Donor Site Scar-Free Gluteal Flap for Perineal Closure Post-APR

Overview

A novel unilateral semicircular gluteal perforator flap, termed the Luna flap, was successfully used to close a perineal defect after abdominoperineal resection complicated by small bowel herniation. This technique allowed effective dead space obliteration without additional donor site scars and facilitated early patient mobilization with favorable wound healing outcomes.

Background

Abdominoperineal resection (APR) is associated with high rates of perineal wound complications, including wound problems in up to 47% of patients and secondary hernia formation in up to 26%. Obliteration of the perineal dead space with well-vascularized tissue is critical to promote healing and prevent complications. Traditional flap options for perineal reconstruction carry risks of donor and recipient site morbidity. The Luna flap represents a modification designed to address these challenges by providing effective coverage without additional scarring.

Data Highlights

The patient underwent emergency surgery 2 months post-APR for pT3N0M0 rectal cancer due to small bowel herniation through an unhealed perineal wound. A 6 × 10 cm acellular biological mesh was used for pelvic floor reconstruction. The Luna flap was created with a maximum 3 cm distance from the perineal defect, incorporating at least one gluteal artery perforator. Postoperatively, the patient was mobilized after 2 days, allowed to sit after 10 days, and discharged after 7 days with drains in situ. At 3 weeks, the perineal wound was well healed, and follow-up at 6 weeks remained uneventful.

Key Findings

• The Luna flap is a unilateral semicircular gluteal perforator flap designed to fill perineal dead space without creating additional donor site scars.
• Pelvic floor reconstruction was performed using a biological mesh (Strattice™) to provide strength in a contaminated environment.
• The flap was deepithelialized and transposed to cover the mesh, effectively obliterating dead space and promoting mesh ingrowth.
• Postoperative management included dual vacuum drains and saline irrigation to manage purulent discharge.
• The patient achieved early mobilization and sitting, with complete wound healing observed at 3 weeks and no complications at 6 weeks.
• The Luna flap offers a promising alternative to traditional VY fasciocutaneous flaps with limited operative time increase and minimal morbidity.

Clinical Implications

The Luna flap technique provides an effective, scar-free option for perineal defect closure after APR, particularly in cases complicated by wound dehiscence or herniation. Using a biological mesh combined with well-vascularized soft tissue coverage reduces the risk of seroma and abscess formation, facilitating improved healing. Early mobilization and minimal donor site morbidity may enhance patient recovery and quality of life.

Conclusion

The Luna flap represents a valuable advancement in perineal reconstruction post-APR, enabling secure dead space obliteration without additional scarring and supporting favorable clinical outcomes. This approach warrants further evaluation as a standard option for managing small perineal defects.

References

1. Abdominoperineal resection morbidity and wound complications
2. Perineal wound problems and hernia formation rates
3. Biological mesh use in pelvic floor reconstruction
4. Donor and recipient site morbidity in perineal defect closure