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Wendelspiess S, Kouba L, Stoffel J, Speck N, Appenzeller-Herzog C, Gahl B, Montavon C, Heinzelmann-Schwarz V, Lariu A, Schaefer DJ, Ismail T, Kappos EA. Perforator versus Non-Perforator Flap-Based Vulvoperineal Reconstruction-A Systematic Review and Meta-Analysis. Cancers (Basel) 2024; 16:2213. [PMID: 38927919 PMCID: PMC11202299 DOI: 10.3390/cancers16122213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Revised: 06/08/2024] [Accepted: 06/10/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND Patients with advanced vulvoperineal cancer require a multidisciplinary treatment approach to ensure oncological safety, timely recovery, and the highest possible quality of life (QoL). Reconstructions in this region often lead to complications, affecting approximately 30% of patients. Flap design has evolved towards perforator-based approaches to reduce functional deficits and (donor site) complications, since they allow for the preservation of relevant anatomical structures. Next to their greater surgical challenge in elevation, their superiority over non-perforator-based approaches is still debated. METHODS To compare outcomes between perforator and non-perforator flaps in female vulvoperineal reconstruction, we conducted a systematic review of English-language studies published after 1980, including randomized controlled trials, cohort studies, and case series. Data on demographics and surgical outcomes were extracted and classified using the Clavien-Dindo classification. We used a random-effects meta-analysis to derive a pooled estimate of complication frequency (%) in patients who received at least one perforator flap and in patients who received non-perforator flaps. RESULTS Among 2576 screened studies, 49 met our inclusion criteria, encompassing 1840 patients. The overall short-term surgical complication rate was comparable in patients receiving a perforator (n = 276) or a non-perforator flap (n = 1564) reconstruction (p* > 0.05). There was a tendency towards fewer complications when using perforator flaps. The assessment of patients' QoL was scarce. CONCLUSIONS Vulvoperineal reconstruction using perforator flaps shows promising results compared with non-perforator flaps. There is a need for the assessment of its long-term outcomes and for a systematic evaluation of patient QoL to further demonstrate its benefit for affected patients.
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Affiliation(s)
- Séverin Wendelspiess
- Department of Medicine, University of Basel, 4056 Basel, Switzerland; (S.W.); (D.J.S.); (T.I.)
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, 4031 Basel, Switzerland; (L.K.)
| | - Loraine Kouba
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, 4031 Basel, Switzerland; (L.K.)
| | - Julia Stoffel
- Department of Medicine, University of Basel, 4056 Basel, Switzerland; (S.W.); (D.J.S.); (T.I.)
| | - Nicole Speck
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, 4031 Basel, Switzerland; (L.K.)
| | - Christian Appenzeller-Herzog
- Department of Medicine, University of Basel, 4056 Basel, Switzerland; (S.W.); (D.J.S.); (T.I.)
- University Medical Library, University of Basel, 4051 Basel, Switzerland
| | - Brigitta Gahl
- Surgical Outcome Research Center, University Hospital Basel, 4031 Basel, Switzerland
| | - Céline Montavon
- Department of Gynecology and Gynecological Oncology, University Hospital Basel, 4031 Basel, Switzerland
| | - Viola Heinzelmann-Schwarz
- Department of Gynecology and Gynecological Oncology, University Hospital Basel, 4031 Basel, Switzerland
| | - Ana Lariu
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, 4031 Basel, Switzerland; (L.K.)
- Faculty of General Medicine, University of Medicine and Pharmacy ‘Iuliu Hațieganu’, 400347 Cluj-Napoca, Romania
| | - Dirk J. Schaefer
- Department of Medicine, University of Basel, 4056 Basel, Switzerland; (S.W.); (D.J.S.); (T.I.)
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, 4031 Basel, Switzerland; (L.K.)
| | - Tarek Ismail
- Department of Medicine, University of Basel, 4056 Basel, Switzerland; (S.W.); (D.J.S.); (T.I.)
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, 4031 Basel, Switzerland; (L.K.)
| | - Elisabeth A. Kappos
- Department of Medicine, University of Basel, 4056 Basel, Switzerland; (S.W.); (D.J.S.); (T.I.)
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, 4031 Basel, Switzerland; (L.K.)
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Jakubietz RG, Jakubietz MG, Meffert RH, Holzapfel B, Schmidt K. Die gestielte, anterolaterale Oberschenkellappenplastik zur Weichteilrekonstruktion im Bereich von Unterbauch, Leiste, Perineum und Hüfte. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2022; 34:372-378. [DOI: 10.1007/s00064-022-00772-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 01/21/2021] [Accepted: 03/12/2021] [Indexed: 11/29/2022]
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Reconstructive Surgery versus Primary Closure following Vulvar Cancer Excision: A Wide Single-Center Experience. Cancers (Basel) 2022; 14:cancers14071695. [PMID: 35406468 PMCID: PMC8997096 DOI: 10.3390/cancers14071695] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 03/21/2022] [Accepted: 03/24/2022] [Indexed: 12/10/2022] Open
Abstract
Simple Summary When it comes to advanced vulval cancer management, there is a critical quandary to consider. This is owing to the severe negative impact of demolitive surgery on women who are afflicted by both functional and psychological consequences of the procedure. Primary closure of vulvar and/or perineal defects can be accomplished without difficulty in many situations, but this is accompanied by tension of the skin closure and distortion of the anatomy. In these circumstances, reconstructive surgery will be required to restore the anatomical and functional characteristics of the vulva. In this paper, we share our substantial expertise of primary closure versus reconstruction after demolitive surgery of advanced vulvar cancer, and we discuss our findings in light of the literature. Abstract (1) Background: plastic reconstruction in vulvar surgery can lead to a better treatment outcome than primary closure. This study aims to compare the preoperative parameters (co-morbidities and tumor size) and postoperative results (tumor free margins and wound healing) between the primary closure and reconstructive surgery after vulvar cancer surgery; (2) Methods: this is a retrospective analysis of prospectively collected data from 2009 to 2021 at a tertiary cancer institution; (3) Results: 177 patients were included in the final analysis (51 patients had primary closure PC and 126 had reconstructive surgery RS). About half (49%) of the PC patients had no co-morbidities (p = 0.043). The RS group had a 45 mm median maximal tumor diameter compared to the PC group’s 23 mm (p = 0.013). More than 90% of RS and 80% of PC had tumor-free margins (p = 0.1). Both groups had anterior vulvar excision as the most common surgery (52.4% RS vs. 23.5% PC; p = 0.001). Both groups had identical rates of wound healing disorders. In a median follow-up of 39 months; recurrent disease was found in 23.5% of PC vs. 10.3% in RS (p = 0.012). In terms of overall survival there was no significant difference between the both groups; (4) Conclusions: reconstructive vulvar surgery enables enhanced complete resection rates of larger vulvar tumors with better anatomical restoration and a comparable wound recovery in comparison to primary closure. This results in a lower recurrence rate despite the increased tumor volume.
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Elia J, Do NTK, Chang TNJ, Lai CH, Chou HH, Chang FCS, Huang JJ. Redefining the Reconstructive Ladder in Vulvoperineal Reconstruction: The Role of Pedicled Perforator Flaps. J Reconstr Microsurg 2021; 38:10-26. [PMID: 33853124 DOI: 10.1055/s-0041-1727199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Gynecological reconstruction is difficult, particularly in cases with recurrence and received previous surgeries and/or radiotherapy and necessitate secondary reconstruction. Perforator flaps can preserve other donor sites for potential later reconstruction, and they also can be better tailored to the defect. We hypothesized that the use of perforator-based flaps can better restore the defect with less complications. METHODS A retrospective review was conducted of all patients who underwent vulvar-perineum reconstruction between 2011 and 2018 by the senior author, and oncologic and reconstructive outcomes and complications were analyzed. RESULTS Thirty-three patients underwent 55 soft tissue reconstructions for vulvar-perineum defects during the study period. The mean follow-up time was 27.6 ± 28.9 months. Squamous cell carcinoma was the most common cancer (45.5%). For 11 patients (33.3%), the procedures were performed for the treatment of recurrent cancer. The average defect size was 39.8 ± 34.3 cm2. The overall survival rate was 90.3%. Profunda artery perforator flaps were the most commonly applied flap for reconstruction in both the primary and recurrent groups. Poor wound healing was the most common complication which occurred in 10 of the 55 flaps (18.2%). Perforator flaps presented fewer complications than myocutaneous flaps or traditional random flaps. Similarly, Island pedicle flap design also presented fewer complications than traditional rotation flaps. With proper reconstruction, previous surgery or radiotherapy did not contribute to an increase in complications. CONCLUSION In our experience, perforator flaps can provide satisfactory reconstruction for perineum reconstruction with low postoperative complications while preserving other donor sites in the event of disease recurrence for repeat resection and reconstruction. Previous surgery or radiotherapy did not increase the complications or preclude its usage. A redefined reconstructive ladder was created to help selecting the best state-of-the-art technique for reconstruction to achieve better results.
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Affiliation(s)
- Jhonatan Elia
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Nicholas T K Do
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Tommy N-J Chang
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chyong-Huey Lai
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
| | - Hung-Hsueh Chou
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
| | - Frank C-S Chang
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Division of Craniofacial Surgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
| | - Jung-Ju Huang
- Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Center for Tissue Engineering, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan
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Vijayasekaran A, Gibreel W, Carlsen BT, Moran SL, Saint-Cyr M, Bakri K, Sharaf B. Maximizing the Utility of the Pedicled Anterolateral Thigh Flap for Locoregional Reconstruction: Technical Pearls and Pitfalls. Clin Plast Surg 2020; 47:621-634. [PMID: 32892805 DOI: 10.1016/j.cps.2020.06.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The pedicled anterolateral thigh (PALT) flap is an underutilized flap for locoregional reconstruction largely because methods to maximize its reach are neither universally implemented nor fully understood. In addition, most of the available literature has focused on the utility of the free anterolateral thigh flap with less emphasis on the PALT flap. Moreover, flap design concepts to maximize its utility and reach and optimize outcomes have not been comprehensively described. In an effort to address this knowledge gap, the authors sought to review their institution's experience with the PALT flap for locoregional reconstruction.
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Affiliation(s)
- Aparna Vijayasekaran
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Waleed Gibreel
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Brian T Carlsen
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Steven L Moran
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Michel Saint-Cyr
- Division of Plastic Surgery, Baylor Scott & White Health, Scott & White Memorial Hospital, MS-01-E443, 2401 South 31st Street, Temple, TX 76508, USA
| | - Karim Bakri
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Basel Sharaf
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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Fin A, Rampino Cordaro E, Guarneri GF, Revesz S, Vanin M, Parodi PC. Experience with gluteal V-Y fasciocutaneous advancement flaps in vulvar reconstruction after oncological resection and a modification to the marking: Playing with tension lines. Int Wound J 2018; 16:96-102. [PMID: 30303301 DOI: 10.1111/iwj.12997] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 08/31/2018] [Indexed: 02/01/2023] Open
Abstract
Many post-vulvectomy vulvar reconstruction solutions, using local fasciocutaneous flaps where possible, have been proposed. We report the use of V-Y advancement flaps from the gluteal fold in medium to large vulvar reconstructions and a simple modification we made to the technique in order to minimise wound-related complications. Between 2006 and 2016, 30 vulvar reconstructions were performed via a total of 59 flaps, 24 of which were raised using the proposed modification to the plasty design. Short- and long-term (24 months) follow-up data were analysed, postoperative flap sensitivity was tested, and any arising complications were recorded. The mean age of patients treated was 75.3 years (51-92 years). The mean monolateral defect dimensions were 7.5 × 4.7 × 2.8 cm. Minor complications were recorded in 23% of patients (14% of flaps). One case of ostial stenosis occurred. Micturition and ambulation recovery was rapid, and flap sensitivity was fully restored 24 months after reconstruction. Scars were well hidden by natural soft tissue folds. The outcomes in this case series confirm that the gluteal V-Y advancement fasciocutaneous flap is a useful and simple technique for reconstructing even large vulvar defects. It has a low functional and aesthetic impact and enables rapid return to autonomy. Moreover, the simple modification to the V-Y flap proposed, designed to reduce tension at the apical part of the wound, appears to reduce the complication rate.
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Affiliation(s)
- Alessandra Fin
- Plastic Surgery Service, Ospedale Santa Maria della Misericordia, Udine, Italy
| | | | - Gianni F Guarneri
- Plastic Surgery Service, Ospedale Santa Maria della Misericordia, Udine, Italy
| | - Susanna Revesz
- Obstetrics and Gynecology Service, Ospedale Civile Sant'Antonio Abate, Udine, Italy
| | - Michele Vanin
- Obstetrics and Gynecology Service, Ospedale Civile Sant'Antonio Abate, Udine, Italy
| | - Pier C Parodi
- Plastic Surgery Service, Ospedale Santa Maria della Misericordia, Udine, Italy
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Vijayasekaran A, Gibreel W, Carlsen BT, Moran SL, Saint-Cyr M, Bakri K, Sharaf B. Maximizing the Utility of the Pedicled Anterolateral Thigh Flap for Locoregional Reconstruction: Technical Pearls and Pitfalls. Clin Plast Surg 2017; 44:371-384. [PMID: 28340669 DOI: 10.1016/j.cps.2016.12.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The pedicled anterolateral thigh (PALT) flap is an underutilized flap for locoregional reconstruction largely because methods to maximize its reach are neither universally implemented nor fully understood. In addition, most of the available literature has focused on the utility of the free anterolateral thigh flap with less emphasis on the PALT flap. Moreover, flap design concepts to maximize its utility and reach and optimize outcomes have not been comprehensively described. In an effort to address this knowledge gap, the authors sought to review their institution's experience with the PALT flap for locoregional reconstruction.
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Affiliation(s)
- Aparna Vijayasekaran
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Waleed Gibreel
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Brian T Carlsen
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Steven L Moran
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Michel Saint-Cyr
- Division of Plastic Surgery, Baylor Scott & White Health, Scott & White Memorial Hospital, MS-01-E443, 2401 South 31st Street, Temple, TX 76508, USA
| | - Karim Bakri
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Basel Sharaf
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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Gentileschi S, Servillo M, Garganese G, Simona F, Scambia G, Salgarello M. Versatility of pedicled anterolateral thigh flap in gynecologic reconstruction after vulvar cancer extirpative surgery. Microsurgery 2016; 37:516-524. [DOI: 10.1002/micr.30077] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 05/01/2016] [Accepted: 05/13/2016] [Indexed: 11/08/2022]
Affiliation(s)
- Stefano Gentileschi
- Department of Plastic and Reconstructive Surgery; Catholic University Sacred Heart, Policlinico Agostino Gemelli; Largo Agostino Gemelli 1 Rome Italy
| | - Maria Servillo
- Department of Plastic and Reconstructive Surgery; Catholic University Sacred Heart, Policlinico Agostino Gemelli; Largo Agostino Gemelli 1 Rome Italy
| | - Giorgia Garganese
- Department of Gynecology; Catholic University Sacred Heart, Policlinico Agostino Gemelli; Largo Agostino Gemelli 1 Rome Italy
| | - Fragomeni Simona
- Department of Gynecology; Catholic University Sacred Heart, Policlinico Agostino Gemelli; Largo Agostino Gemelli 1 Rome Italy
| | - Giovanni Scambia
- Department of Gynecology; Catholic University Sacred Heart, Policlinico Agostino Gemelli; Largo Agostino Gemelli 1 Rome Italy
| | - Marzia Salgarello
- Department of Plastic and Reconstructive Surgery; Catholic University Sacred Heart, Policlinico Agostino Gemelli; Largo Agostino Gemelli 1 Rome Italy
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