Abstract: “Please Turn Over (PTO) Perforator Flap”: A New Technique to Reconstruct Perineal Defects Following Extralevator Abdominoperineal Excision (ELAPE)

Abstract

INTRODUCTION: Locally advanced low rectal cancer is now increasingly treated with an extralevator abdominoperineal excision (ELAPE) as ELAPE has been deemed to provide superior oncological clearance than traditional abdominoperineal excision (APE).1 However, the extended perineal dissection performed in ELAPE creates a perineal wound that is more demanding in terms of reconstruction. This is because a larger perineal cavity and potential dead space is created and less gluteal skin is excised when compared to standard APE.1 These two characteristics along with the neo-adjuvant chemo-radiation effects on wound healing have been associated with increased perineal wound morbidity, making uneventful perineal reconstruction post-ELAPE challenging to plastic surgeons whose assistance is sought in 67% of ELAPE cases. We present a new technique for perineal reconstruction post-ELAPE, using a perforator, islanded, turn over, de-epithelialized local flap (PTO – Perineal Turn Over perforator flap). METHODS: The PTO flap is raised based on perforators from internal pudendal artery. In the current literature perineal perforator based flaps have been described for vulva reconstruction but not for perineal reconstruction after ELAPE.2 The concept of the flap is based on two components: a) the thick gluteal dermis acts as an autologous dermal vascularised substitute for the excised pelvic floor muscles providing a tension free repair that prevents perineal hernia formation b) the gluteal subcutaneous fat obliterates the dead space reducing fluid collections and preventing infections. This was a retrospective review of patients undergoing reconstruction with the PTO flap following ELAPE. Data included patients’ demographics, neo-adjuvant chemo-radiotherapy, histopathology, duration of surgery, follow-up period and complications. RESULTS: Fourteen patients were identified. Median operating time for the PTO flap was 49 min. There were no cases of flap loss, donor site morbidity or major wound complications. Superficial skin dehiscence and perineal hernia formation were reported in 2 patients respectively. None of the patients developed chronic perineal pain. All patients reported excellent satisfaction with the aesthetic outcome. CONCLUSION: The PTO flap is a reliable option for perineal reconstruction after ELAPE that provides many advantages over other reconstructive techniques including primary closure, myocutaneous flaps, and biologic meshes. Reference Citations: 1. Holm T. Controversies in abdominoperineal excision Surg Oncol Clin N Am 23 (2014) 93–111 2. Kim JT, Ho SY, Hwang JH, Lee JH. Perineal perforator-based island flaps: the next frontier in perineal reconstruction. Plast Reconstr Surg. 2014 May; 133(5): 683e-687e.