How I do it

V-Y Island flaps for repair of large perianal defects

Imran Hassan, M.D., Alan F. Horgan, M.B., B.Ch., Santhat Nivatvongs, M.D.*Division of Colon and Rectal Surgery, Mayo Clinic, 200 First Street, SW, Rochester, MN 55905, USA

Manuscript received October 11, 2000; revised manuscript January 2, 2001

Abstract

Background: Some perianal diseases such as Paget disease and Bowen disease are extensive and require a wide circumferential excisionincluding the entire anoderm of the anal canal.Methods: We describe a technique of V-Y island flaps to cover the large perianal defects and the denuded anal canal. It is important toexcise the base of the flaps in order to fit them into the anal canal.Results: There were 10 women and 5 men with an average age of 54 years (range 32 to 77). The mean follow-up was 45 months (range6 to 92). The underlying pathology included various kinds of neoplastic and nonneoplastic diseases. There were no major complications suchas flap loss or infection. Most complications were minor, including superficial wound separation, flap hematoma, and anal stricture.Although initially all patients had some degree of incontinence for gas and liquid stool or discharge, none of them had significant fecalincontinence at the time of last follow-up. A diverting ileostomy or colostomy was created in 5 patients. Its role was not clear but it didhelp in the management of the wounds and minimized the pain. © 2001 Excerpta Medica, Inc. All rights reserved.

Keywords:V-Y Island flaps; Perianal defects; Perianal diseases

The treatment of several perianal pathologies such as Pagetdisease, Bowen disease, squamous cell carcinoma, and ex-tensive ectropion require wide local excision of the skin andsubcutaneous tissue in the perianal region. This results in alarge perianal defect that can not be closed primarily with-out undue tension and resultant complications. Varioustechniques have been described in the literature for therepair of these defects such as healing by secondary inten-tion and split thickness skin grafts [1]. However, theseapproaches are associated with unfavorable long term re-sults because of subsequent anal stenosis and ectropion.More recently several authors have reported favorable re-sults using various transposition or rotation skin flaps, myo-cutaneous flaps of the gluteal and thigh muscles, and V-Yisland flaps to cover these areas of tissue loss [2–5].

In this report we present our experience with V-Y peri-anal island flaps that were performed to cover large bilateral(both sides of the anus) defects resulting from wide localexcision of various perianal pathologies.

Surgical technique

A mechanical bowel preparation and prophylactic anti-biotics were used. The procedure was performed with thepatients in prone jackknife position under endotracheal gen-eral anesthesia. The perianal lesion was widely excised deepto the subcutaneous tissue, with negative margins confirmedby frozen section examination. In most cases the excisionwas extended 5 mm proximal to the dentate line of the analcanal. A pear-shaped flap was made on each side of theperianal skin with the size matching the defect (Fig. 1). Theflaps were prepared deep down to the subcutaneous fat.Dissection was continued until the islands of the flaps easilyreached the upper anal canal without tension. Tongues ofskin at the base of each flap were excised in order toaccommodate it into the anal canal (Fig. 2). The flaps werethen slid into the anal canal and sutured to the mucosaof the anal canal all around, using 3-0 Vicryl (Fig. 3). Therest of the flaps were closed with interrupted subcuticularsutures of 3-0 PDS. The completed flaps had a Y-shapedconfiguration (Fig. 3, inset). A suction drain was not rou-tinely placed. Postoperatively (Fig. 4) the patient would bestarted on a clear liquid diet and advanced with return ofbowel function.

* Corresponding author. Tel.:11-507-284-4985; fax:11-507-284-1794.

E-mail address:snivatvongs@mayo.edu

The American Journal of Surgery 181 (2001) 363–365

0002-9610/01/$ – see front matter © 2001 Excerpta Medica, Inc. All rights reserved.PII: S0002-9610(01)00578-5

Results

From January 1991 to December 1999, 15 patients un-derwent the V-Y perianal island flaps. Patients charts werereviewed for indications for surgery, postoperative compli-cations, and subsequent clinical course. Information regard-ing recurrence of primary pathology, bowel function, andfecal continence was obtained through clinic follow-up ortelephone calls to the patients if necessary.

There were 10 women and 5 men. The mean age atsurgery was 54 years (range 32 to 77) and the mean durationof follow-up was 45 months (range 6 to 92). The underlyinganal pathology was Paget disease in 8 patients, Bowendisease in 4 patients, squamous cell carcinoma in 1 patient,circumferential ectropion in 1 patient and a giant condylomaacuminata in 1 patient (Table 1). The wide local excisionresulted in large perianal defects on both sides of the anus inall cases. A diverting ileostomy or colostomy was created in5 patients, which was subsequently reversed in 4 patients,but 1 patient elected not to have the stoma taken down. Themean length of stay in the hospital was 6 days (range 1 to12). In the early postoperative period 6 patients had super-ficial wound separation, anal stenosis requiring serial dila-tation in 3 patients, and a flap hematoma in 1 patient. Onlythe patient with the perianal hematoma required operative

drainage, otherwise all other complications were managedconservatively. There were no cases of skin necrosis or flaploss or any infectious complications. Patients who did nothave a diverting ileostomy or colostomy had some degreesof incontinence for gas and liquid stool for the first fewmonths. Further information regarding bowel function andcontinence was obtained in 12 patients through telephonefollow-up. Four patients reported having difficulty withpassage of stool and constipation postoperatively: 2 patientsrequired serial dilatations with Hegar dilators, and 2 patientsrequired regular use of stool softeners. None of the patientsreported significant fecal incontinence at the time of lastfollow-up.

One patient with Paget disease developed the disease atthe vulva, which was excised. One patient, who initially hadPaget disease, developed an invasive carcinoma of the rec-tum and underwent an abdominoperineal resection. Anotherpatient with Paget disease developed a squamous cell car-cinoma of the anal canal and underwent an abdominoperi-neal resection. One patient with Bowen disease developedcarcinoma of the cervix and was appropriately treated.There has been no recurrence of the primary disease at theskin flaps.

Fig. 1. An outline of a pear-shaped flap on perianal skin. Note the shadedarea of tongues of skin to be excised to fit into the anal canal.

Fig. 2. The fully mobilized island flaps.

Fig. 3. The flaps slid into the anal canal and sutured to the mucosa of theupper anal canal.Inset: Y shape at completion.

Fig. 4. The appearance of anus at 10 month after the operation.

364 I. Hassan et al. / The American Journal of Surgery 181 (2001) 363–365

Comments

Adequate soft tissue coverage to repair large bilateralperianal defects while maintaining acceptable functionalresults is a difficult task. Various techniques have beendescribed to achieve wound healing of the perineum. Theseinclude leaving it to close by secondary intention, primaryclosure, or split thickness skin grafts [1,6]. However theseapproaches are limited by the size of wounds that can berepaired and the extent of the disease involving the analcanal. Wound coverage in the perianal region has also beendescribed using various types of transposition or rotationflaps such as the S-plasty [3,7], house flaps [2], diamondflaps [4], and rhomboid flaps [8]. These flaps as well asseveral of their modifications have been primarily used forthe repair of anal stenosis and ectropion. There have alsobeen several individual reports of using V-Y sliding flaps torepair large perianal defects that result from wide localexcision of various perianal pathologies [5,9,10]. Anotheroption for tissue coverage of large defects is myocutaneousflaps, which commonly include the gluteal, rectus abdomi-nis and gracilis muscles [11,12]. These, however, requireextensive soft tissue dissection and manipulation, and aremore appropriate for extensive areas of tissue loss. Situa-tions in which the perianal defect is large enough that itcannot be closed primarily, yet a myocutaneous flap wouldbe too excessive, V-Y subcutaneous island flaps are an idealtechnique. When the anoderm of the anal canal needs to beexcised, it is essential to cut out a tongue of skin at the baseof each flap (Fig. 1). This important step will allow the flapsto fit into the anal canal and avoid anal stenosis and ectro-pion.

Our experience with large bilateral perianal defects whounderwent repair with V-Y island perianal flaps confirmsthat this technique is indeed simple and effective. It isassociated with minor flap-related complications in a sig-nificant number of the patients but all could be managedconservatively and eventually resolved. A wide range ofcomplication rates (12% to 66%) have been reported in the

literature for island flaps used for treatment of anal stenosisand ectropion [2]; however, most flaps were small andinvolved only one side of the perianal area.

The main long-term morbidity was associated with analstenosis or stricture. In order to adequately excise the analpathology with negative margins, the entire anoderm wasexcised and the leading edges of the flaps were sewn to theanal mucosa above the dentate line. This made the analopening prone to narrowing causing difficult defecation.The problem could be easily corrected with serial dilatationsusing Hegar dilators. There were no clear indications for adiverting ileostomy or colostomy, as the wound complica-tion rate did not differ amongst those who were diverted andthose who were not. However, we recommend it wheneverfeasible since it helps in the postoperative fecal inconti-nence and wound healing; in particular, it minimizes pain inthe early postoperative period. It is important to note that 4of 12 patients with Paget and Bowen disease developed asecondary malignancy. These patients require a long-termsurveillance.

References

[1] Seckel BR, Schoetz DJ, Coller JA. Skin grafts for circumferentialcoverage and perianal wounds. Surg Clin North Am 1985;65:365–71.

[2] Sentovich SM, Falk PM, Christensen MA, et al. Operative results ofhouse advancement anoplasty. Br J Surg 1996;83:1242–4.

[3] Gonzalez AR, DeOliveira O, Verzaro R, et al. Anoplasty for stenosisand other anorectal defects. Am Surg 1995;61:526–9.

[4] Pearl RK, Hooks VH, Abcarian H, et al. Island flap anoplasty for thetreatment of anal stricture and mucosal ectropion. Dis Colon Rectum1990;33:581–3.

[5] Core GB, Bite U, Pemberton JH, et al. Sliding V-Y perineal islandflaps for large perianal defects. Ann Plast Surg 1994;32:328–31.

[6] Beck DE. Paget’s disease and Bowen’s disease of the anus. SeminColon Rect Surg 1995;6:143–9.

[7] Oh C, Albanese C. S-plasty for various anal lesions. Am J Surg1992;163:606–8.

[8] Lopez-Rios FL. Rhomboid flap in proctologic reconstruction. DisColon Rectum 1990;33:73–7.

[9] Zoetmulder FAN, Boris G. Wide resection and reconstruction pre-serving fecal continence in recurrent anal cancer. Report of threecases. Dis Colon Rectum 1995;38:80–4.

[10] Ricchi E, Fundaro S, Spallanzani A, et al. Vertical subcutaneouspedicle flaps for posterior perineal reconstruction. Report of threecases. Dis Colon Rectum 1996;39:353–7.

[11] Murakami K, Tanimura H, Ishimoto K, et al. Reconstruction withbilateral gluteus maximus myocutaneous rotation flap after wide localexcision for perianal extramammary Paget’s disease. Report of twocases. Dis Colon Rectum 1996;39:227–31.

[12] Solomon MJ, Atkinson K, Quinn MJ, et al. Gracilis myocutaneousflap to construct large perineal defects. Int J Colorect Dis 1996;11:49–51.

Table 1Indications for wide excision

Condition Number

Paget disease 8Bowen disease 4Squamous cell carcinoma 1Ectropion 1Giant condyloma acuminata 1Total 15

365I. Hassan et al. / The American Journal of Surgery 181 (2001) 363–365