Teardrop flap for a perianal lesion – A video vignette

Dear Editor, The perianal region is the hairbearing skin that lies within a 5 cm radius of the anal verge and is composed of keratinized squamous epithelium. Squamous cell carcinomas (SCCs) in this region are less common than those of the anal canal and can have more favourable outcomes if treated early [1]. These cancers usually have nonspecific symptomatology including pruritis, bleeding, lump or discharge. Due to these nonspecific symptoms and improper examination of this sensitive and complex region, missed diagnosis and delays in treatment can occur. The typical lesion consists of an ulcerated lesion with rolled edges [2, 3]. Staging of perianal SCC is based upon the American Joint Committee on Cancer (AJCC) TNM staging. Treatment includes both surgery and chemoradiotherapy dependent on the size, staging and sphincter involvement. Smaller lesions with no sphincter or lymph node involvement can be treated with wide local excision; however, excision of larger lesions can lead to large tissue defects and the risk of faecal incontinence if there is involvement of the anal sphincter [1, 4]. We present the case of a 34yearold man with a 3 month history of bleeding from the perianal region without any significant risk factors for SCC. Initially the bleeding was presumed to be haemorrhoidal in origin; however, thorough physical examination demonstrated a perianal lesion measuring approximately 20 mm in diameter. This lesion was biopsied and confirmed to be SCC. Further workup with colonoscopy demonstrated only internal haemorrhoids and CT and endoanal ultrasound demonstrated that this lesion was localized without any lymph node or sphincter involvement. Given the localized nature of the disease and following discussion with the patient and a multidisciplinary team meeting the decision was made to proceed to wide local excision for definitive management. To achieve the adequate recommended margins of 10 mm we proceeded with a wide local excision with a modified V– Y ‘teardrop’ advancement flap as follows (Video S1):