Outcomes of Immediate Internal Pudendal Artery Perforator Flap Reconstruction for Irradiated Abdominoperineal Resection Defects.

BACKGROUND: There are many previous reports for using the internal pudendal artery perforator flap in vulvovaginal reconstruction; however, reports of this flap for perineal reconstruction after abdominoperineal excision of the rectum are scarce. OBJECTIVE: The purpose of this study was to evaluate the outcomes of immediate internal pudendal artery perforator flap reconstruction for irradiated abdominoperineal resection defects. DESIGN: This was a prospective case series. SETTINGS: This flap could represent a step forward over other perineal flap approaches or primary closure. PATIENTS: A total of 73 consecutive patients with anorectal tumors were included. INTERVENTIONS: The study included immediate perineal reconstruction using 122 internal pudendal artery perforator flaps after abdominoperineal excision of the rectum. MAIN OUTCOME MEASURES: Dimensions of the perineal defect (in centimeters squared), hospital stay (days), healing time (days), and postoperative complications (Clavien-Dindo grades) were measured. RESULTS: The means of the perineal defect, hospital stay, and healing time were 51.62 cm, 15.94 days, and 38.52 days. The higher the patient BMI, the longer healing time (p = 0.02); Clavien-Dindo complications grades III to IV were greater in patients with perineal defect ≥60 cm (p = 0.03; OR = 10.56); postoperative complications were higher both in patients with anal squamous cell carcinoma (p = 0.005; OR = 6.09) and in patients with comorbidities (p = 0.04; OR = 2.78); hospital stay (p= 0.001) and healing time (p < 0.001) were higher in patients who had postoperative complications. The complete perineal wound healing at 12 weeks was achieved by 95% of patients, and our 30-day mortality rate was 4%. LIMITATIONS: As a nonrandomized study, our results have to be interpreted with caution. CONCLUSIONS: Multiple previously described advantages associated with internal pudendal artery perforator flap were also observed here, reinforcing the idea that it is reliable, versatile, and a useful option for perineal reconstruction after abdominoperineal excision of the rectum. Therefore, we propose that this flap could be considered as the first choice for perineal reconstruction in selected patients with moderate and some large defects after abdominoperineal excision of the rectum. See Video Abstract at http://links.lww.com/DCR/A367.

Chimerical anterolateral thigh flap for plantar reconstruction.

OBJECTIVE: The purpose of this study is to evaluate the results of reconstruction and rehabilitation of patients with plantar defects by using a chimerical flap of muscle and skin from anterolateral thigh. METHODS: Twenty-five patients with plantar defects were reconstructed with a chimerical anterolateral thigh (ALT) flap, composed by a vastus lateralis muscle segment and a thinned skin island. Neurorrhaphy between lateral femoral cutaneous nerve and calcaneal nerve was performed in 7 patients. Evaluation of flap contour and stability and patient ambulation was performed 6 and 12 months after surgery. Evaluation of cutaneous sensiblity of ALT flap and contralateral thigh was performed 12 months after surgery using Pressure Specified Sensory Device™ (PSSD™). RESULTS: Flap viability was complete in 23 patients and 2 patients had complications with partial flap loss of its cutaneous component. Six months postoperatively, flap contour, and stability was considered good in 19 and 21 patients respectively, and all 25 patients presented good ambulation. Twelve months postoperatively, all 25 patients presented good flap contour and stability, as well as good ambulation. All 7 flaps undergoing to reinnervation partially recovered cutaneous sensibility in comparison to donor site (contralateral thigh). Cutaneous tactile thresholds (g/mm(2) ) of static one-point test and moving one-point test from the ALT flap and the contralateral thigh presented statistically significant differences, for both comparisons (P = 0.009, P = 0.002). CONCLUSION: This flap is suitable for reconstruction of plantar defects, with good flap contour and stability, proper patient ambulation and low complication rates.

Evaluation of cutaneous sensibility of the internal pudendal artery perforator (IPAP) flap after perineal reconstructions.

BACKGROUND: In oncological perineal reconstructions, the internal pudendal artery perforator (IPAP) flap is our flap of choice, supplied by perforator vessels from the internal pudendal artery and innervated by branches from the pudendal nerve and the posterior femoral cutaneous nerve. Data related to the evaluation of its cutaneous sensibility are scarce, discrepant, and subject to methodological criticism. OBJECTIVE: The objective of this study was to evaluate the cutaneous sensibility of the IPAP flap 12 months after perineal reconstruction and compare it with the preoperative cutaneous sensibility of the gluteal fold (flap donor area). METHODS: A prospective study of 25 patients undergoing abdominoperineal excision of rectum (APER) and reconstruction with bilateral VY advancement IPAP flap was conducted. The tactile, pain, thermal, and vibration sensibilities were analyzed in four areas of the gluteal fold preoperatively and in the four corresponding areas of the flap 12 months after surgery. Tactile sensibility was assessed using the Pressure Specified Sensory Device™ (PSSD™), which measures the pressure applied to the skin. The other types of sensibility were analyzed using a needle for pain, hot/cold contact for thermal, and a tuning fork for vibration sensibility. RESULTS: A comparison between tactile sensibility thresholds on the gluteal fold preoperatively and on the flap 12 months after surgery showed no statistically significant difference, with p values>0.05 in all four areas evaluated. All patients had preserved pain, thermal, and vibration sensibility in all four areas, postoperatively. CONCLUSION: In oncological perineal reconstructions after APER, it is expected that the cutaneous sensibility on the IPAP flap be maintained.

Anatomical comparison among the anterolateral thigh, the parascapular, and the lateral arm flaps.

OBJECTIVE: This study aims to compare the major anatomical aspects among anterolateral thigh, parascapular and lateral arm flaps. METHODS: Sixty flaps were dissected in 20 human cadavers, comparing their vascular pedicle length, flap thickness and arterial/venous pedicle diameters. RESULTS: The vascular pedicle length (from the origin of the vascular pedicle to its entry into the skin flap) of anterolateral thigh flap (13.43 ± 3.92 cm, lateral circumflex femoral artery) was longer than parascapular (9.07 ± 1.20 cm, circumflex scapular artery) and lateral arm flap (8.90 ± 1.65 cm, posterior collateral radial artery) (P < 0.001). The thickness of lateral arm flap (6.32 ± 2.33 mm) was lesser than parascapular (8.59 ± 2.93 mm) and anterolateral thigh flap (9.30 ± 3.54 mm) (P < 0.001). The arterial/venous pedicle diameters of lateral arm flap (2.37 ± 0.69 mm / 2.61 ± 0.74 mm) were lesser than parascapular (3.46 ± 0.80 mm / 4.07 ± 0.87 mm) and anterolateral thigh flap (3.26 ± 0.74 mm / 3.87 ± 0.70 mm) (P < 0.001). CONCLUSIONS: The vascular pedicle length of anterolateral thigh flap was the longest and that lateral arm flap presented a pedicle with the smallest arterial and venous diameters, in addition to being the thinnest flap.

The thoracodorsal artery perforator flap in the treatment of axillary hidradenitis suppurativa: effect on preservation of arm abduction.

UNLABELLED: Hidradenitis suppurativa is a chronic, recurrent inflammatory disease of the skin characterized by abscesses and scars. The axillary region is predominantly affected, leading to limited mobility of the arm due to scar retraction. This prospective study aimed to analyze the surgical treatment of severe lesions of axillary hidradenitis suppurativa by using the thoracodorsal artery perforator flap while focusing on the preservation of arm abduction. We enrolled 12 patients with severe axillary hidradenitis suppurativa who underwent bilateral surgical treatment of their lesions by radical excision, followed by immediate reconstruction with the thoracodorsal artery perforator flap. The amplitude of arm abduction was measured preoperatively and 6 months postoperatively by goniometry, and statistical analysis was performed using Student's t test. Preoperative and 6-month postoperative mean amplitude of arm abduction were 98.7 degrees and 152.7 degrees, respectively, with a significant mean increase of 54 degrees (p<0.0001). The thoracodorsal artery perforator flap can be used as a good option for axillary reconstruction after radical excision of severe lesions of hidradenitis suppurativa, and its use would allow a significant increase in the amplitude of arm abduction. It has several other advantages when compared with other types of coverage, including its anatomical proximity to the axilla, similar thickness, and high-quality skin. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Involvement of the parabrachial nucleus in the pressor response to chemoreflex activation in awake rats.

Activation of the chemoreflex with potassium cyanide (KCN, 40 microg/rat, i.v.) in awake rats produces pressor and bradycardic responses as well as a tachypneic response. In the present study, we evaluated the involvement of the periaqueductal gray matter (PAG) and the parabrachial nucleus (PBN) in the neural pathways of the cardiovascular responses to chemoreflex activation. The cardiovascular responses to chemoreflex activation were evaluated before and after bilateral microinjection of 2% lidocaine, a local anesthetic, into the PBN or PAG in order to block in a reversible manner the neuronal activity and axonal conduction of fibers of passage in these areas. The data show that the pressor response to chemoreflex activation 3 min after bilateral microinjection of lidocaine into the dorsolateral aspect of the PBN was significantly reduced in comparison to the control response (32 +/- 5 vs. 48 +/- 4 mm Hg, n = 7), with no significant changes in the bradycardic responses. The effect of lidocaine was reversible since the pressor response was back to control levels 15 min after microinjection of this anesthetic. Bilateral microinjections of lidocaine into the dorsolateral (n = 11) or lateral (n = 8) columns of the PAG in distinct groups of rats produced no significant changes in the pressor or bradycardic responses of the chemoreflex. These data indicate that the PBN is part of the neuronal pathways involved in the sympathoexcitatory component of the chemoreflex while the PAG is not.