Internal Pudendal Artery Perforator Flap for Reconstruction of Perineal Complex Wound after Trauma – Case Report

Abstract

Perineal reconstruction is a widely discussed topic in medical literature due to the major difficulties found in tumor resection in the perineal region, such as vulvovaginal and anorectal neoplasms. Although the post-traumatic perineal reconstruction is less explored, this case highlights the complexity and high mortality rates associated with perineal wounds, frequently linked to other traumas. As the pelvis represents a considerable challenge in reconstructive surgery, the approach can vary from skin grafts to major flaps depending on the extension of the wound. This case report emphasizes the importance of choosing an adequate surgical technique to guarantee the proper coverage of the defect in the affected area.

 

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Keywords

case reports - perineum - perforator flap - surgical flaps - wounds and injuries

Introduction

The literature widely discusses the perineal approach, with excellent surgical technique options, mainly due to the challenges after resecting tumors in this region, such as vulvovaginal and anorectal neoplasms. However, evidence is scarcer about perineal reconstruction secondary to perineal trauma.[1]

The low incidence of trauma with significant tissue loss in the perineal region is notorious due to the anatomical protection of the lower limbs and the low exposure to the most common trauma mechanisms. Although the epidemiology of isolated perineal traumas is not fully known, approximately 0.1% to 3.3% of traumas probably correspond to perineal injuries.[2] [3]

Due to the frequent association with other injuries, perineal trauma presents a certain complexity and has high morbidity and mortality. In addition, it may include urogenital and colorectal traumas and hemodynamic instability secondary to injury to large vessels or the pelvis.[2] The pelvis poses a challenge for reconstructive surgery, as integumentary defects in this area usually require large flaps for reconstruction and coverage.[1] [3]

Even though there is no consensus on the best form of perineal protection, the literature covers several technical alternatives, from cutaneous to extensive flaps, depending on the primary extent of the injury.[4]

In men, the indication for primary suturing or advancement flaps with residual scrotal tissue occurs when the loss of scrotal skin is lower than 50%, considering the elementary principle that the choice should ideally include the coverage of dead spaces, promote tissue mobility, and have good vascularization.[4] [5] Therefore, extensive damage requires the consideration of more complex surgeries to cover the ideal principles, since flaps for perineal reconstruction have lower dehiscence rates. In women, flaps allow for vulva and vagina repair.[6]

As such, the main options currently described for perineal reconstruction are myocutaneous flaps, such as rectus abdominis, gracilis and gluteus maximus, and fasciocutaneous flaps from perforating vessels of the gluteal and pudendal arteries.

The dissection of internal pudendal artery flaps can occur in several ways, resulting in pudendal artery flaps, gluteal fold flaps, Singapore flaps, perineal advancement flaps, and lotus petal flaps.[1] [4] [7] External pudendal artery flaps are also a good option for covering perineal lesions, especially the superomedial thigh flap, consisting of the external pudendal artery and branches of the obturator artery and the medial femoral circumflex artery.[5] [7]

 

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Case Report

A 53-year-old man sustained a perineal trauma in a fall from agricultural machinery. He suffered tissue loss, perineal injury, and extensive coverage failure, presenting with a detached wound from the pubis to the anus, including the penis, and suspected rectal trauma. ([Fig. 1]).

Fig. 1 Detaching wound involving the penis and scrotum - image immediately after initial medical care.

Initial treatment occurred in the emergency room of another institution. Due to the presence of rectal and anal sphincter injuries, the patient underwent surgery with loop colostomy and inclusion of the testicles on the medial side of both thighs by the general surgery team ([Fig. 2]).

Fig. 2 Complex perineal wound after first surgical approach with inclusion of the testicles on the medial aspect of the thighs bilaterally.

After 4 days, the plastic surgery team was asked to evaluate the surgical reconstruction of the complex perineal wound. Initially, we performed dressings and slough debridement for bed preparation.

On the 14^th day after the trauma, the patient underwent reconstruction of the perineal defect with a fasciocutaneous flap from the perforating branches of the internal pudendal artery ([Figs. 3], [4], and [5]). The testicles, previously inserted on the medial side of the thigh, were released and joined medially to simulate the appearance of the scrotum. Next, we dissected the flaps, sparing the area around the ischial tuberosity, the site of origin of most of the perforating vessels that irrigate it. In addition, we prepared a partial skin graft to cover the penis, harvested from the left thigh using an electric dermatome with 0.2-mm thickness ([Fig. 6]). We ruled out the potential use of a flap from the branches of the external pudendal artery as they could have been damaged due to the surgical procedure performed at another institution.

Fig. 3 Flap from the perforating branches of the internal pudendal artery.

Fig. 4 Flap from on the perforating branches of the internal pudendal artery.

Fig. 5 Flap from on the perforating branches of the internal pudendal artery.

Fig. 6 Immediate postoperative period of perineal lesion reconstruction with bilateral flaps from the perforating branches of the internal pudendal arteries and partial skin graft on the penis.

The patient progressed well in the first few weeks, without infectious complications. Flaps were viable, except for a small area of bilateral distal skin damage. Twenty days after surgery, we delimited the distal necrosis, and the patient underwent debridement and resuturing with approximation of the local tissues ([Fig. 7]). He is currently being followed up as an outpatient and has no complaints. The patient reports local sensitivity and preserved urinary and sexual functions, as he had before the trauma ([Fig. 8]).

Fig. 7 Postoperative period, 4 weeks after surgery.

Fig. 8 Late postoperative period, 18 months after surgery.

 

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Discussion

Despite its low incidence, perineal trauma requires a thorough and individualized approach, ideally by plastic surgeons.[8] The effective participation of Plastic Surgery in trauma centers is of great value, especially in critically ill patients who have future surgical planning, to spare the vascular pedicles for later reconstruction.

In most cases, the basis for learning about such reconstructions comes from well-established experience in pelvic oncology cases, which are more common in the daily practice of plastic surgeons.[9]

The wide range of surgical techniques allows the use of local flaps, whether cutaneous, fasciocutaneous, or myocutaneous, which have the versatility to provide superficial and deep coverage, fill dead spaces, if necessary, allow local mobility, and often preserve regional sensitivity. Thus, the choice of procedure should be based on the previous technical experience of each surgeon and the availability of vascular pedicles.

 

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Conclusion

Complex perineal wounds usually require a combination of skin grafts, local flaps, and neighboring flaps. We present a successful case of post-traumatic perineal reconstruction with partial skin graft for penile reconstruction and flaps from the perforating branches of the internal pudendal artery for reconstruction of the scrotum and perineum.

 

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Conflict of Interests

The authors have no conflict of interest to declare.

Authors' Contribution

Juliana Hernandes Seribeli: data analysis, interpretation, or both, final manuscript approval, data collection, conceptualization, study conception and design, project management, investigation, methodology, performance of surgeries, experiments, or both, writing - original draft preparation, writing - review & editing, visualization; Gabriel Garcia Schmitt: data analysis, interpretation, or both, final manuscript approval, data collection, conceptualization, study conception and design, project management, investigation, methodology, writing – original draft preparation, writing - review & editing, visualization; Jayme Adriano Farina Junior: data analysis, interpretation, or both, final manuscript approval, funding acquisition, conceptualization, study conception and design, resource management, project management, investigation, methodology, performance of surgeries, experiments, or both, writing - original draft preparation, writing - review & editing, supervision, validation, visualization; Pedro Soler Coltro: data analysis, interpretation, or both, final manuscript approval, funding acquisition, conceptualization, study conception and design, resource management, project management, investigation, methodology, performance of surgeries, experiments, or both, writing - original draft preparation, writing - review & editing, supervision, validation, visualization.

• Referências

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• 9 Coltro PS, Busnardo FF, Farina Junior JA, Gemperli R. Comments on: “Immediate vaginal and perineal reconstruction after abdominoperineal excision using the Inferior Gluteal Artery Perforator Flap (V-IGAP)”. J Plast Reconstr Aesthet Surg 2022; 75 (01) 439-488

Publication History

Received: 12 November 2024

Accepted: 24 March 2025

Article published online:
10 July 2025