Perineal Reconstruction Flashcards
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
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
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.
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
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
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
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
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
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
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
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These grade according to severity, location,
and degree ofscaring
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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
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staphyloccocus species are
predominant in many ofthe chronic abscess
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chronic lesions often are
polymicrobial, in which anaerobic bacteria predominate
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Antibiotic therapies do not treat the underlying problem, which
is an abnormal inflammatory response.
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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.
T
new areas ofhidradenitis may still occur adjacent to the treated areas
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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.
T
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.
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Rotational flaps have been described to cover larger wounds.
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If hidradenitis is left to fester as chronic
wound, over time, squamous cell carcinoma can arise in it, also
known as a Marjolin ulcer
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Larger wounds option of coverage
STSG
Local rotational flap
SECONDARY INTENTION
Fibrosis from neoadjuvant
radiation therapy can compromise local tissues available for reconstruction
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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
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Adjuvant radiation therapy can also cause
stenosis of the perinea! structures, such as the vagina
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The need for
creating stomas must be taken into consideration when planning
flaps and possible rectus muscle harvest in case of prevously radiated area
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Given the challenges of perinea! reconstruction in
oncologic patients, combination of closure with flaps decreases major
wound complications compared to primary closure
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Malignancies of the vulva constitute 1 % of female malignancies
and 5% genital cancers
T
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
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Vaginal defects can result from primary vaginal malignancy, such as
sarcoma. More often, acquired defects are due to colorectal, gynecologic, or urologic malignancies
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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
T
choices in perineal reconstruction, depending on»_space;»
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
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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
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Small defects can be closed primarily or with local undermining
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Defects in which primary
closure would cause perinea! distortion or dehiscence require closure going up the reconstructive ladder
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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.
T
can often be reconstructed with
a split-thickness skin graft.if the patients has not received radiation therapy or planed to receive one
T
Defects larger than 20 cm or those that
have been or will be radiated can be reconstructed with a pedicled
anterolateral thigh flap
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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.
T
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
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Type IA flaps are most often addressed with the pudenda! thigh flaps,
also known as the Singapore flap
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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
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For type IIA reconstruction, reconstruction
a rolled transverse rectus abdominus myocutaneous is often used.
For type IIB, the option for total vaginal
reconstruction
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is bilateral gracilis myocutaneous flaps, which would
provide adequate tissue for obliteration of dead space as well as vaginal reconstruction.
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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
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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.
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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
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Postoperative penile-vaginal penetrative sex is
approximately 50%, and it is most correlated with preoperative activity.
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In men, perinea! reconstruction can be necessary without concurrent
genital reconstruction
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In scrotal reconstruction larger defects can be reconstructed with split-thickness skin grafts
with or without local tissue mobilization
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Partial defects of the glans and/or distal corporectomy can be
reconstructed with a split thickness skin graft
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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
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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
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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
T
scrotal reconstruction
can be performed with split-thickness skin grafts or thigh flaps
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Hidradenitis
Suppurativa, meaning suppurative sweat gland
T
A perifollici.!lar lymphocytic infiltration results in inflammation, which prompts hyperkeratosis of the epithelium of the
infundibulum
T
Chronic suppressive
therapy may result in resistance in HS
T
Though staphyloccocus species are
predominant in many ofthe acute abscess
T
chronic lesions often are
polymicrobial, in which anaerobic bacteria predominate
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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
T
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
T
Given the challenges of perinea! reconstruction in
oncologic patients, combination of closure with flaps decreases major
wound complications compared to primary closure
T
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
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The sitting position will put pressure on internal
pudenda] artery VY advancement flaps from the ischium and
tension from the hip flexion
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