Perineal Reconstruction Flashcards by M A

Support of pelvic contents and obliteration of any dead
space is essential in perinea! reconstruction

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The
anterior triangle contains the urogenital structures,

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The deep fascia is contiguous to the Colles fascia in peroneal area

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The challenges of reconstructing the perineum

dependent pressure during postoperative
recovery, bacterial contamination from urogenital and perianal areas,
and the propensity for radiation therapy to be used when oncologic
resection is necessary

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Adult burned etiology is typically due to flame,
whereas pediatric etiology is usually due to scald burns

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Perineal burn is moe common in male more than female

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The presence ofa
perinea! burn is an independent risk factor for an increase in morbidity and mortality

T although this is not from injuries to the urogenital
structures, but is thought to be related to increased bacteremia and/
or relationship to more extensive injuries

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Long-term
catheterization risks infection and urethral stenosis.

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Unlike burns on other areas ofthe body, genitalia burns are typically not treated with early excision

T The exception
to this is the presence ofextensive, deep necrotic tissue.

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Perinea!
wounds heal well with secondary intention after eschar excision

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If the perinea! burn is part of more extensive burns, the other areas of
burns have priority for skin grafts from available donor sites

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All wound of the perineum can heal by secondary intension well without grafting

F Larger
wounds may require excision and grafting to prevent deformities

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Mortality rates range between 10% and 40% in Fournier gangrene

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Ideally, blood cultures should be drawn prior to
antibiotic initiation

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we can use HPO in Fournier gangrene

There are conflicting reports on the benefits and cost-effectiveness of hyperbaric oxygen therapy

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Orchiectomy should be performed only ifthe testicle itselfis
not viable

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Hidradenitis suppurativa a disease arising from inflammation of apocrine glands with subsequent bacterial superinfection

F Previously was thought that the disease occures in the apocrine glands now understood to be
a disease process of the terminal hair follicle, or the infundibulum

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Pathophysiology

The resulting occlusion causes dilation of the follicle bulb and cyst formation. Eventually, the cyst ruptures, releasing keratin debris and other follicular contents, such as bacteria,
into the dermis, resulting in an acute neutrophilic inflammatory
response that progresses to a granulomatous stage with the presence of foreign body giant cells

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If the inflammatory response is
extensive, abscess formation occurs, creating further destruction of
other follicles as well as apocrine and eccrine glands.

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Advances in understanding the
pathophysiology ofhidradenitis suppurativa has given rise to the
term acne inversa.

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The incidence ofhidradenitis is around 1%

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There is a 3: I male
to female predominance and tends to manifest in the second or third

F There is a 3: I female
to male predominance and tends to manifest in the second or third

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There is no role of hormonal component in HS

There may be a hormonal component associated with it, noting a decrease in severity after menopause

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It is also associated with
obesity, diabetes mellitus, metabolic syndrome, and nicotine use as
well as other inflammatory disease processes, such as inflammatory
bowel disease, pyoderma gangrenosum, arthritis, and polycystic
ovarian disease

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There are two commonly accepted scales describing the level of severity of hidradenitis, the Hurley Scale and the modified Sartorius Scale

These grade according to severity, location, and degree ofscaring

Treatment of HS ?

Life style modafication ,smoking secession, weight loss, and avoidance of compression and friction Intralesional triamcinolone has been described to decrease erythema, induration, pain, and lesion size in flare-ups, topical treatments such as clindamycin gel and oral therapies such as tetracycline, ampicillin, .....

treatments ranging from 2 to 6 weeks

staphyloccocus species are predominant in many ofthe chronic abscess

chronic lesions often are polymicrobial, in which anaerobic bacteria predominate

Antibiotic therapies do not treat the underlying problem, which is an abnormal inflammatory response.

Patient with HS can improve on laser therapy

T Though improvement was noted, recurrence can still occur

Surgical excision is the only method at present to definitively treat the scars and sinus tracts ofchronic hidradenitis.

new areas ofhidradenitis may still occur adjacent to the treated areas

any nodule can be incise in HS ?

F Incision and drainage can relieve pain from fluctuant abscesses but should be avoided in firm, solid nodules that are not purulent

Local excision procedure such as unroofing sinus tract or tangential excision may spare skin but are subject to higher recurrence rates compared to wide excision.

Local excision of the for sinus tract should be closed by suturing

F These wounds are left to heal by secondary intention

The smaller wounds can be closed primarily. Larger wounds can be covered with split-thickness skin grafting.

Rotational flaps have been described to cover larger wounds.

If hidradenitis is left to fester as chronic wound, over time, squamous cell carcinoma can arise in it, also known as a Marjolin ulcer

Larger wounds option of coverage

STSG Local rotational flap SECONDARY INTENTION

Fibrosis from neoadjuvant radiation therapy can compromise local tissues available for reconstruction

The need to start adjuvant radiation therapy can limit the available time for postoperative healing as well as create the need for more durable coverage

Adjuvant radiation therapy can also cause stenosis of the perinea! structures, such as the vagina

The need for creating stomas must be taken into consideration when planning flaps and possible rectus muscle harvest in case of prevously radiated area

Given the challenges of perinea! reconstruction in oncologic patients, combination of closure with flaps decreases major wound complications compared to primary closure

Malignancies of the vulva constitute 1 % of female malignancies and 5% genital cancers

50% of the cancers are squamous cell carcinoma (Bowen and Paget disease

F Ninety-five percent of the cancers are squamous cell carcinoma (Bowen and Paget disease

human papillomavirus is the leading cause of cancer in all age group in female

F In younger patients, human papillomavirus is the leading cause of cancer, whereas in older patients, lichen sclerosus is often the culprit

Oncologic defects tend to be limited to skin and subcutaneous tissue

Vaginal defects can result from primary vaginal malignancy, such as sarcoma. More often, acquired defects are due to colorectal, gynecologic, or urologic malignancies

Cordeiro et al. described a classification of full-thickness vaginal defects

Type I defects are partial, noncircumferential vaginal defects. This is further subdivided into type IA for anterior and lateral wall defects and type IB for posterior wall defects. Type II defects are circumferential defects and are subclassified as type IIA for the upper one to two-thirds and type IIB for total vaginectomies

Most scrotal tumor resections are due to squamous cell carcinoma, Paget disease or human papilloma virus-related processes

choices in perineal reconstruction, depending on >>>>

the size and location of the defect the presence or need for radiation therapy, need for pelvicsupport, and presence of a dead space

If the flap chosen for reconstruction lacks adequate volume, an omental flap can be added to obliterate pelvic dead space

Patient-specific factors

include amount of skin laxity, obesity, and other medical comorbidities that may restrict the extent of surgery the patient can tolerate

In obese patients, myocutaneous flaps such as the gracilis or rectus abdominus myocutaneous flaps may be converted to muscle flaps with skin grafting

Small defects can be closed primarily or with local undermining

Defects in which primary closure would cause perinea! distortion or dehiscence require closure going up the reconstructive ladder

Perforator and muscle-sparing techniques have been applied to traditional myocutaneous flaps and advancement flaps why?

to minimize donor site morbidity, improve arc of rotation, and provide thinner, better matching tissues

How many zones we can divide the valva to?

the vulva can be divided into three zones. The upper third spans the mons to the labia, the middle third consists of the labia minora and majora, and the lower third involves the vaginal introitus and perineum.

Upper-third defects that are small ( <20 cm)can often be closed primarily or with local flaps such as rhomboid and advancement flaps.

can often be reconstructed with a split-thickness skin graft.if the patients has not received radiation therapy or planed to receive one

Defects larger than 20 cm or those that have been or will be radiated can be reconstructed with a pedicled anterolateral thigh flap

Middle-third defects

with Singapore flaps or lotus petal flaps if the field has not been radiated Gracilis myocutaneous flaps or gluteal fold flaps are options if the field was previously irradiated or the pudenda! perforators were ligated during the resection

Lower-third defects are well covered by gluteal fold flaps or VY-advancement based offof the internal pudenda! artery perforators.

In case of the defect cross the midline we can extend the flap to cover the other side

F In the case of defect that crosses midline, bilateral flaps are recommended rather than crossing the midline with the reconstruction because this can lead to perfusion problems or distortion of the various orifices

For valvular reconstruction, Partial-thickness defects may be amenable to split-thickness skin grafts or buccal mucosa! grafts

Type IA flaps are most often addressed with the pudenda! thigh flaps, also known as the Singapore flap

Type IB flaps are most typically reconstructed with rectus abdominus myocutaneous flap The skin paddle can be oriented in a vertical or horizontal manner

F The skin paddle can be oriented in a vertical or oblique manner

Perforator and muscle-sparing techniques reduce donor site morbidity by limiting the amount of rectus facia and muscle that are harvested This can spare rectus function, especially if multiple ostomies are necessary

For type IIA reconstruction, reconstruction

a rolled transverse rectus abdominus myocutaneous is often used.

For type IIB, the option for total vaginal reconstruction

is bilateral gracilis myocutaneous flaps, which would provide adequate tissue for obliteration of dead space as well as vaginal reconstruction.

In case of the patient has multiple ostomies are necessary What the option to reconstruct the type IIB vaginal defect

is bilateral gracilis myocutaneous flaps

In obese patients, in whom a myocutaneous flap would be too thick, or those with multiple medical comorbidities, a rectus abdominis or gracilis muscle flap paired with a split thickness skin graft may suffice

Vaginal stents to bolster the skin graft with or without negative pressure dressings can be useful in this area where prevention of shear is difficult.

for total vaginal reconstruction, an inner diameter of about 8 cm is desired

F for total vaginal reconstruction, an inner diameter of about 4 cm is desired

a flap width of about 12 to 15 cm

Postoperative penile-vaginal penetrative sex is approximately 50%, and it is most correlated with preoperative activity.

In men, perinea! reconstruction can be necessary without concurrent genital reconstruction

In scrotal reconstruction larger defects can be reconstructed with split-thickness skin grafts with or without local tissue mobilization

Partial defects of the glans and/or distal corporectomy can be reconstructed with a split thickness skin graft

Partial or complete penectomy can be performed with phalloplasty techniques

T Basic principles include a tube within a tube design to reconstruct the urethra with the penis in a single flap.

The radial forearm free flap provides thin, sensate tissue that allows for both urethral and penile reconstruction

Rotational anterior lateral thigh flaps have also been described, but these can be bulky depending on the thickness of the patient's subcutaneous fat and more subject to urethral complications and revisions

we can use TRAM flap for vaginal reconstruction iiA

F Only vertical or oblique TRAM ONLY FOR IIB

Necrotizing soft tissues risk factor

diabetes ■ Recent surgery to perinea] structures ■ Malignancy ■ Alcoholism ■ Morbid obesity ■ Immunocompromise

Negative pressure wound dressings are helpful in controlling the wound once the infection is adequately debrided and treated in necrotizing faciates

scrotal reconstruction can be performed with split-thickness skin grafts or thigh flaps

Hidradenitis Suppurativa, meaning suppurative sweat gland

A perifollici.!lar lymphocytic infiltration results in inflammation, which prompts hyperkeratosis of the epithelium of the infundibulum

Chronic suppressive therapy may result in resistance in HS

Though staphyloccocus species are predominant in many ofthe acute abscess

chronic lesions often are polymicrobial, in which anaerobic bacteria predominate

Several monoclonal antibody antiinflammatory therapies have been studied. Adalimumab, which targets and blocks TNF-cx, is approved by the US Food and Drug Administration for treatment ofhidradenitis

Local excision procedure such as unroofing sinus tract or tangential excision may spare skin but are subject to higher recurrence rates compared to wide excision

Given the challenges of perinea! reconstruction in oncologic patients, combination of closure with flaps decreases major wound complications compared to primary closure

Scrotal Reconstruction

pedicled pudenda! thigh flaps are possible. Other flaps that have been described include anterior lateral thigh flaps and superficial circumflex iliac perforator flaps

The Singapore flap is pudenda! thigh flap. It receives its perfusion from the posterior labial artery and derives sensory innervation from the perinea! branches of the posterior cutaneous nerve of the thigh

The sitting position will put pressure on internal pudenda] artery VY advancement flaps from the ischium and tension from the hip flexion