S-Plasty Repair of Whitehead Deformity of the Anus* A. THOMAS HUDSON, M.D.

Active Staff, Ferguson Clinic, Grand Rapids, Michigan

S U R G I C A L R E P A I R O f a Whitehead deform- ity of the anus, utilizing an S-plasty tech- nic, was first described by Ferguson 1 in 1959.

The term Whitehead deformity is actually a misnomer; however, it does convey a concise impression of the anal deformity. I t is caused by an improperly performed amputat ive type of hemorrhoidectomy, originally described by Walter Whitehead in 1882. I t is characterized by ectropion of the rectal mucosa after complete excision of the skin of the anal canal and the imme- fliate perianal margins. T h e exposed mu- Cous membrane causes excessive moisture, erosion with passage of bright red blood, a'~d persistent discomfort which is annoying and many times disabling. In many in- stances the patient tolerates the discomfort fqr years. T h e deformity is easily recog- nized and, to correct it, surgical repair is required.

T h e surgical technic required to Correct a Whi tehead deformity includes removal o~ the exposed mucosa, mobilization and transfer of viable skin to cover the exposed sphincter muscle fibers.

T h e operative procedure is performed in the following manner: A circular incision is made at the abnormal mucocutaneous junction, the mucosa is dissected free and amputa ted at approximately the normal level of the pectinate line. The external and internal sphincter muscle fibers are clearly exposed (Fig. 1).

With the denuded anal canal as the center, an S-shaped incision is out l ined as shown by the dotted lines in Figure 1. T h e skin flaps a to a ~ and b to b ~ are then out- lined. T h e bases of the flaps are opposite each other and each base is as great as or greater than the length of its respective flap.

* Read at the meet ing of the American Procto- logic Society, Cleveland, Ohio, June 20 to 22, 1966.

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Fro. I. Schematic representat ion of anal canal after removal of ectropion. Note skin flap outl ines a to al and b to bl; S, skin; F, muscle fibers, and M, mucosa.

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FIG. 2. Right flap has been elevated and b rough t into place. Lef t flap is being elevated. Note full thickness of skin flaps and accurate approx ima t ion of flap edges a and b~, al and b.

58 HUDSON

Fro. 3. Perianum at initial examination. Note ectropion of rectal mucosa.

Ful l - th ickness skin flaps are then mobi l -

ized. T h e skin flaps are ro t a t ed in to tile

ana l canal in such a mannm7 as to cover

the exposed sph inc te r muscle fibers so tha t

they come in to appos i t i on wi th the edge

of the lower rec ta l mucosa to form an ana-

tomica l ly accurate anorec ta l j u n c t i o n (Fig.

9). N o p r e l i m i n a r y sutures are p]aced in

the free mucosa l edge, no r are a n c h o r i n g

sutures used subcu taneous ly on the mobi l -

ized skin flaps. T h e free skin edge is

a t t ached to the mucosa l edge by i n t e r r u p t e d

000 ca tgut sutures (Fig~ 9 yyy). W h e n the flaps are moved to thei r new

posi t ion, it wil l be n o t e d tha t the edges a

and b' and a ' and b meet in the pos te r io r

and an t e r io r midl ines , respect ively, where

they are su tu red together . T h e final resul t

Fro. 4. hnmediate postoperanve appearance of perianum. Note skin flaps rotated into place, nor- mal perianal contour, exposed donor sites, and tension-free approximation of skin edges.

is an ana l cana l l ined wi th n o r m a l v iab le

skin. P recau t ions tha t shou ld be observed

in this p rocedu re i nc lude m o b i l i z a t i o n of

lu l l - th ickness skin flaps a n d r o t a t i o n of the

skirt flaps so tha t there wi l l be no tens ion

on the su tu re l ine. N o p a r t i c u l a r effort is

r equ i r ed to close the e x t e r n a l donor sites

because they ep i the l i a l i ze r ap id ly , bu t un-

due tens ion may cause e m b a r r a s s m e n t of

the b lood supp ly to the flaps.

P reope ra t ive p r e p a r a t i o n inc ludes a l iq-

u id diet , a p p l i c a t i o n of i n t r a l u m i n a l ant i -

b io t ic agents, and m e c h a n i c a l c ieans ing o[

the colon. Pos tope ra t ive care consists of a

l i q u i d d ie t for 5 days, p a r e n t e r a ! adminis -

t r a t ion of a n t i b io t i c agents, and local

w o u n d care.

S-PLASTY REPAIR OF "~VHITEHEAD DEFORMITY 5 9

Fro. 5. Perianum 10 days. after operation showing donor sites with good granulating bases.

M o d e r a t e fecal i n c o n t i n e n c e m a y o c c u r

at first, b u t u s u a l l y i t is s e l f - l im i t ed a n d

causes n o d i s a b i l i t y a f t e r r e e s t a b l i s h m e n t

of t o n e of the s p h i n c t e r muscles .

F e r g u s o n r e p o r t e d f o u r cases of W h i t e -

h e a d d e f o r m i t y in w h i c h th is t e c h n i c was

e m p l o y e d . R e s u l t s w e r e e x c e l i e n t in all

cases, a n d f ina l ly t h e r e was a p l i ab l e ,

a d e q u a t e , a n d n o r m a l l y - f u n c t i o n i n g a n a l

cana l . M i n i m a l nec ros i s of a sk in f lap

o c c u r r e d in o n e p a t i e n t a n d the r e s u l t a n t

de fec t h e a l e d u n e v e n t f u l l y w i t h o u t func-

t i o n a l def ic iency .

R e p o r t o f a Case

A 38-year-old white man presented himself with

a history of bright red bleeding from the rectum, continuous discharge of mucus, severe perianal

Fro. 6. Perianuria 3 weeks after operation showing ahnost complete epithelization of donor sites. Note normal perianaI contour.

excoriation, pain and discomfort. He also had rela-

tive fecal incontinence. These signs and symptoms had been present since

an amputative type of hemorrhoidectomy was per- formed iI years prior to admission. The remainder

of the past history was of no consequence. Anorectal

examination revealed an ectropion of rectal mucosa within the anaI canal and extending to the perianal

margins (Fig. 3). Sigmoidoscopy was normal to the

level of -°5 cm. X-ray studies of the colon after a

barium enema were negative. After appropriate preoperative preparation, the

anal deformit~ ,vas repaired, employing the S-plasty

technic. Although loss of blood appeared great during the operauon, actually the total loss was

minima! anct shoutd not alarm a surgeon when he

first attempts to perform the procedure: The imme- diate postoperative condition is shown in Figure 4, and Figures ,5 and G illustrate the progress in heal-

ing noted, respectively, at 10 days and 3 weeks

after the operation. Figures 5" and 8 re~eal the condition of the peri-

60 HUDSON

FIc. 7. Perianum 3 months after operation. Donor sates and incisions are completely healed. Scars are soft and pliant.

anum and anal canal, respectively, 3 months after surgical repair. I t will be observed that the pert- anal contour is normal and the anal canal is lined with normal viable skin which is 'soft and pliant.

The patient experienced some fecal incontinence during the first 2 weeks, but this corrected itself later without further attention.

Summary a n d C o n c l u s i o n s

A m e t h o d of s u r g i c a l r e p a i r of e c t r o p i o n

of m u c o s a o c c u r r i n g a f t e r a n i m p r o p e r l y -

p e r f o r m e d a m p u t a t i v e t ype of h e m o r r h o i d -

FIG. 8. Anal ca.nal 3 months after operatmn. Note anaI canal is lined with normal viabIe skin. Perianal contour is normal.

e c t o m y h a s b e e n d e s c r i b e d . R e s u l t s a f t e r

a n o p l a s t y , e m p l o y i n g t i le S -p las ty t e c h n i c ,

h a v e b e e n e x c e l l e n t .

T o c o r r e c t a W h i t e h e a d d e f o r m i t y of t he

a n u s , s u r g i c a l r e p a i r is r e q u i r e d .

R e f e r e n c e

I. Ferguson, J. A.: Repair of "Whitehead de- formity" of the anus. Surg., Gynec. & Obst. 108: II5, 1959.