Internal Pudendal Artery Perforator Research Articles

Modified Internal Pudendal Artery Perforator Flap Interposition for Rectovaginal Fistula.

Rectovaginal fistula (RVF) is a challenging condition associated with recurrences and significant functional impairment. The internal pudendal artery perforator (IPAP) flap has become a viable option for reconstructing the vagina and perineal regions. This study aims to introduce a modified technique of IPAP flap interposition and evaluate its postoperative outcomes in the treatment of low RVF. Sixteen patients with RVF who underwent modified IPAP flap interposition between 2016 and 2021 were retrospectively enrolled. Recurrence rate, the satisfaction of vulvar appearance (Visual Analog Scale), and quality of sexual life (Female Sexual Function Index score) were followed up and analyzed. All patients presented with low fistula with a mean diameter of 8.3 mm. The mean width and length of the IPAP flaps were 3.8 and 6.2 cm, respectively. The mean follow-up period was 14.1 months. All patients achieved successful healing without recurrence. High satisfaction was reported for the cosmetic effect of the vulva with a mean Visual Analog Scale score of 8.4. The proportion of female sexual disorder exhibited a statistically significant reduction, decreasing from 100% preoperatively to 38% after surgery (P < 0.05). The modified IPAP flap interposition is a reliable and safe option for repairing low RVF, with high success rates and minimal donor site morbidity. Moreover, this procedure provides a suitable volume flap and preserves the vaginal physiological environment, which benefits postoperative sexual function.

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.

Perineal defect reconstruction after surgery for advanced or locally recurrent rectal cancer involving organ resection: Multiple flaps combined with lining repair.

The aim of this study was to investigate the efficacy of multiple perineal perforator flaps in repairing deep perineal defects after pelvic exenteration for locally advanced or recurrent rectal cancer. We investigated the outcomes of eight patients whose repairs involved a novel method of using an internal pudendal artery perforator (IPAP) flap combined with an inferior gluteal artery perforator (IGAP) flap. There were four male and four female patients with a mean age of 56 years (36-72 years). Bilateral IPAP flaps combined with bilateral IGAP flaps were used in five patients, unilateral IPAP flaps combined with bilateral IGAP flaps were used in two patients and bilateral IPAP flaps were used in one patient. There were no functional limitations in daily activities during the 6-month follow-up period. Our study showed that using multiple perineal perforator flaps combined with lining repair is feasible for repairing deep perineal defects in patients who have undergone rectal cancer surgery that includes pelvic exenteration.

A Simplified Algorithmic Approach to Vulvar Reconstruction According to Various Types of Vulvar Defects.

Various surgeons adopt various vulvar reconstruction methods for different types of vulvar defects to restore anatomical structures. Vulvar reconstruction has relatively few references as it is performed in many different ways. Our report aimed to create a simplified reconstruction algorithm that can be used to select the reconstruction flap and to compare clinical outcomes. The patients who underwent vulvar reconstruction between April 2017 and May 2020 were retrospectively reviewed. The reconstruction flap was selected according to a suggested algorithm, which accounted for the defect location depending on the vulvo-thigh junctional crease-the visual landmark of the inferior pubic ramus-and proper perforator location. Postoperative surgical complications, functional outcomes, and oncologic outcomes were analyzed according to the histologic and flap types. Forty-seven patients underwent reconstruction with 31 internal pudendal artery perforator flaps (66%) and 16 profunda artery perforator flaps or transverse upper gracilis flaps (34%). The histologic type included 21 extramammary Paget disease (44.7%), 20 squamous cell carcinoma (42.6%), and 6 other types (12.8%). Postoperative complications, including wound and functional complications, occurred in 10 patients (21.3%). There were more cases of wound complications with profunda artery perforator flaps and transverse upper gracilis flaps (37.5%) than those with internal pudendal artery perforator flaps (12.9%) (P = 0.04). There were 7 cases (14.9%) of 2-year oncologic recurrence with no significant differences in terms of histologic or flap types. According to our suggested simplified algorithm, various types of flaps resulted in reliable surgical outcomes with minimal complication rates and acceptable functional and oncologic outcomes, and the primary goals of vulvar reconstruction were achieved effectively. Using our algorithm, selection of the reconstruction method could be simplified and specified despite the complexity of vulvar defects.

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.

Radiographic Study Evaluating Perforator Vessels in the Ischiorectal Fossa for Safe Elevation of Island Flaps.

Background:Perforator flaps based on the ischiorectal fossa (IRF) (ie, internal pudendal artery perforator flaps) are useful for perineal reconstruction. The three-dimensional characterization of perforator arteries in the IRF remains unclear, as the IRF contains thick adipose tissue as well as organs, such as the rectum, vagina, and urethra. This study aimed to evaluate perforators in the IRF to guide the safe elevation of skin flaps designed based on the IRF.Methods:IRF vessels were examined in 200 bilateral computed tomography angiography scans performed in 100 patients. We examined branching patterns arising from the internal iliac artery and the origins of the skin perforators in the IRF.Results:The branching patterns of the internal iliac artery were divided into three groups: perforators derived exclusively from the internal pudendal artery (78%), perforators derived from the internal pudendal artery and the inferior gluteal artery (18%), and perforators derived exclusively from the inferior gluteal artery (4%). The average number of perforators in the IRF was 1.5 ± 0.7. The number of perforators was significantly higher in women than in men. The perforator arteries were found exclusively around the medial and dorsal sides of the ischial tuberosity.Conclusions:We found that perforators in the IRF were stable. All cases had more than one skin perforator, which was mainly derived from the internal pudendal artery. Although perforators cannot be identified during flap elevation because the fatty tissue in the IRF is very thick, physicians must focus on preserving the perforator-containing fatty tissue around the ischial tuberosity.

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

Perineal Turn over Perforator Flap: A Novel Surgical Technique for Combined Perineal and Posterior Vaginal Wall Reconstruction

Extralevator Abdominoperineal Excision (ELAPE) and Abdominoperineal Resection create complex perineal defects made more challenging when combined with additional resection of the posterior vaginal wall. This composite defect requires the restoration of a functional vagina, in addition to the obliteration of the large perineal dead space, a need to reduce donor site, and perineal wound morbidity. Previously described fasciocutaneous and myocutaneous flaps for such defects are associated with long operations requiring intra-operative mobilization and are linked to post-operative complications including herniation, evisceration, flap loss, donor site morbidity and poor cosmetic outcome, amongst other issues. Herein we describe the case of a 60-year-old female patient that underwent combined ELAPE and posterior vaginectomy for anal squamous cell carcinoma. This complex defect was reconstructed using an extended version of the Perineal Turn-Over (PTO) flap based on the Internal Pudendal artery perforator.

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.

Repair of skin and soft tissue defects of vulva, vagina, and buttock with internal pudendal artery perforator " angel wing" island flaps in six cases

From November 2015 to July 2017, six patients with skin and soft tissue defects of vulva, vagina, and buttock after resection of vulvar tumors were hospitalized in our unit. All patients were female, aged 45-70 years. Among them, four patients had bilateral defects, and two patients had unilateral defect. The defect area on each side ranged from 6 cm×4 cm to 12 cm×6 cm. Internal pudendal artery perforator " angel wing" island flaps were used to repair and reconstruct the defects. The area of flaps ranged from 7 cm×5 cm to 14 cm×7 cm. The donor sites were sutured directly. All 10 flaps of 6 patients survived. Two patients had local incision infection 3 days after operation. One of the two patients was healed 2 weeks after dressing change, and the other one underwent debridement and suture 1 week after dressing change and was healed 1 week after surgery. Follow-up for 6-12 months after surgery showed no recurrence of tumors, no eversion of vagina, better shape of vulva in bilateral reconstruction cases, and slightly worse symmetry in unilateral reconstruction cases. The skin of the reconstructed area was soft, with sensations of pain, temperature, and touch recovered in varying degrees. The distance of a two-point discrimination was 20-30 mm. Linear scars were left in the flap donor sites, with no impact on squatting or striding. In vaginal examination, 1.5 to 2.0 fingers could be inserted in bilateral reconstruction cases, while 2.0 to 3.0 fingers could be inserted in unilateral reconstruction cases. The anus functioned well during defecation.

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.

Abstract: Perineal Reconstruction after Extralevator Abdominoperineal Excision (ELAPE): Current Trends-What Is the Future?

AIM: Extralevator abdominoperineal excision (ELAPE) is becoming the main treatment modality for locally advanced low rectal cancer as substantial evidence link ELAPE with superior oncological outcomes than conventional abdominoperineal excision.1 However, the extended resection performed in ELAPE creates an extensive three-dimensional soft tissue perineal defect within a previously irradiated field, increasing perineal wound complications to 40–60%.1 Various methods have been described in order to reduce perineal wound morbidity including primary closure, flaps and biological meshes but the ideal technique remains controversial, making perineal reconstruction post-ELAPE challenging for the plastic surgeon.1 The primary objective of this study is to appraise the post-ELAPE perineal reconstruction techniques in a UK tertiary institution. The secondary aim is to identify the technique that fulfils the principles of an ideal perineal reconstruction (function, reliability, and cosmesis). METHODS: All patients that had undergone ELAPE and perineal reconstruction between 2009 and 2017 were reviewed retrospectively. Data included patients’ demographics, neo-adjuvant chemo-radiotherapy, histopathology, imaging, duration of surgery, reconstructive method, follow-up period and complications. RESULTS: Seventy-three (n=73) cases were identified. 81% of the patients had neo-adjuvant chemoradiotherapy. Gluteus maximus muscular flaps (35%, 26) were associated with a higher complication rate(62%). These included perineal collection(36%), perineal pain(35%) and perineal hernia(19%). Vertical Rectus Abdominal Muscular flaps’ (9,5%, 7) complication rate was 33% (1 flap necrosis, 1 perineal sinus and 1 perineal collection). Lotus petal (8%, 4) and Inferior Gluteal Artery Perforator V-Y advancement flaps’ (8%, 4) complication rates were 75% and 16% respectively. The above flaps required an average of 134 min (range 118–145) additional operating time. Internal pudendal artery (IPA) perforator flaps, predominantly the PTO (Perineal Turn Over) flap2, were introduced in 2014 and gained popularity (35%, 26) as they are quick (mean operating time 52 min) and provide good results with only 8.6% complication rate (1 perineal hernia and 1 superficial wound dehiscence). Review of this group’s radiotherapy scans showed that IPA perforators are consistently out of radiotherapy zone. Overall complications in all flaps were higher in irradiated patients and smokers. CONCLUSION: Techniques involving muscular dissection are associated with higher morbidity rates (20–62%) reflecting similar trends in the literature.1 IPA turnover perforator flaps such as the PTO flap2, that do not involve perforator transposition at 90° angle (as in lotus petal flaps) are associated with the lowest morbidity rate. Their concept supports the ideal reconstruction principles: a) Function: the thick gluteal dermis acts as an autologous (as opposed to biological meshes) dermal vascularised substitute that strengthens the pelvic floor and prevents perineal hernia 2 b) Reliability: the perforators are consistent and always protected from radiotherapy ensuring good flap vascularity; the gluteal subcutaneous fat obliterates the dead space reducing collections and infections.2 c) Cosmesis: recreation of the natal cleft providing good aesthetic outcome.

The pedicled internal pudendal artery perforator (PIPAP) flap for ischial pressure sore reconstruction: Technique and long-term outcome of a cohort study

The ischial region is the site most affected by pressure sores and has the highest recurrence and complication rates compared to other affected sites. We developed a practical and safe pedicled flap for reconstruction of ischial pressure sores based on the rich available perforators from the internal pudendal artery and the surplus of skin at the infragluteal fold. A retrospective cohort study was conducted in all patients who underwent ischial pressure ulcer reconstruction using the PIPAP flap between March 2010 and March 2017. The skin flap was designed along the gluteal fold. The skin perforators of the pudendal artery were marked with a Doppler probe in the medial region of the gluteal fold. Surgery was performed in the jackknife position, and flaps were elevated in the suprafascial plane. Patients were assessed for minor (requiring no additional surgery) and major complications (requiring additional surgery). Twenty-seven patients (34 flaps) were identified. The median follow-up period was 38 months (IQR 37). Primary closure of the donor-site was achieved in all procedures, only one flap required muscle flap transposition in order to fill the dead space. The mean operating time was 60 ± 21 minutes. In six flaps (9%) wound healing problems were noted that did not require an additional operative procedure. Among the nine flaps (27%) that required a second procedure, 3 (9%) were necessary due to recurrent ulcers. The PIPAP flap is a safe and reliable alternative for ischial pressure sore reconstruction, certainly when compared to available techniques. Moreover, it has significant advantages over other techniques including minimal donor-site morbidity, preservation of posterior thigh skin, buttock-line integrity and reliable vascularity.

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.

Radiological anatomy of the perforators of the gluteal region: The "radiosome" based anatomy.

The superior (SGA) and the inferior gluteal artery (IGA) perforator flaps are widely used in pressure-sore repair and in breast reconstruction. The aim was to exhaustively depict the topographical anatomy of the whole system of perforators in the buttock. Eighty lower-extremity computed tomographic angiography (CTA) of patients (20 males/20 females, mean age 61-years old, range 38-81) were considered. The source artery, location, type, and caliber of gluteal perforators were analyzed. The location of perforators was reproduced using a standardized two-dimensional grid on the coronal plane, centered onto defined bone landmarks. We defined "radiosome" the cutaneous vascular territory of a source artery inferred through the representation of its whole perforator system at the exit point through the deep fascia. A mean number of 25.6 ± 5.7 perforators in the gluteal region was observed, distributed as follows: 11.6 ± 4.8(45.2%) from SGA; 7.9 ± 4.5(30.8%) from IGA; 1.5 ± 0.8(5.8%) from fifth lumbar artery; 1.2 ± 0.8(4.7%) from internal pudendal artery; 1.2 ± 1(4.8%) from lateral circumflex femoral artery; 0.3 ± 0.7(1.2%) from circumflex iliac superficial artery. At least one large (internal diameter > 1 mm) SGA septocutaneous perforator was present in 77.5% of patients. The gluteal region is vascularized by perforators of multiple source arteries. Septocutaneous perforators of SGA and IGA were planned along a curve drawn from the posterior-superior border of the iliac crest to the greater trochanter. The lumbar artery perforators are clustered over the apex of the iliac crest; the internal pudendal artery perforators are clustered medially to the ischiatic tuberosity. Contributions can also come from the sacral and superficial circumflex iliac arteries.

Aesthetic Penoscrotal Resurfacing: Creating Propeller Flaps from Gluteal Folds

BackgroundReconstruction of extensive penoscrotal defects is a surgical challenge. Resurfacing defects in highly complex three-dimensional structures and restoring their function are an essential part of the reconstruction of penoscrotal regions. ObjectiveWe describe a technique using internal pudendal artery perforator (IPAP) pedicled propeller flaps created from the gluteal fold. This could be a reliable surgical option that maintains a natural looking scrotal pouch with minimal donor site morbidity and optimal sexual activity. Design, setting, and participantsWe retrospectively reviewed data for 10 consecutive patients who had undergone penoscrotal reconstruction using IPAP pedicled propeller flaps between January 2011 and March 2015. Surgical procedureThe IPAP was identified using a hand-held Doppler ultrasound device. This was the pivot around which the flap was internally rotated more than 90° in a tension-free manner. The long axis of the flap was centred on the gluteal fold to provide a better-orientated donor site scar. MeasurementsComplications and patient satisfaction with respect to size, colour match, scar appearance, and sexual activity were evaluated. Results and limitationsAnatomic and aesthetic penoscrotal reconstruction was performed without any major complications in the follow-up period (mean, 19.7 mo). The mean width of the IPAP pedicled propeller flaps was 6.7cm, and the mean length was 11.7cm. Partial distal flap necrosis occurred in only one case, and healed spontaneously. All of the patients were satisfied with the cosmetic and functional results. ConclusionsOn the basis of reliable perforators, donor site morbidity, flap thickness, and a better orientated scar, our technique using IPAP pedicled propeller flaps created from the gluteal fold could be a reasonable surgical option for extensive penoscrotal reconstruction. Patient summaryThe creation of pedicled propeller flaps using an internal pudendal artery perforator could be a reliable surgical option for reconstruction of extensive penoscrotal defects. The approach yields functional and aesthetically acceptable surgical results.