What is perineal reconstruction?

Perineal reconstruction is rebuilding of damaged or deformed tissue between the genitals and anus.
Perineal reconstruction is rebuilding of damaged or deformed tissue between the genitals and anus.

Perineal reconstruction is rebuilding of damaged or deformed tissue between the genitals and anus. Perineal reconstruction is typically done for acquired and congenital deformities or reconstruction following cancer surgery in genital and urinary parts of the body. It is usually performed by a plastic surgeon using tissue flap techniques.

Why is perineal reconstruction done?

Perineal reconstruction is indicated when the anticipated defect is large and cannot be enclosed with simple sutures. Hence, it is performed to close defects and restore perineal function. It may also include penile or vaginal reconstruction.

The surgeon assesses the patient’s nutritional status, blood parameters, the degree and nature of the expected perineal wound or defect and function. This assessment often follows traumatic procedures such as cancer ablation. Based on the assessment of the individual, the surgeon decides the particular flap type used for reconstruction.

What are flaps in reconstructive surgery?

Flap is a tissue lifted from a donor site and moved to a site of defect with an intact blood supply.

Types of flaps include

  • Cutaneous flaps contain full thickness of skin and superficial fascia. Ideal for small defects.
  • Fascio-cutaneous flaps contain full thickness of skin, superficial fascia, subcutaneous tissue, deep fascia and more blood supply with ability to fill a larger defect.
  • Musculocutaneous or myocutaneous flaps contain an addition of muscle layer to fascio-cutaneous flap. Provides bulk to fill deeper defects and restore function.
  • Muscle flaps contain only muscle tissue to fill defects and restore function. Skin may be used to cover it if needed.
  • Bone flaps contain bone tissue and are used with bony defects. 

What are the flaps used in perineal reconstruction?

Many regions of the body are suitable to be used as flaps in perineal reconstruction. The choice of flap depends on the defect that needs to be covered and the surgeon’s discretion.

The following flaps may be considered:

  • Gracilis myocutaneous flaps (most commonly used)  
  • Abdominal flaps 
  • Thigh flaps
  • Groin flaps
  • Gluteal (buttocks) flaps
  • Rectus femoris flaps
  • Perforator flaps

What is the gracilis myocutaneous flap?

The gracilis muscle is one of the muscles found in the groin. It starts at the upper area of the pubic bone and extends down to the upper middle shaft of the shinbone (tibia).

Gracilis myocutaneous flap uses the gracilis muscle -- along with skin, subcutaneous tissue, and fat with a rich blood supply. It is used for reconstruction of small- to medium-sized soft tissue defects in the perineum, upper and lower extremities, as well as head and neck. 

Advantages of myocutaneous flap

  • Muscle provides a well-vascularized (rich blood supply) soft tissue that is relatively resistant to infection and helps wounds heal.
  • It is commonly used and preferred to eradicate infection, fill defects following trauma or surgery and restore function.

Advantages of gracilis muscle 

  • An expendable muscle; its absence rarely causes lower extremity weakness
  • Ability to transfer only a part of the muscle
  • Good contractile force
  • Reliably accessible for the surgeon 
  • Rich blood supply 
  • Low incidence of infection or other problems from the donor site 

Disadvantages of gracilis muscle

  • Excessive bulk
  • Skin tethering (skin dimpling from the adhered muscle’s tension)
  • Wide donor site scar, which may require treatment
  • Secondary refining procedures are often necessary.

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Is the perineal reconstruction surgery painful?

  • The surgery is performed with anesthesia, hence there is no pain during the surgery.
  • Post-operative pain may vary based on the patient’s tolerance. 
  • The pain can be managed by oral or injectable pain killers successfully.

How long does it take to recover after perineal reconstruction surgery?

  • Post-surgical swelling, pain and bruising subsides in a week or two.
  • After five to seven days, patients are usually able to walk around comfortably.
  • The results may take a few months following surgery.
  • Patients are generally able to resume pre-operative activities including sexual intercourse and exercise after four to six weeks.
  • Patients may feel weak or tired in the first six weeks.
  • Regular follow-up is required to monitor healing.

What are the complications of perineal reconstruction?

People suffering from vascular disease in the lower extremities (limbs) should avoid this surgery because the condition may cause or exacerbate complications.  

Complications of perineal reconstruction surgery include:

  • Ischemia (loss of tissue oxygen) of the overlying skin causing delayed healing or partial or complete skin loss. 
  • Local wound problems: 
    • pain 
    • infection
    • bleeding
    • delayed healing
  • Temporary sciatic nerve palsy (largest nerve in the body running from the lower back to the toes)
  • Issues related to scarring:
    • Pruritus (itching)
    • Discoloration
    • Scar width
    • Sensitivity
  • Tingling
  • Pain
  • Hypoesthesia (diminished sensation of touch) 
  • Temporary weakness lasting an average of six months
  • Persistent weakness that may interfere with running, walking, or sports
  • Poor reaction to anesthesia 

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Medically Reviewed on 5/21/2020
References
Medscape Medical Reference