Surgical technique (Fig. 1)

Surgical technique for immediate synchronous perineo-vaginal reconstruction using gluteal flap after APE^a for anorectal malignancy

Surgical resection, including en bloc vaginal resection, and harvest of the gluteal myocutaneous flap for perineal reconstruction is performed as previously described [14]. To make vaginal reconstruction possible, an additional caudally based fasciocutaneous transposition flap is harvested adjacent to the pelvic midline defect. The flap is designed individually for each patient according to the size of the defect, e.g., 4 cm wide at the base and 12 cm in length. Sufficient mobilization achieves reach to the posterior vaginal wall. Perforator vessels are not visualized and the base of the flap is left as a bulk of fatty tissue securing sufficient blood supply from random circulation of the inferior gluteal and pudendal vessels. After mobilization, the fasciocutaneous transposition flap is rotated 180 degrees along a cranio-caudal axis into the midline defect which allows for the gluteal skin to be used for reconstruction of the dorsal vaginal wall. When necessary, the flap is trimmed cranially to fit the defect. Using a single layer of interrupted resorbable sutures, the flap is sutured to the cut edges of the vagina. For patients in whom the most distal part of vagina is not resected and the introitus remains intact, the caudal part of the transposition flap can be deepithelialized to allow the gluteal skin in the cranial part of the flap to reach the defect in the posterior vaginal wall.

Subsequently, the cranially based myocutaneous gluteal flap is rotated over the midline defect and sutured to the opposite side gluteal muscle. Postoperatively, the patient is kept on a decubital mattress and mobilized according to a specific schedule [14].

All reconstructive surgery for patients included in this report was performed by board-certified plastic surgeons.