The need for reconstruction must be balanced with the physiological state of the patient . Overall determination of the patient’s health is key to planning the operative repair of a perineal defect; a patient too sick for surgery will not benefit from even the best reconstructive effort. For those patients healthy enough for surgery, accurate assessment of the surgical site should be performed, perhaps under anesthesia if necessary, as in the case of prior failed primary closure. The long term prognosis of the patient is also a contributor to this equation. Reconstruction will have tremendous positive impacts on quality of life so it may be considered in palliative cases too.

The most fundamental goal of the reconstructive surgeon is to replace missing tissue with the most similar tissue possible—replace “like with like,” as the saying goes. Reconstructive efforts proceed from simple to complex schemes, as dictated by the nature of the wound. The functional aim of any reconstruction is to fill dead space and provide a tension-free closure.

Local flaps are a desirable option for surgeons to recapitulate form and function with similar tissue. Axial pattern flaps are the backbone of perineal reconstructions and are supplied by named blood vessels. They may be prepared as myocutaneous (muscle with skin), fasciocutaneous (deep muscle fascia with skin), or myofasciocutaneous (muscle, deep fascia, and skin) depending on the surgeon’s needs for restoring resected tissue.

Microvascular free tissue transfer is similar to local flaps in that the tissue used for reconstruction is supplied by a named blood vessel. The key difference is that this tissue originates from elsewhere in the body; in the process of the reconstruction, the native blood supply will be severed, and a new anastomosis will be created at the site of the defect, using the named recipient blood vessels and the flap’s donor vessels. Again, the nature of the defect will determine the specific origin and tissue composition (skin, adipose, fascia, muscle) of the donor flap. Microvascular free tissue transfer provides a handful of advantages, chief among them being the ability to recruit similar tissue from distant body sites, increasing the odds of a favorable functional and esthetic outcome. Another important advantage is as a source of viable, vascularized tissue for repair of previously irradiated or infected defects with compromised tissue. Limitations of this approach derive from donor-site morbidity and extended operation times. Pedicled soft tissue flaps are always the first line of therapy for the reconstruction of perineal wounds. Free flap microvascular transfer of soft tissue flaps to the perineum is a final option if all other local and pedicled options are exhausted.

As mentioned earlier, the most important aspect of reconstructive surgery is replacing “like with like”. Classifying a defect through identification of which structures are missing and/or compromised is the first step toward remediating the defect and recapitulating normal form and function. Perineal defects are organized according to the scheme presented in Table 15.1.

For male patients with advanced rectal cancer, the penis, scrotum, and pelvic floor musculature are at risk of disruption during resection. Fortunately, total penile resection is rarely necessary. In those uncommon instances in which it is necessary, the goals of reconstruction are threefold: provide acceptable cosmesis, allow for normal urination, and facilitate normal sexual activity. Local flaps have been shown to be ineffective so free tissue approaches have been devised with greater success [9, 10]. Female patients have similar susceptibility to pelvic floor musculature injury along with potential need for vaginal vault reconstruction. The construction of a neovagina is aimed at providing a sexually functional vagina while closing the perineal wound and providing bulk filling to the pelvis to prevent bowel herniation. Many techniques have been used in the past with marginal success including skin-only grafts, intestinal grafts, and omental flaps [11]. The preferred approach is myocutaneous or fasciocutaneous flaps, such as vertical rectus abdominis myocutaneous (VRAM) flap or anterolateral thigh (ALT) flap, as discussed below [12].

Once a defect has been identified and appropriately classified, the quality of the tissue must be assessed. Viable vascularized tissue is essential for a successful reconstruction. Local flaps are the ideal, first-line reconstructive options. Potential donor sites will require adequate rotational lengths and soft tissue coverage of donor defects. Abdominal wall, thigh, or buttocks sites are frequently adequate donors. Should free tissue transfer be necessary, the patency of recipient vessels will need to be verified; failing this, appropriate planning for an arteriovenous loop should be undertaken. This can be performed using a saphenous vein graft anastomosed to femoral vessels or lumbar perforators.