Background <p>There is lack of consensus to the best approach to perineal reconstruction following extra levator abdominoperineal excision (ELAPE) for recurrent anorectal cancer and anal SCC including invasive perianal Paget’s disease often represents a challenge to reconstructive surgeons.</p> Methods <p>We propose a comprehensive consensus for the best joint approach based on a case series from January 2015 to January 2026, 95 consecutive patients prospectively identified by single surgeon (MA). We have enhanced our previously published our reconstructive algorithm at the EJPS April 2022 describing four key surgical techniques, we introduced a three-tire system tailoring the reconstruction to patient’s defect with improved outcome using a detailed postoperative wound care and rehabilitation protocol.</p> Results <p>We have observed increase trend toward using robotic assisted bowel resection. Metastasis to the regional lymph nodes found in 9.3% of patients with anorectal cancer. We have developed a rationalised enhanced tailored three tier approach. Majority had tier one, (n=66, 69.4 %) patients received de-epithelialized 4-layered vertical buttock closure (DEVBC). Tier 2, (n=19, 20 %) had bilateral buttock rotation flaps (BBRF) and bilateral buttock V–Y advancement flaps (BBV-YF). Tire 3, (n=10, 10.5%) had modified Vertical Rectus Myocutaneous Flap (MVRAM) and pedicled Gracilis myocutaneous flap. We introduced our novel adipofascial flap to provide pelvic floor support performed in over two third of our patients (n=71, 74.7 %). The overall complications rate with regards to perineal wound healing (n= 6, 6.3%).</p> Conclusions <p>Our rationalised enhanced algorithmic approach using three tier system tailoring reconstruction to individual patient’s defect followed by strict postoperative wound care and rehabilitation protocol improves out and minimise complications and donor site morbidity. </p> <p>Level of Evidence: Level III, risk / prognostic study.</p>