Scand J Plast Reconstr Surg Hand Surg, 2009; 43: 142
147

ORIGINAL ARTICLE

V-Y fasciocutaneous flap of the medial thigh including the long

saphenous vein for reconstruction of intrapelvic dead space

TOSHIHIKO YAMAUCHI, KENSUKE KIYOKAWA, YOJIRO INOUE &

HIDEAKI RIKIMARU

Department of Plastic and Reconstructive Surgery and Maxillofacial Surgery, Kurume University School of Medicine,
Fukuoka, Japan

Abstract
Some patients develop an intrapelvic infection and fistula caused by the presence of intrapelvic dead space after the
resection of rectal cancer, and the treatment is sometimes quite difficult. We have developed a new surgical technique for the
treatment and prevention of such fistulas that uses a fasciocutaneous flap from the medial thigh. A V-shaped fasciocutaneous
flap with a pedicle on the anterior side of the thigh is designed on the medial thigh and gluteal region. After raising the
fasciocutaneous flap that contains the long saphenous vein, the gluteal section including a thick layer of fatty tissue is
de-epithelialised, and the flap is rotated and advanced towards the dead space to fill it. Four patients were operated on using
our technique. One was a secondary reconstruction: the patient had developed a small fistula after reconstructive surgery,
but it healed with conservative treatment. As a result, all four patients achieved satisfactory outcomes. The advantages of
our technique include: no change in the position of the body is required for reconstruction; operations are simple; sufficient
volume of tissue is obtained from the thick fatty tissues of the gluteal region; and the fasciocutaneous flap contains the long
saphenous vein and has good venous circulation. We consider this technique useful for the reconstruction of intrapelvic
dead space.

Key Words: Intrapelvic dead space, reconstruction, V-Y fasciocutaneous flap, long saphenous vein

Introduction the patient is placed in this position before the start

After resection of rectal cancer, the intrapelvic dead
space sometimes induces intrapelvic infection and
fistulas. If a fistula forms, treatment becomes
difficult and also impairs the patient’s quality of life
(QOL). Various flaps have been prepared to fill the
dead space and prevent or treat fistulas. We have
developed a unilateral or bilateral fasciocutaneous
flap from the medial thigh that includes the long
saphenous vein, and used it on four patients. Clinical
results were good.
Operative technique
The patient is laid supine on the operating table
with a pillow under the hip. This creates a space
under the gluteal region. In primary reconstruction,
of resection of the tumour to allow immediate
reconstruction.
The first step of reconstruction is the design of a
large unilateral, or bilateral, V-shaped fasciocu-
taneous flap that ranges from the medial thigh to
the gluteal region, with a pedicle on the anterior side
of the body. After the incision has been made, the
flap is raised with the subfascial layer together with
the long saphenous vein. The gluteal section that will
fill the intrapelvic dead space is de-epithelialised.
This area has thick, subcutaneous fatty tissues and
sufficient volume of tissue (Figure 1a). If the volume
of de-epithelialised tissue is inadequate and a dead
space remains at the back of pubic bone, a gracilis
muscle flap can be raised from the same operative
angle and used to fill this space (Figure 1b). The

Correspondence: Kensuke Kiyokawa, MD, PhD, Department of Plastic and Reconstructive Surgery and Maxillofacial Surgery, Kurume University School of
Medicine, 67 Asahi-machi, Kurume-shi, Fukuoka, 830-0011, Japan. Tel: 81-942-31-7569. Fax: 81-942-34-0834. E-mail: prsmf@med.kurume-u.ac.jp

(Accepted 26 November 2008)

ISSN 0284-4311 print/ISSN 1651-2073 online # 2009 Informa UK Ltd. (Informa Healthcare, Taylor & Francis As)
DOI: 10.1080/02844310902771657

fasciocutaneous flap is then slightly rotated and
advanced towards the dead space. The donor site
of the flap is sutured in the same manner as the
preparation of a V-Y advancement flap (Figure 1c).
After the dead space has been filled, two or three
drains are left in the filled space, the donor sites of
the fasciocutaneous flap, and that of the gracilis
muscle flap.
Patients and Results
From March 1991 to April 2001 four patients had
their intrapelvic dead space reconstructed after
excision of rectal cancer using our technique. The
patients, three men and one woman, were aged
between 39 and 68 years. Three had had primary
reconstruction after abdominoperineal resection of
the rectum and extended perianal skin resection, and
the other case was secondary closure of a fistula that
Table I. Summary of surgical treatment and outcome of the four patients.
Case No. Age (years) Sex Reconstruction
1 68 M Primary
2 62 F Primary
3 51 M Primary
4 39 M Secondary
Reconstruction of intrapelvic dead space 143
Figure 1. (a) Design of the fasciocutaneous flap. (b) Raising of the
fasciocutaneous flap. (c) Postoperatively.
developed after total pelvic exenteration, which had
been done for recurrent rectal cancer (Table I).
The three patients having primary reconstruction
were cured without complications, and there was no
scar contracture on the thigh and gluteal regions. In
the case of secondary closure, a portion of the suture
on the thigh opened and a small fistula developed in
the filled area, but the wound healed after about two
months with maintenance treatment and split-thick-
ness skin grafting.
Two representative cases
Case 3 (Table I). A 51-year-old man had a rectal
cancer that invaded the anal area and created an
abscess. He had an abdominoperineal resection of
the rectum and simultaneous resection of the skin
around the anus (about 10 cm in diameter). Bilateral
fasciocutaneous flaps were designed on the medial
Surgical treatment Complication
Abdominoperineal resection of rectumremoval None
of anal skin
Abdominoperineal resection of rectumremoval None
of anal skin
Abdominoperineal resection of rectumremoval None
of anal skin
Fistula after total pelvic exenteration Small fistula, opening of
wound on the thigh
144 T. Yamauchi et al.
side of the thighs (Figure 2a) and raised with the
long saphenous vein. Bilateral gracilis flaps were then
raised (Figure 2b), and were placed into the back of
the pubic bone. The gluteal areas of the fasciocu-
taneous flaps, which have thick fatty tissues, were de-
epithelialised (Figure 2c), rotated and advanced, and
closed with sutures in a way that would fill the dead
space (Figure 2d). The wound healed without
complications. The scar did not contract and there
were no related problems (Figure 2e).
Case 4 (Table I). A 39-year-old man had an abdo-
minoperineal resection of the rectum two years ago
for rectal cancer. One year later, he had total pelvic
exenteration for local recurrence; he then developed
inflammation of the pelvic dead space, for which he
Figure 2. A 51-year-old male patient. (a) Preoperatively. The
defect after abdominoperineal resection of the rectum and
simultaneous resection of the skin around the anus, and the
design of the fasciocutaneous flaps. (b) The flaps were raised with
the gracilis flaps. (c) The flaps were de-epithelialised. (d)
Immediately after the operation. (e) Three months postoper-
atively.
was treated by retraction and debridement. He was
referred to us to have the dead space filled. On
examination, there was a fist-sized space in the
perineal region (Figure 3a). The space was filled
using the flap that we designed (Figure 3b, c).
Postoperatively he developed a small fistula. It was
retracted, and after waiting for thickening of the flesh,
we applied split-thickness skin grafts two months
after the reconstruction. The lesion then healed.
Contracture of the gluteal region was released, and
he had good functional improvement.
Discussion
Inflammation of the pelvic dead space after resection
of rectal cancer is quite common. Maintenance
treatment of fistulas lead to gradual growth of tissue,
 Reconstruction of intrapelvic dead space 145

Figure 3. A 39-year-old male patient. (a) A fistula developed as a result of inflammation in the intrapelvic dead space after
abdominoperineal resection of the rectum. (b) The design of the flap. (c) Immediately postoperatively.

but complete cure is rarely achieved. Even when
complete cure is achieved, it is only after a long
period of treatment during which the QOL of the
patient is affected because of difficulty in sitting on a
chair because of contracture of the gluteal region. To
prevent inflammation of the pelvic dead space, it is
important to fill that space. Examples of fillers are a
gracilis muscle flap [1,2], a rectus abdominis
myocutaneous flap [3
6], an omental flap, an antero-
lateral thigh flap [7], and a free latissimus dorsi
myocutaneous flap. Each one has advantages and
disadvantages (Table II), and the optimal flap should
be chosen according to the size of the dead space and
other factors. The gracilis muscle flap is relatively
easy to raise and the procedure does not require a
change in the position of the body of the patient; it is
therefore often used for reconstruction of the pelvic
cavity. However, a muscular flap alone cannot
provide sufficient volume of tissue, and only the tip
of the muscular flap can be used for filling the dead
space because of the location of nutrient vessels. If
the flap is attached with a skin island and used as a
myocutaneous flap, blood circulation in the skin
island is unstable. Another method creates a skin
flap including the sartorius muscle [8,9], but the
volume of tissue is still insufficient. The rectus
abdominis myocutaneous flap has a stable blood
circulation, allows grafting of sufficient volume of
tissue without a change in the position of the body,
and is grafted intraperitoneally. However, the posi-
tion of the stoma must be planned before operation,
and this flap is difficult to apply to secondary

Table II. Comparison of reconstructive materials for intrapelvic dead space.

Volume of Change in body

Flap tissue Procedure position Blood circulation Others

Fascial skin flap Small Easy No need Unstable in skin island

Rectus abdominis myocutaneous flap Large Rather complicated No need Stable Position of stoma
Greater omental flap Small Easy No need Stable

Tensor fascia lata myocutaneous flap and Large Complicated Needed Stable

anterolateral thigh skin flap
Free latissimus dorsi myocutaneous flap Large Complicated Needed Stable

Our fascial skin flap that includes the Large Very easy No need Stable

long saphenous vein
146 T. Yamauchi et al.
reconstructions and recurrences in patients who
already have a stoma. Examples of skin flaps with
pedicles that are applicable to reconstruction include
the anterolateral thigh flap, gluteus maximus
myocutaneous flap [10,11], omental flap, tensor
fasciae lata myocutaneous flap, and posterior thigh
skin flap. These flaps are not the first choice because
of the necessity of changing the body’s position
during operation and an insufficient volume of
tissue. Another report described a case in which a
latissimus dorsi myocutaneous flap was used as a
free skin flap. This can provide a large volume of
tissue, but it is also used only in special cases because
its preparation requires a change in the body’s
position, and procedures become complicated if
vascular anastomosis is required.
A method for creating a V-Y fasciocutaneous flap
from the thigh has previously been reported [12],
but it was used for covering perineal skin loss. The
objective in that case differed from the technique
discussed in this report, which was used to recon-
struct intrapelvic dead space.
In addition, our technique is advantageous on
many aspects, for example: a change in the position
of the body is not required after resection of the
tumour; the preparation technique is easy, and this
permits reconstruction within a short time; the
gluteal region of the flap that is used for filling a
dead space has thick subcutaneous fatty tissue and
can be collected from both thighs, so sufficient
volume of tissue for filling can be obtained; if a
gracilis muscle flap is needed because the dead space
is large, this flap is easily raised from the same
operation field; our fasciocutaneous flap can be
advanced in the same manner as a V-Y flap, and
this allows reconstruction of a dead space with a
large resection of skin around the anus (Figure 2);
our flap rarely causes deformation or contracture of
the gluteal region; and the donor site does not need
skin grafting for closure.
Our flap is basically a random pattern flap.
However, it has good venous blood circulation
because the long saphenous vein is included in the
flap. Blood circulation in our flap is the same as the
veno-accompanying-artery fasciocutaneous (VAF)
flap [13], and there is no problem with circulation.
The large scar on the medial side of the thigh is rarely
visible, and it does not cause serious problems
because there are no functional disorders caused by
contracture.
Our technique is therefore a highly efficient and
useful method of reconstruction for the defect and
space in the pelvis and anus after resection of rectal
cancer. This flap is indicated as the first choice for
cases in which the defect is equal to, or slightly larger
than, the fist of the patient. When the dead space is
Table III. Reconstructive materials.
Size Reconstructive materials
Egg-sized Gracilis muscle flapsplit-thickness skin grafting
Egg-to Fascial skin flap from medial side of the thigh
fist-sized (gracilis flap)
Larger than Rectus abdominis myocutaneous flap
fist
small or egg-sized, a unilateral or bilateral gracilis
muscle flap and free skin grafting are sufficient for
reconstruction. When the dead space is larger, such
as the case of primary reconstruction after total
pelvic exenteration, use of a rectus abdominis
muscular flap is indicated (Table III).
For patients with large dead space who are
expected to develop a fistula, primary reconstruction
would be the optimal indication. Among our cases,
the patient who had secondary reconstruction had a
recurrence of a small fistula, and cure was reached
only after some time. Primary reconstruction that is
not associated with infections or formation of scars
results in better clinical outcomes, and would
improve patients’ QOL sooner.
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