Perineal and Lower Extremity Reconstruction

Duke University, Durham, North Carolina, United States
Plastic and Reconstructive Surgery (Impact Factor: 3.33). 11/2011; 128(5):551e-563e. DOI: 10.1097/PRS.0b013e31822b6b87
Source: PubMed

ABSTRACT After reading this article, the participant should be able to: 1. Perform a preoperative assessment of patients undergoing perineal and lower extremity reconstruction. 2. Describe the various tissue flaps used to perform these reconstructions and the advantages and disadvantages of each. 3. Provide appropriate postoperative care and interventions to maximize outcomes.
The lower extremity and perineum provide the foundation for upright posture and ambulation. These areas are made up of intricate contours with variable skin types and must withstand the functional demands of organ orifice support and weight-bearing forces. Successful reconstruction calls for careful preoperative planning and consideration of the site-specific demands.
The authors reviewed literature regarding the most current treatment strategies for lower extremity and perineal reconstruction.
Perineal reconstruction is typically related to genitourinary or digestive tract abnormalities, mainly malignancies. Local and regional flaps are the mainstay of therapy, depending on their availability and the need for adjuvant therapy. Postoperatively, pressure reduction and closed-suction drainage are of major consideration. The lower extremities are prone to trauma, and these wounds often involve underlying and exposed bony abnormalities, and this must be considered in operative planning. Significant defects may be reconstructed with local or regional flaps and free-tissue transfer. The location of the wound and extent of surrounding tissue compromise are of major concern when determining flap coverage. Postoperatively, transition to ambulation and weight-bearing status is paramount.
Reconstruction of the lower extremity and perineum requires recognition of the high functional demands of these areas. Local and regional flaps and free tissue transfer allow reconstruction of complex wounds in these areas. Selecting the correct flap and navigating the postoperative recovery to arrive at functional restoration remain a significant challenge.

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    ABSTRACT: Perineal reconstruction is a challenging prospect. Conventional flap reconstruction often involves the sacrifice of a source artery and muscle, resulting in significant donor morbidity. Perforator flaps sought to overcome this but required tedious dissection. In this article, the authors introduce a new concept in perineal reconstruction using perforator-based island flaps. The perineal perforator-based island flap is raised based on perforators that most commonly arise from the perineal artery. The flap is designed in the inguinal and gluteal folds in order to achieve aesthetic, tension-free primary closure of the donor site. Eleven patients underwent perineal reconstruction using this approach. Patients ranged in age from 8 to 75 years, with a female-to-male ratio of 10:1. All 11 operations were performed by a single surgeon (S.Y.M.H.). There were no cases of flap loss or donor-site complications, as defined by wound infection, dehiscence, or keloid formation. All 11 patients reported excellent satisfaction with regard to donor-site aesthetics. Perineal perforator-based island flaps represent one of the most successful outcomes of the perforator concept. There is no sacrifice of donor vessels or muscle and minimal donor morbidity. The flap is also easily harvested and allows for challenging free-form flap design because it is based on reliable perforators. Therapeutic, IV.
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