xx,1e6 1 63 2 64 3 65 4 66 5 67 6 68 7 69 8 70 9 71 10 72 11 73 12 Lower gluteal muscle flap and buttock 74 13 75 14 fascio-cutaneous rotation flap for reconstruction 76 15 77 16 78 17 of perineal defects after abdomino-perineal 79 18 80 19 resections 81 20 82 21 83 a, a a b 22 Q2 B.K. Tan *, Goh Terence , C.H. Wong , Sim Richard 84 23 85 24 86 25 a Department of Plastic, Reconstructive and Aesthetic Surgery, Singapore General Hospital, Outram Road, Singapore, 87 26 Singapore 88 27 b Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore 89 28 90 29 91 30 Received 10 October 2011; accepted 17 July 2012 92 31 93 32 94 33 95 34 96 35 KEYWORDS Summary Background: Abdomino-perineal resection (APR) in the treatment of anal and low 97 36 Abdomino-perineal; rectal cancers is associated with perineal wound problems, especially after pre-operative 98 37 APR; radiotherapy. Immediate reconstruction of defects after APR with flaps has been shown to 99 38 Gluteus maximus; reduce postoperative morbidity. The combined gluteal muscle and buttock fascio-cutaneous 100 39 Reconstruction rotation flap is useful for this purpose. The dual blood supply of the gluteus maximus muscle 101 40 allows it to be split into superior and inferior halves. The inferior fibres are used to fill the 102 41 pelvic cavity, whilst the superior fibres are preserved to maintain hip function. The buttock 103 42 rotation flap is used for skin closure. 104 43 Methods: Eight patients who underwent APR for low rectal (n Z 5) and anal (n Z 3) carcinomas 105 44 had immediate reconstruction with the gluteal muscle and buttock fascio-cutaneous rotation 106 flap. The size of the perineal defects ranged from 5 7 to 13 9 cm. The indications for recon- 45   107 46 struction were: skin defects too large for primary closure (n Z 7) and previous failed flaps (n Z 1). 108 47 Results: All the flaps survived without major complications. The minor complications were 109 48 superficial wound dehiscence (n Z 1) and seroma (n Z 1). Both wounds healed with conservative 110 49 treatment. All patients were ambulating well within 1 month with full range of active and passive 111 50 motion at the hips, and had completed postoperative radiotherapy without perineal wound 112 51 complications. 113 52 Conclusions: The gluteus maximus muscle and fascio-cutaneous buttock rotation flap is useful 114 53 for reconstructing perineal defects after abdomino-perineal resection. 115 54 ª 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by 116 55 Elsevier Ltd. All rights reserved. 117 56 118 57 119 58 * Corresponding author. Tel.: 65 63214794. 120 þ 59 E-mail address: [email protected] (B.K. Tan). 121 60 122 61 1748-6815/$ - see front matter ª 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. 123 62 http://dx.doi.org/10.1016/j.bjps.2012.07.013 124 Please cite this article in press as: Tan BK, et al., Lower gluteal muscle flap and buttock fascio-cutaneous rotation flap for reconstruction of perineal defects after abdomino-perineal resections, Journal of Plastic, Reconstructive & Aesthetic Surgery (2012), http://dx.doi.org/ 10.1016/j.bjps.2012.07.013 PRAS3334_proof ■ 31 July 2012 ■ 2/6 + MODEL 2 B.K. Tan et al. 1 125 Abdomino-perineal resection (APR) is indicated for the disinserted and transposed medially to fill the pelvic cavity 187 126 treatment of rectal carcinoma situated in the distal third of (Figure 1(C)). It is then secured to the walls of the pelvic 188 127 the rectum as well as for recurrent or residual anal carci- cavity with 2/0 Vicryl sutures to reconstruct the pelvic 189 128 noma following combination chemoradiotherapy. APR floor. The superior half of the gluteus maximus muscle is 190 129 involves removal of the anus, the rectum and part of the preserved. Finally, the perforator-based buttock fas- 191 130 sigmoid colon with their associated lymph nodes, through ciocutaneous flap is rotated in to close the perineal wound 192 131 incisions made in the abdomen and perineum. With the (Figure 1(D)). The additional surgical time inclusive of re- 193 132 advances in radiotherapy and ultra-low anterior resection positioning is approximately 2.5 h. 194 133 techniques, the incidence of APR has reduced. However, it Drains are placed separately underneath the buttock 195 134 is still indicated in cases where there is advanced tumour or flap and in the pelvic cavity. They are removed after 2 196 135 where radiotherapy has failed. weeks when daily drainage drops to less than 20 ml. The 197 136 APRs that include wide resections of anus and perianal patient is nursed in the prone position for 10 days to avoid 198 137 skin are best reconstructed with well-vascularised tissue, as pressure on the buttock flap. Pillows are placed under the 199 138 opposed to primary closure. This is especially pertinent left chest and hip to avoid compression on the colostomy in 200 139 when the patient has underdone pre-operative radio- prone position. Thereafter, ambulation is allowed and the 201 2e5 140 therapy to downstage the tumour. Primary reconstruc- patient is discharged once all the drains are removed. 202 141 tion has been shown to reduce the incidence of wound The patient is reviewed in the out-patient clinic and 203 2e9 142 infections and dehiscence. The preferred flaps for stitches are usually removed after 2 weeks. When the 204 143 perineal defects have traditionally been the vertical rectus perineal wound is healed, the patient is referred for radi- 205 10 11 144 abdominis myocutaneous (VRAM) and gracilis flaps. The ation therapy. The patient continues to be reviewed in the 206 145 transpelvic VRAM is a well-established technique but with clinic for radiation-related wound problems. 207 146 a potential risk of weakening the abdominal wall. Gracilis 208 flaps have insufficient bulk for cavernous defects. 147 Results (Table 1) 209 148 The purpose of this article is to describe the use of the 210 149 gluteus maximus flap in conjunction with the fascio- 211 150 cutaneous buttock rotation flap. This approach fulfils the The mean patient age was 56 (48e68) years. Perineal skin 212 dual goals of dead space obliteration and skin cover. defect size ranged from 5 7 to 11 12 cm. The patients 151   213 152 were followed-up for a mean period of 44 (29e66) months. 214 All patients underwent reconstruction employing 153 Patients and methods 215 154 a combined buttock rotation flap and a gluteus muscle flap 216 155 in the same setting. Uncomplicated healing was achieved in 217 Between 1999 and 2004, eight patients (seven males, one 156 6 of 8 patients. Of the two wounds with complicated 218 female) with large perineal defects following APRs under- 157 healing, one developed a superficial wound dehiscence that 219 went reconstruction using dual flaps. All patients received 158 healed with dressing and another had a seroma that 220 pre-operative radiation therapy to downstage the disease. 159 resolved after aspiration. None of the patients developed 221 The indications for reconstruction were: defects deemed 160 perineal hernia during the period of follow-up. 222 too large for primary closure (n Z 7); failed primary 161 223 reconstruction with gracilis flaps resulting in wound dehis- 162 224 cence (n Z 1). Illustrative case reports 163 225 164 Patient 2 (Figure 2(A)e(F)) 226 165 Technique (Figure 1(A)e(D)) 227 166 228 A 67-year-old male presented with chronic discharging 167 APR with a permanent end-colostomy is performed by 229 perianal sinus for 30 years. Incision and drainage of bilat- 168 colorectal surgeons. After closure of the laparotomy inci- 230 eral ischio-rectal fossae was performed and the histological 169 sion, the patient is repositioned prone in a slight jack-knife 231 findings confirmed the diagnosis of adenocarcinoma 170 position for exposure of the gluteal region. 232 involving the rectum and the anus (Figure 2(A) and (B)). He 171 A superiorly based buttock rotation flap is designed and 233 underwent neo-adjuvant chemotherapy combined with 172 elevated using a curvilinear incision along the buttock 234 radiotherapy to downstage the tumour before undergoing 173 crease to expose the gluteus maximus muscle (Figure 1(A)). 235 an APR. An end-colostomy was fashioned in the left iliac 174 It should be as broad-based and as large as possible to allow 236 fossa. The resultant perineal defect (Figure 2(C)) measured 175 re-rotation if the wound breaks down. A bloodless field is 237 11 12 cm. He underwent reconstruction with a right 176 critical to ensure visibility and to avoid inadvertent ligation 238 gluteus muscle and perforator-sparing buttock fascio- 177 of the perforators to the skin. Use of perforator dissection 239 cutaneous flap based on the inferior gluteal vessels 178 techniques also ensures that there is minimal blood loss. 240 (Figure 2(D) and (E)). He was discharged 3 weeks later and 179 These skin perforators from the inferior gluteal artery are 241 completed postoperative radiation therapy to the perineum 180 carefully preserved and mobilised to facilitate rotation of 242 without any wound breakdown (Figure 2(F)). 181 the buttock skin. 243 182 The gluteus maximus muscle is split into two halves 244 183 along its long axis, isolating the inferior fibres on the infe- Patient 3 (Figure 3(A)e(F)) 245 184 rior gluteal artery (Figure 1(B)).