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Fasciocutaneous Lotus Petal Flap for Perineal Wound Reconstruction after Extralevator Abdominoperineal Excision: Application for Reconstruction of the Pelvic Floor and Creation of a Neovagina

  • Reconstructive Oncology
  • Published:
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Abstract

Background

The extralevator abdominoperineal excision (ELAPE) procedure creates an extensive soft tissue defect of the pelvic floor. It has been suggested that primary reconstruction reduces the risk of wound infection and delayed wound healing in this high-risk area. Use of myocutaneous flaps or omentoplasty are associated with functional limitations and complications. We performed the perineal variant of the lotus petal flap, which was originally described for vulvar reconstruction. We aimed to verify if application of the lotus petal flap in pelvic floor reconstruction after ELAPE meets the goals of an ideal reconstruction.

Methods

We performed a retrospective study of 28 patients who underwent the lotus petal flap procedure for pelvic floor reconstruction after ELAPE between January 2011 and March 2014.

Results

Median age was 62.1 years and 78.6 % of patients were female. In most patients the tumor was preoperatively irradiated (89.3 %) and in 28.6 % of the reconstructions a biological mesh was applied. No total flap loss occurred. Six (21.4 %) patients had no complications, while 13 (46.4 %) patients had minor complications (Clavien–Dindo grade I–II). Reoperation (Clavien–Dindo grade IIIb) was performed in nine patients (32.1 %), three of whom required a second lotus petal flap reconstruction. Median time until wound healing was 14 weeks. No additional surgery was performed for aesthetic problems.

Conclusions

Reconstruction of the pelvic floor after ELAPE using the fasciocutaneous lotus petal flap has limited major complications, but still with a high incidence of minor wound complications. This retrospective cohort study shows limited consequences on form and function.

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References

  1. Bullard KM, Trudel JL, Baxter NN, Rothenberger DA. Primary perineal wound closure after preoperative radiotherapy and abdominoperineal resection has a high incidence of wound failure. Dis Colon Rectum. 2005;48(3):438–443.

    Article  PubMed  Google Scholar 

  2. Christian CK, Kwaan MR, Betensky RA, Breen EM, Zinner MJ, Bleday R. Risk factors for perineal wound complications following abdominoperineal resection. Dis Colon Rectum. 2005;48(1):43–48.

    Article  PubMed  Google Scholar 

  3. Foster JD, Pathak S, Smart NJ, Branagan G, Longman RJ, Thomas MG, et al. Reconstruction of the perineum following extralevator abdominoperineal excision for carcinoma of the lower rectum: a systematic review. Colorectal Dis. 2012;14(9):1052–1059.

    Article  CAS  PubMed  Google Scholar 

  4. Nisar PJ, Scott HJ. Myocutaneous flap reconstruction of the pelvis after abdominoperineal excision. Colorectal Dis. 2009;11(8):806–816.

    Article  CAS  PubMed  Google Scholar 

  5. Pellino G. Extralevator abdominoperineal excision for rectal cancer: “extended” is the only correct route. J Gastroenterol Hepatol Res. 2014;3(1):937–938.

    Google Scholar 

  6. Winterton RI, Lambe GF, Ekwobi C, Oudit D, Mowatt D, Murphy JV, et al. Gluteal fold flaps for perineal reconstruction. J Plast Reconstr Aesthet Surg. 2013;66(3):397–405.

    Article  CAS  PubMed  Google Scholar 

  7. Khoo AK, Skibber JM, Nabawi AS, Gurlek A, Youssef AA, Wang B, et al. Indications for immediate tissue transfer for soft tissue reconstruction in visceral pelvic surgery. Surgery. 2001;130(3):463–469.

    Article  CAS  PubMed  Google Scholar 

  8. Mohr Z, Palmer B, Zender FJ, Willis S, Lehnhardt M, Daigeler A, et al. Primary interdisciplinary reconstruction of perineal defects to reduce wound complications after abdominoperineal resection. Zentralbl Chir. 2014;139 Suppl 2:e55–62.

    PubMed  Google Scholar 

  9. Butt HZ, Salem MK, Vijaynagar B, Chaudhri S, Singh B. Perineal reconstruction after extra-levator abdominoperineal excision (eLAPE): a systematic review. Int J Colorectal Dis. 2013;28(11):1459–1468.

    Article  PubMed  Google Scholar 

  10. Zenn M, Jones G. Reconstructive surgery, anatomy, technique and clinical applications. 1st ed. St. Louis: Quality Medical Publishing; 2012.

    Google Scholar 

  11. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240(2):205–213.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Yii NW, Niranjan NS. Lotus petal flaps in vulvo-vaginal reconstruction. Br J Plast Surg 1996;49(8):547–554.

    Article  CAS  PubMed  Google Scholar 

  13. Niranjan NS. Perforator flaps for perineal reconstruction. Semin Plast Surg. 2006;20:133–143.

    Article  PubMed Central  Google Scholar 

  14. Pantelides NM, Davies RJ, Fearnhead NS, Malata CM. The gluteal fold flap: a versatile option for perineal reconstruction following anorectal cancer resection. J Plast Reconstr Aesthet Surg. 2013;66(6):812–820.

    Article  CAS  PubMed  Google Scholar 

  15. Sawada M, Kimata Y, Kasamatsu T, Yasumura T, Onda T, Yamada T, et al. Versatile lotus petal flap for vulvoperineal reconstruction after gynecological ablative surgery. Gynecol Oncol. 2004;95(2):330–335.

    Article  PubMed  Google Scholar 

  16. McMenamin DM, Clements D, Edwards TJ, Fitton AR, Douie WJ. Rectus abdominis myocutaneous flaps for perineal reconstruction: modifications to the technique based on a large single-centre experience. Ann R Coll Surg Engl. 2011;93(5):375–381.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  17. Franchelli S, Leone MS, Bruzzone M, Muggianu M, Puppo A, Gustavino C, et al. The gluteal fold fascio-cutaneous flap for reconstruction after radical excision of primary vulvar cancers. Gynecol Oncol. 2009;113(2):245–248.

    Article  CAS  PubMed  Google Scholar 

  18. Warrier SK, Kimble FW, Blomfield P. Refinements in the lotus petal flap repair of the vulvo-perineum. ANZ J Surg. 2004;74(8):684–688.

    Article  PubMed  Google Scholar 

  19. Bodin F, Weitbruch D, Seigle-Murandi F, Volkmar P, Bruant-Rodier C, Rodier JF. Vulvar reconstruction by a “supra-fascial” lotus petal flap after surgery for malignancies. Gynecol Oncol. 2012;125(3):610–613.

    Article  CAS  PubMed  Google Scholar 

  20. Christensen HK, Nerstrom P, Tei T, Laurberg S. Perineal repair after extralevator abdominoperineal excision for low rectal cancer. Dis Colon Rectum. 2011;54(6):711–717.

    Article  PubMed  Google Scholar 

  21. Anderin C, Martling A, Lagergren J, Ljung A, Holm T. Short-term outcome after gluteus maximus myocutaneous flap reconstruction of the pelvic floor following extra-levator abdominoperineal excision of the rectum. Colorectal Dis. 2012;14(9):1060–1064.

    Article  CAS  PubMed  Google Scholar 

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Disclosures

Joke Hellinga, Patrick C.K.H. Khoe, Boudewijn van Etten, Patrick H.J. Hemmer, Klaas Havenga, Martin W. Stenekes, and Yassir Eltahir have no conflicts of interest and no sources of funding to report.

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    Authors and Affiliations

    1. Department of Plastic and Reconstructive Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands

      Joke Hellinga MD, Patrick C. K. H. Khoe MD, Martin W. Stenekes MD, PhD & Yassir Eltahir MD

    2. Department of Surgical Oncology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands

      Boudewijn van Etten MD, PhD, Patrick H. J. Hemmer MD & Klaas Havenga MD, PhD

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    1. Joke Hellinga MD
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    2. Patrick C. K. H. Khoe MD
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    Correspondence to Yassir Eltahir MD.

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    Joke Hellinga and Patrick C.K.H. Khoe have contributed equally to this work.

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    Hellinga, J., Khoe, P.C.K.H., van Etten, B. et al. Fasciocutaneous Lotus Petal Flap for Perineal Wound Reconstruction after Extralevator Abdominoperineal Excision: Application for Reconstruction of the Pelvic Floor and Creation of a Neovagina. Ann Surg Oncol 23, 4073–4079 (2016). https://doi.org/10.1245/s10434-016-5332-y

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    • DOI: https://doi.org/10.1245/s10434-016-5332-y

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