Gluteal Fold Flap Research Articles

The role of the multidisciplinary team in surgical management of intractable tubo-ovarian abscess as a late sequelae of challenging Crohn's disease in the modern era: A case report and review of current literature.

Chronic, severe Crohn's disease in a young female patient can result in surgical complexity. The rarity of the presentation of intractable pelvic abscesses within this etiology with additional considerations given to fertility concerns and hence requirement for input from a multi-disciplinary team makes this a vital case in building a consensus for evidence-based surgical management. A 29-year-old nulliparous woman was referred to our tertiary centre for surgical management of Crohn's disease with known tubo-ovarian abscess and abdominoperineal and abdominal wall sinuses. Her previous surgical history included 4 midline laparotomies, subtotal colectomy and proctectomy with stoma formation. The patient underwent egg collection to preserve fertility. This was followed by midline laparotomy and abdominoperineal resection, which involved a retrograde radical modified hysterectomy using the Hudson technique, alongside excision of the perineal sinus, with reconstruction of the perineal defect using an internal pudendal artery perforator gluteal fold flap, and in addition to excision and drainage of the abdominal wall abscess. Involvement was sought from gynecological oncology, colorectal, urology, plastics, stoma, fertility, microbiology, and gastroenterology teams, which enabled successful preservation of end organ function and improvement in patient psychological well-being. This case is a paradigm of surgical challenge, requiring expert gynecological oncology techniques including a retroperitoneal approach, nerve and vessel sparing considerations alongside colorectal and urological procedures. Moreover, we believe that our blueprint for effective multi-disciplinary practice will inform the future management of gynecological surgery. Therefore this report aims to contribute towards the optimum management of the gynecological sequelae of Crohn's disease.

1231 Radical Vulvectomy and Reconstruction for Severe, Refractory Crohn's Disease of the Vulva: A Case Report

Abstract Vulval Crohn’s disease (VCD) is rare and can arise from direct infiltration, through fistulae or as non-contiguous lesions, so called metastatic disease. We present a case of a 32-year-old female with severe, refractory vulval Crohn’s disease (VCD), requiring radical vulvectomy and reconstruction. She had a subtotal colectomy for Crohn’s disease 8 years previously, and for one year had experienced vulval swelling and pain associated with perianal fistulae for which she underwent an abdomino-perineal resection. Though she achieved long term remission of her gastrointestinal disease, she continued to experience severe vulval symptoms with recurrent infections and abscesses despite treatment with immunomodulators and biologics over a period of 10 years. She then underwent a radical vulvectomy with bilateral gluteal fold flap reconstruction and skin grafting. She made an uncomplicated post-operative recovery. Histopathology showed active non-caseating granulomatous vulvitis. At 1 year follow up, there were no further disease flares, with significant improvement of her pain. Further plastic surgery is being considered. Our case demonstrates the value of surgical management in refractory VCD to improve symptoms, function and quality of life. Though medical therapy with immunosuppressive agents is recommended as first-line treatment, the course of VCD is unpredictable and often relapses on treatment cessation. VCD may persist for long after remission of gastrointestinal disease and may require more aggressive surgery using a multispecialty approach even in the context of active infective disease.

Vessel-preserving en-bloc excision of groin recurrence of vulval carcinoma with tensor fasciae latae flap reconstruction in a previously irradiated field

Objectives: Groin node dissection for recurrent vulval cancer in a previously irradiated field presents many surgical challenges - risk of vascular involvement, ill-defined planes and poor tissue quality for closure and healing. Our case demonstrates the feasibility of surgical management and value of flap reconstruction in managing disease relapse in such patients. Methods: We present the surgical approach to recurrent squamous cell carcinoma (SCC) vulva in a patient who has undergone previous radical radiotherapy to the site of relapse. Download : Download high-res image (268KB) Download : Download full-size image Results: In 2019 - a 70 year old lady underwent radical vulvectomy and left gluteal fold flap reconstruction, followed by radical radiotherapy and concomitant cisplatin for stage IIIc SCC vulva. A total of 12 months later, the patient presented with a clinically palpable, fixed left groin swelling. Imaging confirmed an FDG-avid 2.6 x 4.2 centimetre (cm) partially necrotic left inguinal lymph node, engulfing the femoral vessels. The patient was counselled pre-operatively by both gynae-oncology and plastic surgery – offering surgical excision of this single site recurrence, anticipating the need for further flap reconstruction for wound closure. Additional challenges included body mass index (BMI) of over 40 kilograms/metre2 and chronic candida of the abdominal pannus. Joint examination under anaesthetic by gynae-oncology and plastic surgery confirmed no vulval recurrence and no palpable right groin nodes. Left thigh perforator vessels were identified and marked using doppler. An 8.6 x 3.1cm elliptical incision was made around the fixed underlying node; and systematic inguino-femoral lymph node dissection performed using both bipolar scissors and an advanced energy device. An en-bloc specimen measuring 6.6 x 3.1 x 6.1cm was obtained. The femoral artery and vein were identified; and long saphenous vein preserved. Wound closure was achieved by raising an 18 x 8cm tensor fasciae latae (TFL) islanded flap, rotating and anchoring into place. Postoperatively, the patient was managed jointly under gynae-oncology and plastic surgery. Intravenous antibiotics, anti-fungals and thromboprophylaxis were given. The patient was advised to avoid sitting for 2 weeks. Drain outputs were monitored; and drains removed day 14. A small area of wound dehiscence occurred along the inferior border of the groin flap – which was healing well by secondary intention at the time of 4 week post-operative review, without need for further management. Final histopathology confirmed excised metastatic SCC, with a plan for ongoing surveillance arranged. Conclusions: In patients having undergone previous radiotherapy - surgery remains the main therapeutic option for recurrence. Undertaking such surgery, however, in a previously irradiated field - with altered anatomy and compromised perfusion - significantly increases the risk of inadvertent vessel or nerve injury and wound breakdown. We have demonstrated an approach, however, in an obese patient that achieved disease clearance through meticulous dissection, achieving wound closure and healing by incorporating TFL flap reconstruction.

A Perineal Hernia following Rectal Resection Successfully Repaired by the Combined Use of Laparoscopy and a Gluteal Fold Flap

A Perineal Hernia following Rectal Resection Successfully Repaired by the Combined Use of Laparoscopy and a Gluteal Fold Flap

The V-Y gluteal fold advancement flap: Outcomes following radical surgery for vulvar malignancies.

To evaluate the feasibility and complication rate of the V-Y gluteal fold flap in surgery for vulvar cancer. From June 2015 to June 2018, 62 patients surgically treated for vulvar cancer were included in the study. Twenty-three (37.1%) underwent plastic reconstructive surgery with V-Y advancement flaps. The mean surgical time was longer for patients undergoing V-Y flap surgery. The margins were positive in six patients (9.7%), close (<8mm) in 10 (16.1%), and adequate (>8mm) in 46 (74.2%). Six (9.7%) patients had dehiscence and two (3.2%) patients suffered from necrosis. In patients undergoing V-Y flap reconstruction, two (8.7%) had a wound dehiscence, no patients had necrosis. In patients undergoing direct closure, four (10.3%) had wound dehiscence and two (5.1%) had necrosis. V-Y gluteal fold advancement technique is a safe procedure, performed in a single surgical session with minimal increase in surgical time and low wound healing complications. Use of this technique was correlated with an increased rate of adequate surgical margins (<8mm) and reduced need for adjuvant radiotherapy.

Surgical outcome for colorectal or urinary tract-related fistula: Usefulness of vascularized tissue transfer—a retrospective study⁎

It is challenging to manage colorectal or urinary tract-related fistula. We typically treat colorectal or urinary tract-related fistula with a vascularized tissue transfer. This study aimed to analyze the outcomes of our surgical treatments for colorectal or urinary tract-related fistula. This retrospective review included all patients who underwent surgical repair of a colorectal or urinary tract-related fistula at our institution from October 2004 to September 2019. Patients whose surgical outcomes could not be evaluated were excluded. The primary outcome was the overall cure rate. We also evaluated the complication rate and compared the outcomes for rectovaginal fistula with those for urorectal fistula. The final analysis included 38 cases, of which 17 were rectovaginal fistula and 16 were urorectal fistula. The transperineal approach was used in 28 cases and transperineal and transabdominal combined in nine cases. A gracilis muscle flap was used in 19 cases and a gluteal fold flap in 13 cases. Although a major leak occurred in nine cases, the fistula was finally cured successfully in 31 cases. A comparison of the outcomes for rectovaginal fistula and urorectal fistula showed that complications occurred in 5/17 cases of rectovaginal fistula and 10/16 cases of urorectal fistula (p = 0.056). Fistulae were cured successfully in 13/17 cases of rectovaginal fistula and 14/16 cases of urorectal fistula (p = 0.656). Our surgical treatment for colorectal or urinary tract-related fistula succeeded in 31 of 38 cases. Thus, vascularized tissue transfer is useful for refractory colorectal or urinary tract-related fistula.

Gluteal-fold flap repair of rectovaginal fistula caused by aluminum potassium sulfate hydrate-tannic acid injection for internal hemorrhoids: a case report

BackgroundRectovaginal fistula (RVF) following aluminum potassium sulfate hydrate-tannic acid (ALTA) injection therapy for hemorrhoids is a rare complication. We report the first case of RVF after ALTA injection therapy successfully treated by gluteal-fold flap.Case presentationA 49-year-old female suffered from a fever and rectal ulcer after undergoing internal hemorrhoid treatment with a submucosal ALTA injection at a previous clinic. One week after ALTA therapy, she noted obvious passage of flatus and stool through the vagina, and was diagnosed with RVF by anoscope at another clinic. She was referred to our hospital 3 weeks after ALTA therapy. Sigmoid colostomy was performed for fecal diversion as a preliminary step for fistula repair. However, the fistula was scarred and the defect between the rectum and vagina did not improve at all. Ten months after ALTA therapy, we performed fistula repair by gluteal-fold flap. Seven months later, sigmoid-colostomy reversal was performed. The patient has experienced no RVF in the 3 years since sigmoid-colostomy reversal.ConclusionsThe gluteal-fold flap strategy is a useful option for severe RVF management.

Reconstruction of Perineal Defects: A Comparison of the Myocutaneous Gracilis and the Gluteal Fold Flap in Interdisciplinary Anorectal Tumor Resection.

Introduction: Resection of anorectal malignancies may result in extensive perineal/pelvic defects that require an interdisciplinary surgical approach involving reconstructive surgery. The myocutaneous gracilis flap (MGF) and the gluteal fold flap (GFF) are common options for defect coverage in this area. Here we report our experience with the MGF/GFF and compare the outcome regarding clinical key parameters.Methods: In a retrospective chart review, we collected data from the Department of Plastic Surgery of the University of Freiburg from December 2008–18 focusing on epidemiological, oncological, and therapy-related data including comorbidities (ASA Classification) and peri-/postoperative complications (Clavien-Dindo-System).Results: Twenty-nine patients were included with a mean follow-up of 17 months. Of the cases, 19 (65.5%) presented with recurrent disease, 21 (72.4%) received radiochemotherapy preoperatively, 2 (6.9%) received chemotherapy alone. Microscopic tumor free margins were achieved in 25 cases (86.2%). 17 patients (7 men, 10 women, rectal adenocarcinoma n = 11; anal squamous cell carcinoma n = 6; mean age 58.5 ± 10.68, mean BMI 23.1, mean ASA score 2.8) received a MGF (unilateral n = 10; bilateral n = 7). Twelve patients (7 men, 5 women, rectal adenocarcinoma n = 7; anal squamous cell carcinoma n = 4, proctodeal gland carcinoma n = 1, mean age 66.2 ± 9.2, mean BMI 23.6, mean ASA score 2.6) received coverage with a GFF (unilateral n = 4; bilateral n = 8). Mean operation time of coverage was 105 ± 9 min for unilateral and 163 ± 11 for bilateral MGFs, 70 ± 13 min for unilateral and 107 ± 14 for bilateral GFFs. Complications affected 62%. There was no significant difference in the complication rate between the MGF- and GFF-group. Complications were mainly wound healing disorders that did not extend the hospital stay. No flap loss and no complication that lead to long-lasting disability was documented (both groups). Pain-free sitting took more time in the GFF-group due to the location of the donor site.Conclusion: MG-flaps and GF-flaps prove to be reliable and robust techniques for perineal/pelvic reconstruction. Though flap elevation is significantly faster for GF-flaps, preoperative planning and intraoperative Doppler confirmation are advisable. With comparable complication rates, we suggest a decision-making based on distribution of adipose tissue for dead space obliteration, intraoperative patient positioning, and perforator vessel quality/distribution.

The adipofasciocutaneous gluteal fold perforator flap a versatile alternative choice for covering perineal defects.

Perineal defects following the resection of anorectal malignancies are a reconstructive challenge. Flaps based on the rectus abdominis muscle have several drawbacks. Regional perforator flaps may be a suitable alternative. We present our experience of using the gluteal fold flap (GFF) for reconstructing perineal and pelvic defects. We used a retrospective chart review and follow-up examinations focusing on epidemiological, oncological (procedure and outcome), and therapy-related data. This included postoperative complications and their management, length of hospital stay, and time to heal. Twenty-two GFFs (unilateral n = 8; bilateral n = 7) were performed in 15 patients (nine women and six men; anal squamous cell carcinoma n = 8; rectal adenocarcinoma n = 7; mean age 65.5+8.2years) with a mean follow-up time of 1year. Of the cases, 73.3% were a recurrent disease. Microscopic tumor resection was achieved in all but one case (93.3%). Seven cases had no complications (46.7%). Surgical complications were classified according to the Clavien-Dindo system (grades I n = 2; II n = 2; IIIb n = 4). These were mainly wound healing disorders that did not affect mobilization or discharge. The time to discharge was 22+9.9days. The oncological outcomes were as follows: 53.3% of the patients had no evidence of disease, 20% had metastatic disease, 20% had local recurrent disease, and one patient (6.7%) died of other causes. The GFF is a robust, reliable flap suitable for perineal and pelvic reconstruction. It can be raised quickly and easily, has an acceptable complication rate and donor site morbidity, and does not affect the abdominal wall.

Usefulness of the Gluteal Fold Flap Using Negative Pressure Wound Therapy for Perianal Lesions

Usefulness of the Gluteal Fold Flap Using Negative Pressure Wound Therapy for Perianal Lesions

Gluteal fold flap for pelvic and perineal reconstruction following total pelvic exenteration

SummaryBackgroundThe rectus abdominis myocutaneous flap has been used as the first choice for pelvic and perineal reconstruction. However, due to previous abdominal surgery and multiple stoma placements in our patients, the rectus abdominis myocutaneous flap could not be used for such reconstruction. Here, we describe the use of bilateral gluteal fold flaps for pelvic and perineal reconstruction following total pelvic exenteration to treat recurrent cervical cancer.MethodsWe performed three bilateral gluteal fold flap operations for perineal reconstruction in three patients between 2008 and 2011. The cause of the perineal defect was total pelvic exenteration, which was performed to treat recurrent cervical cancer in all patients.ResultsAll flaps completely survived and there were no severe postoperative complication. Good cosmetic results were achieved in all patients.ConclusionsThe gluteal fold flap is a useful option for reconstructing extensive pelvic and perial defect after total pelvic exenteration because of sufficient soft tissue volume, reliable blood supply, cosmetic results and minimal donor-site morbidity.

Repeated Use of Gluteal Fold Flaps for Post-Oncologic Vulvoperineal Reconstruction.

Because of the associated high recurrence rate, future reconstructive options should be reckoned with during surgical treatment of primary or recurrent (pre)malignant vulvoperineal lesions. One of the claimed advantages of the gluteal fold flap is the possibility of repeated use of the flap in case of recurrence. We present our experience with such reuse of gluteal fold flaps to illustrate this possibility. A mean of 27 months after initial use, 10 subcutaneously pedicled or perforator-based V-Y advancement or propeller-rotation flaps were elevated from previously used gluteal fold flaps in 9 women presenting with recurrent vulvoperineal (pre)malignancy. Five of these women had undergone radiotherapy prior to flap reuse. Although short-term complications were observed in 3 women, all flaps survived and healed completely. We showed the feasibility of successful reuse of subcutaneous pedicled or perforator-based gluteal fold flaps for repeated vulvoperineal reconstruction, both in nonirradiated and irradiated women. This concept of reuse of the gluteal fold flap is useful for recurring (pre)malignant vulvoperineal defects, and reconstructive surgeons and patients may benefit from this potential option.

Bilateral V-Y advancement gluteal fold flaps following vulvo-vaginal melanoma resection

The soft tissue defects of the anterior perineum can be caused by tumour excision, trauma, burns, Fournier’s gangrene and genital mutilation. Various reconstruction methods were described: vacuum-assisted closure, skin grafts and skin substitutes, pedicled or free flaps. In the case of defects following oncologic surgery, flaps are the reconstructive method of choice. We present the case of a 65 year-old woman diagnosed with stage III A vulvo-vaginal melanoma affecting also the distal urethra. Radical vulvectomy and en-bloc excision of the anterior third of the vagina and distal urethra, along with bilateral inguinal lymphadenectomy was performed. The resulting defect was covered with bilateral V-Y advancement gluteal fold flaps. A local vaginal recurrence appeared 18 months after surgery and was safely removed. The patient followed chemotherapy with Dacarbazine. The gluteal fold flap offered good defect coverage and survived completely. Follow-up period was two years without distant metastases. Functional result was excellent, urinary function being normal and patient satisfaction high. Due to the gluteal flap’s advantages (appropriate thickness, good vascularity, minimal donor site morbidity, and same operative field allowing for shorter operating time), reconstruction of the anterior perineum after oncological resection with bilateral V-Y advancement gluteal flaps is a viable solution.

Subunit principle of vulvar reconstruction: algorithm and outcomes.

BackgroundVulvar defects result chiefly from oncologic resection of vulvar tumors. Reconstruction of vulvar defects restores form and function for the purpose of coitus, micturition, and defecation. Many surgical options exist for vulvar reconstruction. The purpose of this article is to present our experience with vulvar reconstruction.MethodsFrom 2007 to 2013, 43 women presented to us with vulvar defects for reconstruction. Their mean age at the time of reconstruction was 61.1 years. The most common cause of vulvar defect was from resection of vulvar carcinoma and extramammary Paget's disease of the vulva. Method s of reconstruction ranged from primary closure to skin grafting to the use of pedicled flaps.ResultsThe main complications were that of long term hypertrophic and/or unaesthetic scarring of the donor site in 4 patients. Twenty-two patients (51%) were able to resume sexual intercourse. There were no complications of flap loss, wound dehiscence, and urethral stenosis.ConclusionsWe present a subunit algorithmic approach to vulvar reconstruction based on defect location within the vulva, dimension of the defect, and patient age and comorbidity. The gracilis and gluteal fold flaps are particularly versatile and aesthetically suited for reconstruction of a variety of vulvar defects. From an aesthetic viewpoint the gluteal fold flap was superior because of the well-concealed donor scar. We advocate the routine use of these 2 flaps for vulvar reconstruction.

Gluteal fold flap in perineal reconstruction for Crohn's disease-associated fistulae

Crohn's disease is increasing in incidence worldwide. It is associated with many complications including fistulae, which may require surgical intervention. Occasionally, formal perineal reconstruction is needed for extensive or definitive fistula surgery. Reconstruction for inflammatory disease presents unique challenges and often calls for innovative solutions. Gluteal fold flaps (GFFs), which have been widely used in vulvo-vaginal malignancy and anorectal cancer surgery, have not hitherto been reported for Crohn's disease-associated fistulae. A 30-year-old female presented with a 5-year history of Crohn's-associated perianal and rectovaginal fistulae. She had a previous small bowel resection and ileostomy. A laparascopic pan-proctocolectomy was carried out followed by perineal reconstruction in a single stage procedure using a pedicled fasciocutaneous GFF. Seven months postoperatively, revisional surgery was carried out using the contralateral GFF due to two areas of persistent wound dehiscence. The outcome was complete resolution of the fistulae, stable wound closure and good cosmesis. This case demonstrates that it is practical to use the GFF for perineal reconstruction following excision of complex Crohn's-associated fistulae. The flap avoids the sequelae associated with sacrifice of regional muscle flaps and specifically circumvents the unavailability of the rectus abdominis flap in slim patients or those with in-situ ileostomies. It is easy and quick to raise and does not require an intra-operative change in the patient's position. The GFF ensured well vascularised skin cover, adequate flap volume with no loss of function and low donor site morbidity.

An Algorithmic Approach to Perineal Reconstruction After Cancer Resection—Experience From Two International Centers

This paper aims to simplify the approach to reconstruction of the perineum after resection of malignancies of the anal canal, lower rectum, vulva, and vagina. The data were collected from 2 centers, namely, Addenbrooke's Hospital, University of Cambridge, United Kingdom and Christchurch Hospital, University of Otago, New Zealand. All patients who underwent perineal reconstruction from 1997 to 2009 at Christchurch Hospital (13 years) and 2001 to 2009 at Addenbrooke's Hospital (9 years) were included. The diagnosis (indication), primary surgery, reconstructive surgery, complications, tumor outcomes (recurrence and survival), and follow-up were entered into a database (Microsoft Excel; Redmond, Wash). The incidence of previous radiotherapy, requirement for adjuvant radiotherapy, and length of inpatient stay were also recorded. Forty-six patients were identified for this study--13 in New Zealand and 33 in Cambridge. Indications for perineal reconstruction included resection of anal and rectal malignancies (24), vulval and vaginal malignancy (19), perineal sarcoma (1), and perineal squamous cell carcinoma arising in an enterocutaneous fistula (Table 1). The reconstructive strategies adopted included rectus abdominis myocutaneous flaps (26), gluteal fold flaps (9), gracilis V-Y or advancement flaps (7) and others (4), gluteal rotation flaps (1), local flap (2), and free latissimus dorsi flaps (1). Although various surgeons performed the reconstructive surgeries at 2 different centers, the essential approach remained the same. Smaller defects were best treated by local flaps, whereas the rectus abdominis flap remained the standard option for larger defects that additionally required closure of dead space. On the basis of our 2 center experience, we propose a simple algorithm to facilitate the planning of reconstructive surgery for the perineum.

The gluteal fold flap: A versatile option for perineal reconstruction following anorectal cancer resection

Gluteal fold flaps (GFFs) have been extensively reported for vulvo-vaginal reconstruction but there are no published series of their use for perineal reconstruction following anorectal cancer excision. In this context, abdominal myocutaneous flaps remain the method of choice but may be unavailable because of pre-existing abdominal scars, or need for a colostomy/urostomy. In addition, their abdominal wall morbidity makes them less acceptable, especially given the increasing use of laparoscopic techniques for the extirpative surgery. We document our experience using GFFs following radical anorectal cancer excision. Data were collected from a single surgeon's consecutive cases performed over a five-year period (October 2007-May 2012). The indication, surgical procedure, complications and follow-up were recorded, as was the incidence of neoadjuvant/adjuvant therapy. Ten gluteal fold fasciocutaneous flaps were performed in seven patients at the time of radical anorectal excision. The GFFs were performed alone (unilateral n=3, bilateral n=3) or in combination with a contralateral anterolateral thigh (ALT) myocutaneous flap (n=1). The indications for anorectal excision were rectal adenocarcinoma (n=3), anal squamous cell carcinoma (n=3) and anal adenocarcinoma (n=1). All flaps survived completely although two patients required further surgery, one for evacuation of a late donor site haematoma and another to close a small, persistent wound dehiscence. The mean follow-up period was 24 months (range 2-57). The GFF is a reliable, versatile and robust option for perineal reconstruction after extended anorectal excision, despite local irradiation, and should be considered for medium and selected large defects in this context.

Reconstruction of the Vulva with Sensate Gluteal Fold Flaps

Soft-tissue reconstruction of the vulva following resection of malignancies is challenging. The function of perineal organs should be preserved and the reconstructed area should maintain an acceptable cosmetic appearance. Reconstruction with local flaps is usually sufficient in the primary phase after a radical vulvectomy. Numerous flaps have been designed for vulvar reconstruction usually based on circulation from the internal pudendal artery branches. In this paper we introduce our modification of the gluteal fold V-Y advancement flap as a primary reconstruction after a radical vulvectomy. Twenty-two patients were operated with a radical vulvectomy because of vulvar malignancies. The operation was primary in eight and secondary in 14 patients. The reconstruction of the vulva was performed in the same operation for each patient. All flaps survived completely. Wound complications were registered in three patients. Late problems with urinary stream were corrected in two patients. A local recurrence of the malignancy was observed in six patients during the follow-up period. Gluteal fold flap is easy to perform, has a low rate of complications and gives good functional results. Even a large defect can be reconstructed reliably with this method. A gluteal fold V-Y advancement flap is sensate and our modification allows the flap to be transposed with lesser dissection as presented before.

Radical resection and reconstruction with bilateral gluteal fold perforator flaps for vulvar hemangiolymphangioma

Hemangiolymphangioma is a rare type of lymphatic malformation characterized by vascular and lymphatic elements on histologic examination [1]. The present paper reports a rare case of vulvar hemangiolymphangioma and the successful surgical reconstruction with bilateral gluteal fold perforator flaps. A 16-year-old patient was referred in August 2012 for progressive swelling of the genitals that had been ongoing for 8 years. The patient complained of intermittent discharge of a white fluid mixed with blood from her perineum since the age of 8 years. On physical examination, erythema and tenderness of the labia majora were present, with friable bleeding upon palpation. Seven months prior to evaluation, the patient had experienced an episode of massive perineal hemorrhage resulting in severe anemia (7 g/dL). The hemorrhage was managed conservatively with pressure and blood transfusions. The following month the patient underwent sclerotherapy, but no subsequent reduction in mass size or symptoms was noted. Given the severity of the patient's condition, the decision was ultimately made to proceed with a radical resection of the involved areas. Bilateral vulvectomy was performed and the resulting defect was reconstructed with bilateral gluteal fold flaps based on internal pudendal artery perforators (Fig. 1). The flap dimensions were 15×6 cm on the right and 17×8 cm on the left side. Both the defect and donor sites were primarily closed (Fig. 2). The postoperative course was

Gluteal fold flaps for perineal reconstruction

Defects of the perineum are created during ablative procedures for gynaecological, urological and colorectal malignancies. The gluteal fold flap is a reliable means of reconstructing these defects. We retrospectively reviewed case notes of gluteal fold flaps performed for perineal reconstruction over four years (2007-2010) in our institution. 77 perineal defects were reconstructed using unilateral or bilateral gluteal fold flaps (127 flaps in total). 50% of all patients are discharged before 11 days, and 90% were discharged within one month. Mean time to discharge was 13.2 days. 70% of all patients were completely healed at 2 months, and 85% completely healed at three months. Pre-operative radiotherapy was found to have a prolonging effect on the time to discharge (P<0.05) but did not reach statistical significance when considering the eventual time to healing. The number of co-morbidities that each patient had at the time of surgery had a prolonging effect on both time to discharge and time to healing (P<0.03). The type of resected areas that required reconstruction did not have a statistically significant effect on the time to discharge, but defects where the anus had been resected did eventually take longer to heal than those were the anus was not resected (P<0.01). 124 flaps were successful (97.6%) with total or partial flap loss occurring in three. Complications were seen in 34 of the 77 patients (44%), with simple wound breakdown resulting in delayed healing seen most frequently (30%). The gluteal fold fasciocutaneous flap is a versatile option for reconstructing a wide range of pelvic and perineal defects. Patients with multiple co-morbidities, cases with radiotherapy and instances where the anus has been resected are more likely to experience longer healing times. We present our algorithm for management for perineal defects after tumour resection.