Purpose: To reconstruct large, deep defects of the perineal area, a pedicled gracilis musculocutaneous flap or a pedicled rectus abdominis musculocutaneous flap is commonly used. However, harvesting the muscle and dissecting the flap pedicle can be difficult. To reconstruct these large defects easily and safely, we have used local skin flaps nourished by the internal pudendal arterial system. Materials: From 1996 through 2003, we transferred skin flaps nourished by the internal pudendal arterial system in 11 patients. Reconstruction was performed for large perineal defects in 5 women, for rectovaginal fistulas in 5 women, and for a large, deep defect of the anal skin and rectal mucosa in 1 man with perianal Pager disease. Methods: In female patients, the vaginal orifice, anus, and ischial tuberosity are marked before surgery. Within this triangle are many skin perforators derived from the internal pudendal arterial system. We design a flap whose medial part contains perforators. The flap is elevated from lateral to medial and includes the skin, subcutaneous tissue, and superficial fascia. This flap can be elevated in only 15 to 20 minutes. For large perineal defects, bilateral flaps are designed and elevated. In 1 of the 10 female patients with a defect involving the anal skin, we designed a flap that included a labium minus and the vestibular mucosa to reconstruct the anus. In the male patient, a scrotal flap (12 x 12 cm) nourished by the posterior scrotal artery derived from pudendal arterial system was designed and rolled into a tube to create rectal mucosa to be inserted into the defect. Results: The maximum size of transferred flaps was 15 x 15 cm. All flaps survived completely without postoperative complications. In two patients in whom the anal skin and mucosa were reconstructed, no contracture developed present around the new anus. Conclusions: Flaps utilizing the internal pudendal arterial system represent a versatile alternative to the various other flaps available for perineal and perianal reconstruction. Such flaps are easy to elevate, are sensate, and have good circulation and a wide skin territory.
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