Extensive perineal reconstruction with chimeric latissimus dorsi flaps

Introduction Wound complications following abdominaoperineal resection (APR) or pelvic exenteration are frequent, particularly in previously irradiated patients.[ 1​ ] Flap-based reconstruction is therefore essential in these patients to address dead space, contamination and radiation damage. The vertical rectus abdominis myocutaneous (VRAM) flap is still the workhorse option, with multiple studies demonstrating reduced wound complications after chemoradiation and APR.[ 2​ ] However, VRAM use is limited in patients with abdominal stomas, prior laparotomies or mesh repairs due to risks of hernia and donor site morbidity.[ 2​ ] Local or regional flaps such as gracilis, gluteal V-Y, or posterior thigh flaps can be effective but may be unreliable in irradiated fields, with limited volume for deep pelvic dead-space obliteration.[ 3​ ] [ ​4​ ] A latissimus dorsi (LD) free flap allows for reconstruction with healthy, non-irradiated tissue without the risks of the VRAM. Reports of free LD flaps for perineal reconstruction are limited, but demonstrate feasibility.[ 5​ ] LD muscle is flat and thin; to maximize volume oblitaration, we used it in a “rolled” manner to reach a cylindrical shape. The addition of a TDAP skin island creates a chimeric flap configuration, allowing independent insetting of muscle and skin components (muscle can obliterate dead space while the skin paddle replaces the irradiated superficial tissues).[ 6​ ] [ ​7​ ] The recently published Bern DAM consensus on pelvic–perineal reconstruction provides a structured algorithmic framework, recommending a stepwise progression from regional pedicled flaps to free tissue transfer when local options are unavailable or unsuitable.[ 8​ ] The present series was conducted in accordance with this philosophy. This article presents three consecutive cases of extensive perineal reconstruction with a chimeric LD–TDAP free flap ([ Table 1 ]). Table 1 Patient characteristics, defect features, reconstructive decision-making and outcomes Case 1 Case 2 Case 3 Age/sex 55/M 78/M 65/M Comorbidities None Smoker, DM type 2 Smoker Weight (Kg) 68 72 79 Oncological diagnosis Anal SCC T2N2M0 Anal SCC T3N1aM0 Anal SCC yT0N0M0 Neoadjuvant RT/CT Yes Yes RT Abdominal stoma Yes Yes Yes Defect type Deep narrow posterior pelvic cavity+large skin defect Large funnel-shaped irradiated cavity+skin defect Wide superficial cutaneous and subcutaneous necrosis Defect size (cm) 19×7×20 20×10×15 25×12×8 LD muscle size (cm) 25×15 22×12 20×10 TDAP paddle size (cm) 18×10 22×7 24×12 Recipient vessels Superior gluteal a.+vv. Superior gluteal a.+vv. Superior gluteal a.+vv. Complications Venous congestion (overpacking) → urgent debulking; second revision for residual pelvic necrosis None Superficial wound dehiscence → surgical debridement Follow-up (m) [24] [18] [12] Final outcome Stable wound closure Stable wound closure Stable wound closure Sitting comfort No limitations No limitations Mild discomfort resolved by month 3 Perineal hygiene Satisfactory Satisfactory Satisfactory Donor-site morbidity Minimal; seroma resolved None None Abbreviations: APR, abdominoperineal resection; CT, chemotherapy; DM, diabetes mellitus; LD, latissimus dorsi; RT, radiotherapy; SCC, squamous cell carcinoma; TDAP, thoracodorsal artery perforator; VRAM, vertical rectus abdominis myocutaneous. Publication History Received: 07 February 2026 Accepted after revision: 09 July 2026 Article published online: 31 July 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany