PMC6968634_01
Perineal area prior to resection.
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A 74-year-old woman affected by radio-recurrent squamous cell carcinoma of the vulva, following multiple previous surgeries including V-Y IGAP flap reconstruction, with presence of extensive area of chronically infected, scarred and macerated skin around urethra, anus, perineum and bilateral glutaeal areas (Figure 1) underwent extensive soft tissue resection of these areas alongside pelvic exenteration, colostomy and ureteric stents.
Perineal defect post-resection.
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Gynecological surgeons performed the resection of uterus and vagina, colorectal surgeons excised rectum, anal canal, urethra, part of the bladder and very large previously irradiated and reconstructed area of soft tissue (Figure 2) followed by colostomy, whilst urologists performed a suprapubic catheterisation in the right side of abdominal wall.
Harvest of Mega chimeric ALT-vastus lateralis.
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The extensive pelvic-perineal-vulvar and glutaeal defect was then reconstructed with, a much wider than planned preoperatively, mega-chimeric pedicled ALT-rectus-vastus lateralis perforator flap harvested from the left thigh measuring 31 cm in width and 40 cm in length (Figure 3).
Patient disposed in lithotomy position. A is marked the perforator for the ALT-vastus lateralis, B is marked one of the perforators for the graclis V-Y advancement flap and C are marked the perforators of the two free style perforator flaps.
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With the help of hand-held Doppler only, we identified two IGAP-perforators, one on each side, to base two additional small triangular-shaped IGAP flaps (Figure 4).
6 months post-operative result.
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Apart from small area of delayed healing at the flap junctions posteriorly, all flaps healed uneventfully, and patient achieved good and stable functional outcome (Figure 5).