Breakdown/Non-healing of Perineal Wound

  • Justin M. Broyles
  • Jonathan E. Efron
  • Justin M. SacksEmail author


The perineum is one of the more difficult sites in the human body to reconstruct due to the significant volume of dead space, proximity of multiple organs, high bacterial counts, and the subjection to direct pressure of the wound bed. Primary closure of large perineal defects, especially in the setting of previous radiation, is associated with unacceptable wound-healing complications ranging as high as 65 %. In the current chapter, we aim to provide a comprehensive overview of the various reconstructive options for perineal defects to elucidate approaches and techniques on how to prevent as well as treat perineal wounds in an effort to maximize patient outcomes.


Perineal wound closure Perineal wound APR closure Non-healing perineal wound Breakdown of perineal wound Flap closure 


  1. 1.
    Nigro ND. An evaluation of combined therapy for squamous cell cancer of the anal canal. Dis Colon Rectum. 1984;27:763–6.CrossRefPubMedGoogle Scholar
  2. 2.
    UKCCR Anal Cancer Trial Working Party. Epidermoid anal cancer: results from the UKCCCR randomized trial of radiotherapy alone versus radiotherapy, 5-fluorouracil, and mitomycin. Lancet. 1996;348:1049–54.CrossRefGoogle Scholar
  3. 3.
    Hollenbeck ST, Toranto JD, Taylor BJ, et al. Perineal and lower extremity reconstruction. Plast Reconstr Surg. 2011;128:551e–63e.CrossRefGoogle Scholar
  4. 4.
    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;48:438–43.CrossRefPubMedGoogle Scholar
  5. 5.
    Krueger JK, Rohrich RJ. Clearing the smoke: the scientific rationale for tobacco abstention with plastic surgery. Plast Reconstr Surg. 2001;108:1063–73. Discussion 1074–1077.CrossRefPubMedGoogle Scholar
  6. 6.
    McWhirter JP, Pennington CR. Incidence and recognition of malnutrition in hospital. BMJ. 1994;308:945–8.CrossRefPubMedCentralPubMedGoogle Scholar
  7. 7.
    Kyle UG, Genton L, Pichard C. Hospital length of stay and nutritional status. Curr Opin Clin Nutr Metab Care 2005;8:397–402.CrossRefPubMedGoogle Scholar
  8. 8.
    Hoffer LJ. Clinical nutrition: 1. Protein-energy malnutrition in the inpatient. CMAJ. 2001;165:1345–9.PubMedCentralPubMedGoogle Scholar
  9. 9.
    Lefevre JH, Parc Y, Kerneis S, et al. Abdomino-perineal resection for anal cancer: impact of a vertical rectus abdominis myocutaneous flap on survival, recurrence, morbidity, and wound healing. Ann Surg. 2009;250:707–11.CrossRefPubMedGoogle Scholar
  10. 10.
    Nisar PJ, Scott HJ. Myocutaneous flap reconstruction of the pelvis after abdominoperineal resection. Colorectal Dis. 2009;11:806–16.CrossRefPubMedGoogle Scholar
  11. 11.
    Morykwas MJ, Argenta LC, Shelton-Brown EI, et al. Vacuum-assisted closure: a new method for wound control and treatment: animal studies and basic foundation. Ann Plast Surg. 1997;38(6):553–62.CrossRefPubMedGoogle Scholar
  12. 12.
    Cunha MS, Nakamoto HA, Herson MR, et al. Tissue expander complications in plastic surgery: a 10-year experience. Rev Hosp Clin Fac Med Sao Paulo. 2002;57:93–7.CrossRefPubMedGoogle Scholar
  13. 13.
    Broyles JM, Abt NB, Sacks JM, Butler CE. Bioprosthetic tissue matrices in complex abdominal wall reconstruction. Plast Reconstr Surg Glob Open. 2013;1(9):e9.Google Scholar
  14. 14.
    Lefevre JH, Parc Y, Kerneis S, et al. Abdomino-perineal resection for anal cancer: impact of a vertical rectus abdominis myocutaneous flap on survival, recurrence, morbidity, and wound healing. Ann Surg. 2009;250:707–11.CrossRefPubMedGoogle Scholar
  15. 15.
    Hinojosa MW, Parikh DA, Menon R, et al. Recent experience with abdominal perineal resection with vertical rectus abdominis myocutaneous flap reconstruction after preoperative pelvic radiation. Am Surg. 2009;75:995–9.PubMedGoogle Scholar
  16. 16.
    Buchel EW, Finical S, Johnson C. Pelvic reconstruction using vertical rectus abdominis musculocutaneous flaps. Ann Plast Surg. 2004;52:22–6.CrossRefPubMedGoogle Scholar
  17. 17.
    Butler CE, Gundeslioglu AO, Rodriguez-Bigas MA. Outcomes of immediate vertical rectus abdominis myocutaneous flap reconstruction for irradiated abdominoperineal resection defects. J Am Coll Surg. 2008;206:694–703.CrossRefPubMedGoogle Scholar
  18. 18.
    Persichetti P, Cogliandro A, Marangi GF, et al. Pelvic and perineal reconstruction following abdominoperineal resection: the role of gracilis flap. Ann Plast Surg. 2007;59:168–72.CrossRefPubMedGoogle Scholar
  19. 19.
    Shibata D, Hyland W, Busse P, et al. Immediate reconstruction of the perineal wound with gracilis muscle flaps following abdominoperineal resection and intraoperative radiation therapy for recurrent carcinoma of the rectum. Ann Surg Oncol. 1999;6:33–7.CrossRefPubMedGoogle Scholar
  20. 20.
    Baird WL, Hester TR, Nahai F, Bostwick J III. Management of perineal wounds following abdominoperineal resection with inferior gluteal flaps. Arch Surg. 1990;125:1486–9.CrossRefPubMedGoogle Scholar
  21. 21.
    Benito P, De Juan A, Cano M, et al. 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. 2008;61:e1–4.CrossRefPubMedGoogle Scholar
  22. 22.
    Gould WL, Montero N, Cukic J, Hagerty RC, Hester TR. The “split” gluteus maximus musculocutaneous flap. Plast Reconstr Surg. 1994;93:330–6.CrossRefPubMedGoogle Scholar
  23. 23.
    Wee JT, Joseph VT. A new technique of vaginal reconstruction using neurovascular pudendal-thigh flaps: a preliminary report. Plast Reconstr Surg. 1989;83:701–9.CrossRefPubMedGoogle Scholar
  24. 24.
    Woods JE, Alter G, Meland B, Podratz K. Experience with vaginal reconstruction utilizing the modified Singapore flap. Plast Reconstr Surg. 1992;90:270–4.CrossRefPubMedGoogle Scholar
  25. 25.
    Neligan PC, Lannon DA. Versatility of the pedicled anterolateral thigh flap. Clin Plast Surg. 2010;37:677–81.CrossRefPubMedGoogle Scholar
  26. 26.
    Wang X, Qiao Q, Burd A, et al. Perineum reconstruction with pedicled anterolateral thigh fasciocutaneous flap. Ann Plast Surg. 2006;56:151–5.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  • Justin M. Broyles
    • 1
  • Jonathan E. Efron
    • 2
  • Justin M. Sacks
    • 1
    Email author
  1. 1.Department of Plastic and Reconstructive SurgeryThe Johns Hopkins Hospital Outpatient CenterBaltimoreUSA
  2. 2.Department of General SurgeryThe Johns Hopkins HospitalBaltimoreUSA

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