* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Ideas and Innovations The Inferior Gluteal Artery Myocutaneous Flap with Vascularized Fascia Lata to Reconstruct Extended Abdominoperineal Defects Damien G. Grinsell, F.R.A.C.S.(Plast.) Edwin Morrison, M.B.B.S. Patrick D. T. Tansley, F.R.C.S.(Plast.) 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.) CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV. A 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, 2013. 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 836e 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. PRSJournal.com). www.PRSJournal.com Volume 132, Number 5 • Abdominoperineal Defect Reconstruction PATIENTS AND METHODS 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. 837e 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. Patients 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 lata. 838e RESULTS 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. DISCUSSION 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, http://links.lww.com/PRS/A888.) 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. CONCLUSIONS 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] references Video. Supplemental Digital Content 1 demonstrates intraoperative evidence of fascia lata being perfused from distal gluteus maximus muscle, http://links.lww.com/PRS/A888. 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. 839e 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 840e 11. 12. 13. 14. 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. 1988;166:169–170. 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.