Perineal reconstruction in fournier’s gangrene: the role of the lotus petal flap in the current paradigm

Abstract

Introduction. Perineal reconstruction after major pelvic resections and in Fournier’s gangrene requires well-vascularized tissue to obliterate dead space with low donor-site morbidity. The lotus petal flap (LPF)—a fasciocutaneous flap based on internal pudendal perforators—provides close skin concordance in color and thickness and notable technical versatility. Methods. Narrative review of current indications, operative steps, and modifiers of outcomes for the LPF, prioritizing recent clinical series and comparative studies, including variants (bilateral, oversized) and Doppler-guided planning. Results. The LPF is valuable for large defects after APR/ELAPE, complex rectovaginal/rectoperineal fistulas, and vulvar/labial reconstruction. Technique: prone design, ischium–scrotum/vagina–anus triangle, Doppler localization of perforators, and a 3–4 cm base; in extensive defects, combine a deepithelialized petal (volume) with a cutaneous petal (cover). Outcomes are influenced by defect size, surgical timing (delay until a clean bed in infection), and comorbidities (diabetes, prior irradiation). Discussion. Predominantly retrospective evidence supports the LPF when high-quality skin coverage and abdominal wall preservation are prioritized; evidence gaps remain versus muscular flaps for very large pelvic cavities.Conclusion. The LPF should be considered the first-line fasciocutaneous option when reliable coverage and moderate dead-space obliteration are needed; success hinges on precise indication, perforator-based design, and appropriate timing.