Surgical Approaches to Perineal Reconstruction: A Narrative Review

The reconstruction of the perineum remains one of the most demanding fields in reconstructive surgery. The region combines a contaminated operative field, a high prevalence of prior radiotherapy, complex three-dimensional dead space, and functional structures (the anus, urethra, and vagina) whose preservation or restoration directly determines the quality of life. The principal indications for perineal reconstruction are oncologic resection, most commonly abdominoperineal resection and pelvic exenteration for anorectal and gynecologic malignancy, radical vulvectomy, and the soft tissue destruction produced by Fournier gangrene. This narrative review traces the historical evolution of perineal reconstruction from the era of open wound packing to modern perforator flap surgery, summarizes the anatomic and physiologic principles that underpin flap-based repair, and appraises the current evidence for the main reconstructive options, including primary closure, biologic mesh, omental flaps, the vertical rectus abdominis myocutaneous (VRAM) flap, gluteal and thigh-based flaps, and fasciocutaneous perforator flaps such as the lotus petal flap. Comparative data from systematic reviews, meta-analyses, and the recent BIOPEX-2 and Nordic Extended Abdominoperineal Excision (NEAPE) randomized trials are discussed, together with functional, sexual, and quality of life outcomes and reconstructive strategy in Fournier gangrene. A defect-oriented algorithmic approach, tailored to the resection performed, the radiation field, patient factors, and donor site availability, currently offers the most rational framework for choosing among reconstructive options.