Double V-Y flap of 15 cm length each and total thickness in the gluteal region.
Late postoperative aspect.
We report a case of a perianal lesion reconstruction surgery with a V-Y flap after the recurrence of perineal cancer. The flaps are complex options for closing large areas. The aim of this type of surgery was to cover, protect, and fill the area of the disease. The perineal region may be affected by extensive lesions, requiring patches for repair1
The flap is a tissue that is mobilized based on its vascular anatomy. The flaps are usually composed of: skin, skin and fascia, skin and muscle or skin, or muscle and bone. For tissue survival, dependence on deployment of the vascular anatomy of skin tissue and underlying tissue is not needed.
Flaps based on the subdermal plexus include bipedicle, advancement (V-Y), rotation, and transposition flaps. Perineum reconstructions are often indicated due to tumors, trauma, infections, burns, or pressure sores. The wounds may be extensive and infections are frequent because of proximity to the urethra and anus. Prostheses and local radiation therapy may aggravate the injury2
Among the muscles that can be used as donors for the damaged area is the sartorius, which has multiple vascular pedicles, which limit its arc of rotation. The gracilis muscle is a bow with two-way rotation and can be used for reconstruction of the groin and perineum, besides the vagina, penis, scrotum, and anal sphincter. The tensor fascia lata, rectus femoris, and rectus abdominis are ideal for irradiated flaps of the perineum, gluteus maximum, and thigh gluteus. The extension flap is important because the larger the flap, the greater the blood supply3,4
The anal region is divided into the anal canal and anal margin. Anatomically, the canal extends from the straight to the perianal skin, with a length of approximately 2.5 to 3.5 cm. The upper part of the canal is lined with mucus similar to that in the rectum, and the bottom part is lined by epithelium similar to that in the perianal skin. Among these regions, the anal and anal valve columns are the dentate line. There are two types of tumors in this region based on the location: those originating from the mucous membranes, called anal cancer, and those from the skin or distal portion of the mucocutaneous junction, called anal margin cancer5,6
Among the histological types of anal cancer, the most prevalent are squamous cell carcinoma (most common histology), adenocarcinoma, melanoma, small cell carcinoma, and sarcomas7
Tumors of the perianal skin region are generally squamous cell carcinomas, and basal cell carcinoma, melanoma, Bowen’s disease, and extramammary Paget’s disease can also exist6,8
Most anal cancers originate from the mucosa cells, and below it are glands that produce mucus. Adenocarcinoma is an anal cancer from these glandular cells6,8
Anal cancer is rare and less common than colon or rectum cancer, but the number of cases is increasing. It is rare in people younger than 35 years and found mainly in older adults with a mean age at onset of 60 years6,8
Despite the knowledge of some risk factors for anal cancer (human papilloma virus infection [HPV], with subtype 16 related to squamous cell carcinoma and 18 to adenocarcinoma, cigarette smoking, low immunity, anal receptive sex, and multiple sexual partners), the exact cause is unknown6,8
Most patients with anal cancer present with initial rectal bleeding symptoms. Pain and rectal mass sensation may occur in up to 30% of cases.
Anal cancer is a predominantly regional disease with local extent of the primary tumor and spread to the lymph nodes of the inguinal and pelvic region. Hematogenous dissemination is rare. Local spread to the rectum and/or the perianal skin occurs in approximately 50% of cases. The deep invasion of the rectovaginal septum occurs in 10% of cases6
The risk of regional recurrence after treatment can reach approximately 30% of cases and is the most frequent recurrence pattern7
. If the cancer recurs in the anus or a nearby lymph injury after treatment, the conduit depends on the treatment performed previously, and generally progresses with colostomy6
Some cases are diagnosed by screening tests, such as digital rectal examination and/or anal Papanicolaou test6,8
Analysis and/or interpretation of data; final approval of the manuscript; conception and design of the study; writing the manuscript or critical review of its contents.EF
Writing the manuscript or critical review of its contents.LPSR
Writing the manuscript or critical review of its contents.IAYK
Writing the manuscript or critical review of its contents.FYK
Writing the manuscript or critical review of its contents.ERGF
Writing the manuscript or critical review of its contents.REFERENCES
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4. Laitano FF, Teixeira LR, Siqueira EJ, Alvarez GS, Oliveira MP. Tumor cutâneo em parede nasal lateral e as opções de retalhos cutâneos para reconstrução após ressecção neoplásica. Rev AMRIGS. 2012;56(3):229-33.
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6. American Cancer Society. Cancer Facts & Figures 2016. Atlanta: American Cancer Society; 2016.
7. Ibañez N, Abrisqueta J, Luján J, Hernández Q, Parrilla P. El colgajo V-Y como método de reparación de defectos perianales extensos. Cir Esp. 2016;94(9):525-30. DOI: http://dx.doi.org/10.1016/j.ciresp.2016.06.006
8. Gürbulak EK, Akgün İE, Ömeroğlu S, Öz A. Giant perianal condyloma acuminatum: Reconstruction with bilateral gluteal fasciocutaneous V-Y advancement flap. Ulus Cerrahi Derg. 2015;31(3):170-3.
1. Clínica Belvivere de Cirurgia Plástica e Laser, Criciéma, SC, Brazil
2. Sociedade Brasileira de Cirurgia Plástica, São Paulo, SP, Brazil
3. Universidade do Extremo Sul Catarinense, Criciéma, SC, Brazil
4. Escola Paulista de Medicina, Universidade Federal de São Paulo, SP, Brazil
Institution: Clínica Belvivere de Cirurgia Plástica e Laser, Criciéma, SC, Brazil.Corresponding author:
Glayse June Sasaki Acacio Favarin
Rua Coronel Pedro Benedet, 505, sala 10
Centro - Criciéma, SC, Brazil - Zip Code 88801-250
Article received: October 22, 2016.
Article accepted: January 26, 2018.
Conflicts of interest: none.