Journal of Plastic, Reconstructive & Aesthetic Surgery (2015) 68, e7ee12
Posterior perineal reconstructions with “supra-fascial” lotus petal flaps ´de ´ric Bodin a,*, Caroline Dissaux a, Fre ´de ´ric Seigle-Murandi a, Silviu Dragomir b, Serge Rohr b, Fre Catherine Bruant-Rodier a a b
Department of Plastic Surgery, Strasbourg Academic Hospital, Strasbourg, France Department of General Surgery, Strasbourg Academic Hospital, Strasbourg, France
Received 25 August 2014; accepted 19 October 2014
KEYWORDS Perineal reconstruction; Lotus petal flap; Gluteal fold flap; Abdominoperineal resection
Summary Background: The lotus petal flap procedure is widely used for vulvovaginal reconstructions after gynecologic resections, but its effectiveness for posterior perineal coverage and filling is not yet well defined. Methods: We conducted a retrospective evaluation of 10 lotus petal flap procedures performed between 2010 and 2014. Six patients were operated upon with posterior transpositions of unilateral (n Z 2) or bilateral (n Z 4) supra-fascial flaps. The patient demographics, comorbidities, and previous surgical treatments were surveyed. The postoperative outcomes, including length of stay, time of healing, and complications, were analyzed. Results: Lotus petal flaps were indicated for filling of the chronic perineal cavity (n Z 4) and for skin resurfacing (n Z 2). The mean patient age was 61.5 years, and four patients previously underwent radiotherapy. The total operative time was 2.2 h on average. No wound complications or flap necrosis instances occurred during the follow-up consultations, which occurred at a mean of 20.5 months. The hospital stay duration was 11.3 days, and the duration of healing was 35.2 days, on average. Each flap transposition achieved the sustainable perineal reconstruction goal. Conclusions: The supra-fascial lotus petal flap is an easy and safe procedure for posterior perineal reconstructions. Whether for an immediate or a delayed operation, unilateral or bilateral flap harvestings allow for effective coverage and filling. Furthermore, the donor-site morbidity remained low because the scars were hidden in the gluteal fold. ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Service de Chirurgie plastique et reconstrutrice, Ho ˆpital civil e 1, place de l’ho ˆpital e B.P. N 426, 67091 Strasbourg cedex, France. Tel.: þ33 388116197; fax: þ33 388115188. E-mail address: [email protected] (F. Bodin). http://dx.doi.org/10.1016/j.bjps.2014.10.028 1748-6815/ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
e8
Introduction Reconstruction of the perineum area remains a challenging surgical procedure because of its high complication risks. Technical modifications and flap evolution have recently contributed to modifying the decision algorithm and simplifying some indications.1 In 1996, Yii and Niranjan described a range of sensitive fascio-cutaneous flaps that were vascularized by the perforators of the internal pudendal vessels.2 The most popular version, which is centered on the gluteal fold, was variably called the lotus petal flap because of its shape,3 the infragluteal skin flap,4 or the gluteal fold flap.5 The pivot point of this flap is placed in the center of the perineum in a triangular area that is delimited by the ischiatic tuberosity, the anus, and the vaginal introitus/scrotal raphe. Flap rotation is then achievable both anteriorly and posteriorly. The lotus petal flap procedure is widely used for vulvovaginal reconstructions after gynecological resections,6 but its effectiveness for posterior perineal defects is not well known. In a retrospective series of 10 flaps, we evaluated the simplicity and efficiency of the posterior supra-fascial lotus petal flap procedure used for immediate or delayed coverage and filling.
Materials and methods Between 2010 and 2014, six patients were treated with unilateral (n Z 2) or bilateral (n Z 4) supra-fascial lotus petal flap posterior transpositions. The indications were an immediate resurfacing after skin resection, one scar contracture release, and four delayed cavity fillings that occurred during an oncological pelvis resection. On the day before surgery, the gluteal fold was drawn on the patients while they were in a standing position. Each patient was placed on the operating table in a prone position with 40 hip flexion and 15 bilateral abduction. The flap was custom-tailored in one or two gluteal fold(s) in a lotus petal shape (Figure 1). The flap dimensions were adapted to the surface and volume needs with the possibility of a primary closure. All of the flaps were elevated, lateral to medial, in a supra-fascial plane. They were 1 cm
F. Bodin et al. thick in the distal area and became progressively thicker towards the pedicle. The dissection was stopped as soon as the flap rotation was sufficient without tension. The triangular area delimited by the ischiatic tuberosity, the anus, and the vaginal introitus/scrotal raphe was cautiously resected. The flap was posteriorly rotated 90 towards the defect and partially de-epithelialized when filling was indicated (Figures 2 and 3). A tension-free closure was performed with corrugated sheet drains under the flaps. In this observational study, the patient demographics, comorbidities, and previous surgical treatments were surveyed. The surgical data, flap characteristics, hospital stay durations, healing times, and complications were retrospectively analyzed.
Results Table 1 summarizes the patient demographics, comorbidities, and treatments. The mean patient age was 61.5 years (range, 47e72 years). The initial diagnosis was a rectal adenocarcinoma in three patients, one prostatic adenocarcinoma, one Paget’s disease, and one necrotizing fasciitis. In addition to resection surgery, three patients received neoadjuvant radio-chemotherapy and two patients received adjuvant radiotherapy. In order to perform reconstructive surgery, flap harvesting was unilateral (n Z 2) or bilateral (n Z 4), for a total of 10 supra-fascial lotus petal flaps. The indications were perineal skin resurfacing, perineal cavity filling, or both (Figures 2 and 3). The main operative data and postoperative outcomes are presented in Table 2. The operating time was on average 2 h and 12 min (range, 1 h and 20 min to 3 h and 10 min). No wound complication or flap necrosis instance occurred in this series. The mean duration of hospital stay was 11.3 days, with a range of 6e19 days. The mean duration of healing was 35.2 days, with a range of 21e60 days. The average follow-up time was 20.5 months, with a range of 4e39 months. For all patients, the posterior perineal reconstruction goal was sustainably achieved without any recurrences of pain, wound dehiscence, perineal infection, or fistula.
Figure 1 Female sagittal section of the perineum. 1: The perineal cavity following an abdominoperineal rectum excision. A bilateral supra-fascial lotus petal flap harvested in the gluteal fold. 2: A distal two-third flap with de-epithelialization and transposition to fill the cavity. The most anterior flap was able to close a vesicovaginal fistula with a distal cutaneous patch.
Turned-back lotus petal flap
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Figure 2 The third patient developed adenocarcinoma in the lower rectum and anal canal. She was successively treated by neoadjuvant radio- and chemotherapy, abdominoperineal resection with a posterior vaginal wall excision, and adjuvant chemotherapy. Nine months later, the clinical examination showed a posterior perineal orifice that was communicating with the vaginal lumen. a: The remains of the inferior rectovaginal wall. b: The preoperative bilateral lotus petal flap landmarks. The perforators of the pudendal vessels arise in a triangular area that is delimited by the ischiatic tuberosity, the anus, and the vaginal introitus. c: A posterior vaginal wall reconstruction with the right lotus petal flap. The right flap border was sutured to the vaginal mucosa whereas the left side was still free. d: The second lotus petal flap was used to close the cutaneous deficit.
Discussion The lotus petal flap or gluteal fold flap is becoming the first surgical option for unilateral, bilateral, partial, or total vulvar reconstructions.7 The procedure is quick and easy to perform in a unique lithotomy position. The flap has proven to be safe because of the excellent blood supply that comes from the terminal internal pudendal vessel branches. On each side, the pedicle arises from the iliac artery through the ischiorectal fossa.2 Additionally, few complications are observed during the follow-up consultations. The donor-site scars are hidden in the gluteal fold without any buttock deformation or chronic pain.3 The lotus petal flap remains sensitive thanks to the pudendal nerves that are included in the pedicle.8 In a previous study, it was also demonstrated that releasing the flap without the muscular fascia was a safe and simplified procedure.7 Anatomical studies of the perineum have shown an abundant anastomotic vascular network running in a subcutaneous position; therefore, the fascia is not essential for flap vascularization.9,10 Other indications for perineal lotus petal flap are not well understood, despite their effectiveness. Scrotal reconstructions after necrotizing fasciitis or genitocrural fold coverage secondary to hidradenitis suppurativa have also been described.11,12 It is also possible to utilize posterior flap rotations to cover and fill the posterior perineum. Some
authors reported successful rectovaginal fistula treatments with the lotus petal flap.13e15 Additionally, three anorectal stricture correction cases were also performed by Tsuchiya et al.16 In our study, patient 2 demonstrated the efficacy of a double lotus petal flap to correct a posterior perineal scar contracture after necrotizing fasciitis. We also reported a perianal Paget’s disease case that was treated by a skin resection and a unilateral lotus petal flap reconstruction (patient 4).17 One of the most underutilized indications of the lotus petal flap is most likely for reconstructions following colorectal disease resection. According to Luna-Pe ´rez et al.,18 abdominoperineal resection (APR) leads to a 46.7% morbidity rate, with a 14.6% postoperative perineal wound infection rate. The main factors influencing these complications are postoperative radiotherapy with or without chemotherapy and age >55 years. Musculocutaneous flaps were long considered to be the best reconstruction procedure following APRs or pelvic exenterations to reduce morbidity. The gracilis flap is, however, associated with a high partial skin necrosis rate,19 and the vertical rectus abdominis musculocutaneous flap may lead to serious donor-site complications or sequelae.20,21 Indeed, recent publications have highlighted the benefit of perforator flaps for pelviperineal reconstructions.22,23 The posteriorly rotated lotus petal flap is presented as the ideal solution for
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F. Bodin et al.
Figure 3 The fifth patient was 72 years old with multiple comorbidities. Rectal adenocarcinoma was treated 16 years earlier by neoadjuvant radiotherapy and surgical resection. Perineal complications led to multiple reoperations, including a colostomy procedure and an abdominoperineal resection of the rectum. a: Surgical treatment of a bilateral-disabling coxarthrosis was rejected because of persistent chronic perineal and gluteal fistulas. b: The first operating steps consisted of fistula and fibrosis resections. Additionally, the coccyx and the fifth sacral bone were resected. c: A double lotus petal flap was performed. The rightsided flap was de-epithelialized and buried in the perineal cavity. d: The left-sided flap was used to complete the filling and to allow for perineal resurfacing.
small or medium defects in the area, but few specific clinical series have been published to date. In this study, we presented four patients (patients 1, 3, 5, and 6) with chronic wound sequelae secondary to
Table 1
radiotherapy and surgical pelvis excisions. Pelviperineal irradiated tissues were affected by scar dehiscence, infected presacral fistulas, and chronically non-healed orifices. Several patients were administered controlled wound
Patient demographics, comorbidities, and treatments.
Patient Age Sex Comorbidity 1
60 M
2
47 M
3
60 F
4 5
66 F 72 M
6
65 M
/
Diagnosis
Rectal adenocarcinoma Hepatitis C Necrotizing fasciitis Active smoking Rectal adenocarcinoma Dyslipidemia Paget disease Cardiovascular Rectal disease, adenocarcinoma diabetes, COPD Chronic renal Prostatic and colic failure adenocarcinoma
Perineal surgery
RX Delay Indication (month)
Plastic reconstruction
APER
Y
Bilateral LPF
Debridement
N 24
APER
Y
Perianal resection APER
N 0 Y 65
1.5
9
Colectomy and Y 24 cysto-prostatectomy
Perineal orifice (8 cm deep 5 cm Ø) Scar contracture
Bilateral LPF
Perineal orifice and Bilateral LPF rectovaginal cloacae Immediate reconstruction Unilateral LPF Pre-sacral fistulae Bilateral LPF (10 cm deep 1.5 cm Ø) Chronic perineal collection and fistulae
Unilateral LPF
RX: perineal radiotherapy; APER: abdominoperineal excision of the rectum; Ø: diameter; LPF: lotus petal flap. COPD: chronic obstructive pulmonary disease.
Turned-back lotus petal flap
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Table 2
Operative data and postoperative outcomes.
Patient
Operating time (hours)
Postoperative stay (days)
Healing time (days)
Complications
Follow-up (month)
1 2 3 4 5 6
2 2 2 1 3 1
8 7 8 6 19 5
21 42 30 28 30 60
0 0 0 1a 0 0
39 34 31 10 5 4
a
h h h h h h
and and and and and and
20 30 05 20 10 45
min min min min min min
Second excision for insufficient margins.
healing with vacuum therapy and iterative general anesthesia. This painful and expansive treatment affected the quality of life of these patients for several months. No healing complications occurred after the reconstructive surgeries were performed with the lotus petal flap, and the patients were spectacularly relieved in 3e8 weeks. The use of the lotus petal flap in this type of specifically delayed indication had yet to be published. Pantelides et al.24 recently reported a similar experience with immediate reconstructions after extended anorectal excisions. Despite local irradiation, the complication rate was low and the lotus petal flaps were considered to be robust without any instances of fat or skin necrosis. In most of the patients (six of seven), the unilateral or bilateral flap transpositions alone provided a volume sufficient to obliterate the pelvic dead space. Recent studies have demonstrated that extralevator abdominoperineal excisions are more efficient than standard abdominoperineal excisions in low rectal cancer cases.25 However, the perineal reconstruction technique following this new procedure remains controversial. Foster’s meta-analysis showed a 31.8% complication rate with conventional flap repair compared to a 28.2% complication rate with biological mesh repairs.26 Owing to its efficiency and simplicity, the recent use of the lotus petal flap for primary or secondary abdominoperineal reconstructions will improve surgical outcomes in future evaluation trials.
Conflict of interest/Funding statement The authors have no conflicts of interest to disclose.
References 1. Sinna R, Alharbi M, Assaf N, et al. Management of the perineal wound after abdominoperineal resection. J Visc Surg 2013; 150:9e18. 2. Yii NW, Niranjan NS. Lotus petal flaps in vulvo-vaginal reconstruction. Br J Plast Surg 1996;49:547e54. 3. Sawada M, Kimata Y, Kasamatsu T, et al. Versatile lotus petal flap for vulvoperineal reconstruction after gynecological ablative surgery. Gynecol Oncol 2004;95:330e5. 4. Knol AC, Hage JJ. The infragluteal skin flap: a new option for reconstruction in the perineogenital area. Plast Reconstr Surg 1997;99:1954e9. 5. Ragoowansi R, Yii N, Niranjan N. Immediate vulvar and vaginal reconstruction using the gluteal-fold flap: long-term results. Br J Plast Surg 2004;57:406e10.
6. Salgarello M, Farallo E, Barone-Adesi L, et al. Flap algorithm in vulvar reconstruction after radical, extensive vulvectomy. Ann Plast Surg 2005;54:184e90. 7. Bodin F, Weitbruch D, Seigle-Murandi F, Volkmar P, BruantRodier C, Rodier JF. Vulvar reconstruction by a «supra-fascial» lotus petal flap after surgery for malignancies. Gynecol Oncol 2012;125:610e3. 8. Moschella F, Cordova A. Innervated island flaps in morphofunctional vulvar reconstruction. Plast Reconstr Surg 2000; 105:1649e57. 9. Sakai S, Soeda S, Haibara H. A subcutaneous pedicle flap for perineal reconstruction. Ann Plast Surg 1989;22:440e3. 10. Hashimoto I, Nakanishi H, Nagae H, Harada H, Sedo H. The gluteal-fold flap for vulvar and buttock reconstruction: anatomic study and adjustment of flap volume. Plast Reconstr Surg 2001;108:1998e2005. 11. Payne CE, Williams AM, Hart NB. Lotus petal flaps for scrotal reconstruction combined with integra resurfacing of the penis and anterior abdominal wall following necrotising fasciitis. J Plast Reconstr Aesthetic Surg 2009;62:393e7. 12. Argenta PA, Lindsay R, Aldridge RB, Siddiqui N, Burton K, Telfer JRC. Vulvar reconstruction using the «lotus petal» fascio-cutaneous flap. Gynecol Oncol 2013;131:726e9. 13. Kosugi C, Saito N, Kimata Y, et al. Rectovaginal fistulas after rectal cancer surgery: incidence and operative repair by gluteal-fold flap repair. Surgery 2005;137:329e36. 14. Onishi K, Ogino A, Saida Y, Maruyama Y. Repair of a recurrent rectovaginal fistula using gluteal-fold flap: report of a case. Surg Today 2009;39:615e8. 15. Altomare DF, Rinaldi M, Bucaria V, Marino F, Lobascio P, Sallustio PL. Overlapping sphincteroplasty and modified lotus petal flap for delayed repair of traumatic cloaca. Tech Coloproctol 2007;11:268e70. 16. Tsuchiya S, Sakuraba M, Asano T, Miyamoto S, Saito N, Kimata Y. New application of the gluteal-fold flap for the treatment of anorectal stricture. Int J Colorectal Dis 2011;26: 653e9. 17. Araki Y, Noake T, Hata H, Momosaki K, Shirouzu K. Perianal Paget’s disease treated with a wide excision and gluteal fold flap reconstruction guided by photodynamic diagnosis: report of a case. Dis Colon Rectum 2003;46:1563e5. 18. Luna-Pe ´rez P, Rodrı´guez-Ramı´rez S, Vega J, Sandoval E, Labastida S. Morbidity and mortality following abdominoperineal resection for low rectal adenocarcinoma. Rev Investig Clı´nica Organo Hosp Enfermedades Nutr 2001;53:388e95. 19. Chen SH, Hentz VR, Wei FC, Chen YR. Short gracilis myocutaneous flaps for vulvoperineal and inguinal reconstruction. Plast Reconstr Surg 1995;95:372e7. 20. Tei TM, Stolzenburg T, Buntzen S, Laurberg S, Kjeldsen H. Use of transpelvic rectus abdominis musculocutaneous flap for anal cancer salvage surgery. Br J Surg 2003;90:575e80. 21. Sunesen KG, Buntzen S, Tei T, Lindegaard JC, Nørgaard M, Laurberg S. Perineal healing and survival after anal cancer salvage surgery: 10-year experience with primary perineal
e12 reconstruction using the vertical rectus abdominis myocutaneous (VRAM) flap. Ann Surg Oncol 2009;16:68e77. 22. John HE, Jessop ZM, Di Candia M, Simcock J, Durrani AJ, Malata CM. An algorithmic approach to perineal reconstruction after cancer resectioneexperience from two international centers. Ann Plast Surg 2013;71:96e102. 23. Sinna R, Qassemyar Q, Benhaim T, et al. Perforator flaps: a new option in perineal reconstruction. J Plast Reconstr Aesthetic Surg 2010;63:e766e774. 24. Pantelides NM, Davies RJ, Fearnhead NS, Malata CM. The gluteal fold flap: a versatile option for perineal reconstruction
F. Bodin et al. following anorectal cancer resection. J Plast Reconstr Aesthetic Surg 2013;66:812e20. 25. Yu H-C, Peng H, He X-S, Zhao R-S. Comparison of short- and long-term outcomes after extralevator abdominoperineal excision and standard abdominoperineal excision for rectal cancer: a systematic review and meta-analysis. Int J Colorectal Dis 2014;29(2):183e91. 26. Foster JD, Pathak S, Smart NJ, et al. Reconstruction of the perineum following extralevator abdominoperineal excision for carcinoma of the lower rectum: a systematic review. Colorectal Dis Off J Assoc Coloproctol G B Irel 2012;14:1052e9.
Posterior perineal reconstructions with “supra-fascial” lotus petal flaps ´de ´ric Bodin a,*, Caroline Dissaux a, Fre ´de ´ric Seigle-Murandi a, Silviu Dragomir b, Serge Rohr b, Fre Catherine Bruant-Rodier a a b
Department of Plastic Surgery, Strasbourg Academic Hospital, Strasbourg, France Department of General Surgery, Strasbourg Academic Hospital, Strasbourg, France
Received 25 August 2014; accepted 19 October 2014
KEYWORDS Perineal reconstruction; Lotus petal flap; Gluteal fold flap; Abdominoperineal resection
Summary Background: The lotus petal flap procedure is widely used for vulvovaginal reconstructions after gynecologic resections, but its effectiveness for posterior perineal coverage and filling is not yet well defined. Methods: We conducted a retrospective evaluation of 10 lotus petal flap procedures performed between 2010 and 2014. Six patients were operated upon with posterior transpositions of unilateral (n Z 2) or bilateral (n Z 4) supra-fascial flaps. The patient demographics, comorbidities, and previous surgical treatments were surveyed. The postoperative outcomes, including length of stay, time of healing, and complications, were analyzed. Results: Lotus petal flaps were indicated for filling of the chronic perineal cavity (n Z 4) and for skin resurfacing (n Z 2). The mean patient age was 61.5 years, and four patients previously underwent radiotherapy. The total operative time was 2.2 h on average. No wound complications or flap necrosis instances occurred during the follow-up consultations, which occurred at a mean of 20.5 months. The hospital stay duration was 11.3 days, and the duration of healing was 35.2 days, on average. Each flap transposition achieved the sustainable perineal reconstruction goal. Conclusions: The supra-fascial lotus petal flap is an easy and safe procedure for posterior perineal reconstructions. Whether for an immediate or a delayed operation, unilateral or bilateral flap harvestings allow for effective coverage and filling. Furthermore, the donor-site morbidity remained low because the scars were hidden in the gluteal fold. ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Service de Chirurgie plastique et reconstrutrice, Ho ˆpital civil e 1, place de l’ho ˆpital e B.P. N 426, 67091 Strasbourg cedex, France. Tel.: þ33 388116197; fax: þ33 388115188. E-mail address: [email protected] (F. Bodin). http://dx.doi.org/10.1016/j.bjps.2014.10.028 1748-6815/ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
e8
Introduction Reconstruction of the perineum area remains a challenging surgical procedure because of its high complication risks. Technical modifications and flap evolution have recently contributed to modifying the decision algorithm and simplifying some indications.1 In 1996, Yii and Niranjan described a range of sensitive fascio-cutaneous flaps that were vascularized by the perforators of the internal pudendal vessels.2 The most popular version, which is centered on the gluteal fold, was variably called the lotus petal flap because of its shape,3 the infragluteal skin flap,4 or the gluteal fold flap.5 The pivot point of this flap is placed in the center of the perineum in a triangular area that is delimited by the ischiatic tuberosity, the anus, and the vaginal introitus/scrotal raphe. Flap rotation is then achievable both anteriorly and posteriorly. The lotus petal flap procedure is widely used for vulvovaginal reconstructions after gynecological resections,6 but its effectiveness for posterior perineal defects is not well known. In a retrospective series of 10 flaps, we evaluated the simplicity and efficiency of the posterior supra-fascial lotus petal flap procedure used for immediate or delayed coverage and filling.
Materials and methods Between 2010 and 2014, six patients were treated with unilateral (n Z 2) or bilateral (n Z 4) supra-fascial lotus petal flap posterior transpositions. The indications were an immediate resurfacing after skin resection, one scar contracture release, and four delayed cavity fillings that occurred during an oncological pelvis resection. On the day before surgery, the gluteal fold was drawn on the patients while they were in a standing position. Each patient was placed on the operating table in a prone position with 40 hip flexion and 15 bilateral abduction. The flap was custom-tailored in one or two gluteal fold(s) in a lotus petal shape (Figure 1). The flap dimensions were adapted to the surface and volume needs with the possibility of a primary closure. All of the flaps were elevated, lateral to medial, in a supra-fascial plane. They were 1 cm
F. Bodin et al. thick in the distal area and became progressively thicker towards the pedicle. The dissection was stopped as soon as the flap rotation was sufficient without tension. The triangular area delimited by the ischiatic tuberosity, the anus, and the vaginal introitus/scrotal raphe was cautiously resected. The flap was posteriorly rotated 90 towards the defect and partially de-epithelialized when filling was indicated (Figures 2 and 3). A tension-free closure was performed with corrugated sheet drains under the flaps. In this observational study, the patient demographics, comorbidities, and previous surgical treatments were surveyed. The surgical data, flap characteristics, hospital stay durations, healing times, and complications were retrospectively analyzed.
Results Table 1 summarizes the patient demographics, comorbidities, and treatments. The mean patient age was 61.5 years (range, 47e72 years). The initial diagnosis was a rectal adenocarcinoma in three patients, one prostatic adenocarcinoma, one Paget’s disease, and one necrotizing fasciitis. In addition to resection surgery, three patients received neoadjuvant radio-chemotherapy and two patients received adjuvant radiotherapy. In order to perform reconstructive surgery, flap harvesting was unilateral (n Z 2) or bilateral (n Z 4), for a total of 10 supra-fascial lotus petal flaps. The indications were perineal skin resurfacing, perineal cavity filling, or both (Figures 2 and 3). The main operative data and postoperative outcomes are presented in Table 2. The operating time was on average 2 h and 12 min (range, 1 h and 20 min to 3 h and 10 min). No wound complication or flap necrosis instance occurred in this series. The mean duration of hospital stay was 11.3 days, with a range of 6e19 days. The mean duration of healing was 35.2 days, with a range of 21e60 days. The average follow-up time was 20.5 months, with a range of 4e39 months. For all patients, the posterior perineal reconstruction goal was sustainably achieved without any recurrences of pain, wound dehiscence, perineal infection, or fistula.
Figure 1 Female sagittal section of the perineum. 1: The perineal cavity following an abdominoperineal rectum excision. A bilateral supra-fascial lotus petal flap harvested in the gluteal fold. 2: A distal two-third flap with de-epithelialization and transposition to fill the cavity. The most anterior flap was able to close a vesicovaginal fistula with a distal cutaneous patch.
Turned-back lotus petal flap
e9
Figure 2 The third patient developed adenocarcinoma in the lower rectum and anal canal. She was successively treated by neoadjuvant radio- and chemotherapy, abdominoperineal resection with a posterior vaginal wall excision, and adjuvant chemotherapy. Nine months later, the clinical examination showed a posterior perineal orifice that was communicating with the vaginal lumen. a: The remains of the inferior rectovaginal wall. b: The preoperative bilateral lotus petal flap landmarks. The perforators of the pudendal vessels arise in a triangular area that is delimited by the ischiatic tuberosity, the anus, and the vaginal introitus. c: A posterior vaginal wall reconstruction with the right lotus petal flap. The right flap border was sutured to the vaginal mucosa whereas the left side was still free. d: The second lotus petal flap was used to close the cutaneous deficit.
Discussion The lotus petal flap or gluteal fold flap is becoming the first surgical option for unilateral, bilateral, partial, or total vulvar reconstructions.7 The procedure is quick and easy to perform in a unique lithotomy position. The flap has proven to be safe because of the excellent blood supply that comes from the terminal internal pudendal vessel branches. On each side, the pedicle arises from the iliac artery through the ischiorectal fossa.2 Additionally, few complications are observed during the follow-up consultations. The donor-site scars are hidden in the gluteal fold without any buttock deformation or chronic pain.3 The lotus petal flap remains sensitive thanks to the pudendal nerves that are included in the pedicle.8 In a previous study, it was also demonstrated that releasing the flap without the muscular fascia was a safe and simplified procedure.7 Anatomical studies of the perineum have shown an abundant anastomotic vascular network running in a subcutaneous position; therefore, the fascia is not essential for flap vascularization.9,10 Other indications for perineal lotus petal flap are not well understood, despite their effectiveness. Scrotal reconstructions after necrotizing fasciitis or genitocrural fold coverage secondary to hidradenitis suppurativa have also been described.11,12 It is also possible to utilize posterior flap rotations to cover and fill the posterior perineum. Some
authors reported successful rectovaginal fistula treatments with the lotus petal flap.13e15 Additionally, three anorectal stricture correction cases were also performed by Tsuchiya et al.16 In our study, patient 2 demonstrated the efficacy of a double lotus petal flap to correct a posterior perineal scar contracture after necrotizing fasciitis. We also reported a perianal Paget’s disease case that was treated by a skin resection and a unilateral lotus petal flap reconstruction (patient 4).17 One of the most underutilized indications of the lotus petal flap is most likely for reconstructions following colorectal disease resection. According to Luna-Pe ´rez et al.,18 abdominoperineal resection (APR) leads to a 46.7% morbidity rate, with a 14.6% postoperative perineal wound infection rate. The main factors influencing these complications are postoperative radiotherapy with or without chemotherapy and age >55 years. Musculocutaneous flaps were long considered to be the best reconstruction procedure following APRs or pelvic exenterations to reduce morbidity. The gracilis flap is, however, associated with a high partial skin necrosis rate,19 and the vertical rectus abdominis musculocutaneous flap may lead to serious donor-site complications or sequelae.20,21 Indeed, recent publications have highlighted the benefit of perforator flaps for pelviperineal reconstructions.22,23 The posteriorly rotated lotus petal flap is presented as the ideal solution for
e10
F. Bodin et al.
Figure 3 The fifth patient was 72 years old with multiple comorbidities. Rectal adenocarcinoma was treated 16 years earlier by neoadjuvant radiotherapy and surgical resection. Perineal complications led to multiple reoperations, including a colostomy procedure and an abdominoperineal resection of the rectum. a: Surgical treatment of a bilateral-disabling coxarthrosis was rejected because of persistent chronic perineal and gluteal fistulas. b: The first operating steps consisted of fistula and fibrosis resections. Additionally, the coccyx and the fifth sacral bone were resected. c: A double lotus petal flap was performed. The rightsided flap was de-epithelialized and buried in the perineal cavity. d: The left-sided flap was used to complete the filling and to allow for perineal resurfacing.
small or medium defects in the area, but few specific clinical series have been published to date. In this study, we presented four patients (patients 1, 3, 5, and 6) with chronic wound sequelae secondary to
Table 1
radiotherapy and surgical pelvis excisions. Pelviperineal irradiated tissues were affected by scar dehiscence, infected presacral fistulas, and chronically non-healed orifices. Several patients were administered controlled wound
Patient demographics, comorbidities, and treatments.
Patient Age Sex Comorbidity 1
60 M
2
47 M
3
60 F
4 5
66 F 72 M
6
65 M
/
Diagnosis
Rectal adenocarcinoma Hepatitis C Necrotizing fasciitis Active smoking Rectal adenocarcinoma Dyslipidemia Paget disease Cardiovascular Rectal disease, adenocarcinoma diabetes, COPD Chronic renal Prostatic and colic failure adenocarcinoma
Perineal surgery
RX Delay Indication (month)
Plastic reconstruction
APER
Y
Bilateral LPF
Debridement
N 24
APER
Y
Perianal resection APER
N 0 Y 65
1.5
9
Colectomy and Y 24 cysto-prostatectomy
Perineal orifice (8 cm deep 5 cm Ø) Scar contracture
Bilateral LPF
Perineal orifice and Bilateral LPF rectovaginal cloacae Immediate reconstruction Unilateral LPF Pre-sacral fistulae Bilateral LPF (10 cm deep 1.5 cm Ø) Chronic perineal collection and fistulae
Unilateral LPF
RX: perineal radiotherapy; APER: abdominoperineal excision of the rectum; Ø: diameter; LPF: lotus petal flap. COPD: chronic obstructive pulmonary disease.
Turned-back lotus petal flap
e11
Table 2
Operative data and postoperative outcomes.
Patient
Operating time (hours)
Postoperative stay (days)
Healing time (days)
Complications
Follow-up (month)
1 2 3 4 5 6
2 2 2 1 3 1
8 7 8 6 19 5
21 42 30 28 30 60
0 0 0 1a 0 0
39 34 31 10 5 4
a
h h h h h h
and and and and and and
20 30 05 20 10 45
min min min min min min
Second excision for insufficient margins.
healing with vacuum therapy and iterative general anesthesia. This painful and expansive treatment affected the quality of life of these patients for several months. No healing complications occurred after the reconstructive surgeries were performed with the lotus petal flap, and the patients were spectacularly relieved in 3e8 weeks. The use of the lotus petal flap in this type of specifically delayed indication had yet to be published. Pantelides et al.24 recently reported a similar experience with immediate reconstructions after extended anorectal excisions. Despite local irradiation, the complication rate was low and the lotus petal flaps were considered to be robust without any instances of fat or skin necrosis. In most of the patients (six of seven), the unilateral or bilateral flap transpositions alone provided a volume sufficient to obliterate the pelvic dead space. Recent studies have demonstrated that extralevator abdominoperineal excisions are more efficient than standard abdominoperineal excisions in low rectal cancer cases.25 However, the perineal reconstruction technique following this new procedure remains controversial. Foster’s meta-analysis showed a 31.8% complication rate with conventional flap repair compared to a 28.2% complication rate with biological mesh repairs.26 Owing to its efficiency and simplicity, the recent use of the lotus petal flap for primary or secondary abdominoperineal reconstructions will improve surgical outcomes in future evaluation trials.
Conflict of interest/Funding statement The authors have no conflicts of interest to disclose.
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