PMC8016381_01
Key steps in combined posterior vaginal wall defect and perineal reconstruction post- Extralevator Abdominoperineal Excision (ELAPE) using Perineal Turnover (PTO) flap. (a-b) The patient in prone jack-knife position post-ELAPE with demonstration of the anterior vaginal wall. (c) A perforator of the Internal Pudendal artery is identified with a handheld Doppler ultrasound at the inferolateral part of the skin defect and a semilunar area of skin incorporating the perforator is marked. (d) The marked flap is incised down to and raised in the supra-fascial plane. (e) The inferior aspect of the flap is rotated inwards and the skin is sutured to the anterior vaginal wall. The thick gluteal dermis of the remaining flap is then sutured to the cut end of the pelvic wall muscles. (f-g) Results at six weeks post-operative
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F1
For the reconstructive operation, the patient remains in the same prone Jackknife position as in the final part of the ELAPE or APR procedure (Figure 1A).  A semilunar area of skin incorporating the perforator was marked along one side of the perineal defect (Figure 1C) where the width of the flap equals the width of the muscle defect in the perineal muscle floor. The marked skin island is incised down to the supra-fascial plane (Figure 1D). The superior 15 cm of the flap was de-epithelialized and turned inwards towards the perineal defect (Figures 1E and 2). This allowed for recreation of the natal cleft (Figure 1G).
Visual illustration of the Perineal Turn Over (PTO) concept for reconstruction of perineal defect following extralevator abdominoperineal excision (ELAPE) and posterior vaginectomy
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F2
The superior 15 cm of the flap was de-epithelialized and turned inwards towards the perineal defect (Figures 1E and 2).