Perineal reconstruction with multiple perforator flaps based on anatomical divisions

Purpose: Reconstruction of perineal defects remains a challenge because such defects can be extensive, complex, and three-dimensional. This report presents a retrospective review of our past 5 years of experience in perineal reconstruction, and suggests a simple algorithmic approach according to anatomical divisions with multiple pedicled perforator flaps for extensive perineal defects. Methods: From January 2011 to December 2015, 16 patients, including 5 men and 11 women, underwent reconstruction of extensive perineal defects. The defect size varied from 11 × 10 cm² to 23 × 28 cm². A total of 37 perforator flaps were used in 16 cases, which included Fournier's gangrene in 4 cases, extramammary Paget's disease in 4, and skin cancer in 8. The defects were categorized according to anatomical location, and were covered by multiple pedicled perforator flaps using the closest perforators based on the perforasome theory. Results: All of the defects achieved tension-free primary closure. An average of 2.31 flaps (range, 2–3 flaps) was used for each patient. All of the flaps survived without partial or total loss, though temporary flap congestion occurred in three patients and minor wound dehiscence occurred in one case. There were no donor–site complications. During an average follow-up of 11.06 months (range, 10–12 months), the reconstructed areas achieved good functional and aesthetic outcomes. Conclusions: Multiple pedicled perforator flaps could supply sufficient dimension to cover extensive perineal defects and achieve tension-free closure. In addition, our simple algorithmic approach according to anatomical divisions could be easily applied to extensive perineal defects.