Perineal defects result due to post-surgical wound in case of genital malignancies, anorectal malignancies, and post radiation ulcer. The reconstruction of the perineum can be quite demanding as one has to preserve both sexual as well as the excretory functions of the perineal area. The perineal defects need to be assessed in three dimensions, the skin defects may be associated with a large dead space in the pelvis following surgical excision of tumors, and it must be remembered that the rigid bony pelvis does not allow the wounds to collapse, resulting in fluid collection. There are many options for reconstruction of the perineum. They range from primary closure, grafting to flaps. Flaps include fasciocutaneous /muscle flap, gracilis myocutaneous flap, rectus abdominis flaps, posterior thigh flaps, groin flap, pudendal fasciocutaneous flap, gluteal flaps, rectus femoris flaps, tensor fascia lata flap, vastus lateralis flap, and perforator flaps. Less commonly used options are internal oblique muscle flap and omental flaps. The gracilis myocutaneous flap, which was first described by Orticochea in 1972 [1], was originally conceptualized as a myocutaneous or muscle flap. The gracilis myocutaneous flap[2-5] is favored by several influential groups of reconstructive surgeons due to the donor site profile and speed of dissections and has tradionally been used to reconstruct small to large size perineal defects [6,7]. It is particularly attractive to patients who do not want abdominal, buttock, or back scars. In gracilis myocutaneous flap, donor site scars are well concealed, and it Keeping donor site morbidity to a minimum, as patients present with significant comorbidity, preoperative radio- and chemotherapy, and a high risk for wound complications[7] It is supplied by the ascending branch of the medial circumflex femoral artery and can be tunnelled into the perineum without microvascular anastomosis, making it ideal for perineal reconstruction in cancer patients. This study reviews our institutional experience with the gracilis myocutaneous flap over four years, focusing on surgical technique, complication rates, and long-term outcomes.

After obtaining approval from the institutional ethics committee, a retrospective review was done of the cases for which a Gracilis flap was utilized to reconstruct perineal defects. The review was conducted in the Department of Surgical Oncology between January 2021 and January 2025. Inclusion Criteria: 1. Patients diagnosed with malignant tumors necessitating surgical resection leading to perineal defects. 2. Individuals for whom the Gracilis Flap was the chosen reconstructive option post-tumor resection. 3. Availability of Comprehensive Medical Records: Cases with detailed preoperative assessments, intraoperative notes, and comprehensive post-operative follow-up records to ensure thorough data collection and analysis. Exclusion Criteria: 1. Cases where reconstructive surgery involved techniques other than the Gracilis muscle flap. 2. Incomplete Medical Records: Patients lacking comprehensive preoperative assessments, intraoperative details, or adequate post-operative follow-up records essential for thorough data collection and analysis. 3. Patients who did not give consent were excluded from the study The study utilized patient discharge cards, follow-up records, and data analysis to examine patient profiles and disease characteristics. All patients were categorized based on AJCC/TNM 2018 classification for their respective types of tumors using clinical and radiological methods such as CECT and CE MRI. Following institutional protocols, patients were monitored for a minimum of one year after surgery. The study assessed the flap's condition, complications of the procedure, and functional outcomes.

Our study involved 20 patients who underwent perineal reconstruction with a gracilis myocutaneous flap (GMCF) following malignant tumor excision over a four-year period. These cases represented all instances where GMCF was selected as the definitive reconstructive option during the study period. The mean age was 49.95 years (range: 34–65 years), with a female predominance (55%, n=11) over males (45%, n=9). The demographic profile, diagnosis, defect size, radiotherapy history, complications, and management are summarized in Table 1. The defect sizes ranged from 7×5 cm (35 cm²) to 24×8 cm (192 cm²), with a mean defect area of ~83.55 cm². The flap length in our series ranged from 7 to 24 cm, and the flap width ranged from 5 to 8 cm, depending on the size of the perineal defect. The skin paddle was designed longitudinally over the gracilis muscle, ensuring inclusion of the dominant vascular perforators for reliable skin survival. Fourteen patients (70%) had received prior radiotherapy to the operative field. Table 1 : Demographic, disease, flap size, complication, and management profiles of patients Case Age/Sex Diagnosis Defect Size (cm) Prior RT Follow-up (months) Donor Site Complications Recipient Site Complications Management 1 52/M Rectal adenocarcinoma 10x8 Yes 14 None None None 2 44/F Vulvar SCC 8x6 Yes 12 Seroma None None 3 59/F Recurrent anal SCC 15x7 yes 15 None Partial necrosis Flap Revision And Suturing 4 38/M Sarcoma 7x5 No 10 None None None 5 47/F Vulvar SCC 9x7 Yes 9 None None None 6 56/M Rectal adenocarcinoma 20x8 Yes 12 None Partial necrosis Flap Revision And Suturing 7 62/F Vulvar SCC 11x8 No 14 None Dehiscence Conservative 8 34/M Sarcoma 8x6 No 6 Seroma None None 9 53/F Vulvar SCC 12x6 Yes 11 Infection None None 10 41/M Rectal adenocarcinoma 9x7 Yes 16 None None None 11 64/F Vulvar SCC 10x8 No 18 None None None 12 49/F Vulvar SCC 16x8 Yes 12 None Partial necrosis Flap Revision And Suturing 13 55/M Rectal adenocarcinoma 9x6 Yes 14 None None None 14 36/F Sarcoma 12x8 No 8 Seroma Recurrence wide local excision and free flap reconstruction 15 48/M Rectal adenocarcinoma 20x6 Yes 13 None complete flap loss Reconstruct with gluteal flap 16 60/F Perianal Paget's disease 8x6 No 11 None None None 17 51/M Recurrent anal SCC 10x8 Yes 15 None Dehiscence Conservative 18 39/F Vulvar SCC 8x6 Yes 12 None None None 19 65/M Rectal adenocarcinoma 24x8 yes 16 Infection Partial necrosis Flap Revision And Suturing 20 46/F Vulvar SCC 9x7 Yes 9 None None None In this series, vulvar squamous cell carcinoma was the most common indication for reconstruction (8 patients), followed by rectal adenocarcinoma in 6 patients, perineal or pelvic sarcoma in 3 patients, recurrent anal squamous cell carcinoma in 2 patients, and perianal Paget’s disease in 1 patient. In all cases, a pedicled gracilis muscle flap was harvested from the ipsilateral medial thigh and tunnelled to the defect site without the need for microvascular anastomosis. All donor sites were closed primarily without tension. Patients with vulvar carcinoma tolerated the procedure well, with excellent postoperative recovery, high cosmetic satisfaction, and no recurrence during follow up (Figure 1). Those with rectal adenocarcinoma who had undergone abdominoperineal resection or pelvic exenteration benefited from robust deep space coverage, reducing the risk of wound breakdown (Figure 2,3). In the two cases of recurrent anal squamous cell carcinoma, both previously irradiated, the flap maintained excellent viability with no postoperative wound breakdown or sinus formation (Figure 4). Reconstruction in perineal and pelvic sarcoma was more challenging due to the aggressive disease and large defect sizes; two patients developed donor site seromas managed conservatively, and one required revision surgery for tumor recurrence unrelated to flap viability. The patient with perianal Paget’s disease achieved complete wound healing within three weeks and reported high functional and aesthetic satisfaction Donor site complications occurred in five patients (25%), with seroma in three patients (15%) managed successfully with aspiration and compression dressings, and infection in two patients (10%) treated with antibiotics and local care. Recipient site complications were observed in eight patients (40%), including partial flap necrosis in four patients (20%) managed with debridement and secondary suturing, wound dehiscence in two patients (10%) treated conservatively, complete flap loss in one patient (5%) salvaged with a gluteal flap, and one case had recurrence in 8 month follow up. Management of complications included flap revision and secondary suturing in four patients (20%), conservative care in two patients (10%), salvage with a gluteal flap in one patient (5%) and wide local excision with free flap reconstruction in one patient (5%) respectively. The mean follow up was 12.35 months (range: 8–15 months), and 19 out of 20 patients (95%) achieved long term flap survival. All surviving flaps demonstrated healthy integration with satisfactory contour, pliability, and colour match. No patient reported significant gait disturbance or persistent donor site discomfort, and donor site morbidity scores on the visual analog scale were less than 3 in most cases, indicating minimal long term functional impairment. Cosmetic satisfaction was particularly high in vulvar reconstruction cases. Overall, the gracilis myocutaneous flap proved to be a reliable, durable, and aesthetically satisfactory reconstructive option for complex perineal defects, including those in previously irradiated fields, with a high success rate and minimal donor site morbidity.

Perineal defects following malignant tumor resection pose a challenging reconstructive problem due to complex pelvic anatomy, high bacterial contamination risk, and the frequent presence of irradiated tissues [8, 9]. The reconstructive strategy must ensure durable coverage, obliteration of dead space, tension free closure, and preservation of function [10]. The gracilis myocutaneous flap is a versatile and reliable option that fulfils these criteria, especially in resource limited settings [11, 12]. The gracilis muscle, situated in the medial thigh, is a long, strap like structure with consistent neurovascular anatomy [13]. It is primarily supplied by the ascending branch of the medial circumflex femoral artery, entering the muscle approximately 8–10 cm below the pubic tubercle [14]. Venous drainage parallels arterial inflow, and innervation is provided by the anterior branch of the obturator nerve [15]. Functionally, the muscle assists in thigh adduction and knee flexion, but its removal causes negligible morbidity in most patients [16]. Its length, pliability, and robust vascularity make the gracilis flap well suited for perineal reconstruction. It can be easily tunnelled subcutaneously to the defect without the need for microvascular anastomosis [11, 17]. In our series of 20 patients, the mean defect size was 11.75 × 6.95 cm, with the largest measuring 24 × 8 cm. Prior radiotherapy was present in 70% of patients, a factor known to increase wound complication risk [9, 18]. Despite this, flap survival was excellent, with primary survival in all cases. Donor site complications occurred in 25% (seroma and infection), and recipient site complications occurred in 40% (partial necrosis, dehiscence, flap loss, or recurrence). These results are consistent with previous reports, where gracilis flap survival rates exceed 95% [11, 12, 19]. Advantages of the gracilis flap include ease of harvest, short operative time, low donor site morbidity, and robust vascularity even in irradiated fields [11, 17]. All donor sites in our study were closed primarily, and the majority of patients reported minimal discomfort (VAS <3). Limitations include the restricted skin paddle size and the potential for partial necrosis if the skin paddle exceeds the dominant vascular territory [19]. Our findings confirm that the gracilis myocutaneous flap remains an effective, safe, and accessible option for reconstructing perineal defects after oncological resection. It should be considered a first line reconstructive method in settings lacking microsurgical expertise, particularly for defects in previously irradiated tissue.

The gracilis myocutaneous flap is a dependable, versatile, and technically straightforward option for the reconstruction of complex perineal defects following malignant tumor resection. Its predictable vascular anatomy, ease of harvest, and low donor site morbidity make it particularly valuable in resource limited settings and in patients with a history of pelvic irradiation. In our series, the flap achieved a 95% survival rate, provided durable coverage, and yielded excellent functional and aesthetic results, even in challenging cases. Given its reliability, minimal functional impairment, and adaptability to varied defect sizes, the gracilis myocutaneous flap should remain a first line reconstructive choice for perineal defects in oncological surgery.

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