Keywords
gluteal reconstruction - musculocutaneous flap - pedicle flap - post oncological defect
Introduction
Patients with multiple chronic discharging sinus in the perianal region rarely present
with squamous cell carcinoma in the gluteal region. Worldwide there have been around
65 cases reported which are mostly attributed to Crohn’s disease. The post-excisional
defects of these patients are generally vast and require large flaps to reconstruct.
Discussion
When defects of the gluteal and sacral region include the entire anatomical site (entire
gluteus or sacral region), the reconstruction becomes complex. The etiology of such
complex defects are mainly pressure sores and posttumor excision defects. The occurrence
of carcinoma in patients with perianal fistula is around 0.7%[1] in patients with Crohn’s disease. According to the authors, the incidence of carcinoma,
especially a squamous type in non–Crohn’s disease is hardly mentioned in the literature.
The primary intention of this article is to reveal the occurrence of such rare malignancies
in patients with simple chronic perianal fistulas within a short span of time. One
of the reasons for the occurrence of such malignant transformation can be chronic
irritation[2] due to the continuous effluent bathing the external skin region from the fistulous
tract.
The flaps that have been utilized commonly for gluteal defects are tensor fascia lata[3] and anterolateral thigh[4] pedicled flap. The inferior gluteal thigh flaps are traditionally suggested to resurface
ischial and trochanteric ulcers[5] and rarely used in resurfacing a part of the gluteal region.[6] The flaps are sensate as the branches of the posterior femoral cutaneous nerves
are in close proximity to the descending branch of the IGA.[7] Low-back defects have also been addressed with latissimus dorsi flaps by increasing
the reach using vein grafts.[8] The other options for a large gluteal defect are a free tissue transfer[9] in the form of anterolateral thigh, latissimus dorsi flap, transverse rectus abdominis
myocutaneous (TRAM), IGA free flap, and deep inferior epigastric artery perforator
flaps.
The use of extended IGA flap incorporating the inferior fibers of gluteus maximus
had been earlier used for obliteration of a pelvic defect.[10] In the article, the author has detached the inferior fibers from both the origin
and insertion to increase the reach of the flap. The current article is novel in the
following ways:
-
The authors have only detached the gluteus maximus insertion partially to keep the
rest of the muscle function intact.
-
The compound flap has been used in total gluteal reconstruction, as well as sacral
reconstruction.
-
The flap design has been used in V–Y pattern for the first time for this particular
defect.
Conclusion
The conjoint inferior gluteal artery flap can be a good flap option for reconstructing
huge gluteal defects. The V–Y design also is technically good for covering such huge
dimensions. The added step of detaching the inferior fibers of gluteus maximus provides
extra advancement of the flap up to the iliac crest.
