Wide Propeller Posterior Thigh Flap to Reconstruct Perineal Defects post Abdominoperineal Resection
Carlos X. Ordenana, MD1, Edoardo Dalla Pozza, MD1, Sayf Said, MD1, Francis Papay, MD1, Hermann Kessler, MD, PhD2, Antonio Rampazzo, MD, PhD1, Bahar Bassiri, MD, PhD1.
1Plastic Surgery Department, Cleveland Clinic, Cleveland, OH, USA, 2Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.
With increasing popularity of laparoscopic and robotic approaches to colectomy during abdominoperineal resection (APR), now thought to account for 40% of all cases (Johnstone et al. 2017), thigh based flaps are becoming the only option for reconstruction of the perineal defect.(Friedman et al, 2010; Hainsworth et al, 2012). Among these the Posterior Thigh Flap (PTF) has historically fallen short of Vertical Rectus Abdominis Muscle (VRAM) flap due to a higher complication rate (43.7% vs 35.8) with wound dehiscence caused by critical distal vascularization being the most common (5-29.9%). (Saito et al, 2014; Winterton et al, 2013; Arnold et al, 2012)
This study hypothesized that a better understanding of the flap vascularity and consequent modification of the flap design could improve the outcomes.
Anatomic dissections were conducted on 14 gluteal and posterior thigh regions of 7 fresh cadavers. Specimens' popliteal arteries were ligated, and red latex (Carolina Biological, Burlington, NC) was injected from the aorta just above its terminal bifurcation. The course and distribution of Inferior Gluteal Artery (IGA), descending branch of IGA, Profunda Femoris Artery (PFA) and perforators directed to the flap was recorded and mapped. The Y-axis was represented by a vertical line going from the ischial tuberosity to the medial femoral condyle and the X-axis was represented by a perpendicular to the Y-axis passing through the ischial tuberosity. The diameter of each vessel was measured with a caliper and recorded. A normalized map of the perforators was created by averaging the XY measurements after converting them to percentages of the distance between the anatomical landmarks.
A Wide Propeller Posterior Thigh Flap (WPTF) including the width of the thigh was designed to increase the reach and survival of the flap.
Nine patients underwent reconstruction of the perineal defect following APR with the WPTF.
The descending branch of the IGA was present in 10 specimens (71.4%), with an average caliber of 2.3±0.2mm. In 4 (28.6%) specimens the main arterial axis of the flap derived from PFA with a main caliber of 2±0.5mm. The origin of the descending branch of the IGA was located at 42±6.5mm (X) and 3±15.8mm (Y). The first perforating branch originating from the PFA was 106.6±22.3mm (X) and 56.4±21.2mm (Y); the second PFA perforator originated at 111.6±17.4mm (X) and 102.6±46.2mm (Y).
All flaps survived completely. One WPTF was sufficient to reconstruct the defect. In two cases the flap was based on the first PFA perforator. Three patients presented complications: 1 urocutaneous fistula because of residual cancer, 1 delayed wound healing at the lateral gluteal region and 1 coccygeal osteomyelitis, treated with debridement.
The descending branch of the IGA is absent in a significant number of patients. In these cases, elevation of a narrow flap to allow direct closure of the donor site can cause distal flap necrosis. Implementation of the propeller design and routine harvest of a wide flap that includes the perforators from PFA can increase the survival and versatility of the flap.
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