International Journal of Colorectal Disease

, Volume 34, Issue 3, pp 501–511 | Cite as

The adipofasciocutaneous gluteal fold perforator flap a versatile alternative choice for covering perineal defects

  • G. KoulaxouzidisEmail author
  • V. Penna
  • H. Bannasch
  • H. P. Neeff
  • P. Manegold
  • F. Aigner
  • C. Witzel
  • M. E. Kreis
  • J. Pratschke
  • G. B. Stark
  • F. M. Lampert
Original Article



Perineal defects following the resection of anorectal malignancies are a reconstructive challenge. Flaps based on the rectus abdominis muscle have several drawbacks. Regional perforator flaps may be a suitable alternative. We present our experience of using the gluteal fold flap (GFF) for reconstructing perineal and pelvic defects.


We used a retrospective chart review and follow-up examinations focusing on epidemiological, oncological (procedure and outcome), and therapy-related data. This included postoperative complications and their management, length of hospital stay, and time to heal.


Twenty-two GFFs (unilateral n = 8; bilateral n = 7) were performed in 15 patients (nine women and six men; anal squamous cell carcinoma n = 8; rectal adenocarcinoma n = 7; mean age 65.5 + 8.2 years) with a mean follow-up time of 1 year. Of the cases, 73.3% were a recurrent disease. Microscopic tumor resection was achieved in all but one case (93.3%). Seven cases had no complications (46.7%). Surgical complications were classified according to the Clavien-Dindo system (grades I n = 2; II n = 2; IIIb n = 4). These were mainly wound healing disorders that did not affect mobilization or discharge. The time to discharge was 22 + 9.9 days. The oncological outcomes were as follows: 53.3% of the patients had no evidence of disease, 20% had metastatic disease, 20% had local recurrent disease, and one patient (6.7%) died of other causes.


The GFF is a robust, reliable flap suitable for perineal and pelvic reconstruction. It can be raised quickly and easily, has an acceptable complication rate and donor site morbidity, and does not affect the abdominal wall.


Gluteal fold flap Perineal reconstruction Pelvic reconstruction Abdominoperineal rectum excision Perforator flap 


Authorship declaration

All authors listed meet the authorship criteria according to the latest guidelines of the International Committee of Medical Journal Editors.

All authors are in agreement with the manuscript.

Compliance with ethical standards

The manuscript has not been submitted simultaneously to another journal.

Conflict of interest

The authors have no financial support or relationships to disclose that may pose a conflict of interest.


  1. 1.
    West NP, Finan PJ, Anderin C, Lindholm J, Holm T, Quirke P (2008) Evidence of the oncologic superiority of cylindrical abdominoperineal excision for low rectal cancer. J Clin Oncol 26(21):3517–3522. CrossRefPubMedGoogle Scholar
  2. 2.
    Beier JP, Croner RS, Lang W, Arkudas A, Schmitz M, Gohl J, Hohenberger W, Horch RE (2015) Avoidance of complications in oncological surgery of the pelvic region : combined oncosurgical and plastic reconstruction measures. Chirurg 86(3):242–250. CrossRefPubMedGoogle Scholar
  3. 3.
    Davidge KM, Raghuram K, Hofer SO, Ferguson PC, Wunder JS, Swallow CJ, Zhong T (2014) Impact of flap reconstruction on perineal wound complications following ablative surgery for advanced and recurrent rectal cancers. Ann Surg Oncol 21(6):2068–2073. CrossRefPubMedGoogle Scholar
  4. 4.
    Sinna R, Alharbi M, Assaf N, Perignon D, Qassemyar Q, Gianfermi M, Deguines JB, Regimbeau JM, Mauvais F (2013) Management of the perineal wound after abdominoperineal resection. J Visc Surg 150(1):9–18. CrossRefPubMedGoogle Scholar
  5. 5.
    Brodbeck R, Horch RE, Arkudas A, Beier JP (2015) Plastic and reconstructive surgery in the treatment of oncological perineal and genital defects. Front Oncol 5:212. CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Choudry U, Harris D (2013) Perineal wound complications, risk factors, and outcome after abdominoperineal resections. Ann Plast Surg 71(2):209–213. CrossRefPubMedGoogle Scholar
  7. 7.
    Kim JT, Ho SY, Hwang JH, Lee JH (2014) Perineal perforator-based island flaps: the next frontier in perineal reconstruction. Plast Reconstr Surg 133(5):683e–687e. CrossRefPubMedGoogle Scholar
  8. 8.
    Mughal M, Baker RJ, Muneer A, Mosahebi A (2013) Reconstruction of perineal defects. Ann R Coll Surg Engl 95(8):539–544.,10.1308/rcsann.2013.95.8.539 CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Singh M, Kinsley S, Huang A, Ricci JA, Clancy TE, Irani J, Goldberg J, Breen E, Bleday R, Talbot SG (2016) Gracilis flap reconstruction of the perineum: an outcomes analysis. J Am Coll Surg 223(4):602–610. CrossRefPubMedGoogle Scholar
  10. 10.
    Vyas RM, Pomahac B (2010) Use of a bilobed gracilis myocutaneous flap in perineal and genital reconstruction. Ann Plast Surg 65(2):225–227. CrossRefPubMedGoogle Scholar
  11. 11.
    Goi T, Koneri K, Katayama K, Hirose K, Takashima O, Mizutani Y, Baba H, Yamaguchi A (2003) Modified gluteus maximus V-Y advancement flap for reconstruction of perineal defects after resection of intrapelvic recurrent rectal cancer: report of a case. Surg Today 33(8):626–629. CrossRefPubMedGoogle Scholar
  12. 12.
    Tan BK, Terence G, Wong CH, Sim R (2012) Lower gluteal muscle flap and buttock fascio-cutaneous rotation flap for reconstruction of perineal defects after abdomino-perineal resections. J Plast Reconstr Aesthet Surg 65(12):1678–1683. CrossRefPubMedGoogle Scholar
  13. 13.
    Takano S, Newman M, Gill K, Wexner SD (2015) Vertical rectus muscle flap repair for perineal defect: abdominoperineal resection and perineal hernia. J Am Coll Surg 220(6):e89. CrossRefPubMedGoogle Scholar
  14. 14.
    Inada R, Yamamoto S, Oshiro T, Takawa M, Fujita S, Akasu T (2014) Case-matched comparison of the short-term outcomes between laparoscopic and open abdominoperineal resection for rectal cancer. Surg Today 44(4):640–645. CrossRefPubMedGoogle Scholar
  15. 15.
    Moghadamyeghaneh Z, Phelan M, Smith BR, Stamos MJ (2015) Outcomes of open, laparoscopic, and robotic abdominoperineal resections in patients with rectal cancer. Dis Colon Rectum 58(12):1123–1129. CrossRefPubMedGoogle Scholar
  16. 16.
    Vaughan-Shaw PG, Cheung T, Knight JS, Nichols PH, Pilkington SA, Mirnezami AH (2012) A prospective case-control study of extralevator abdominoperineal excision (ELAPE) of the rectum versus conventional laparoscopic and open abdominoperineal excision: comparative analysis of short-term outcomes and quality of life. Tech Coloproctol 16(5):355–362. CrossRefPubMedGoogle Scholar
  17. 17.
    Lefevre JH, Parc Y, Kerneis S, Shields C, Touboul E, Chaouat M, Tiret E (2009) Abdomino-perineal resection for anal cancer: impact of a vertical rectus abdominis myocutaneus flap on survival, recurrence, morbidity, and wound healing. Ann Surg 250(5):707–711. CrossRefPubMedGoogle Scholar
  18. 18.
    Nelson RA, Butler CE (2009) Surgical outcomes of VRAM versus thigh flaps for immediate reconstruction of pelvic and perineal cancer resection defects. Plast Reconstr Surg 123(1):175–183. CrossRefPubMedGoogle Scholar
  19. 19.
    Sinna R, Qassemyar Q, Benhaim T, Lauzanne P, Sabbagh C, Regimbeau JM, Mauvais F (2010) Perforator flaps: a new option in perineal reconstruction. J Plast Reconstr Aesthet Surg 63(11):e766–e774. CrossRefPubMedGoogle Scholar
  20. 20.
    Hashimoto I, Abe Y, Nakanishi H (2014) The internal pudendal artery perforator flap: free-style pedicle perforator flaps for vulva, vagina, and buttock reconstruction. Plast Reconstr Surg 133(4):924–933. CrossRefPubMedGoogle Scholar
  21. 21.
    Ragoowansi R, Yii N, Niranjan N (2004) Immediate vulvar and vaginal reconstruction using the gluteal-fold flap: long-term results. Br J Plast Surg 57(5):406–410. CrossRefPubMedGoogle Scholar
  22. 22.
    Yii NW, Niranjan NS (1996) Lotus petal flaps in vulvo-vaginal reconstruction. Br J Plast Surg 49(8):547–554. CrossRefPubMedGoogle Scholar
  23. 23.
    Pantelides NM, Davies RJ, Fearnhead NS, Malata CM (2013) The gluteal fold flap: a versatile option for perineal reconstruction following anorectal cancer resection. J Plast Reconstr Aesthet Surg 66(6):812–820. CrossRefPubMedGoogle Scholar
  24. 24.
    Winterton RI, Lambe GF, Ekwobi C, Oudit D, Mowatt D, Murphy JV, Ross GL (2013) Gluteal fold flaps for perineal reconstruction. J Plast Reconstr Aesthet Surg 66(3):397–405. CrossRefPubMedGoogle Scholar
  25. 25.
    Clavien PA, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, de Santibanes E, Pekolj J, Slankamenac K, Bassi C, Graf R, Vonlanthen R, Padbury R, Cameron JL, Makuuchi M (2009) The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg 250(2):187–196. CrossRefGoogle Scholar
  26. 26.
    Nielsen LB, Wille-Jorgensen P (2014) National and international guidelines for rectal cancer. Colorectal Dis 16(11):854–865. CrossRefPubMedGoogle Scholar
  27. 27.
    Scott-Conner CE, Christie DW (1995) Cancer staging using the American Joint Committee on Cancer TNM system. J Am Coll Surg 181(2):182–188PubMedGoogle Scholar
  28. 28.
    Okaro AC, Worthington T, Stebbing JF, Broughton M, Caffarey S, Marks CG (2006) Curative resection for low rectal adenocarcinoma: abdomino-perineal vs anterior resection. Colorectal Dis 8(8):645–649. CrossRefPubMedGoogle Scholar
  29. 29.
    Habr-Gama A (2006) Salvage abdominoperineal resection and perineal wound healing in local recurrent or persistent anal cancer. Tech Coloproctol 10(4):382; discussion 382. CrossRefPubMedGoogle Scholar
  30. 30.
    Nisar PJ, Scott HJ (2009) Myocutaneous flap reconstruction of the pelvis after abdominoperineal excision. Colorectal Dis 11(8):806–816. CrossRefPubMedGoogle Scholar
  31. 31.
    Butler CE, Gundeslioglu AO, Rodriguez-Bigas MA (2008) Outcomes of immediate vertical rectus abdominis myocutaneous flap reconstruction for irradiated abdominoperineal resection defects. J Am Coll Surg 206(4):694–703. CrossRefPubMedGoogle Scholar
  32. 32.
    Holm T, Ljung A, Haggmark T, Jurell G, Lagergren J (2007) Extended abdominoperineal resection with gluteus maximus flap reconstruction of the pelvic floor for rectal cancer. Br J Surg 94(2):232–238. CrossRefPubMedGoogle Scholar
  33. 33.
    Wang ED, Conkling N, Xu X, Chern H, Finlayson E, Varma MG, Hansen SL, Foster RD, Hoffman WY, Sbitany H (2015) Perineal flap reconstruction following oncologic anorectal extirpation: an outcomes assessment. Plast Reconstr Surg 135(1):176e–184e. CrossRefPubMedGoogle Scholar
  34. 34.
    Sunesen KG, Buntzen S, Tei T, Lindegaard JC, Norgaard M, Laurberg S (2009) Perineal healing and survival after anal cancer salvage surgery: 10-year experience with primary perineal reconstruction using the vertical rectus abdominis myocutaneous (VRAM) flap. Ann Surg Oncol 16(1):68–77. CrossRefPubMedGoogle Scholar
  35. 35.
    Devulapalli C, Jia Wei AT, DiBiagio JR, Baez ML, Baltodano PA, Seal SM, Sacks JM, Cooney CM, Rosson GD (2016) Primary versus flap closure of perineal defects following oncologic resection: a systematic review and meta-analysis. Plast Reconstr Surg 137(5):1602–1613. CrossRefPubMedGoogle Scholar
  36. 36.
    Ferenschild FT, Vermaas M, Hofer SO, Verhoef C, Eggermont AM, de Wilt JH (2005) Salvage abdominoperineal resection and perineal wound healing in local recurrent or persistent anal cancer. World J Surg 29(11):1452–1457. CrossRefPubMedGoogle Scholar
  37. 37.
    Chessin DB, Hartley J, Cohen AM, Mazumdar M, Cordeiro P, Disa J, Mehrara B, Minsky BD, Paty P, Weiser M, Wong WD, Guillem JG (2005) Rectus flap reconstruction decreases perineal wound complications after pelvic chemoradiation and surgery: a cohort study. Ann Surg Oncol 12(2):104–110. CrossRefPubMedGoogle Scholar
  38. 38.
    Tei TM, Stolzenburg T, Buntzen S, Laurberg S, Kjeldsen H (2003) Use of transpelvic rectus abdominis musculocutaneous flap for anal cancer salvage surgery. Br J Surg 90(5):575–580. CrossRefPubMedGoogle Scholar
  39. 39.
    Petrie N, Branagan G, McGuiness C, McGee S, Fuller C, Chave H (2009) Reconstruction of the perineum following anorectal cancer excision. Int J Color Dis 24(1):97–104. CrossRefGoogle Scholar
  40. 40.
    Althumairi AA, Canner JK, Gearhart SL, Safar B, Fang SH, Wick EC, Efron JE (2016) Risk factors for wound complications after abdominoperineal excision: analysis of the ACS NSQIP database. Colorectal Dis 18(7):O260–O266. CrossRefPubMedGoogle Scholar
  41. 41.
    Althumairi AA, Canner JK, Gearhart SL, Safar B, Sacks J, Efron JE (2016) Predictors of perineal wound complications and prolonged time to perineal wound healing after abdominoperineal resection. World J Surg 40(7):1755–1762. CrossRefPubMedGoogle Scholar
  42. 42.
    Pang J, Broyles JM, Berli J, Buretta K, Shridharani SM, Rochlin DH, Efron JE, Sacks JM (2014) Abdominal- versus thigh-based reconstruction of perineal defects in patients with cancer. Dis Colon Rectum 57(6):725–732. CrossRefPubMedGoogle Scholar
  43. 43.
    Agochukwu N, Bonaroti A, Beck S, Liau J (2017) Laparoscopic harvest of the rectus abdominis for perineal reconstruction. Plastic Reconstr Surg Glob Open 5(11):e1581. CrossRefGoogle Scholar
  44. 44.
    Benito P, De Juan A, Cano M, Elena E (2008) Reconstruction of an extensive perineal defect using two modified V-Y flaps based on perforators from the gluteus maximus muscle. J Plast Reconstr Aesthet Surg 61(9):e1–e4. CrossRefPubMedGoogle Scholar
  45. 45.
    Mathes SJ, Nahai F (1981) Classification of the vascular anatomy of muscles: experimental and clinical correlation. Plast Reconstr Surg 67(2):177–187. CrossRefPubMedGoogle Scholar
  46. 46.
    Chong TW, Balch GC, Kehoe SM, Margulis V, Saint-Cyr M (2015) Reconstruction of large perineal and pelvic wounds using gracilis muscle flaps. Ann Surg Oncol 22(11):3738–3744. CrossRefPubMedGoogle Scholar
  47. 47.
    Persichetti P, Cogliandro A, Marangi GF, Simone P, Ripetti V, Vitelli CE, Coppola R (2007) Pelvic and perineal reconstruction following abdominoperineal resection: the role of gracilis flap. Ann Plast Surg 59(2):168–172. CrossRefPubMedGoogle Scholar
  48. 48.
    Abood A, Niranjan NS (2014) Perineal reconstruction: from lotus petal to “canopy”. An alternative to the standard surgical algorithm. J Plast Reconstr Aesthet Surg 67(5):738–739. CrossRefPubMedGoogle Scholar
  49. 49.
    Cormack GC, Lamberty BG (1984) A classification of fascio-cutaneous flaps according to their patterns of vascularisation. Br J Plast Surg 37(1):80–87. CrossRefPubMedGoogle Scholar
  50. 50.
    Ayestaray B, Proske YM (2015) Perineal and posterior vaginal wall reconstruction with a superior gluteal artery dual perforator-pedicled propeller flap. Microsurgery 35(1):64–67. CrossRefPubMedGoogle Scholar
  51. 51.
    Nakamura Y, Ishitsuka Y, Nakamura Y, Xu X, Hori-Yamada E, Ito M, Onizawa S, Kawachi Y, Otsuka F (2010) Modified gluteal-fold flap for the reconstruction of vulvovaginal defects. Int J Dermatol 49(10):1182–1187. CrossRefPubMedGoogle Scholar
  52. 52.
    Pusic AL, Mehrara BJ (2006) Vaginal reconstruction: an algorithm approach to defect classification and flap reconstruction. J Surg Oncol 94(6):515–521. CrossRefPubMedGoogle Scholar
  53. 53.
    Woods JE, Alter G, Meland B, Podratz K (1992) Experience with vaginal reconstruction utilizing the modified Singapore flap. Plast Reconstr Surg 90(2):270–274. CrossRefPubMedGoogle Scholar
  54. 54.
    Staiano JJ, Wong L, Butler J, Searle AE, Barton DP, Harris PA (2009) Flap reconstruction following gynaecological tumour resection for advanced and recurrent disease--a 12 year experience. J Plast Reconstr Aesthet Surg 62(3):346–351. CrossRefPubMedGoogle Scholar
  55. 55.
    Grinsell DG, Morrison E, Tansley PD (2013) The inferior gluteal artery myocutaneous flap with vascularized fascia lata to reconstruct extended abdominoperineal defects. Plast Reconstr Surg 132(5):836e–840e. CrossRefPubMedGoogle Scholar
  56. 56.
    Hainsworth A, Al Akash M, Roblin P, Mohanna P, Ross D, George ML (2012) Perineal reconstruction after abdominoperineal excision using inferior gluteal artery perforator flaps. Br J Surg 99(4):584–588. CrossRefPubMedGoogle Scholar
  57. 57.
    Morrison EJ, Shoukath S, Tansley P, Grinsell D (2013) Donor site morbidity of an islanded inferior gluteal artery myocutaneous flap with vascularized fascia lata. J Plast Reconstr Aesthet Surg 66(7):962–967. CrossRefPubMedGoogle Scholar
  58. 58.
    Godbout E, Farmer L, Bortoluzzi P, Caouette Laberge L (2013) Donor-site morbidity of the inferior gluteal artery perforator flap for breast reconstruction in teenagers. Can J Plast Surg 21(1):19–22CrossRefGoogle Scholar
  59. 59.
    Jakubietz RG, Jakubietz MG, Jakubietz DF, Koehler G, Zeplin PH, Meffert RH, Schmidt K (2009) Ischial pressure sores: reconstruction using the perforator-based reverse flow musculocutaneous 180 degrees propeller flap. Microsurgery 29(8):672–675. CrossRefPubMedGoogle Scholar
  60. 60.
    Wong S, Garvey P, Skibber J, Yu P (2009) Reconstruction of pelvic exenteration defects with anterolateral thigh-vastus lateralis muscle flaps. Plast Reconstr Surg 124(4):1177–1185. CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Plastic and Reconstructive Surgery, Department of SurgeryCharité-Universitätsmedizin BerlinBerlinGermany
  2. 2.Department of Plastic and Hand Surgery, Faculty of MedicineUniversity of Freiburgim BreisgauGermany
  3. 3.Clinic for General and Visceral Surgery, Faculty of MedicineUniversity of Freiburgim BreisgauGermany
  4. 4.Department of SurgeryCharité-Universitätsmedizin BerlinBerlinGermany
  5. 5.Department of General, Visceral and Vascular SurgeryCharité-Universitätsmedizin BerlinBerlinGermany

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