Perineal reconstruction using single gracilis myocutaneous flaps

Bilateral gracilis myocutaneous flaps were originally used as part of a technique for creating a neovagina following total pelvic exenteration. Based upon this experience, we began using single flaps for primary repair and closure of large surgical defects in the perineal area that require alternate tissue sources to replace lost skin, mucosa, or adjacent deep tissues. Eighteen single gracilis flaps were used for major vulvovaginal reconstructions in 17 women during the past 5 years. Women undergoing unilateral flap reconstructions included 6 with anorectal cancers and 11 with vulvovaginal tumors. Most patients were being treated for recurrence after failed primary therapy (n = 7) or were receiving multimodal treatment for advanced local disease (n = 7). All cases involved complex resections followed by simultaneous reconstruction; mean total operative time was 377 min with a mean estimated blood loss of 1010 cc. Reconstruction involved external flap placement on the vulva or perineum in 7 cases and internal placement to replace excised portions of the vagina in the other 11. Mean flap size was 6.6 × 11.4 cm. Necrosis of flap skin occurred in 3 patients; minor wound separations or flap edge necrosis was seen in 5 cases. Hospital stay averaged 18.4 days. Nine women had recurrent disease and died over 4-30 months; the remaining 8 are alive and disease free with a median follow-up of 25 months. The single gracilis flap provides a versatile method for providing anatomic reconstruction of large perineal defects in women who have undergone extensive resection.