Original article

Perineal reconstruction after abdominoperineal excision

using inferior gluteal artery perforator flaps
A. Hainsworth1 , M. Al Akash1 , P. Roblin2 , P. Mohanna2 , D. Ross2 and M. L. George1
Departments of 1 Colorectal and 2 Plastic Surgery, St Thomas’ Hospital, London, UK
Correspondence to: Miss A. Hainsworth, Department of Surgery, St Thomas’ Hospital, Westminster Bridge Road, London SE1 7EH, UK
(e-mail: allyhainsworth@googlemail.com)

Background: Perineal wound complications following abdominoperineal excision (APE) for low rectal
tumours remain an important cause of morbidity and prolonged hospital stay, particularly after
chemoradiotherapy. The aim was to assess outcomes after using inferior gluteal artery perforator
(IGAP) flaps for immediate perineal reconstruction, and to compare these with the authors’ previous
experience and published literature on myocutaneous flaps.
Methods: A series of patients who underwent immediate IGAP flap reconstruction after APE between
April 2008 and December 2010 were examined retrospectively to determine patient demographics,
length of operation, complications (perineal wound and general) and length of hospital stay.
Results: Forty patients with rectal adenocarcinoma (33 primary and 7 recurrent disease) underwent
immediate IGAP flap reconstruction following APE. Median follow-up was 9 months. Neoadjuvant
chemoradiotherapy was received by 98 per cent of the patients. Thirty-two patients underwent APE
plus IGAP flaps (25 open, 7 laparoscopic), with a median operating time of 402 min, and eight patients
had multivisceral resection (MVR) plus IGAP flaps (7 total pelvic exenteration (TPE), 1 abdominosacral
resection), with a median duration of surgery of 561 min. There was one death (fatal stroke) and four
major flap complications (10 per cent) (1 enteroperineal fistula, and 3 deep wound infections). Median
length of hospital stay was 13 days after APE plus IGAP flaps and 27 days following MVR plus IGAP
flaps. Late complications occurred in two patients who had vaginal reconstruction and developed perineal
hernias requiring revisional surgery.
Conclusion: Although operating times are long, the IGAP flap is robust, with no flap necrosis observed
in this series.

Presented to the International Surgical Congress of the Association of Surgeons in Great Britain and Ireland, Liverpool,
UK, April 2010, and the Royal Society of Medicine Coloproctology Symposium, London, UK, January 2010
Paper accepted 31 October 2011
Published online 9 January 2012 in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.7822

Introduction single-stage reconstruction after APE in the presence of

Radical pelvic surgery is used increasingly to treat
locally advanced or recurrent rectal carcinoma to achieve
long-term survival1,2 . In comparison with standard
surgery, extralevator abdominoperineal excision (APE)3
is associated with a reduction in circumferential margin
involvement but an increase in perineal wound complica-
tions, from 20 to 38 per cent4 . Preoperative radiotherapy
decreases local recurrence rates5 – 10 , but doubles the rate
of total and major perineal wound complications11,12 . An
evidence-based review of 36 studies supported the use of
chemoradiotherapy to reduce wound morbidity13 ; how-
ever, others have reported a primary tension-free repair
with low morbidity14 .
The use of myocutaneous flaps (vertical rectus abdominis
(VRAM)/gracilis flaps) reduces the length of hospital stay
and the perineal wound complication rate15 – 19 . However,
VRAM flaps are not suitable for laparoscopic APE, have
a flap failure rate of 2·3–10 per cent13,15 , a major wound
complication rate of 15–22 per cent16,17,20,21 and a high
rate of donor-site morbidity13,15,21 . The inferior gluteal
artery perforator (IGAP) flap, which allows the transfer

 2012 British Journal of Surgery Society Ltd British Journal of Surgery 2012; 99: 584–588
Published by John Wiley & Sons Ltd
Perineal reconstruction after abdominoperineal excision 585

of skin and fat but is muscle-sparing22,23 , provides a good

option for perineal reconstruction24 . This study examined
the outcome of patients with IGAP flaps.

Methods

Data on successive patients from April 2008 to December

2010 undergoing prone extralevator APE or multivisceral
APE (MVR) for rectal adenocarcinoma with immediate
IGAP flap reconstruction were collected retrospectively.
Patients having APE for gynaecological malignancy (4
patients), salvage anal cancer surgery (3) or with morbid
obesity (1) were excluded. Data were collected on patient
demographics, pathology, chemoradiotherapy, type and
length of operation, length of hospital stay, postoperative
complications (flap-related and general) and length of Fig. 1The perforating vessels pass through the muscle into the
follow-up. Major wound complications were defined as flap (arrows)
any wound requiring reoperation or readmission11 .
The rectum was mobilized, laparoscopically or by an
open technique, in the mesorectal plane towards the pelvic
floor, the abdomen was closed and an end colostomy
matured. An extralevator perineal dissection was performed
with the patient prone, and the plastics team raised
the IGAP flaps. These IGAP flaps were fasciocutaneous
perforator flaps and designed in a V-Y fashion, with the
lower border placed in the buttock crease and the lateral
extension medial to the greater trochanter.
The flaps were raised from lateral to medial in
a subfascial plane. This allowed identification of the
perforating vessels passing through the muscle into the
flap (Fig. 1). At the junction of the lateral and middle thirds
of the flap, a consistent lateral perforator vessel was usually
identified. This was isolated and dissected down between Fig. 2 The first flap is buried deep inside the pelvis and the
the muscle fibres to allow it to move freely. Once this vessel contralateral flap is advanced medially to close the wound in a
had been dissected and preserved, the flap was raised from double-breasted fashion. The resultant suture line recreates the
the medial border. Perforators in the medial and central natal cleft
areas of the flaps were isolated. The number of perforators
used and the degree to which they were dissected free from For women undergoing posterior vaginectomy, vaginal
their muscular attachments was determined by the degree reconstruction could be performed. Where the anterior
of medial transposition required. vaginal wall remained, the medial flap edges were sutured
The flaps were advanced medially. The first flap was to its lateral edges. In total vaginectomy, the leading medial
advanced into the pelvis and the buried portion de- edges of both flaps were not de-epithelialized as these were
epithelialized. This was secured superiorly to the anterior rotated internally and laterally to create the neovagina.
surface of the sacrum and the remaining pelvic outlet. The After surgery a supine position was avoided for the first
contralateral flap was advanced medially to close the wound 24 h and sitting was avoided for 4 days. The flaps were
in a double-breasted fashion. The leading medial edge of reviewed daily by the plastics team and wound swabs taken
this flap was rolled over internally and de-epithelialized, if indicated. The patients were allowed to mobilize on the
placing the resultant suture line vertically in the midline to first postoperative day. They were placed in a compression
recreate the natal cleft (Fig. 2). The wounds were closed in garment continuously for 2 weeks and then during the day
layers and a suction drain placed bilaterally (removed on for the next 2 weeks. All patients were supplied with a
day 6). pressure-relieving cushion.

 2012 British Journal of Surgery Society Ltd www.bjs.co.uk British Journal of Surgery 2012; 99: 584–588
Published by John Wiley & Sons Ltd
586 A. Hainsworth, M. Al Akash, P. Roblin, P. Mohanna, D. Ross and M. L. George

Table 1 Patient and surgical details

Primary rectal Recurrent rectal Duration of Length of hospital

cancer (n = 33) cancer (n = 7) surgery (min)* stay (days)*

Age (years)* 67 (28–79) 64 (44–75)

Sex ratio (M : F) 25 : 8 3:4
Chemoradiotherapy 32 7
Type of operation
APE (n = 32; 25 open, 7 laparoscopic) 402 (210–568) 13 (6–28)
APE 27 1 392 (240–568)
Panproctocolectomy/APE 2 0 427·5 (360–495)
APE and lymphoma splenectomy 1 0 504
Perineal excision 0 1 210
MVR (n = 8) 561 (350–636) 27 (11–140)
Total pelvic exenteration 3 4 553 (360–608)
Abdominosacral resection 0 1 636
Overall (n = 40) 33 7 417 (210–636) 14 (6–140)

*Values are median (range). APE, abdominoperineal excision; MVR, multivisceral resection.

The research and development department of Guy’s and
St Thomas’ NHS Foundation Trust approved the use of
patients’ data for this study.
Results
Forty patients underwent perineal excision with immediate
IGAP flap reconstruction (4 with vaginal reconstruction)
for rectal adenocarcinoma; 33 had primary rectal cancer
(32 of whom received neoadjuvant chemoradiotherapy) and
seven had recurrent rectal cancer (all received neoadjuvant
chemoradiotherapy). Type of operation, duration of
surgery and length of hospital stay are shown in Table 1.
Median length of follow-up was 9 (range 3–28) months.
Flap complications
There were four major flap complications (10 per cent).
One patient undergoing TPE for recurrent rectal cancer
developed sepsis secondary to an enteroperineal fistula
caused by a drain. Despite laparotomy, exteriorization of
the fistula, multiple debridements, vacuum-assisted closure
(VAC) dressings and appropriate antibiotics, the patient
died 4 months later from sepsis and malnutrition. One
patient undergoing TPE was taken back to theatre for
debridement and VAC therapy.
Two other patients undergoing APE initially made
an uneventful recovery, but were readmitted 4 days after
discharge with deep-seated wound infections beneath the
IGAP flaps. Both required return to theatre, one for a
single washout and the other for debridement and VAC
therapy. Both recovered well, with minimal discomfort and
early mobilization.
There were four minor wound complications (10 per
cent). Two patients had cellulitis surrounding the wound
that required oral antibiotics. Two patients had an area
of superficial wound dehiscence; one healed without
intervention and the other required closure under local
anaesthetic.
Two of four women developed perineal hernias 18 and
22 months after vaginal reconstruction and underwent
revisional surgery using a Surgisis Biodesign
TM
mesh
(Cook Medical, Bloomington, Indiana, USA).
Other complications
One patient died from multiple organ failure on day 13 after
surgery in the intensive care unit, following a stroke. Two
patients developed prolonged ileus, one an intra-abdominal
collection that required computed tomography-guided
drainage and one a urinary leak from an ileal conduit
that required nephrostomies and ureteric stents.
Discussion
The treatment of lower-third rectal cancer with preop-
erative chemoradiotherapy and extralevator APE results
in a large perineal defect with a risk of perineal wound
complications. Previous studies using myocutaneous flaps
have shown a decrease in perineal wound morbidity13,15
and a reduced length of hospital stay15 . However, there is
flap failure13,15 , donor-site morbidity21 and incompatibility
with laparoscopic APE.
The present report is the largest series of immediate
perineal reconstruction using IGAP flaps following radical
surgery for rectal cancer published to date. Rates of flap
necrosis were lower than with myocutaneous flaps15 . With

 2012 British Journal of Surgery Society Ltd www.bjs.co.uk British Journal of Surgery 2012; 99: 584–588
Published by John Wiley & Sons Ltd
Perineal reconstruction after abdominoperineal excision
39 (98 per cent) of the 40 patients having preoperative
chemoradiotherapy, the total wound complication rate (8
of 40, 20 per cent) was comparable to that of previously
published series of myocutaneous flaps16 – 18,21 . Operating
times were longer with the IGAP flap than for other
myocutaneous flaps15 . This is because coloproctologists
and plastic surgeons can operate simultaneously when
performing a VRAM or gracilis flap, but this is not possible
with IGAP flaps.
Donor-site morbidity for perforator artery flaps is
low22,25 . Unlike the VRAM flap, IGAP flaps are compatible
with both laparoscopic and open surgery, do not interfere
with stoma formation1 and carry no increased risk of
abdominal hernia15 . The IGAP flap avoids the use of
irradiated tissue and enables the import of local vascularized
tissue to provide a bulky, robust flap for reconstruction of
the irradiated perineum and neovagina1 . Myocutaneous
flaps have more initial bulk as muscle is taken with the
fasciocutaneous component of the flap, but this muscle
atrophies with time and it seems unnecessary to take
muscle as this adds to morbidity and pain. In addition,
when raising the IGAP flap there is no transection of the
gluteus maximus muscle1,22 – 24,26,27 .
There are still questions surrounding sexual function
following vaginal reconstruction with IGAP flaps. A
recent study reported that all 14 women undergoing
perineal reconstruction with inferior or superior gluteal
artery perforator flaps following perineal cancer resection
resumed sexual intercourse1 . This compares with findings
in a series using VRAM flaps for reconstruction, where
85·2 per cent resumed sexual activity28 .
Neovaginal reconstruction affords not only psycho-
social benefit but the incorporation of healthy tissue into
the pelvic cavity1,29,30 . This has been shown previously
to decrease the incidence of fistula, small bowel obstruc-
tion, infection and haemorrhage29,30 . Unfortunately, two
women who had uncomplicated surgery developed post-
operative perineal herniation. This was managed with mesh
sacrocolpopexy in one patient and a ‘mesh cradle’ sutured
at the pelvic brim in the other. The authors hypothesize
that this herniation was related to construction of the neo-
vagina, whereby it is more difficult to securely fixate the
tissue deep inside the pelvis and to obliterate the pelvic
dead space. They now take measures at primary operation
to prevent this from occurring, by using an internal mesh
to suspend the small bowel out of the pelvis.
Follow-up in this small study of 40 patients was short,
and longer-term data are required to assess donor-site
morbidity with regard to pain, discomfort and perineal
herniation. This was not a randomized controlled trial
comparing VRAM with IGAP flaps, and the data have
 2012 British Journal of Surgery Society Ltd
Published by John Wiley & Sons Ltd
587
been compared with outcomes from other studies that
included more patients with anal cancer and variable rates
of radiotherapy. Nevertheless, this experience has shown
that the IGAP flap is a reliable and safe option for perineal
and vaginal reconstruction.
Disclosure
The authors declare no conflict of interest.
References
1 Wagstaff MJ, Rozen WM, Whitaker IS, Enajat M,
Audolfsson T, Acosta R. Perineal and posterior vaginal wall
reconstruction with superior and inferior gluteal artery
perforator flaps. Microsurgery 2009; 29: 626–629.
2 Ferron G, Martel P, Querleu D. [Vaginal reconstruction
after pelvic exenteration: when and which techniques?] Bull
Cancer 2003; 90: 435–440.
3 Shihab OC, Heald R, Rullier E, Brown G, Holm T,
Moran BJ. Defining the surgical planes on MRI improves
surgery for cancer of the low rectum. Lancet Oncol 2009; 10:
1207–1211.
4 West NP, Anderin C, Smith KJ, Holm T, Quirke P;
European Extralevator Abdominoperineal Excision Study
Group. Multicentre experience with extralevator
abdominoperineal excision for low rectal cancer. Br J Surg
2010; 97: 588–599.
5 Gérard A, Buyse M, Nordlinger B. Preoperative
radiotherapy as adjuvant treatment in rectal cancer. Final
results of a randomised study of the European Organisation
for Research and Treatment of Cancer (EORTC). Ann Surg
1988; 208: 606–614.
6 Stockholm Rectal Cancer Study Group. Preoperative short
term radiation therapy in operable rectal carcinoma. A
prospective randomized trial. Cancer 1990; 66: 49–55.
7 Garciá-Aguilar J, Hernandez de Anza E, Sirivongs P,
Lee SH, Madoff RD, Rothenberger DA. A pathological
complete response to preoperative chemoradiation is
associated with lower local recurrence and improved survival
in rectal cancer patients treated by mesorectal excision. Dis
Colon Rectum 2003; 46: 298–304.
8 Theodoropoulos G, Wise W, Padmanabhan A, Kerner BA,
Taylor CW, Aguilar PS. T-level downstaging and complete
pathological response after preoperative chemoradiation for
advanced rectal cancer result in decreased recurrence and
improved disease free survival. Dis Colon Rectum 2004; 47:
279–286.
9 Janjan N, Khoo V, Abbruzzese J. Tumor downstaging and
sphincter preservation with preoperative chemoradiation in
locally advanced rectal cancer: the M. D. Anderson Cancer
Center experience. Int J Radiat Oncol Biol Phys 1999; 44:
1027–1038.
10 Crane CH, Skibber JM, Feig BW, Vauthey JN,
Thames HD, Curley SA et al. Response to preoperative
www.bjs.co.uk British Journal of Surgery 2012; 99: 584–588
588 A. Hainsworth, M. Al Akash, P. Roblin, P. Mohanna, D. Ross and M. L. George
chemoradiation increases the use of sphincter-preserving
surgery in patients with locally advanced low rectal cancer.
Cancer 2003; 97: 517–524.
11 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:
438–443.
12 El-Gazzaz G, Kiran RP, Lavery I. Wound complications in
rectal cancer patients undergoing primary closure of the
perineal wound after abdominoperineal resection. Dis Colon
Rectum 2009; 52: 1962–1966.
13 Nisar PJ, Scott HJ. Myocutaneous flap reconstruction of the
pelvis after abdominoperineal excision. Colorectal Dis 2008;
11: 806–816.
14 Bebenek M. Abdominosacral amputation of the rectum
(ASAR) for low rectal cancers – ten years of experience. Ann
Surg Oncol 2009; 16: 2211–2217.
15 Chan S, Miller M, Ng R, Ross D, Roblin P, Carapeti E et al.
The use of myocutaneous flaps for perineal closure following
abdominoperineal excision of the rectum for
adenocarcinoma. Colorectal Dis 2010; 12: 555–560.
16 Buchel EW, Finical S, Johnson C. Pelvic reconstruction
using rectus abdominis musculocutaneous flaps. Ann Plast
Surg 2004; 52: 22–26.
17 Chessin DB, Hatley J, Cohen AM, Mazumdar M,
Cordeiro P, Mehara B et al. Rectus flap reconstruction
decreases perineal wound complications after pelvic
chemoradiation: a cohort study. Ann Surg Oncol 2005; 12:
104–110.
18 Bell SW, Dehni N, Chaouat M, Lifante JC, Parc R, Tiret E.
Primary rectus abdominis myocutaneous flap for repair of
perineal and vaginal defects after extended abdominoperineal
resection. Br J Surg 2005; 92: 482–486.
19 Lefevre J, Parc Y, Kemeis S, Shields C, Touboul E,
Chaouat M 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: 707–711.
20 Goldberg GL, Sukumvanich P, Einstein MH, Smith HO,
 2012 British Journal of Surgery Society Ltd
Published by John Wiley & Sons Ltd
Anderson PS, Fields AL. Total pelvic exenteration: the
Albert Einstein College of Medicine/Montefiore Medical
Center experience (1987 to 2003). Gynecol Oncol 2006; 101:
261–268.
21 Nelson RA, Butler CE. Surgical outcomes of VRAM versus
thigh flaps for immediate reconstruction of pelvis and
perineal cancer resection defects. Plast Reconstr Surg 2009;
123: 175–183.
22 Scheufler O, Farhadi J, Kovach SJ, Kukies S, Pierer G,
Levin LS et al. Anatomical basis and clinical application of
the infragluteal perforator flap. Plast Reconstr Surg 2006; 118:
1389–1400.
23 Kim YS, Lew DH, Roh TS, Yoo WM, Lee WJ, Tark KC.
Inferior gluteal artery perforator flap: a viable alternative for
ischial pressure sores. J Plast Reconstr Aesthet Surg 2009; 62:
1347–1354.
24 Sinna R, Qassemyar Q, Benhaim T, Lauzanne P, Sabbagh C,
Regimbeau JM et al. Perforator flaps: a new option in
perineal reconstruction. J Plast Reconstr Aesthet Surg 2010;
63: 766–774.
25 Saint-Cyr M, Schaverien MV, Rohrich RJ. Perforator
flaps: history, controversies, physiology, anatomy, and
use in reconstruction. Plast Reconstr Surg 2009; 123:
132e–145e.
26 Higgins JP, Orlando GS, Blondeel PN. Ischial pressure sore
reconstruction using an inferior gluteal artery perforator
(IGAP) flap. Br J Plast Surg 2002; 55: 83–85.
27 Koshima I, Moriguchi T, Soeda S, Kawata S, Ohta S,
Ikeda A. The gluteal perforator-based flap for repair of sacral
pressure sores. Plast Reconstr Surg 1993; 91: 678–683.
28 Casey WJ III, Tran NV, Petty PM, Stulak JM, Woods JE.
A comparison of 99 consecutive vaginal reconstructions: an
outcome study. Plast Surg 2004; 52: 27–30.
29 Benson C, Soisson AP, Carlson J, Culbertson G,
Hawley-Bowland C, Richards F. Neovaginal reconstruction
with a rectus abdominis myocutaneous flap. Obstet Gynecol
1993; 81: 871–875.
30 Judge B, Garcı́a-Aguilar J, Landis GH. Modification of the
gluteal perforator-based flap for reconstruction of the
posterior vagina. Dis Colon Rectum 2000; 43: 1020–1022.
www.bjs.co.uk British Journal of Surgery 2012; 99: 584–588