the lack of local tissue options leads one to consider regional flaps and synthetic mesh for reconstruction .
there are multiple approaches and several regional tissue or synthetic options [ 2 , 3 ] .
the trans - abdominal approach allows better visualization of the pelvic floor , but re - entering an operated abdomen has risk of bowel injury .
the perineal approach mitigates risk to the bowel , but it is more difficult to secure the repair . the use of bone anchors to help secure mesh in perineal reconstruction has been described .
recently , bone anchors have also been used to secure the biologic mesh . when the perineum has been radiated as part of cancer treatment ,
regional flaps such as the vertical rectus abdominismyocutaneous ( vram ) flap or thigh based flaps are often used . traditionally , these flaps are secured to surrounding soft tissues with sutures .
we report the first known case of use of bone anchors to secure an autologous flap for perineal reconstruction .
a 64-year - old female presented to our office with a perineal hernia ( fig .  1 )
she had a history of recurrent low - lying rectal cancer for which she received neoadjuvent external beam radiation and chemotherapy , followed by apr .
the patient reported not being able to sit due to pain related to the hernia .
she also did have a large ventral hernia related to her previous abdominal surgeries . 

due to her history of perineal radiation , we decided to treat her with a vram ( fig . 
there was concern about securing the flap in the perineum due to the size of the defect and previous radiation making the tissues friable . in light of this
she also underwent abdominal wall reconstruction with separation of components and mesh placement during the same operation . 

several fastin mitek brand ( raynham , ma ) bone anchors were placed in the bones surrounding the pelvic outlet , including the fecal promintory , pubic tubercle and pelvic rim ( fig . 
care was taken not to injure the ureters , sacral venous plexus , surrounding nerves and blood vessesl .
the flap was parachuted down into the pelvis and the sutures were tied to secure the flap in place .
this created a pelvic sling to close off the pelvic inlet from the abdominal cavity . 

the suture is attached to the bone anchor and is seen running in the handle . a mitek fastin bone anchor .
the suture is attached to the bone anchor and is seen running in the handle .
the perineal repair at that time was intact . at 18 month follow - up , there was good healing of all the wounds and no recurrence of either hernia ( fig .  4 ) . 

. there are multiple risk factors for the development of a perineal hernia including female sex , major abominopelvic surgery and irradiation as was seen in our patient .
smoking is also a well - known risk factor for hernia and again our patient had this risk factor . despite these risks ,
use of synthetic and biologic meshes in hernia repair has widely been reported [ 2 , 4 , 5 ] .
use of bone anchor fixation techniques has also recently been reported [ 4 , 5 ] .
bone anchors provide reliable fixation of mesh that is not reliant on soft tissue strength [ 4 , 5 ] .
there use in orthopedics is widely reported and their use in ventral hernia repair has been recently described [ 8 , 9 ] .
in addition , their use in pelvic reconstruction has been reported by urologists for bladder slings . when the patient has been irradiated , the challenge becomes greater .
placement of mesh in these patients is not ideal and can lead to further complication such as mesh erosion , infection and recurrence . in these patients ,
there are multiple options including the vram , gracilis , thigh - based flaps , omental flaps [ 6 , 7 ] .
it does , however , require trans - abdominal approach and can lead to donor site morbidity such as ventral hernia .
traditionally , the vram is secured into place using suture to the surround pelvic ring soft tissues or periosteium .
however , in irradiated patients , we feel that this does not provide the strength needed to secure the flap to prevent recurrence .
we applied the use of bone anchors to provide a secure platform on which to secure the autologous flap . in our patient ,
the bone anchors enabled us to securely fixate our autologous flap on a stable platform for pelvic floor reconstruction .
this is the first report of use of bone anchors to aid in autologous reconstruction of the pelvic floor .
we recommend the use of bone anchors to secure autologous soft tissue flaps when surrounding tissues are not suitable for suture fixation .
 the purpose of this case report is to demonstrate the use of bone anchors with an autologous flap in perineal reconstruction . 
 this technique has not been reported before . 
 a 64-year - old female presented to our office with a chief complaint of perineal hernia 1.5 years after abdominoperineal resection . 
 she had a history of recurrent rectal cancer for which she received chemotherapy , radiation and surgery . to repair the hernia , 
 a standard vertical rectus abdominismyocutaneous was harvested and de - epithelialized . 
 it was secured into place in the pelvis utilizing several bone anchors . 
 mesh was used to repair the donor site defect . at 18 month 
 follow - up , there was good healing of all the wounds and no recurrence of the hernia . 
 she was pain free and able to resume her activities of daily living . 
 bone anchor fixation is a viable technique for fixation of autologous flaps in perineal reconstruction . 
INTRODUCTION
CASE REPORT
DISCUSSION