Internal Pudendal Artery Perforator Flap Research Articles

ASO Author Reflections: Early Postoperative Mobilization as a New Standard Approach in the Reconstruction of Irradiated Perineal Defects with Internal Pudendal Artery Perforator Flap

ASO Author Reflections: Early Postoperative Mobilization as a New Standard Approach in the Reconstruction of Irradiated Perineal Defects with Internal Pudendal Artery Perforator Flap

Effect of Early Postoperative Mobilization on Functional Recovery, Hospital Length of Stay, and Postoperative Complications After Immediate Internal Pudendal Artery Perforator Flap Reconstruction for Irradiated Abdominoperineal Resection Defects: A Prospective, Randomized Controlled Trial

Effect of Early Postoperative Mobilization on Functional Recovery, Hospital Length of Stay, and Postoperative Complications After Immediate Internal Pudendal Artery Perforator Flap Reconstruction for Irradiated Abdominoperineal Resection Defects: A Prospective, Randomized Controlled Trial

The use of the internal pudendal artery perforator flap after abdominoperineal reconstruction: A single center study

Abdominoperineal resection (APR) is still a valuable option in the presence of cancer recurrences or salvage surgery. Primary perineal closure after conventional APR curries a high rate of wound complications. A multidisciplinary approach with perineal soft tissue reconstruction surgical time improves the immediate and long-term prognosis of these patients. The aim of the study is to report our experience with the use of the internal pudendal artery perforator flap in perineal region reconstruction after APR. We performed 11 perineal region reconstructions after conventional APR between September 2016 and December 2020. In 8 cases the reconstruction was performed on previously irradiated tissues while in 2 cases the radiotherapy was carried out on the perineal tissues solely for adjuvant therapy. A rotation perforating flap was harvested in 8 cases, an advance island flap in 2 cases, and a propeller type in one case. All 11 flaps survived with no immediate postoperative major complications. Only one case showed dehiscence of the donor site wound healed with conservative treatment. Average hospitalization time was 11 days internal pudendal artery perforator flap represents a valid and reliable reconstructive solution after APR showing low complication rates and minimal donor site morbidity even in patients with previous radiotherapy.

Oversized lotus petal flap for reconstruction of extensive perineal defects following abdomino perineal resection

Abdominoperineal resection (APR) of low rectal and anal tumors are performed for optimal oncological outcome but results in large defects in the perineum. Although vertical rectus abdominus (VRAM) flap is commonly employed for extensive perineal reconstruction, donor site morbidity remains problematic. The fascio-cutaneous "lotus petal" flap is an appealing option for reconstructing perineal defects as it may benefit from less donor site morbidity than other techniques. The purpose of this study is to demonstrate that the lotus flap should not only be limited to small and moderate sized defects, but can also be applied to extensive APR. A systematic review of the literature on the outcomes and dimensions of the lotus flap was performed. Articles with clear anatomical landmarks and internal pudendal artery flaps dimensions were identified. Afterwards, the lotus flap technique was applied on a series of patients with extensive perineal defects following APR treated in our center. Four articles on internal pudendal artery perforator flap were selected. The average reported size of this flap was 13cm×6cm. In our center, reconstruction of the perineum with oversized lotus flaps was performed on 10 consecutive patients. None had partial/complete flap loss or donor-site morbidity. The use of a Jack-Knife surgical position, indocyanide green fluorescence imaging, and preservation of a proximal skin bridge can extend the size of a secure flap to up to 20cm in length. The oversized lotus flap is a reliable option for reconstruction after extensive APR.

Filling of an Internal Pudendal Artery Perforator Flap for Rectovaginal Fistula after Intersphincteric Rectal Resection

Filling of an Internal Pudendal Artery Perforator Flap for Rectovaginal Fistula after Intersphincteric Rectal Resection

Selection and effects of flap/myocutaneous flap repair methods for the defect after perineum tumor resection

Objective: To explore the selection and effects of flap/myocutaneous flap repair methods for the defect after perineum tumor resection. Methods: From January 2011 to February 2017, 31 patients with vulvar tumor who were admitted to Hunan Cancer Hospital underwent repair of wound after tumor resection with various flaps/myocutaneous flaps. The patients were composed of 5 males and 26 females, aged 39-76 years, with 27 vulvar cancer and 4 Paget's disease in primary diseases. The size of defects after vulvar tumor radical resection ranged from 8.0 cm×4.5 cm to 27.5 cm×24.0 cm. According to the theory of perforasome, the defects were repaired by the external pudendal artery perforator flap, deep inferior epigastric artery perforator flap, rectus abdominis myocutaneous flap, anterolateral thigh flap, internal pudendal artery perforator flap, gracilis myocutaneous flap, and profunda artery perforator flap based on the specific size and location of perineum and groin where the defect was located. According to the blood supply zone of flap, totally 17 local translocation flaps, 18 axial flaps/myocutaneous flaps, and 7 V-Y advancement flaps were resected, with an area of 7.0 cm×4.0 cm to 21.0 cm×13.0 cm. All the flaps/myocutaneous flaps were transferred in pedicled fashion, and the donor sites were closed without tension. The number of flaps/myocutaneous flaps, wound closure, flaps/myocutaneous flaps survival, and follow-up were observed and recorded. Results: Altogether 42 flaps/myocutaneous flaps were harvested in 31 patients. Two flaps/myocutaneous flaps were used in 11 cases for large circular defect repair. All the defects achieved tension-free primary closure. The blood supply of 32 flaps/myocutaneous flaps was good, while insufficient blood supply was noted in the other 10 flaps/myocutaneous flaps. Seventeen flaps/myocutaneous flaps survived smoothly. Wound dehiscence occurred in 5 flaps/myocutaneous flaps 8 to 14 days postoperatively, which was healed with dressing change. Temporary congestion was noted in 7 flaps/myocutaneous flaps 2 to 5 days postoperatively, which recovered without special treatment. Three flaps/myocutaneous flaps had infection 7 to 15 days postoperatively, two of which recovered after dressing change, while the other one had partial necrosis and received debridement and direct closure. Two flaps/myocutaneous flaps were totally necrotic 8 to 15 days postoperatively, which were repaired with pedicled rectus abdominis myocutaneous flap after debridement. Seven flaps/myocutaneous flaps had partial necrosis 7 to 20 days postoperatively and were healed after dressing change. Twenty-four patients were followed up for 9-38 months. The color of flaps/myocutaneous flaps was similar to that of the surrounding skin, the shape of vulva was natural, the movement of hip joint was not limited, the function of micturition and defecation was not affected, and tumor recurrence was noted in 3 patients. Conclusions: For the complicated large defect after perineum tumor resection, the flexible application of different forms of flaps/myocutaneous flaps to repair according to different areas regains the appearance and function. However, there are many complications, so it is necessary to further strengthen the postoperative care.

Comparative Study Using Internal Pudendal Artery Perforator Flap and Superior Medial Thigh Flap for Scrotal and Perennial Reconstruction

Comparative Study Using Internal Pudendal Artery Perforator Flap and Superior Medial Thigh Flap for Scrotal and Perennial Reconstruction

Re: A Reliable Technique in the Reconstruction of Large Penoscrotal Defect: Internal Pudendal Artery Perforator Flap.

Re: A Reliable Technique in the Reconstruction of Large Penoscrotal Defect: Internal Pudendal Artery Perforator Flap.

A Reliable Technique in the Reconstruction of Large Penoscrotal Defect: Internal Pudendal Artery Perforator Flap

To reconstruct the defect secondary to Fournier's gangrene, which is an infection localized in the perineum and the lower abdominal region, characterized by large tissue loss following debridement. A large tissue loss caused by Fournier's gangrene brings with repair problems. The primary goal is to achieve cosmetically and functionally successful results. The purpose of this article is to share the results of reconstruction of large penoscrotal defects with internal pudendal artery perforator (IPAP) flap. The data of 13 patients, who were operated with the diagnosis of Fournier's gangrene between October 2014 and September 2018, and whose resulting large scrotal defect repair was carried out with IPAP flap, were evaluated retrospectively. The age of the patients ranged from 32 to 80 years (mean 54.3 years). The smallest flap area was 84 cm2 and the largest flap area was 171 cm2 (mean 120 cm2). The mean follow-up time was 26 months. One patient developed hematoma and 1 patient developed limited necrosis. The remaining defect was repaired primarily in the second surgery. The goal of the repair of the scrotal region is to obtain successful results that will please the patients both cosmetically and functionally. The IPAP flap is close to the defect area and is an easy-to-perform technique. The most important advantages are that it does not require dissection in the muscle tissue, and that successful results can be achieved in the reconstruction of large scrotal defects.

Double-sided folded internal pudendal artery perforator flap for the repair of a recurrent rectovaginal fistula.

Double-sided folded internal pudendal artery perforator flap for the repair of a recurrent rectovaginal fistula.

Outcomes of Immediate Internal Pudendal Artery Perforator Flap Reconstruction for Irradiated Abdominoperineal Resection Defects.

There are many previous reports for using the internal pudendal artery perforator flap in vulvovaginal reconstruction; however, reports of this flap for perineal reconstruction after abdominoperineal excision of the rectum are scarce. The purpose of this study was to evaluate the outcomes of immediate internal pudendal artery perforator flap reconstruction for irradiated abdominoperineal resection defects. This was a prospective case series. This flap could represent a step forward over other perineal flap approaches or primary closure. A total of 73 consecutive patients with anorectal tumors were included. The study included immediate perineal reconstruction using 122 internal pudendal artery perforator flaps after abdominoperineal excision of the rectum. Dimensions of the perineal defect (in centimeters squared), hospital stay (days), healing time (days), and postoperative complications (Clavien-Dindo grades) were measured. The means of the perineal defect, hospital stay, and healing time were 51.62 cm, 15.94 days, and 38.52 days. The higher the patient BMI, the longer healing time (p = 0.02); Clavien-Dindo complications grades III to IV were greater in patients with perineal defect ≥60 cm (p = 0.03; OR = 10.56); postoperative complications were higher both in patients with anal squamous cell carcinoma (p = 0.005; OR = 6.09) and in patients with comorbidities (p = 0.04; OR = 2.78); hospital stay (p= 0.001) and healing time (p < 0.001) were higher in patients who had postoperative complications. The complete perineal wound healing at 12 weeks was achieved by 95% of patients, and our 30-day mortality rate was 4%. As a nonrandomized study, our results have to be interpreted with caution. Multiple previously described advantages associated with internal pudendal artery perforator flap were also observed here, reinforcing the idea that it is reliable, versatile, and a useful option for perineal reconstruction after abdominoperineal excision of the rectum. Therefore, we propose that this flap could be considered as the first choice for perineal reconstruction in selected patients with moderate and some large defects after abdominoperineal excision of the rectum. See Video Abstract at http://links.lww.com/DCR/A367.

Pedicled Perforator Flaps for Vulvar Reconstruction – A Versatile, Less Invasive and Simple Way with Favorable Results

BACKGROUND: Vulvar reconstruction after cancer surgery remains a great challenge for reconstructive surgeons. Vulvar area is an easy-contaminated region by secretions. Soft tissue reconstruction is a superior choice over skin graft for better wound healing, tolerable tissue for further radiotherapy and better cosmetic results.1 MATERIALS AND METHODS: A retrospective review identified 23 flaps in 13 patients with vulvar reconstruction using island pedicled perforator flaps. The average patients’ age was 58.5 ± 17.6 (Range: 22-85). The average of BMI was 24±3.7 (range: 18.8-28.5). All of them received vulectomy for cancer or pre-cancer lesions. Three patients had unilateral vulvar reconstruction while the others 10 patients had bilateral vulvar reconstruction. The perforator flaps included were profunda artery perforator flaps (n=12), gracilis perforator flaps (n=7), external pudendal artery perforator flap (n=2), medial thigh perforator flap (n=2), and internal pudendal artery perforator flap (n=4). 9 of the flaps were designed as V-Y fashion to facilitate donor site wound closure in larger defect reconstruction and the rest 14 flaps were designed as fusiform shape. RESULTS: All the flaps survived with a 100% successful rate. Three patients experienced small wound disruption that requires wound debridement and wound closure after the reconstruction. All the donor sites were closed primarily. One patient developed temporary peroneal nerve palsy. None of them presented with medical complications. With follow-up, none of the patients presented with donor site morbidities. All the patients were satisfied with the cosmetic and functional results except that one patient received flap debulky procedure three months after surgery. The thickness of the flap caused discomfort during her walking. DISCUSSION AND CONCLUSION: Comparing to traditional myocutaneous flaps, perforator flaps provides thinner fasciocutaneous flaps for vulvar reconstruction with favorable reconstruction results and few donor site morbidities.2-4 The medial or inner thigh is a region rich of perforators. These perforators allow a versatile flap design depending on the location and extension of the vulvar defect after vulectomy. Furthermore, most of the donor site can be closed primarily without complications.

The Internal Pudendal Artery Perforator Flap

Reconstruction of the vulva, vagina, and buttocks following cancer ablation is challenging. Restoring the shape, volume, and function is the key to the best reconstruction for these regions. Perineal reconstruction with a free-style flap based on skin perforators from the internal pudendal artery was evaluated. The internal pudendal artery perforator flap was designed based on information about the skin perforators. The flap base contained the arterial sounds, which were identified by a handheld Doppler device, on and around the ischiorectal fossa. Types of flaps used included propeller flaps, traditional transposition flaps, and V-Y advancement flaps. Seventy-one flaps were transplanted in 45 cases. The reconstructed regions included vulvar skin in 36 cases, buttock skin in 10 cases, vagina in nine cases, anus in six cases, and pelvic cavity in six cases. The flaps were transplanted in the lithotomy or prone position. Sixty-seven of these flaps survived completely. Four flaps showed partial necrosis, but no total flap failures occurred. Thinning of the fatty tissue of the flap was performed in all cases except pelvic cavity reconstruction. An additional operation to remove bulkiness of the flaps following the initial reconstruction was required in one case. Propeller flaps, transposition flaps, and V-Y flaps were used in 35, three, and seven cases, respectively. This study revealed that the blood circulation of this flap is reliable and that it offers suitable volume not only for vulvar, vaginal, and anal reconstruction, which requires a thin flap, but also for pelvic floor reconstruction, which requires flap volume. Therapeutic, IV.

Penoscrotal Reconstruction With Gracilis Muscle Flap and Internal Pudendal Artery Perforator Flap Transposition

Extensive defects of the perineal area, with exposure of the testes, are difficult to reconstruct. For the reconstruction of these defects, we applied gracilis muscle flap combined with pudendal artery perforator fasciocutaneous flap, which provided us a reliable cutaneous flap and allowed us to cover exposed testes with sufficient muscular volume. We retrospectively analyzed 7 patients from 2004-2011 whose penoscrotal defects had been reconstructed using gracilis muscle flap and an internal pudendal artery perforator flap. Six had Fournier's gangrene and 1 had extramammary Paget's disease. We examined characteristics of the patients, preoperative management, operative procedure, and their clinical courses. All flaps survived during the entire follow-up periods. The mean width of the defects was 10.14 cm and the mean length was 9.29 cm. The width of the fasciocutaneous flap was approximately 6-10 cm, whereas the length ranged from 10-15 cm. The reconstructed areas were in good functional and esthetic conditions. The combination of the gracilis muscle flap and the internal pudendal artery perforator fasciocutaneous flap provides pliable and reliable soft tissue coverage for extensive penoscrotal defects with adequate bulkiness and minimal donor site morbidity.

Editorial Comment

Fournier's gangrene had historic mortality rates that ranged from 20–88%. However, in contemporary population-based studies, its mortality is substantially less likely(only 7.5%) because of the advent of better surgical and intensive care unit care, especially at tertiary hospitals. 1 Sorensen M.D. Krieger J.N. Rivara F.P. et al. Fournier's gangrene: management and mortality predictors in a population based study. J Urol. 2009; 182: 2742-2747 Abstract Full Text Full Text PDF Scopus (79) Google Scholar , 2 Sorensen M.D. Krieger J.N. Rivara F.P. et al. Fournier's gangrene: population based epidemiology and outcomes. J Urol. 2009; 181: 2120-2126 Abstract Full Text Full Text PDF PubMed Scopus (165) Google Scholar Attention to the best methods of genital reconstruction after Fournier's gangrene is important because most patients now survive the acute infection. Extensive debridement in the treatment of Fournier's gangrene leads to large tissue defects that are closed with local flaps or treated with extensive skin grafts. Management of the testes, which usually are salvageable, is variable and the options after the scrotum has been removed include orchiectomy, placement of the testes in subcutaneous thigh pouches, skin grafts, or local flaps for reconstruction of a neoscrotum. Penoscrotal Reconstruction With Gracilis Muscle Flap and Internal Pudendal Artery Perforator Flap TranspositionUrologyVol. 79Issue 6PreviewExtensive defects of the perineal area, with exposure of the testes, are difficult to reconstruct. For the reconstruction of these defects, we applied gracilis muscle flap combined with pudendal artery perforator fasciocutaneous flap, which provided us a reliable cutaneous flap and allowed us to cover exposed testes with sufficient muscular volume. Full-Text PDF ReplyUrologyVol. 79Issue 6PreviewFournier's gangrene is a disease that occurs and progresses suddenly with a high mortality risk. If the disease is not treated and controlled in the early stage, it could prove fatal to the patients by failure of multiple organs and infection spreading. Therefore, aggressive treatment should be done in the acute phase to improve the overall survival rate, which includes administration of broad-spectrum antibiotics and prompt but extensive debridement with conservative wound management.1 Reconstruction would not be considered as an option in this phase. Full-Text PDF