Download IGAM

yes no Was this document useful for you?
   Thank you for your participation!

* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project

Document related concepts
no text concepts found
Ideas and Innovations
The Inferior Gluteal Artery Myocutaneous Flap
with Vascularized Fascia Lata to Reconstruct
Extended Abdominoperineal Defects
Damien G. Grinsell,
Edwin Morrison, M.B.B.S.
Patrick D. T. Tansley,
Melbourne, Victoria, Australia
Summary: Abdominoperineal resections have evolved to the point where
increasing amounts of skin and pelvic floor are removed, resulting in extensive defects. Many patients receive neoadjuvant chemoradiotherapy and may
require adjuvant treatment; thus, primary wound healing is essential. Existing reconstructive techniques may be inadequate and predispose to postoperative complications including wound breakdown and perineal herniation.
The authors have developed a novel innervated gluteal flap reconstruction
with significant advantages, including preservation of abdominal wall integrity,
prone harvest, reliable vascularity, bulky volume, and tailored inset. This robust
technique addresses all components required for successful perineal reconstruction comprising dead space obliteration, reconstruction and maintenance
of perineal floor integrity, and importation of nonirradiated skin to facilitate
primary wound healing. Indications can be extended to include reconstruction of the posterior vaginal wall and large sarcoma/sacrectomy defects.
(Plast. Reconstr. Surg. 132: 836e, 2013.)
bdominoperineal resections have evolved
to the point where increasing amounts of
skin and pelvic floor are removed, resulting in extensive perineal defects1 (Fig. 1). Robust
reconstructive techniques are needed to achieve
primary wound healing, especially in the setting
of neoadjuvant chemoradiotherapy and subsequent adjuvant therapy.
Existing reconstructive techniques are inadequate. Primary closure of irradiated tissue commonly results in dehiscence and perineal hernias
(35 to 63 percent).2,3 Local skin flaps may introduce
irradiated tissue, resulting in similar dehiscence
rates.4 Regional rectus abdominis myocutaneous
flaps, considered workhorse flaps for abdominoperineal reconstruction, may be unsatisfactory
in the extended resection setting. Typically, a
From Western Health and St. Vincent’s Hospitals.
Received for publication January 6, 2013; accepted May 13,
Presented at the 81st Annual Scientific Congress of the Royal
Australasian College of Surgeons, in Kuala Lumpur, May
6 through 10, 2012; and the British Association of Plastic,
Reconstructive and Aesthetic Surgeons Winter Meeting, in
London, United Kingdom, December 4 through 6, 2012.
Copyright © 2013 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0b013e3182a3c0cd
vertical/oblique rectus abdominis myocutaneous flap is raised before the resection, ignoring
reconstructive principles; if harvested too short,
it cannot be extended. Atrophy of denervated
muscle reduces reconstructive bulk, donor-site
fascial closure may require mesh reinforcement in
a contaminated field, and stoma placement may
be compromised by muscle harvest. We also consider the recti nonexpendable, as harvest appears
counterintuitive given abdominal wall dehiscence
and delayed incisional hernia rates of less than 35
Disclosure: None of the authors has received any
financial support for this work or has any related financial interests, commercial associations, or financial disclosures that might create a conflict of interest
with the information presented in this article.
Supplemental digital content is available for
this article. Direct URL citations appear in the
text; simply type the URL address into any Web
browser to access this content. Clickable links
to the material are provided in the HTML text
of this article on the Journal’s Web site (www.
Volume 132, Number 5 • Abdominoperineal Defect Reconstruction
Fig. 1. Example of extensive skin and perineal floor defect.
percent because of loss of abdominal support.5
Other regional techniques include gracilis myocutaneous and omental flaps, but neither is ideal.6–9
In this context, we have developed an alternative reconstruction, the inferior gluteal artery
myocutaneous flap. It differs significantly from
other gluteal flaps, which have included rotation, advancement, island, transposition and perforator designs.4,10–12 A three-phase evolution of
inferior gluteal artery myocutaneous 1 (myocutaneous) and inferior gluteal artery myocutaneous
2 (muscle only) flaps has resulted in the current
inferior gluteal artery myocutaneous flap 3 flap
(myocutaneous including a longer skin paddle
and vascularized fascia lata to reconstruct the perineal floor).13,14
Inferior gluteal artery myocutaneous flaps are
raised with the patient in the prone position without intraoperative position change, as extended
abdominoperineal reconstruction is completed in
this position. They are bulky regional flaps, vascularized and innervated on perforating vessels
of the inferior gluteal neurovascular bundle, preserving reconstructive bulk. Further advantages
include preservation of abdominal wall integrity,
no interference with stoma placement, direct pelvic floor reconstruction, and provision of reliably
vascularized, nonirradiated tissue with extended
skin paddle and tailored tension-free inset.
Indications are principally rectal carcinoma
but include chronic postsurgical perineal hernia,
necrotizing fasciitis, and chronic ulceration/pelvic sepsis. Extended indications include reconstructions of the posterior vaginal wall, sacrectomy
defects, and sarcoma resections. We describe the
evolution and operative technique of our current
perineal reconstructive flap of choice, the inferior
gluteal artery myocutaneous 3.
Operative Technique
Surface markings are from the coccyx to the
greater trochanteric tuberosity. An islanded skin
paddle is designed from the edge of the defect
over the inferior one-fourth to one-third of the
gluteus maximus muscle (Fig. 2). It is oriented at
45 degrees, asymmetrical to the inferior muscle
edge, which lies at approximately 30 degrees from
the horizontal. The skin flap is raised and the inferior border of the gluteus maximus is dissected out
in the subfascial plane, which allows identification
and preservation of the posterior cutaneous nerve
of the thigh. The sciatic nerve is deep and covered
by a separate fascial layer consisting of loose perineural areolar tissue. Recognition of this layer and
its preservation during dissection allows protection of the nerve. The upper fibers of the muscle
are then split along their line of orientation to
dissect out the vascular supply. Perforator dissection should be avoided; however, the descending
branch of the inferior gluteal artery may require
division to allow sufficient mobility for flap transposition and inset into the perineal floor.
This initial myocutaneous design (inferior
gluteal artery myocutaneous 1) evolved into a
muscle-only construct (inferior gluteal artery
myocutaneous 2), using identical harvest technique but without a skin component, to reconstruct patients with smaller skin defects that could
be directly closed.13,14 The inferior gluteal artery
myocutaneous 3 flap is designed and raised as for
the inferior gluteal artery myocutaneous 1 flap but
incorporates two additional features: an extended
skin flap and vascularized fascia lata/iliotibial tract
adjoining the distal gluteus maximus. Although
perforating vessels supplying proximal skin are
Fig. 2. Intraoperative planning.
Plastic and Reconstructive Surgery • November 2013
protected, distal skin can be released by 30 to 40
percent to tailor inset. During dissection of the
deep fusion plane between the gluteus maximus
and fascia lata, the trochanteric bursa should be
avoided. Fascia lata measuring approximately 10
× 10 cm can be raised, and no donor-site closure
is required.
The inferior gluteal artery myocutaneous 3
flap therefore comprises a three-layered flap construct of skin, muscle, and vascularized fascia lata
(Fig. 3). The vascularized fascia lata is first inset
around the pelvic brim using 0 polydioxanone
sutures to recreate a neoperineal floor. If the posterior vaginal wall also requires reconstruction,
the skin flap is folded and inset secondarily. Threelayer closure is completed over drains placed in
the abdominoperineal cavity and donor site. Sitting is avoided for 4 weeks, but patients may lie
on either side or they may stand or walk. A truss
garment is worn for 6 weeks. Follow-up includes
assessments for perineal herniae, sensory perception, and aesthetic outcome.
Between 2007 and 2011, 27 consecutive male
patients (overall mean age, 66 years) with stage
I to IIIC rectal carcinoma were studied. Twentysix underwent neoadjuvant chemoradiotherapy
before extended abdominoperineal reconstruction and immediate inferior gluteal artery myocutaneous transposition flap reconstructions
comprising inferior gluteal artery myocutaneous
1 (n = 8), inferior gluteal artery myocutaneous 2
(n = 4), and inferior gluteal artery myocutaneous
3 (n = 15) flaps. Reconstructive and postoperative
outcomes were assessed.
Fig. 3. Three-layer construct demonstrating skin paddle (distal
end released), gluteus maximus muscle, and vascularized fascia
In all cases, there was good operative closure
of the extended abdominoperineal reconstruction defect. Detailed results of the inferior gluteal
artery myocutaneous 1 and 2 groups have been
reported previously and so will not be repeated.13,14
In the currently described inferior gluteal artery
myocutaneous 3 flap variant of the technique
(n = 15; mean age, 65 years; range, 57 to 82 years),
mean follow-up extends to 16 months (range, 6
to 34 months; median, 15 months). There have
been no partial/total flap failures. Two patients
suffered small areas of delayed wound healing
requiring simple débridement and closure and
two donor-site seromas required aspiration. Clinically, there was no gluteus maximus or tensor fasciae latae weakness and no sciatic nerve injuries or
posterior femoral cutaneous nerve of thigh neuroma formation. Three patients reported reduced
donor-site sensation and 10 reported reduced/
absent flap sensation. All but one were satisfied
with the aesthetics of their scar. There has been
no late hernia formation.
The gluteus maximus is a bulky muscle protecting the sciatic nerve. One-third of the muscle
is expendable and can obliterate perineal resection dead space. This was achieved by inferior
gluteal artery myocutaneous 1 and 2 flaps but,
although short-term perineal floor integrity was
good, delayed appearance of hernias followed in
some cases. We hypothesized that this was related
to attrition of innervated muscle from the weight
of pelvic contents and would require design modification. In addition, some seroma and wound
healing problems in inferior gluteal artery myocutaneous 2 flaps also suggested that importation
of nonirradiated skin was essential. The inferior
gluteal artery myocutaneous 1 flap was therefore
considered better than the inferior gluteal artery
myocutaneous 2 flap, but an additional fascial
replacement layer was considered essential for
reconstructing the perineal floor. Allografts/autografts and synthetic replacements are potential
infective risks in a radiotherapy field. As such, we
used proximal fascia lata/iliotibial tract vascularized by the gluteus maximus muscle. Along with
increased skin paddle length, this is the final evolution defining the inferior gluteal artery myocutaneous 3 flap.
Regarding vascularization of the proximal fascia lata/iliotibial tract, the tensor fasciae latae and
gluteus maximus muscles insert into the iliotibial
Volume 132, Number 5 • Abdominoperineal Defect Reconstruction
tract. Whereas the blood supply of the tensor fasciae latae is reported to be from either the ascending or transverse branches of the lateral femoral
circumflex artery, the gluteus maximus is supplied by the superior and inferior gluteal arteries. As all tendons and their insertions receive
blood supply from the muscles inserting into
them, the proximal portion of the fascia lata/iliotibial tract harvested with the gluteus maximus
muscle in an inferior gluteal artery myocutaneous 3 flap will receive its blood supply from the
inferior gluteal artery. This was noted clinically
during our dissections, and supporting intraoperative video evidence of fascia lata being perfused
from distal gluteus maximus muscle is attached.
(See Video, Supplemental Digital Content 1,
which demonstrates intraoperative evidence of
fascia lata being perfused from distal gluteus
maximus muscle,
The senior author has extensive experience with
the anterolateral thigh flap and has not identified
significant vascular supply to the iliotibial tract
from the descending branch of the lateral femoral
circumflex artery at the proximal level at which
the inferior gluteal artery myocutaneous flap is
harvested. Although the descending branch of
the lateral femoral circumflex artery may contribute some supply to the iliotibial tract at a lower
level in the thigh, this has not been well studied.
Skin flap orientation at 45 degrees versus
muscle at 30 degrees optimizes donor-site closure.
Intraoperatively, orientation of gluteus maximus
muscle can be more vertical than predicted preoperatively, and the pivot point of the inferior gluteal artery can be more lateral than expected. The
longer skin flap allows reconstruction of extended
defects such as the posterior vaginal wall. Flap
Fig. 4. Example of final result at 12 months.
innervation can be confirmed postoperatively by
palpation of voluntarily contracting muscle.
The inferior gluteal artery myocutaneous
3 flap is a robust, novel technique with a short
learning curve and extended indications. Evolution has been a process with few complications. The procedure contains all components
required for successful perineal reconstruction,
comprising maintenance of perineal floor integrity, obliteration of dead space, and importation
of nonirradiated skin to facilitate primary wound
healing (Fig. 4). It offers significant advantages
over existing techniques and should be considered primarily for the reconstruction of extended
abdominoperineal reconstruction defects.
Damien G. Grinsell, F.R.A.C.S.(Plast.)
Northern Plastic Surgery
19 Winifred Street
Essendon, Victoria 3040, Australia
[email protected]
Video. Supplemental Digital Content 1 demonstrates intraoperative evidence of fascia lata being perfused from distal gluteus
maximus muscle,
1. West NP, Finan PJ, Anderin C, Lindholm J, Holm T, Quirke
P. Evidence of the oncologic superiority of cylindrical
abdominoperineal excision for low rectal cancer. J Clin
Oncol. 2008;26:3517–3522.
2. Bullard KM, Trudel JL, Baxter NN, Rothenberger DA.
Primary perineal wound closure after preoperative radiotherapy and abdominoperineal resection has a high incidence of wound failure. Dis Colon Rectum 2005;48:438–443.
3. Petrelli N, Rosenfield L, Herrera L, Mittelman A. The morbidity of perineal wounds following abdominoperineal resection for rectal carcinoma. J Surg Oncol. 1986;32:138–140.
4. Baird WL, Hester TR, Nahai F, Bostwick J III. Management of
perineal wounds following abdominoperineal resection with
inferior gluteal flaps. Arch Surg. 1990;125:1486–1489.
Plastic and Reconstructive Surgery • November 2013
5. Tei TM, Stolzenburg T, Buntzen S, Laurberg S, Kjeldsen H.
Use of transpelvic rectus abdominis musculocutaneous flap
for anal cancer salvage surgery. Br J Surg. 2003;90:575–580.
6. Friedman J, Dinh T, Potochny J. Reconstruction of the
perineum. Semin Surg Oncol. 2000;19:282–293.
7. Pezim ME, Wolff BG, Woods JE, Beart RW Jr, Ilstrup DM.
Closure of postproctectomy perineal sinus with gracilis muscle flaps. Can J Surg. 1987;30:212–214.
8. Hay JM, Fingerhut A, Paquet JC, Flamant Y. Management
of the pelvic space with or without omentoplasty after
abdominoperineal resection for carcinoma of the rectum:
A prospective multicenter study. The French Association for
Surgical Research. Eur J Surg. 1997;163:199–206.
9. John H, Buchmann P. Improved perineal wound healing
with the omental pedicle graft after rectal excision. Int J
Colorectal Dis. 1991;6:193–196.
10. Holm T, Ljung A, Häggmark T, Jurell G, Lagergren J.
Extended abdominoperineal resection with gluteus maximus
flap reconstruction of the pelvic floor for rectal cancer. Br J
Surg. 2007;94:232–238.
Wagstaff MJ, Rozen WM, Whitaker IS, Enajat M, Audolfsson
T, Acosta R. Perineal and posterior vaginal wall reconstruction with superior and inferior gluteal artery perforator
flaps. Microsurgery 2009;29:626–629.
Bostwick J III, Moore J, McGarity WC. Inferior gluteal
musculocutaneous flap for the obliteration of acute and
chronic proctocolectomy defects. Surg Gynecol Obstet.
Boccola MA, Rozen WM, Ek EW, Teh BM, Croxford M,
Grinsell D. Inferior gluteal artery myocutaneous island transposition flap reconstruction of irradiated perineal defects. J
Plast Reconstr Aesthet Surg. 2010;63:1169–1175.
Boccola MA, Rozen WM, Ek EW, Grinsell D, Croxford MA.
Reconstruction of the irradiated extended abdominoperineal excision (APE) defect for locally advanced colorectal
cancer. J Gastrointest Cancer 2011;42:26–33.