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Evaluation of cutaneous sensibility of the internal pudendal artery perforator (IPAP) flap after perineal reconstructions
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Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) xx, 1e10
Evaluation of cutaneous sensibility of the internal pudendal artery perforator (IPAP) flap after perineal reconstructions ´bio F. Busnardo a, Pedro S. Coltro a,*, Marcus C. Ferreira b, Fa Marcelo V. Olivan a, Thiago Ueda b, Victor A. Grillo b, ´rgio C. Nahas c, Carlos F. Marques c, Caio S. Nahas c, Se Rolf Gemperli b a Institute of Cancer of the State of Sa˜o Paulo, Division of Plastic Surgery, University of Sa˜o Paulo School of Medicine, Sa˜o Paulo, Brazil b Division of Plastic Surgery, University of Sa˜o Paulo School of Medicine, Sa˜o Paulo, Brazil c Institute of Cancer of the State of Sa˜o Paulo, Division of Gastroenterology Surgery and Coloproctology, University of Sa˜o Paulo School of Medicine, Sa˜o Paulo, Brazil
Received 28 July 2014; accepted 25 September 2014
KEYWORDS Sensory thresholds; Perforator flap; Reconstruction; Perineum; Rectal neoplasms; Anus neoplasms
Summary 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.
* Corresponding author. Alameda Jauaperi 943 Apto 172, Indiano ´polis, Sa ˜o Paulo 04523-014, Brazil. Tel.: þ55 (11) 99190 5832; fax: þ55 (11) 2661 6636. E-mail address: [email protected] (P.S. Coltro). http://dx.doi.org/10.1016/j.bjps.2014.09.049 1748-6815/ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Coltro PS, et al., Evaluation of cutaneous sensibility of the internal pudendal artery perforator (IPAP) flap after perineal reconstructions, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/ j.bjps.2014.09.049
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P.S. Coltro et al. 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. ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Introduction The treatment of anorectal and vulvovaginal malignancies requires resection resulting in extensive perineal defects, whose reconstruction is a challenge.1 In some lower rectum tumors and in persistent or recurrent anal tumors after chemoradiotherapy, abdominoperineal excision of rectum (APER) remains an essential component of the treatment.2e5 Perineal defects after APER benefit from flap reconstruction.4,6e11 The need for reconstruction is particularly important in the pelvic and perineal regions. The pelvis has a peculiar anatomic conformation in which its sidewalls are limited by bone structures that are not capable of collapsing to fill defects resulting from the surgical resections. Furthermore, most of this area is located outside the peritoneal cavity and hence does not have the peritoneal absorptive superfice.12 Perineal reconstruction using flaps is associated with lower rates of wound dehiscence,13 and it allows the repair of the vulva and vagina if needed.14,15 Other benefits include the use of a well-vascularized tissue, located outside the radiation field.12,16 Flaps supplied by branches from the internal pudendal artery are used for vulvovaginal and perineal reconstruction, as perineal flaps,17,18 pudendal flaps,19,20 lotus petal flaps,21,22 and its variants, such as the gluteal fold flaps.23,24 These flaps have names, shapes, and different patterns of mobility, but all of them have the same source of vascular supply, branches from the internal pudendal artery. Therefore, they are together called internal pudendal artery perforator (IPAP) flaps.25,26
Figure 1
Demarcation of the IPAP flap of rotation.
The IPAP flap is planned on the perineal and gluteal fold area, vascularized by direct cutaneous perforator branches from the internal pudendal artery and vein, and innervated by branches of the pudendal nerve and the femoral posterior cutaneous nerve.14,19 The IPAP flap can be dissected and mobilized through uni- or bi-lateral rotation (Figure 1), uni- or bi-lateral VY advancement (Figure 2), or combined flaps.1,12 Recent studies demonstrate that the IPAP flap can be used for perineal reconstruction after APER with some advantages when compared with primary closure of the defect or to other flaps; it is considered a reliable and versatile option for closure of the perineal wound.12,16,27 Sensation receptors on the skin are able to perceive and distinguish four modalities of sensibility: tactile (pressure), pain, thermal, and vibration. The analysis of cutaneous sensibility is complete if all these modalities are studied. The assessment and measurement of the skin sensibility can be performed through a number of neurosensory tests, based on the knowledge about the type of skin innervation.28 Temporary or permanent changes to the skin sensibility may occur after several procedures in plastic surgery, in particular when there is cutaneous dissection or movement of tissues, such as flaps used in reconstructive surgeries.29 So far, data related to assessment of the cutaneous sensibility of IPAP flaps are scarce, discrepant, and subject to methodological criticism.23,24,30 We could not find any study of the cutaneous sensibility of the IPAP flap after APER and perineal reconstruction; in addition, no comparative study of this flap sensibility, preand post-operatively, was found.
Figure 2
Demarcation of the IPAP flap of VY advancement.
Please cite this article in press as: Coltro PS, et al., Evaluation of cutaneous sensibility of the internal pudendal artery perforator (IPAP) flap after perineal reconstructions, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/ j.bjps.2014.09.049
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Cutaneous sensibility of the IPAP flap
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The purpose of this study was to assess the cutaneous sensibility of the IPAP flap 12 months after perineal reconstruction in APER, and compare it with the cutaneous sensibility of the gluteal fold (flap donor area) preoperatively.
Patients and methods This prospective study was conducted at the Institute of Cancer of the State of Sa ˜o Paulo, University of Sa ˜o Paulo School of Medicine, Brazil, from 2012 to 2014, and it received approval from our institutional review board. None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript. We included 25 patients with lower rectum or anal malignancies that would be submitted to APER, followed by immediate perineal reconstruction with bilateral VY advancement IPAP flap, which was indicated for patients with perineal defect from 20 to 60 cm2, considered moderated in size.31 Eleven patients were male and 14 female, aged 31e77 years, mean 59 years, and median 60 years. The diagnosis was lower rectum adenocarcinoma in 20 patients and anal squamous cell carcinoma in five patients (Table 1). Preoperative chemotherapy and radiotherapy were performed in all 25 patients.
Table 1
Evaluation of cutaneous sensibility of the gluteal fold The same examiner tested two types of tactile sensibility, and also the pain, thermal, and vibration sensibility on the gluteal fold, preoperatively, as the long axis of the IPAP flap would be marked on the gluteal fold. Pressure Specified Sensory Device (PSSD) was used in the study of tactile sensibility. The device consists of a force transducer coupled to a computer, with a software able to encode an electrical signal into pressure (in g/mm2). The examination consisted of a touch with the metal rod of the transducer on the skin over the gluteal fold (Figure 3). The patient held a bell and was instructed to press it just as he/ she felt the touch of the metal rod. Thus, the software recorded the perceived value of pressure at the time the bell was triggered by the patient. The test was repeated five times in each area and the mean obtained corresponded to the cutaneous pressure threshold of this area. The gluteal fold was tested in four areas (Figure 4):
right proximal gluteal fold (RPGF), right distal gluteal fold (RDGF), left proximal gluteal fold (LPGF), and left distal gluteal fold (LDGF).
Patient characteristics, surgeries performed, flap characteristics, and evolution of patients.
Patient
Age/Sex
Diagnosis
Surgeries
Defect size (cm2)
Flap size (cm)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
47/M 55/F 60/M 47/F 63/M 46/F 75/F 64/F 76/M 77/M 60/F 51/M 60/F 31/M 72/F 49/F 73/M 55/M 66/F 59/M 52/F 59/F 69/M 54/F 34/F
LRAC ASCC LRAC LRAC ASCC ASCC LRAC LRAC LRAC LRAC LRAC LRAC LRAC LRAC LRAC ASCC LRAC LRAC LRAC LRAC LRAC LRAC LRAC ASCC LRAC
APER þ RP þ PH APER þ HYS þ EVPW APER APER þ EVPW APER þ PE APER APER þ EVPW APER þ EVPW APER APER APER APER APER þ PH þ EVPW AAPR þ HEP APER þ PE APER þ PE APER APER þ PE APER APER þ PE APER APER APER APER þ EVPW APER
48 54 35 54 42 32 54 48 45 50 40 48 60 48 54 60 32 48 36 48 32 35 40 54 48
12 14 12 13 12 13 12 15 12 13 14 12 13 13 12 15 12 13 12 13 12 15 13 14 16
8 9 7 9 7 8 9 8 9 10 10 8 10 8 9 10 8 8 9 8 8 9 10 9 12
Length of stay (days)
Complications
Healing time (days)
Follow-up (months)
11 40 5 6 7 7 8 30 13 20 13 5 11 9 17 11 21 18 9 13 11 7 12 30 9
PC MID e MID e MID e MID e e e MID e e e MAD PTE e e e e MPN e LI þ MID e
21 90 30 40 30 40 21 55 45 30 25 75 45 42 45 90 27 26 28 35 45 45 40 93 28
15 18 17 17 12 15 16 14 16 18 16 15 15 12 14 13 12 17 16 14 14 15 16 14 14
M: male; F: female; LRAC: lower rectum adenocarcinoma; ASCC: anal squamous cell carcinoma; APER: abdominoperineal excision of rectum; RP: radical prostatectomy; PH: partial hepatectomy; HYS: hysterectomy; EVPW: excision of vaginal posterior wall; PE: pelvic exenteration; PC: pelvic collection; MID: minor dehiscence, MAD: major dehiscence; PTE: pulmonary thromboembolism; MPN: minor partial necrosis; LI: local infection.
Please cite this article in press as: Coltro PS, et al., Evaluation of cutaneous sensibility of the internal pudendal artery perforator (IPAP) flap after perineal reconstructions, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/ j.bjps.2014.09.049
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P.S. Coltro et al.
Figure 3 (Above, left) Tactile sensibility test using the PSSD. (Above, right) Pain sensibility test using needle. (Below, left) Thermal sensibility test using hot/cold contact. (Below, right) Vibration sensibility test using 128-Hz tuning fork.
In order to assess tactile sensibility, two types of tests were performed on each of these four areas: Static one-point test (1PS): This test was conducted by the simple touch of the transducer on the skin and used to evaluate the slowly adapting sensory fibers; it provides data from cutaneous sensory thresholds to static pressure. Moving one-point test (1PM): This test was conducted by moving the transducer touching the skin and used to evaluate the quickly adapting sensory fibers; it provides data from cutaneous sensory thresholds to motion pressure. Evaluation of other methods of sensibility was also tested in the same areas tested earlier (RPGF, RDGF, LPGF,
and LDGF), using the “forced-choice” method. For this, the patient was asked to detect the presence or absence of sensation for pain and vibration tests, and the type of sensation (hot or cold) for the thermal sensibility test. Each test was repeated five times in each of the four areas evaluated, considering a combination of at least four correct answers as positive. The pain sensibility was tested with a superficial touch using a 30 0.7 mm needle, applying a slight pressure on the skin surface without perforating it, just to trigger the pain stimulus (Figure 3). The thermal sensibility analysis was performed by skin contact with a plastic tube containing water at 45e50 C, perceived as hot, or 10e15 C, perceived as cold (Figure 3). The vibration sensibility was tested by a touch perpendicular to the skin using a tuning fork vibrating at 128 Hz for 5 s (Figure 3).
Surgical procedure
Figure 4 Areas of the gluteal fold where cutaneous sensibility tests were performed preoperatively.
Immediately after APER, with the patient kept in the lithotomy position (Figure 5), the plastic surgery team proceeded with the perineal reconstruction. The gluteal fold had been identified prior to the surgery and demarcated bilaterally with the patient standing. The long axis of the IPAP flap was centered on the gluteal fold and the flap dimensions were adjusted according to the size of the defect and the need for associated reconstruction of the posterior vaginal wall. The base of the flap was located in a triangle formed by the ischial tuberosity, anus, and vaginal introitus or scrotum.14,27 Perforator vessels from the internal pudendal artery are located within this triangle, along with the branches from the pudendal nerve (Figure 6). The IPAP flap was dissected in the plane between the fascia and the gluteus maximus muscle, starting from the
Please cite this article in press as: Coltro PS, et al., Evaluation of cutaneous sensibility of the internal pudendal artery perforator (IPAP) flap after perineal reconstructions, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/ j.bjps.2014.09.049
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Cutaneous sensibility of the IPAP flap
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Figure 5 (Above, left) A 55-year-old man underwent APER and pelvic exenteration, showing the perineal defect in the lithotomy position. (Above, right) Reconstruction with bilateral VY advancement IPAP flaps. (Below, left) IPAP flaps dissected and mobilized to fill the perineal defect. (Below, right) Primary closure of the donor area.
distal to proximal direction (Figure 5). The fascia was included with the flap to preserve the branches from the posterior femoral cutaneous nerve, which runs through a supra-fascial path. The IPAP flap was mobilized in bilateral VY advancement for perineal reconstruction (Figure 5). The proximal portions of the flaps were denuded and introduced to fill the perineal defect. When necessary, the upper proximal portions of the flap were maintained with skin and used for reconstruction of the vulva and the posterior vaginal wall, and the rest was denuded to fill the perineal defect. The donor area was closed primarily (Figure 5). Postoperatively, patients were maintained with the legs adducted, ambulation was released after 5 days, and they were allowed to sit after 14 days.
Assessment of the cutaneous sensibility on the IPAP flap Evaluation of the four modes of cutaneous sensibility was again performed 12 months after surgery, now on the skin of the IPAP flap. Examination of tactile sensibility was performed using the PSSD and other modalities of sensation (pain, thermal, and vibration) were analyzed by the “forced-choice” method, similar to the method used preoperatively. The flap regions that were tested (Figure 7) corresponded to the gluteal fold areas previously tested:
right proximal flap (RPF), right distal flap (RDF), left proximal flap (LPF), and left distal flap (LDF).
Variables were described and statistical tests were calculated using GraphPad Prism, Prism 6 for Mac OS X (GraphPad Software, Inc. e version 6.0e). Values <0.05 were considered significant.
Results Reconstructive procedure The 25 patients of the study underwent APER and reconstruction was performed with the bilateral VY advancement IPAP flap, totaling 50 flaps (Figure 8). All patients had moderated defects (20e60 cm2); the mean defect was 45.8 cm2, median 48 cm2, and range 32e60 cm2 (Table 1). As for the evolution of the flaps, 49 of them showed good result and no signs of ischemia, congestion, or necrosis, but a small and partial distal necrosis appeared in one flap. Other minor complications occurred in 10 patients (Table 1), with a complication rate of 40%. The mean length of hospital stay was 13.7 days, a median of 11 days, ranging from 5 to 40 days. The mean time for healing was 43.6 days, median 40 days, ranging from 21 to 93 days. The mean time of postoperative follow-up was 15 months, median 15 months, ranging from 12 to 18 months (Table 1). During the postoperative follow-up, five deaths occurred, all of them 12 months after surgery, after completion of the sensibility tests.
Cutaneous sensibility Cutaneous tactile thresholds to the static (1PS) and moving (1PM) one-point tests for the gluteal fold preoperatively and for the IPAP flap 12 months after surgery are shown, respectively, in Tables 2 and 3, and in Figure 9.
Please cite this article in press as: Coltro PS, et al., Evaluation of cutaneous sensibility of the internal pudendal artery perforator (IPAP) flap after perineal reconstructions, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/ j.bjps.2014.09.049
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Figure 6 Triangle of reference for location of perforator vessels (blue).
On the four flap areas studied (RPF, RDF, LPF, and LDF), the mean and median tactile thresholds were similar to those found on the corresponding areas of the gluteal fold (RPGF, RDGF, LPGF, and LDGF) preoperatively. Statistical tests to compare these thresholds showed differences not statistically significant for the four areas studied, in both tests (1PS and 1PM), with values >0.05 (Figure 9). Therefore, we consider that the tactile sensibility of the IPAP flap 12 months postoperatively was similar to that of its donor area (gluteal fold). As the pain, thermal, and vibratory sensibility from the gluteal fold preoperatively and the IPAP flap 12 months postoperatively, all patients present these three modalities of perception in all four areas studied. Therefore, the same way as in tactile sensibility, we consider that the pain, thermal, and vibratory sensibility of the IPAP flap was similar to that of the gluteal fold.
Discussion Since the late 1980s, flaps supplied by branches from the internal pudendal artery have been described for vulvovaginal and perineal reconstruction.17e24 As perforator flaps, they do not have some of the disadvantages of myocutaneous flaps; anatomical vascular studies conducted on such flaps contributed to the spread of their indications.14,27,32 IPAP flaps are thinner and easier to dissect, and have similar skin; therefore, they are widely used for the reconstruction of vulvar and vaginal defects.22,30,33e35 Recent case reports and case series using IPAP flaps after excision of anorectal neoplasms indicate that this flap can be considered a reliable and versatile option for perineal reconstruction.12,16,27 In this study, we examined immediate IPAP flap results only in cases of perineal reconstructions in which APER defects were moderated in size (20e60 cm2), representing the vast majority of our patients. The multiple benefits with IPAP flaps were also observed in this series, reinforcing the idea that this flap is a good option for perineal reconstruction after APER. In our service, the IPAP flap is the main option for reconstruction of moderated perineal defects and for some of the most extensive ones. For the other larger defects, we used the vertical rectus abdominis myocutaneous (VRAM) flap.
P.S. Coltro et al. In order to avoid urinary or sexual dysfunction after APER, step perineal resection is performed, whenever possible, preserving the pelvic splanchnic nerves, the superior and inferior hypogastric plexus, the pudendal nerves, and its terminal branches. Pudendal nerve injury can lead to urinary incontinence and impotence, and it is directly related to the extension of the pelvic dissection.36 During the perineal step of APER, branches from the pudendal nerve may be injured due to difficulty of clearly identifying them during anterior and lateral dissection. However, this nerve damage could be avoided in most patients by identifying anatomical landmarks and the recognition and preservation of these nerves.37 Studies on cadavers about APER steps also demonstrated that the branches from the pudendal nerve are at a risk of inadvertent injury, especially in the anterior surgical resection plane. Perineal branches from the pudendal nerve run along a path near the rectum and the anterior plane of resection, along with the perineal branches from the internal pudendal vessels. To avoid injury to these neurovascular structures, it is important to recognize some anatomic landmarks. As the perineal branches from the pudendal nerve run behind the superficial transverse perineal muscles and the perineal body, the preservation of these structures work together to protect these nerves.37,38 Only few studies have analyzed the cutaneous sensibility of the IPAP flap based on sensorial tests.23,24,30 However, in none of these studies, the tests were performed comparing the postoperative with the preoperative sensibility and some data about the methodology of the sensory tests were lacking. In addition, the methods used to study cutaneous tactile sensibility (the superficial contact and the slight touch) could be considered, nowadays, underrepresentative. According to these studies,23,24,30 the evaluation of the cutaneous sensibility of the IPAP flap was discrepant and subject to methodological criticism. Moreover, they were only related to the use of IPAP flaps for vulvovaginal reconstructions. In our study, we determined the cutaneous sensibility of the IPAP flap 12 months after perineal reconstruction and compared it with the preoperative cutaneous sensibility of the gluteal fold. More importantly, we used more precise
Figure 7 Areas of the IPAP flap where cutaneous sensibility tests were performed on 12 months postoperatively.
Please cite this article in press as: Coltro PS, et al., Evaluation of cutaneous sensibility of the internal pudendal artery perforator (IPAP) flap after perineal reconstructions, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/ j.bjps.2014.09.049
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Cutaneous sensibility of the IPAP flap
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Figure 8 (Above, left) A 64-year-old woman underwent APER and excision of vaginal posterior wall, showing the perineal and vulvovaginal defect. (Above, center) Bilateral VY advancement IPAP flaps dissected and mobilized. (Above, right) Medial upper portions of flaps remained with skin to reconstruct the posterior vaginal wall (yellow arrow) and medial inner portions of flaps denuded to fill the perineal defect (green arrow). (Below, left) Immediate postoperative, showing primary closure of the flap donor area. (Below, center) 12 months postoperatively in the lithotomy position. (Below, right) 12 months postoperatively in the standing position, with good scar camouflage at the gluteal fold.
tests for sensibility, the PSSD, extensively used for measuring tactile sensation in other areas by Dellon et al.28 and in the present study.29 The cutaneous thresholds of static and moving pressure sensation were assessed and the data were similar, showing differences not statistically significant in all four areas of the skin tested, for both tests (static and moving). Likewise, other modalities of sensation (pain, thermal, and vibratory) remained present, so no evidence of sensation loss was noted comparing the preoperative examination with the postoperative examination. We believe that the cutaneous sensibility of the IPAP flap in perineal reconstructions after APER is maintained because its source of innervation, given by branches from the pudendal nerve and the posterior femoral cutaneous nerve, can be preserved. Nerve injuries, if they occur, are likely to achieve full recovery (nerve injuries grades I and II). Branches from the pudendal nerve can be preserved along with the internal pudendal vessels that vascularize
the IPAP flap, located near the ischial tuberosity. During dissection of the flap, it is not necessary to have a direct view or to dissect the perforator vessels in most cases. Preserving the adipose tissue around the ischial tuberosity should preserve the perforator vessels of the flap, as well as the pudendal nerve branches.14,27,32 Branches from the posterior femoral cutaneous nerve can also be preserved on the path above the perineal fascia and the fascia of the gluteus maximus muscle, which are included together during the dissection of the IPAP flaps, and mobilized in advance along with the flap to closure the perineal wound.39 Thus, damage in these branches can be prevented, contributing to the maintenance of the cutaneous sensibility of the flap. Our results indicate that the cutaneous sensibility of the IPAP flap can be preserved in perineal reconstruction after APER. Maintenance of the flap sensation is important in these cases because the flap will be located in an area of
Table 2 Cutaneous tactile thresholds (g/mm2) of the static one-point test (1PS) and the moving one-point test (1PM) from the four gluteal fold areas preoperatively.
Table 3 Cutaneous tactile thresholds (g/mm2) of the static one-point test (1PS) and the moving one-point test (1PM) from the four IPAP flap areas 12 months postoperatively.
RPGF
M SD MD Min Max
RDGF
LPGF
LDGF
1PS
1PM
1PS
1PM
1PS
1PM
1PS
1PM
0.39 0.069 0.38 0.29 0.59
0.39 0.073 0.39 0.31 0.61
0.378 0.074 0.37 0.29 0.63
0.388 0.086 0.37 0.26 0.63
0.391 0.099 0.35 0.29 0.66
0.393 0.085 0.37 0.31 0.67
0.38 0.065 0.37 0.29 0.55
0.372 0.074 0.37 0.26 0.53
RPGF: right proximal gluteal fold; RDGF: right distal gluteal fold; LPGF: left proximal gluteal fold; LDGF: left distal gluteal fold; 1PS: static one-point test; 1PM: moving one-point test; M: mean; DP: standard deviation; MD: median; Min: minimum value; Max: maximum value.
RPF
M SD MD Min Max
RDF
LPF
LDF
1PS
1PM
1PS
1PM
1PS
1PM
1PS
1PM
0.416 0.071 0.40 0.33 0.63
0.406 0.059 0.39 0.33 0.57
0.406 0.093 0.37 0.31 0.69
0.414 0.077 0.41 0.29 0.66
0.428 0.1 0.39 0.31 0.66
0.406 0.071 0.39 0.31 0.57
0.413 0.091 0.39 0.31 0.63
0.409 0.086 0.39 0.31 0.57
RPF: right proximal flap; RDF: right distal flap; LPF: left proximal flap; LDF: left distal flap; 1PS: static one-point test; 1PM: moving one-point test; M: mean; DP: standard deviation; MD: median; Min: minimum value; Max: maximum value.
Please cite this article in press as: Coltro PS, et al., Evaluation of cutaneous sensibility of the internal pudendal artery perforator (IPAP) flap after perineal reconstructions, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/ j.bjps.2014.09.049
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Figure 9 Box-plot graphs for the cutaneous tactile thresholds (g/mm2) of 1PS and 1PM to the four gluteal fold areas preoperatively and the four corresponding IPAP flap areas 12 months postoperatively.
Please cite this article in press as: Coltro PS, et al., Evaluation of cutaneous sensibility of the internal pudendal artery perforator (IPAP) flap after perineal reconstructions, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/ j.bjps.2014.09.049
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Cutaneous sensibility of the IPAP flap support during the act of sitting. As an instrument of protective sensation, it collaborates other benefits in cases where the flap is used for simultaneous reconstruction of vulva and vagina.14,40 This study represents the first evaluation of the cutaneous sensibility of the IPAP flap in perineal reconstruction after APER, the first comparing the cutaneous sensibility of the flap skin postoperatively with the donor area preoperatively and the first that uses the PSSD as a method of analysis of cutaneous static and moving pressure thresholds. Thus, the documentation and assessment of cutaneous sensibility have been consolidated as important tools for scientific studies, for generation of clinical and surgical expertise and patient follow-up postoperatively.
Conclusion The cutaneous tactile thresholds measured with the PSSD on the IPAP flap 12 months after perineal reconstruction were similar to those measured on its donor area, the gluteal fold, preoperatively, with differences not statistically significant, as well as no losses noted in pain, thermal, and vibration sensibility. Therefore, we can expect maintenance of cutaneous sensibility on the perineum using the IPAP flap in reconstruction after APER.
Funding None.
Conflict of interest None.
References 1. Niranjan NS. Perforator flaps for perineal reconstructions. Semin Plast Surg 2006;20:133e43. 2. Miles WE. A method of performing abdominoperineal excision for carcinoma of the rectum and of the terminal portion of the pelvic colon. Lancet 1908;2:1812e3. 3. Rothenberger DA, Wong WD. Abdominoperineal resection for adenocarcinoma of the low rectum. World J Surg 1992;16: 478e85. 4. Chessin DB, Hartley J, Cohen AM, et al. Rectus flap reconstruction decreases perineal wound complications after pelvic chemoradiation and surgery: a cohort study. Ann Surg Oncol 2005;12:104e10. 5. Campos FG, Habr-Gama A, Nahas SC, Perez RO. Abdominoperineal excision: evolution of a centenary operation. Dis Colon Rectum 2012;55:844e53. 6. Bullard KM, Trudel JL, Baxter NN, Rothenberger DA. Primary perineal wound closure after preoperative radiotherapy and abdominoperineal resection has a high incidence of wound failure. Dis Colon Rectum 2005;48:438e43. 7. Butler CE, Rodriguez-Bigas MA. Pelvic reconstruction after abdominoperineal resection: is it worthwhile? Ann Surg Oncol 2005;12:91e4. 8. Butler CE, Gu ¨ndeslioglu AO, Rodriguez-Bigas MA. Outcomes of immediate vertical rectus abdominis myocutaneous flap reconstruction for irradiated abdominoperineal resection defects. J Am Coll Surg 2008;206:694e703.
9 9. Lefevre JH, Parc Y, Kerne ´is S, et al. Abdomino-perineal resection for anal cancer: impact of a vertical rectus abdominis myocutaneous flap on survival, recurrence, morbidity, and wound healing. Ann Surg 2009;250:707e11. 10. Sunesen KG, Buntzen S, Tei T, Lindegaard JC, Nørgaard M, Laurberg S. Perineal healing and survival after anal cancer salvage surgery: 10-year experience with primary perineal reconstruction using the vertical rectus abdominis myocutaneous (VRAM) flap. Ann Surg Oncol 2009;16:68e77. 11. Barker T, Branagan G, Wright E, Crick A, McGuiness C, Chave H. Vertical rectus abdominis myocutaneous flap reconstruction of the perineal defect after abdominoperineal excision is associated with low morbidity. Colorectal Dis 2013;15:1177e83. 12. Winterton RI, Lambe GF, Ekwobi C, et al. Gluteal fold flaps for perineal reconstruction. J Plast Reconstr Aesthet Surg 2013; 66:397e405. 13. Petrie N, Branagan G, McGuiness C, McGee S, Fuller C, Chave H. Reconstruction of the perineum following anorectal cancer excision. Int J Colorectal Dis 2009;24:97e104. 14. Hashimoto I, Nakanishi H, Nagae H, Harada H, Sedo H. The gluteal-fold flap for vulvar and buttock reconstruction: anatomic study and adjustment of flap volume. Plast Reconstr Surg 2001;108:1998e2005. 15. Crosby MA, Hanasono MM, Feng L, Butler CE. Outcomes of partial vaginal reconstruction with pedicled flaps following oncologic resection. Plast Reconstr Surg 2011;127:663e9. 16. Pantelides NM, Davies RJ, Fearnhead NS, Malata CM. The gluteal fold flap: a versatile option for perineal reconstruction following anorectal cancer resection. J Plast Reconstr Aesthet Surg 2013;66:812e20. 17. Hagerty RC, Vaughn TR, Lutz MH. The perineal artery axial flap in reconstruction of the vagina. Plast Reconstr Surg 1988; 82(2):344e5. 18. Giraldo F. Cutaneous neovaginoplasty using the Ma ´laga flap (vulvoperineal fasciocutaneous flap): a 12-year follow-up. Plast Reconstr Surg 2003;111:1249e56. 19. Wee JT, Joseph VT. A new technique of vaginal reconstruction using neurovascular pudendal-thigh flaps: a preliminary report. Plast Reconstr Surg 1989;83:701e9. 20. Woods JE, Alter G, Meland B, Podratz K. Experience with vaginal reconstruction utilizing the modified Singapore flap. Plast Reconstr Surg 1992;90:270e4. 21. Yii NW, Niranjan NS. Lotus petal flaps in vulvo-vaginal reconstruction. Br J Plast Surg 1996;49:547e54. 22. Warrier SK, Kimble FW, Blomfield P. Refinements in the lotus petal flap repair of the vulvo-perineum. ANZ J Surg 2004;74: 684e8. 23. Lee PK, Choi MS, Ahn ST, Oh DY, Rhie JW, Han KT. Gluteal fold V-Y advancement flap for vulvar and vaginal reconstruction: a new flap. Plast Reconstr Surg 2006;118:401e6. 24. Ragoowansi R, Yii N, Niranjan N. Immediate vulvar and vaginal reconstruction using the gluteal-fold flap: long-term results. Br J Plast Surg 2004;57:406e10. 25. Sinna R, Qassemyar Q, Benhaim T, et al. Perforator flaps: a new option in perineal reconstruction. J Plast Reconstr Aesthet Surg 2010;63:e766e74. 26. Abood A, Niranjan NS. Perineal reconstruction: from lotus petal to “canopy”. An alternative to the standard surgical algorithm. J Plast Reconstr Aesthet Surg 2014;67:738e9. 27. Hashimoto I, Abe Y, Nakanishi H. The internal pudendal artery perforator flap: free-style pedicle perforator flaps for vulva, vagina, and buttock reconstruction. Plast Reconstr Surg 2014; 133:924e33. 28. Dellon AL. Invited discussion: sensibility of the breast following reduction mammaplasty. Ann Plast Surg 2003;51:6e9. 29. Coltro PS, Alves HR, Gallafrio ST, Busnardo FF, Ferreira MC. Sensibility of the ear after otoplasty. Ann Plast Surg 2012;68: 120e4.
Please cite this article in press as: Coltro PS, et al., Evaluation of cutaneous sensibility of the internal pudendal artery perforator (IPAP) flap after perineal reconstructions, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/ j.bjps.2014.09.049
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10 30. Lazzaro L, Guarneri GF, Rampino Cordaro E, et al. Vulvar reconstruction using a “V-Y” fascio-cutaneous gluteal flap: a valid reconstructive alternative in post-oncological loss of substance. Arch Gynecol Obstet 2010;282:521e7. 31. John HE, Jessop ZM, Di Candia M, Simcock J, Durrani AJ, Malata CM. An algorithmic approach to perineal reconstruction after cancer resection e experience from two international centers. Ann Plast Surg 2013;71:96e102. 32. Hashimoto I, Murakami G, Nakanishi H, et al. First cutaneous branch of the internal pudendal artery: an anatomical basis for the so-called gluteal fold flap. Okajimas Folia Anat Jpn 2001; 78:23e30. 33. Salgarello M, Farallo E, Barone-Adesi L, et al. Flap algorithm in vulvar reconstruction after radical, extensive vulvectomy. Ann Plast Surg 2005;54:184e90. 34. Lee JH, Shin JW, Kim SW, et al. Modified gluteal fold V-Y advancement flap for vulvovaginal reconstruction. Ann Plast Surg 2013;71:571e4. 35. Benedetti Panici P, Di Donato V, Bracchi C, et al. Modified gluteal fold advancement V-Y flap for vulvar reconstruction
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after surgery for vulvar malignancies. Gynecol Oncol 2014;132: 125e9. Moszkowicz D, Alsaid B, Bessede T, et al. Where does pelvic injury occur during rectal surgery for cancer? Colorectal Dis 2011;13:1326e34. Stelzner S, Holm T, Moran BJ, et al. Deep pelvic anatomy revisited for a description of crucial steps in extralevator abdominoperineal excision for rectal cancer. Dis Colon Rectum 2011;54:947e57. Ac ¸ar HI, Kuzu MA. Perineal and pelvic anatomy of extralevator abdominoperineal excision for rectal cancer: cadaveric dissection. Dis Colon Rectum 2011;54:1179e83. Tubbs RS, Miller J, Loukas M, Shoja MM, Shokouhi G, CohenGadol AA. Surgical and anatomical landmarks for the perineal branch of the posterior femoral cutaneous nerve: implications in perineal pain syndromes. Laboratory investigation. J Neurosurg 2009;111:332e5. Moschella F, Cordova A. Innervated island flaps in morphofunctional vulvar reconstruction. Plast Reconstr Surg 2000; 105:1649e57.
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Journal of Plastic, Reconstructive & Aesthetic Surgery (2014) xx, 1e10
Evaluation of cutaneous sensibility of the internal pudendal artery perforator (IPAP) flap after perineal reconstructions ´bio F. Busnardo a, Pedro S. Coltro a,*, Marcus C. Ferreira b, Fa Marcelo V. Olivan a, Thiago Ueda b, Victor A. Grillo b, ´rgio C. Nahas c, Carlos F. Marques c, Caio S. Nahas c, Se Rolf Gemperli b a Institute of Cancer of the State of Sa˜o Paulo, Division of Plastic Surgery, University of Sa˜o Paulo School of Medicine, Sa˜o Paulo, Brazil b Division of Plastic Surgery, University of Sa˜o Paulo School of Medicine, Sa˜o Paulo, Brazil c Institute of Cancer of the State of Sa˜o Paulo, Division of Gastroenterology Surgery and Coloproctology, University of Sa˜o Paulo School of Medicine, Sa˜o Paulo, Brazil
Received 28 July 2014; accepted 25 September 2014
KEYWORDS Sensory thresholds; Perforator flap; Reconstruction; Perineum; Rectal neoplasms; Anus neoplasms
Summary 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.
* Corresponding author. Alameda Jauaperi 943 Apto 172, Indiano ´polis, Sa ˜o Paulo 04523-014, Brazil. Tel.: þ55 (11) 99190 5832; fax: þ55 (11) 2661 6636. E-mail address: [email protected] (P.S. Coltro). http://dx.doi.org/10.1016/j.bjps.2014.09.049 1748-6815/ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Coltro PS, et al., Evaluation of cutaneous sensibility of the internal pudendal artery perforator (IPAP) flap after perineal reconstructions, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/ j.bjps.2014.09.049
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P.S. Coltro et al. 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. ª 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Introduction The treatment of anorectal and vulvovaginal malignancies requires resection resulting in extensive perineal defects, whose reconstruction is a challenge.1 In some lower rectum tumors and in persistent or recurrent anal tumors after chemoradiotherapy, abdominoperineal excision of rectum (APER) remains an essential component of the treatment.2e5 Perineal defects after APER benefit from flap reconstruction.4,6e11 The need for reconstruction is particularly important in the pelvic and perineal regions. The pelvis has a peculiar anatomic conformation in which its sidewalls are limited by bone structures that are not capable of collapsing to fill defects resulting from the surgical resections. Furthermore, most of this area is located outside the peritoneal cavity and hence does not have the peritoneal absorptive superfice.12 Perineal reconstruction using flaps is associated with lower rates of wound dehiscence,13 and it allows the repair of the vulva and vagina if needed.14,15 Other benefits include the use of a well-vascularized tissue, located outside the radiation field.12,16 Flaps supplied by branches from the internal pudendal artery are used for vulvovaginal and perineal reconstruction, as perineal flaps,17,18 pudendal flaps,19,20 lotus petal flaps,21,22 and its variants, such as the gluteal fold flaps.23,24 These flaps have names, shapes, and different patterns of mobility, but all of them have the same source of vascular supply, branches from the internal pudendal artery. Therefore, they are together called internal pudendal artery perforator (IPAP) flaps.25,26
Figure 1
Demarcation of the IPAP flap of rotation.
The IPAP flap is planned on the perineal and gluteal fold area, vascularized by direct cutaneous perforator branches from the internal pudendal artery and vein, and innervated by branches of the pudendal nerve and the femoral posterior cutaneous nerve.14,19 The IPAP flap can be dissected and mobilized through uni- or bi-lateral rotation (Figure 1), uni- or bi-lateral VY advancement (Figure 2), or combined flaps.1,12 Recent studies demonstrate that the IPAP flap can be used for perineal reconstruction after APER with some advantages when compared with primary closure of the defect or to other flaps; it is considered a reliable and versatile option for closure of the perineal wound.12,16,27 Sensation receptors on the skin are able to perceive and distinguish four modalities of sensibility: tactile (pressure), pain, thermal, and vibration. The analysis of cutaneous sensibility is complete if all these modalities are studied. The assessment and measurement of the skin sensibility can be performed through a number of neurosensory tests, based on the knowledge about the type of skin innervation.28 Temporary or permanent changes to the skin sensibility may occur after several procedures in plastic surgery, in particular when there is cutaneous dissection or movement of tissues, such as flaps used in reconstructive surgeries.29 So far, data related to assessment of the cutaneous sensibility of IPAP flaps are scarce, discrepant, and subject to methodological criticism.23,24,30 We could not find any study of the cutaneous sensibility of the IPAP flap after APER and perineal reconstruction; in addition, no comparative study of this flap sensibility, preand post-operatively, was found.
Figure 2
Demarcation of the IPAP flap of VY advancement.
Please cite this article in press as: Coltro PS, et al., Evaluation of cutaneous sensibility of the internal pudendal artery perforator (IPAP) flap after perineal reconstructions, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/ j.bjps.2014.09.049
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Cutaneous sensibility of the IPAP flap
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The purpose of this study was to assess the cutaneous sensibility of the IPAP flap 12 months after perineal reconstruction in APER, and compare it with the cutaneous sensibility of the gluteal fold (flap donor area) preoperatively.
Patients and methods This prospective study was conducted at the Institute of Cancer of the State of Sa ˜o Paulo, University of Sa ˜o Paulo School of Medicine, Brazil, from 2012 to 2014, and it received approval from our institutional review board. None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript. We included 25 patients with lower rectum or anal malignancies that would be submitted to APER, followed by immediate perineal reconstruction with bilateral VY advancement IPAP flap, which was indicated for patients with perineal defect from 20 to 60 cm2, considered moderated in size.31 Eleven patients were male and 14 female, aged 31e77 years, mean 59 years, and median 60 years. The diagnosis was lower rectum adenocarcinoma in 20 patients and anal squamous cell carcinoma in five patients (Table 1). Preoperative chemotherapy and radiotherapy were performed in all 25 patients.
Table 1
Evaluation of cutaneous sensibility of the gluteal fold The same examiner tested two types of tactile sensibility, and also the pain, thermal, and vibration sensibility on the gluteal fold, preoperatively, as the long axis of the IPAP flap would be marked on the gluteal fold. Pressure Specified Sensory Device (PSSD) was used in the study of tactile sensibility. The device consists of a force transducer coupled to a computer, with a software able to encode an electrical signal into pressure (in g/mm2). The examination consisted of a touch with the metal rod of the transducer on the skin over the gluteal fold (Figure 3). The patient held a bell and was instructed to press it just as he/ she felt the touch of the metal rod. Thus, the software recorded the perceived value of pressure at the time the bell was triggered by the patient. The test was repeated five times in each area and the mean obtained corresponded to the cutaneous pressure threshold of this area. The gluteal fold was tested in four areas (Figure 4):
right proximal gluteal fold (RPGF), right distal gluteal fold (RDGF), left proximal gluteal fold (LPGF), and left distal gluteal fold (LDGF).
Patient characteristics, surgeries performed, flap characteristics, and evolution of patients.
Patient
Age/Sex
Diagnosis
Surgeries
Defect size (cm2)
Flap size (cm)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
47/M 55/F 60/M 47/F 63/M 46/F 75/F 64/F 76/M 77/M 60/F 51/M 60/F 31/M 72/F 49/F 73/M 55/M 66/F 59/M 52/F 59/F 69/M 54/F 34/F
LRAC ASCC LRAC LRAC ASCC ASCC LRAC LRAC LRAC LRAC LRAC LRAC LRAC LRAC LRAC ASCC LRAC LRAC LRAC LRAC LRAC LRAC LRAC ASCC LRAC
APER þ RP þ PH APER þ HYS þ EVPW APER APER þ EVPW APER þ PE APER APER þ EVPW APER þ EVPW APER APER APER APER APER þ PH þ EVPW AAPR þ HEP APER þ PE APER þ PE APER APER þ PE APER APER þ PE APER APER APER APER þ EVPW APER
48 54 35 54 42 32 54 48 45 50 40 48 60 48 54 60 32 48 36 48 32 35 40 54 48
12 14 12 13 12 13 12 15 12 13 14 12 13 13 12 15 12 13 12 13 12 15 13 14 16
8 9 7 9 7 8 9 8 9 10 10 8 10 8 9 10 8 8 9 8 8 9 10 9 12
Length of stay (days)
Complications
Healing time (days)
Follow-up (months)
11 40 5 6 7 7 8 30 13 20 13 5 11 9 17 11 21 18 9 13 11 7 12 30 9
PC MID e MID e MID e MID e e e MID e e e MAD PTE e e e e MPN e LI þ MID e
21 90 30 40 30 40 21 55 45 30 25 75 45 42 45 90 27 26 28 35 45 45 40 93 28
15 18 17 17 12 15 16 14 16 18 16 15 15 12 14 13 12 17 16 14 14 15 16 14 14
M: male; F: female; LRAC: lower rectum adenocarcinoma; ASCC: anal squamous cell carcinoma; APER: abdominoperineal excision of rectum; RP: radical prostatectomy; PH: partial hepatectomy; HYS: hysterectomy; EVPW: excision of vaginal posterior wall; PE: pelvic exenteration; PC: pelvic collection; MID: minor dehiscence, MAD: major dehiscence; PTE: pulmonary thromboembolism; MPN: minor partial necrosis; LI: local infection.
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Figure 3 (Above, left) Tactile sensibility test using the PSSD. (Above, right) Pain sensibility test using needle. (Below, left) Thermal sensibility test using hot/cold contact. (Below, right) Vibration sensibility test using 128-Hz tuning fork.
In order to assess tactile sensibility, two types of tests were performed on each of these four areas: Static one-point test (1PS): This test was conducted by the simple touch of the transducer on the skin and used to evaluate the slowly adapting sensory fibers; it provides data from cutaneous sensory thresholds to static pressure. Moving one-point test (1PM): This test was conducted by moving the transducer touching the skin and used to evaluate the quickly adapting sensory fibers; it provides data from cutaneous sensory thresholds to motion pressure. Evaluation of other methods of sensibility was also tested in the same areas tested earlier (RPGF, RDGF, LPGF,
and LDGF), using the “forced-choice” method. For this, the patient was asked to detect the presence or absence of sensation for pain and vibration tests, and the type of sensation (hot or cold) for the thermal sensibility test. Each test was repeated five times in each of the four areas evaluated, considering a combination of at least four correct answers as positive. The pain sensibility was tested with a superficial touch using a 30 0.7 mm needle, applying a slight pressure on the skin surface without perforating it, just to trigger the pain stimulus (Figure 3). The thermal sensibility analysis was performed by skin contact with a plastic tube containing water at 45e50 C, perceived as hot, or 10e15 C, perceived as cold (Figure 3). The vibration sensibility was tested by a touch perpendicular to the skin using a tuning fork vibrating at 128 Hz for 5 s (Figure 3).
Surgical procedure
Figure 4 Areas of the gluteal fold where cutaneous sensibility tests were performed preoperatively.
Immediately after APER, with the patient kept in the lithotomy position (Figure 5), the plastic surgery team proceeded with the perineal reconstruction. The gluteal fold had been identified prior to the surgery and demarcated bilaterally with the patient standing. The long axis of the IPAP flap was centered on the gluteal fold and the flap dimensions were adjusted according to the size of the defect and the need for associated reconstruction of the posterior vaginal wall. The base of the flap was located in a triangle formed by the ischial tuberosity, anus, and vaginal introitus or scrotum.14,27 Perforator vessels from the internal pudendal artery are located within this triangle, along with the branches from the pudendal nerve (Figure 6). The IPAP flap was dissected in the plane between the fascia and the gluteus maximus muscle, starting from the
Please cite this article in press as: Coltro PS, et al., Evaluation of cutaneous sensibility of the internal pudendal artery perforator (IPAP) flap after perineal reconstructions, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/ j.bjps.2014.09.049
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Figure 5 (Above, left) A 55-year-old man underwent APER and pelvic exenteration, showing the perineal defect in the lithotomy position. (Above, right) Reconstruction with bilateral VY advancement IPAP flaps. (Below, left) IPAP flaps dissected and mobilized to fill the perineal defect. (Below, right) Primary closure of the donor area.
distal to proximal direction (Figure 5). The fascia was included with the flap to preserve the branches from the posterior femoral cutaneous nerve, which runs through a supra-fascial path. The IPAP flap was mobilized in bilateral VY advancement for perineal reconstruction (Figure 5). The proximal portions of the flaps were denuded and introduced to fill the perineal defect. When necessary, the upper proximal portions of the flap were maintained with skin and used for reconstruction of the vulva and the posterior vaginal wall, and the rest was denuded to fill the perineal defect. The donor area was closed primarily (Figure 5). Postoperatively, patients were maintained with the legs adducted, ambulation was released after 5 days, and they were allowed to sit after 14 days.
Assessment of the cutaneous sensibility on the IPAP flap Evaluation of the four modes of cutaneous sensibility was again performed 12 months after surgery, now on the skin of the IPAP flap. Examination of tactile sensibility was performed using the PSSD and other modalities of sensation (pain, thermal, and vibration) were analyzed by the “forced-choice” method, similar to the method used preoperatively. The flap regions that were tested (Figure 7) corresponded to the gluteal fold areas previously tested:
right proximal flap (RPF), right distal flap (RDF), left proximal flap (LPF), and left distal flap (LDF).
Variables were described and statistical tests were calculated using GraphPad Prism, Prism 6 for Mac OS X (GraphPad Software, Inc. e version 6.0e). Values <0.05 were considered significant.
Results Reconstructive procedure The 25 patients of the study underwent APER and reconstruction was performed with the bilateral VY advancement IPAP flap, totaling 50 flaps (Figure 8). All patients had moderated defects (20e60 cm2); the mean defect was 45.8 cm2, median 48 cm2, and range 32e60 cm2 (Table 1). As for the evolution of the flaps, 49 of them showed good result and no signs of ischemia, congestion, or necrosis, but a small and partial distal necrosis appeared in one flap. Other minor complications occurred in 10 patients (Table 1), with a complication rate of 40%. The mean length of hospital stay was 13.7 days, a median of 11 days, ranging from 5 to 40 days. The mean time for healing was 43.6 days, median 40 days, ranging from 21 to 93 days. The mean time of postoperative follow-up was 15 months, median 15 months, ranging from 12 to 18 months (Table 1). During the postoperative follow-up, five deaths occurred, all of them 12 months after surgery, after completion of the sensibility tests.
Cutaneous sensibility Cutaneous tactile thresholds to the static (1PS) and moving (1PM) one-point tests for the gluteal fold preoperatively and for the IPAP flap 12 months after surgery are shown, respectively, in Tables 2 and 3, and in Figure 9.
Please cite this article in press as: Coltro PS, et al., Evaluation of cutaneous sensibility of the internal pudendal artery perforator (IPAP) flap after perineal reconstructions, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/ j.bjps.2014.09.049
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Figure 6 Triangle of reference for location of perforator vessels (blue).
On the four flap areas studied (RPF, RDF, LPF, and LDF), the mean and median tactile thresholds were similar to those found on the corresponding areas of the gluteal fold (RPGF, RDGF, LPGF, and LDGF) preoperatively. Statistical tests to compare these thresholds showed differences not statistically significant for the four areas studied, in both tests (1PS and 1PM), with values >0.05 (Figure 9). Therefore, we consider that the tactile sensibility of the IPAP flap 12 months postoperatively was similar to that of its donor area (gluteal fold). As the pain, thermal, and vibratory sensibility from the gluteal fold preoperatively and the IPAP flap 12 months postoperatively, all patients present these three modalities of perception in all four areas studied. Therefore, the same way as in tactile sensibility, we consider that the pain, thermal, and vibratory sensibility of the IPAP flap was similar to that of the gluteal fold.
Discussion Since the late 1980s, flaps supplied by branches from the internal pudendal artery have been described for vulvovaginal and perineal reconstruction.17e24 As perforator flaps, they do not have some of the disadvantages of myocutaneous flaps; anatomical vascular studies conducted on such flaps contributed to the spread of their indications.14,27,32 IPAP flaps are thinner and easier to dissect, and have similar skin; therefore, they are widely used for the reconstruction of vulvar and vaginal defects.22,30,33e35 Recent case reports and case series using IPAP flaps after excision of anorectal neoplasms indicate that this flap can be considered a reliable and versatile option for perineal reconstruction.12,16,27 In this study, we examined immediate IPAP flap results only in cases of perineal reconstructions in which APER defects were moderated in size (20e60 cm2), representing the vast majority of our patients. The multiple benefits with IPAP flaps were also observed in this series, reinforcing the idea that this flap is a good option for perineal reconstruction after APER. In our service, the IPAP flap is the main option for reconstruction of moderated perineal defects and for some of the most extensive ones. For the other larger defects, we used the vertical rectus abdominis myocutaneous (VRAM) flap.
P.S. Coltro et al. In order to avoid urinary or sexual dysfunction after APER, step perineal resection is performed, whenever possible, preserving the pelvic splanchnic nerves, the superior and inferior hypogastric plexus, the pudendal nerves, and its terminal branches. Pudendal nerve injury can lead to urinary incontinence and impotence, and it is directly related to the extension of the pelvic dissection.36 During the perineal step of APER, branches from the pudendal nerve may be injured due to difficulty of clearly identifying them during anterior and lateral dissection. However, this nerve damage could be avoided in most patients by identifying anatomical landmarks and the recognition and preservation of these nerves.37 Studies on cadavers about APER steps also demonstrated that the branches from the pudendal nerve are at a risk of inadvertent injury, especially in the anterior surgical resection plane. Perineal branches from the pudendal nerve run along a path near the rectum and the anterior plane of resection, along with the perineal branches from the internal pudendal vessels. To avoid injury to these neurovascular structures, it is important to recognize some anatomic landmarks. As the perineal branches from the pudendal nerve run behind the superficial transverse perineal muscles and the perineal body, the preservation of these structures work together to protect these nerves.37,38 Only few studies have analyzed the cutaneous sensibility of the IPAP flap based on sensorial tests.23,24,30 However, in none of these studies, the tests were performed comparing the postoperative with the preoperative sensibility and some data about the methodology of the sensory tests were lacking. In addition, the methods used to study cutaneous tactile sensibility (the superficial contact and the slight touch) could be considered, nowadays, underrepresentative. According to these studies,23,24,30 the evaluation of the cutaneous sensibility of the IPAP flap was discrepant and subject to methodological criticism. Moreover, they were only related to the use of IPAP flaps for vulvovaginal reconstructions. In our study, we determined the cutaneous sensibility of the IPAP flap 12 months after perineal reconstruction and compared it with the preoperative cutaneous sensibility of the gluteal fold. More importantly, we used more precise
Figure 7 Areas of the IPAP flap where cutaneous sensibility tests were performed on 12 months postoperatively.
Please cite this article in press as: Coltro PS, et al., Evaluation of cutaneous sensibility of the internal pudendal artery perforator (IPAP) flap after perineal reconstructions, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/ j.bjps.2014.09.049
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Figure 8 (Above, left) A 64-year-old woman underwent APER and excision of vaginal posterior wall, showing the perineal and vulvovaginal defect. (Above, center) Bilateral VY advancement IPAP flaps dissected and mobilized. (Above, right) Medial upper portions of flaps remained with skin to reconstruct the posterior vaginal wall (yellow arrow) and medial inner portions of flaps denuded to fill the perineal defect (green arrow). (Below, left) Immediate postoperative, showing primary closure of the flap donor area. (Below, center) 12 months postoperatively in the lithotomy position. (Below, right) 12 months postoperatively in the standing position, with good scar camouflage at the gluteal fold.
tests for sensibility, the PSSD, extensively used for measuring tactile sensation in other areas by Dellon et al.28 and in the present study.29 The cutaneous thresholds of static and moving pressure sensation were assessed and the data were similar, showing differences not statistically significant in all four areas of the skin tested, for both tests (static and moving). Likewise, other modalities of sensation (pain, thermal, and vibratory) remained present, so no evidence of sensation loss was noted comparing the preoperative examination with the postoperative examination. We believe that the cutaneous sensibility of the IPAP flap in perineal reconstructions after APER is maintained because its source of innervation, given by branches from the pudendal nerve and the posterior femoral cutaneous nerve, can be preserved. Nerve injuries, if they occur, are likely to achieve full recovery (nerve injuries grades I and II). Branches from the pudendal nerve can be preserved along with the internal pudendal vessels that vascularize
the IPAP flap, located near the ischial tuberosity. During dissection of the flap, it is not necessary to have a direct view or to dissect the perforator vessels in most cases. Preserving the adipose tissue around the ischial tuberosity should preserve the perforator vessels of the flap, as well as the pudendal nerve branches.14,27,32 Branches from the posterior femoral cutaneous nerve can also be preserved on the path above the perineal fascia and the fascia of the gluteus maximus muscle, which are included together during the dissection of the IPAP flaps, and mobilized in advance along with the flap to closure the perineal wound.39 Thus, damage in these branches can be prevented, contributing to the maintenance of the cutaneous sensibility of the flap. Our results indicate that the cutaneous sensibility of the IPAP flap can be preserved in perineal reconstruction after APER. Maintenance of the flap sensation is important in these cases because the flap will be located in an area of
Table 2 Cutaneous tactile thresholds (g/mm2) of the static one-point test (1PS) and the moving one-point test (1PM) from the four gluteal fold areas preoperatively.
Table 3 Cutaneous tactile thresholds (g/mm2) of the static one-point test (1PS) and the moving one-point test (1PM) from the four IPAP flap areas 12 months postoperatively.
RPGF
M SD MD Min Max
RDGF
LPGF
LDGF
1PS
1PM
1PS
1PM
1PS
1PM
1PS
1PM
0.39 0.069 0.38 0.29 0.59
0.39 0.073 0.39 0.31 0.61
0.378 0.074 0.37 0.29 0.63
0.388 0.086 0.37 0.26 0.63
0.391 0.099 0.35 0.29 0.66
0.393 0.085 0.37 0.31 0.67
0.38 0.065 0.37 0.29 0.55
0.372 0.074 0.37 0.26 0.53
RPGF: right proximal gluteal fold; RDGF: right distal gluteal fold; LPGF: left proximal gluteal fold; LDGF: left distal gluteal fold; 1PS: static one-point test; 1PM: moving one-point test; M: mean; DP: standard deviation; MD: median; Min: minimum value; Max: maximum value.
RPF
M SD MD Min Max
RDF
LPF
LDF
1PS
1PM
1PS
1PM
1PS
1PM
1PS
1PM
0.416 0.071 0.40 0.33 0.63
0.406 0.059 0.39 0.33 0.57
0.406 0.093 0.37 0.31 0.69
0.414 0.077 0.41 0.29 0.66
0.428 0.1 0.39 0.31 0.66
0.406 0.071 0.39 0.31 0.57
0.413 0.091 0.39 0.31 0.63
0.409 0.086 0.39 0.31 0.57
RPF: right proximal flap; RDF: right distal flap; LPF: left proximal flap; LDF: left distal flap; 1PS: static one-point test; 1PM: moving one-point test; M: mean; DP: standard deviation; MD: median; Min: minimum value; Max: maximum value.
Please cite this article in press as: Coltro PS, et al., Evaluation of cutaneous sensibility of the internal pudendal artery perforator (IPAP) flap after perineal reconstructions, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/ j.bjps.2014.09.049
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Figure 9 Box-plot graphs for the cutaneous tactile thresholds (g/mm2) of 1PS and 1PM to the four gluteal fold areas preoperatively and the four corresponding IPAP flap areas 12 months postoperatively.
Please cite this article in press as: Coltro PS, et al., Evaluation of cutaneous sensibility of the internal pudendal artery perforator (IPAP) flap after perineal reconstructions, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/ j.bjps.2014.09.049
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Cutaneous sensibility of the IPAP flap support during the act of sitting. As an instrument of protective sensation, it collaborates other benefits in cases where the flap is used for simultaneous reconstruction of vulva and vagina.14,40 This study represents the first evaluation of the cutaneous sensibility of the IPAP flap in perineal reconstruction after APER, the first comparing the cutaneous sensibility of the flap skin postoperatively with the donor area preoperatively and the first that uses the PSSD as a method of analysis of cutaneous static and moving pressure thresholds. Thus, the documentation and assessment of cutaneous sensibility have been consolidated as important tools for scientific studies, for generation of clinical and surgical expertise and patient follow-up postoperatively.
Conclusion The cutaneous tactile thresholds measured with the PSSD on the IPAP flap 12 months after perineal reconstruction were similar to those measured on its donor area, the gluteal fold, preoperatively, with differences not statistically significant, as well as no losses noted in pain, thermal, and vibration sensibility. Therefore, we can expect maintenance of cutaneous sensibility on the perineum using the IPAP flap in reconstruction after APER.
Funding None.
Conflict of interest None.
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Please cite this article in press as: Coltro PS, et al., Evaluation of cutaneous sensibility of the internal pudendal artery perforator (IPAP) flap after perineal reconstructions, Journal of Plastic, Reconstructive & Aesthetic Surgery (2014), http://dx.doi.org/10.1016/ j.bjps.2014.09.049