The management of perineal wounds

Abstract

Management of perineal wounds can be very frustrating as these invariably get contaminated from the ano-genital tracts. Moreover, the apparent skin defect may be associated with a significant three dimensional dead space in the pelvic region. Such wounds are likely to become chronic and recalcitrant if appropriate wound management is not instituted in a timely manner. These wounds usually result after tumor excision, following trauma or as a result of infective pathologies like hideradenitis suppurativa or following thermal burns. Many options are available for management of perineal wounds and these have been discussed with illustrative case examples. A review of literature has been done for listing commonly instituted options for management of the wounds in perineum.

Keywords: Muscle flaps; perforator flaps; perineum; reconstructive options; skin grafts; vacuum assisted.

Figure 1

(a) Urethral loss after road side trauma (b) The urethra is planned to be made from the scarred epithelium (c) The reconstructed urethra has been covered with gracilis muscle flap covered with split skin graft (d) Patient passing urine normally from the tip

Figure 2

(a) Chronic non healing wound perineum following trauma to rectum and anal region. A colostomy can be seen. (b) The defect has been recreated and skin island is marked on the gracilis muscle. (c) Appearance on the third postoperative day

Figure 3

(a) Extensive injury to the anorectal, penoscrotal, groin, and upper thigh in a road accident, (b) The penoscrotal region has been grafted; appearance on day 7 after injury showing necrotic wound in groin with exposed femoral vessels. (c) A contra-lateral rectus musculocutaneous island flap with an oblique skin paddle designed. (d) Flap transferred into the defect (e) Well healed wound at 1 month

Figure 4

(a) Radical vulvo-vaginectomy defect. There was a large dead space in the pelvis. (b) Design of rectus musculocutaneous island flap with and oblique skin design. (c) The flap was tunneled though the pelvis to obliterate the dead space. The skin island resurfaced the skin defect in the vulval region. A perforator based V-Y advancement flap from the medial thigh has also been used to resurface the skin defect. (d) The flaps on 5th postoperative day.

Figure 5

(a) Sacral and ischial pressure sores in a paraplegic patient. The superior and inferior half of gluteus maximus muscle has been marked. (b) schematic description of the superior and inferior musculocutaneous units based upon superior and inferior gluteal artery. (c) well healed flaps at 1 month period

Figure 6

(a) Post tumor excision defect lower sacrum. A perforator has been identified by Doppler. (b) The skin island has been isolated on a perforator (c) Healed flap at 10th days postoperative

Figure 7

(a) Fournier's gangrene after debridement. (b) Split skin graft applied. (c-d) Healed wound at 6 months postoperative

Figure 8

(a) Extensive hideradenitis suppurativa. (b) Defect after excision. A local perforator based flap planned. (c) Flaps sutured into the defect. (c) Appearance at 2 weeks

Figure 9

(a-b) Post burn extensive perineal contracture. (c) Perforator based flaps transferred into the defect after release. (d-e) Healed wound at 1 month

Figure 10

(a) Vulval carcinoma. (b) Defect after excision. (c) Perforator based flaps planned. (d) Flaps sutured into the defect

Figure 11

Algorithm for perineal reconstruction