The combined use of pedicled profunda artery perforator and bilateral gracilis flaps for pelvic reconstruction, a cohort study

Abstract The result of an extra-levator abdominoperineal excision of the rectum is a composite three-dimensional defect. This is performed for locally advanced anorectal cancer, and may involve partial excision of the vagina. The aim of reconstruction is to achieve wound healing, restore the pelvic floor and to allow micturition and sexual function. We aim to evaluate the concurrent use of profunda artery perforator and bilateral gracilis flaps for vaginal and pelvic floor reconstruction. We performed a retrospective casenote review of patients undergoing pelvo-perineal reconstruction with combined gracilis and profunda artery perforator flaps between July 2018 and December 2019. Eighteen pedicled flaps were performed on six patients with anal or vulval malignancies. All underwent pre-operative radiotherapy. Four patients had extended abdominoperineal tumour resections, two patients underwent total pelvic exenteration. The median; age was 57 (range 47–74) years, inpatient stay was 22 (11–47) days and the follow-up was 10 (5–21) months. Four patients developed partial perineal wound dehiscence, of which one was re-sutured. One patient had a post-operative bleed requiring radiological embolisation of an internal iliac branch and had subsequent 1cm profunda artery perforator flap loss. All other flaps survived completely. Median time to heal was 4 (1-6) months. This is the first series reporting combined bilateral gracilis and profunda artery perforator flaps for pelvic reconstruction. The wound dehiscence rate and healing times were expected in the context of irradiation and radical pelvic tumour resection. This is a reliable technique for perineal and vaginal reconstruction with minimal donor site morbidity.