Abstract: Extended Propeller Gluteal Thigh Flap to Reconstruct Perineal Defects Following Abdominoperineal Resection (Plastic Surgery The Meeting (September 28

Sunday, September 30, 2018: 11:10 AM

Edoardo Dalla Pozza, MD , Plastic Surgery, Cleveland Clinic, Cleveland, OH

Carlos Ordenana, MD , Plastic Surgery, Cleveland Clinic, Cleveland, OH

Sayf Al-deen Said, MD , Plastic Surgery, Cleveland Clinic, Cleveland, OH

Francis A. Papay, MD , Plastic Surgery, Cleveland Clinic, Cleveland, OH

Hermann Kessler, MD, PhD , Colorectal Surgery Department, Cleveland Clinic, Cleveland, OH

Antonio Rampazzo, MD, PhD , Plastic Surgery, Cleveland Clinic, Cleveland, OH

Bahar Bassiri Gharb, MD, PhD , Plastic Surgery, Cleveland Clinic, Cleveland, OH

Introduction:

With increasing popularity of minimally invasive approaches to abdominoperineal resection, thigh based flaps are becoming the preferable option for reconstruction of perineal defects.^{1, 2} The Posterior Thigh Flap (PTF) was historically ascribed of a high complication rate mostly due to its critical distal vascularization(5-29.9%).^{3, 4}

This study hypothesized that a better understanding of the flap vascularity and consequent modification of the flap design could improve the outcomes.

Methods:

Anatomic dissections were conducted on 22 gluteal and posterior thigh regions of 11 fresh latex-injected cadavers. The course, distribution and diameter of perforators from Inferior Gluteal Artery (IGA) and Profunda Femoris Artery (PFA) was recorded and mapped on a XY-axis. A normalized map of the perforators was created to guide dissections and minimize inter-sample variability.

An Extended Propeller Gluteal Thigh Flap (EPGTF) including the conventional Gluteal thigh flap and a wider posterior thigh flap was designed to increase the reach and survival of the flap.

Nine patients underwent reconstruction of the perineal defect following APR with the EPGTF.

Results:

The descending branch of the IGA was present and dominant in 16 specimens (72.7%). In 5 (22.7%) specimens the main arterial axis of the flap derived from the PFA’s 1^st and 2^nd perforators. In 1 case there was a double vascularization. The descending branch of the IGA could be mapped at -11.1±19.4 mm on the Y-axis and 46±7.96 mm on the X-axis. Its average caliber measured 2.18±0.3 mm. The 1^st and 2^nd perforators from the PFA were located respectively at 101.6±17.9 and 104.5±15.5 mm on the X-axis; 35.9±27.1 and 89.2±37.6 mm on the Y-axis. Their average diameters were 1.84±0.41mm (1^st) and 1.48±0.3mm (2^nd).

All nine flaps survived completely. In 2/9 cases the flap was based on the first PFA perforator. Three patients presented complications, all unrelated to the distal flap viability.

Conclusions:

The descending branch of the IGA is absent in a significant number of patients. In these cases, elevation of a narrow posterior thigh 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 can include the perforators from PFA can increase the survival and versatility of the flap.

Bibliography

Friedman JD, Reece GR, Eldor L. The utility of the posterior thigh flap for complex pelvic and perineal reconstruction. Plastic and reconstructive surgery. 2010;126:146-155.
Hainsworth A, Al Akash M, Roblin P, et al. Perineal reconstruction after abdominoperineal excision using inferior gluteal artery perforator flaps. The British journal of surgery. 2012;99:584-588.
Johnstone MS. Vertical Rectus Abdominis Myocutaneous Versus Alternative Flaps for Perineal Repair After Abdominoperineal Excision of the Rectum in the Era of Laparoscopic Surgery. Annals of plastic surgery. 2017;79:101-106.
Saito A, Minakawa H, Saito N, et al. Posterior thigh flap revisited: clinical use in oncology patients. Surgery today. 2014;44:1013-1017.

35342 Extended Propeller Gluteal Thigh Flap to Reconstruct Perineal Defects Following Abdominoperineal Resection