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Reconstructive Procedures

Reconstructive Procedures

Reconstructive Procedures

Trunk And Perineal Reconstruction

Trunk and Perineal Reconstruction-2

Which areas encompass the trunk and perineum?

The trunk and perineum encompass the chest, abdomen, pelvis, back, buttocks, and groin.

Wounds and defects in these regions can occur due to multiple reasons including trauma, infection, and cancer excision. Occasionally, these defects can be iatrogenic (caused by previous medical intervention) arising from prior surgery or as a complication of a recent surgery.

The resultant defects vary in size and depth, and can involve multiple tissues and layers, potentially leading to loss of protection of deeper abdominal or chest (visceral) contents. Whilst smaller, partial thickness wounds can potentially be closed, larger and full thickness wounds require robust, dependable reconstruction to seal off the viscera, prevent deep infection and reduce risk of hernia formation.

Reconstructive surgery of the trunk and perineum aims to protect visceral contents, provide solid and dependable reinforcement to reduce herniation of internal organs, maximize appearance through replacing like with like as much as possible whilst minimizing scarring, and allow return to normal function.

What conditions lead to defects of the trunk and perineum and how are they reconstructed?

Defects of the trunk and perineum can arise from congenital disorders, trauma, infection, cancer extirpation, and can be iatrogenic. Examples of iatrogenic defects include sternal wounds occurring due to infection after open heart surgery, or abdominal hernias resulting from previous surgical incisions.

Depending on the cause of the defect, appropriate assessment is required to determine the layers involved and the key elements that require reconstruction. A decision must be made as to whether other manufactured materials such as meshes must be used, and where tissue can be taken in the form of grafts or flaps to provide reinforcement and external coverage. Flaps can be in the form of local, pedicled or free tissue transfer. Mesh coverage is especially pertinent when there is significant loss of domain coverage, such as in the chest where multiple ribs are removed, or in the abdomen where previous infection or surgery has led to loss of abdominal muscle and fascial coverage.

What happens before surgery?

If there is a chronic or infected wound present, you will need adequate wound bed preparation through debridement and wash, dressings as well as antibiotic treatment (if needed).

In complex defects, you may be required to undergo scans to help delineate the extent of the wound and/or plan for reconstruction.

You may be required to see an anaesthetist, and blood tests and other investigations to determine your suitability for anaesthesia may be performed.

If your reconstruction is performed in relation to cancer removal, you may require neo-adjuvant treatments such as radiotherapy or chemotherapy. Your cancer surgeon will discuss this with you.

During the procedure

Your reconstruction is usually performed under general anaesthesia (GA). If there is a resection to be performed by another surgeon, the reconstruction can be performed concurrently. Complex reconstructions involving multiple tissues and microvascular work can take many hours to perform. During the procedure, you will be monitored closely by the surgeon and anaesthetist to ensure your well-being is kept at an optimal state, which may include blood transfusions if there is a significant amount of blood loss. You may have drains and catheters inserted during the procedure which will gradually be removed over the post-operative course.

Post-operative care

After the reconstruction is performed, the wound, graft and/or flap will be monitored closely for a few days, with adjuncts such as bed rest or special positioning required. You may require a few days’ observation in the intensive care or high dependency unit right after the operation. Whilst lying in bed, you will be seen by the physiotherapists as well as possibly be placed on calf compression devices and blood thinning medication to prevent chest infections or deep vein thrombosis.

You will be allowed to get out of bed a few days after surgery. This will be with the aid of therapists to get you used to walking again. You will likely need some form of compression to support the reconstruction, such as an abdominal binder. Drains will gradually be removed over the subsequent days. Once you are reasonably independent, you will be allowed to be discharged. Time spent as an inpatient varies but a good ballpark figure to have in mind is a week of hospital stay.

To determine the success of the reconstruction, further scans may be ordered for you.

If your reconstruction is performed in relation to cancer removal, you may require adjuvant treatments such as radiotherapy or chemotherapy. Your cancer surgeon will discuss this with you.
Trunk and Perineal Reconstruction-1

Potential risks and complications

As with any surgery, general risks include pain, bleeding, and infection. Post-operative pain is usually well controlled after surgery with medication, and the risk of bleeding and infection leading to the need for another procedure is low. There is also the general anaesthetic risk, which will be explained to you by the anaesthetist, and is typically low especially if you are healthy. There is also a small risk that the reconstruction will not be successful or may have partial loss. These can be managed conservatively or with further reconstruction. Specific to microvascular reconstruction, if there is any sign of problems with the blood supply to the transferred tissue, you may be brought back to the operating theatre expediently. Other known sequelae include scarring and numbness at the operative sites. These can be managed quite well on an outpatient basis.

Why choose Polaris Plastic Surgery?

At Polaris Plastic and Reconstructive Surgery, Dr Adrian has spent many years training in and performing reconstruction for all types of trunk and perineal reconstruction. In particular, he has performed many cases of pelvic and perineal reconstruction with his urological, colorectal, and orthopedic colleagues during his time at the Singapore General Hospital, as well as abdominal incisional hernia repairs with his general surgical colleagues, with excellent success rates. He believes the key is in working closely with other specialists and therapists involved to achieve satisfactory outcomes.

Schedule a consultation with Dr Adrian to assess your needs and goals. He will communicate with you regarding your concerns, and in discussion formulate and perform the reconstructive procedure with appropriate outcomes.

FAQ

After pregnancy, I have found that there is a bulge in my abdomen. Can this be fixed?

Due to the natural process of pregnancy, the abdomen can be stretched significantly by the uterus and foetus. This leads to a form of tissue expansion of the muscle, fascia, and skin of the abdominal wall, which while maintaining some form of elasticity may unfortunately never return to its original quality, much like a balloon that has been filled with air for a long time.

In most instances, these defects are small and do not cause much problem. However, there is a subset of women who develop significant widening between the abdominal six-pack muscles (diastasis recti) and who even develop para-umbilical hernias. These can be the cause of much distress and potentially pain, despite exercising or binding. In addition, there is usually a significant amount of loose skin which is not amenable to conservative management.

In these instances, truncal reconstruction can be performed by way of a mini- or full abdominoplasty. The defect in the muscle and fascia can be repaired and excess skin removed, thus restoring the silhouette you desire along with allowing you to return to normal function.

I have a bulge in my abdomen from where I had previous surgery. Can this be fixed?

Most abdominal surgeries and surgical scars heal without issues. However, there occasionally can be a breakdown in the fascial and muscle repair of the abdominal wall, leading to an incisional hernia. Risk factors for these include obesity, diabetes mellitus or previous infection at the surgical site. The bulges resulting from the incisional hernia can be quite significant, and lead to difficulty with daily activities. A plastic surgeon, commonly with general surgical support, is well trained to repair these defects in a sequential, safe manner with long term success.

Can my pressure sore be reconstructed?

A pressure sore usually arises from prolonged pressure on the soft tissue over a bony surface. In the trunk, this is usually the sacral and hip bone areas, and are common in patients who are immobile for a prolonged period. These sores can range from superficial to deep, and if chronic can even involve bony infection.

Methods to treat pressure sores include conservative measures with dressings and antibiotics, along with pressure off-loading by way of regular turning or pressure-relief devices. It is also important to keep the perineal area clean. In severe cases, or where the patient is motivated to maintain pressure off-loading, surgery is an option. The wound is first cleaned thoroughly, before reconstruction is performed, usually with surrounding tissue from the thighs or buttocks. Whilst not everyone with a pressure sore is a candidate for surgery, it can potentially lead to significantly improved quality of life without the need for constant dressings.


References
1.Ooi A, Foo L, Tan BK, Ng SW. Massive sacral chordoma resection and reconstruction with a combination of pedicled and free flaps. J Reconstr Microsurg. 2015 Jan;31(1):76-8.

2. Patel, N. G., Ratanshi, I. & Buchel, E. W. The Best of Abdominal Wall Reconstruction. Plastic and Reconstructive Surgery 141, 113e–136e (2018).

3. Wong, C.-H., Lin, C., Fu, B. & Fang, J.-F. Reconstruction of Complex Abdominal Wall Defects with Free Flaps: Indications and Clinical Outcome. Plastic and Reconstructive Surgery 124, 500–509 (2009).

4. Khansa, I. & Janis, J. E. Complex Open Abdominal Wall Reconstruction. Plastic and Reconstructive Surgery 142, 125S-132S (2018).

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