The inferior gluteal flap in the difficult vulvar and perineal reconstruction

Perforator versus Non-Perforator Flap-Based Vulvoperineal Reconstruction-A Systematic Review and Meta-Analysis

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.

Pedicled anterolateral thigh flap: A versatile flap for complex regional defect reconstruction

Objectives

Soft-tissue defects of the lower abdomen, perineum, groin, and trochanteric area often involve the loss of composite tissue components and are technically challenging to reconstruct. The goals of reconstruction should include the replacement of the defect with a suitable soft-tissue flap that provides stable coverage while protecting important exposed structures. However, there are limited locations in this region for the creation of pedicled flaps for complex defect reconstruction. The pedicled anterolateral thigh (ALT) flap is considered superior to other comparable flaps due to its varying soft-tissue components and long pedicle with consistent anatomy that allow the reconstruction of locations that are difficult to reach without significant flap donor site morbidity. Herein, we present a case series of our experience of using a pedicled ALT flap to reconstruct regional defects over a range of locations.

Methods

The present study comprised ten patients who underwent surgical reconstruction of soft-tissue defects of the lower abdomen, groin, trochanteric, scrotal, and penoscrotal defects using a pedicled ALT flap over a two-year period. The flap was customized according to the defect when required.

Results

In our case series, flap loss was not observed with only a few minor complications. All patients accepted the aesthetic appearance of the flap recipient site area without requesting revision surgery. The donor site was closed primarily in half of all cases, with split skin grafting applied in the remaining patients. Graft take at the flap donor site was satisfactory in all cases.

Conclusion

A pedicled ALT flap is a reliable and suitable option for complex soft-tissue reconstruction for regional soft-tissue defects of the lower abdomen and perineum.

Perineal perforator switch flap for three-dimensional vulvovaginal reconstruction

BACKGROUND

Vulvovaginal reconstruction is challenging. In this study, we evaluated the outcomes of vulvovaginal reconstruction with "perineal perforator switch flap" (PPSF) and compared it with other conventional flaps. In addition, the long-term esthetic results were compared with the perineal perforator propeller flap (PPPF), which we previously used.

METHODS

We retrospectively reviewed the clinical data of 16 patients (27 flaps) who underwent vulvovaginal reconstruction with PPSF. After tumor resection, perineal perforators close to the genitofemoral sulcus were identified. The flap was designed as an island with the perforator at the center. The flap was elevated while preserving the soft tissue surrounding the pedicle, and transferred to the defect via the subcutaneous tunnel without pedicle skeletonization.

RESULTS

All flaps survived and no major surgical complications were observed. The total follow-up period was 16.13±3.38 months. The mean operation time was 79.38±19.65 min, and the initiation of walking and the length of hospitalization were 1.69 ± 0.79 and 5.69 ± 0.79 days, respectively. Perineal function was well preserved. Comparison of esthetic results with PPPF showed that PPSF showed better results in symmetrical and labial shape (2.29 ± 0.73 vs. 3.13 ± 0.81; p=0.015, 2.43 ± 1.02 vs. 3.25 ± 0.68; p=0.031, respectively), and in total score. (10.29 ± 2.16 vs. 12.31 ± 1.82; p=0.017).

CONCLUSION

PPSF was technically simple and significantly reduced the duration of operation and the overall recovery time. PPSF also prevented delay in radiation. Therefore, PPSF is a promising method for vulvovaginal reconstruction.

How Big Is Too Big?: The Effect of Defect Size on Postoperative Complications of Vertical Rectus Abdominis Flap Reconstruction

BACKGROUND

The vertical rectus abdominis myocutaneous (VRAM) flap has been frequently used for perineal reconstruction given the high potential for wound complications associated with direct closure of this area. However, the relationship between defect size and postoperative complications remains undefined.

METHODS

A retrospective chart review of the last 20 years for VRAM flaps was performed. Defect size, age, body mass index (BMI), cause of defect, sex, radiation, and flap donor laterality were recorded. Complications of infection, partial flap loss, total flap loss, minor wounds, treated nonoperatively, and major wound, which required reoperation, were analyzed with respect to defect size. Descriptive statistics were used to summarize the demographic and clinical characteristics of the included patients. Associations were assessed using binary logistic regression analysis, and difference in means for compared groups was assessed using the independent samples t test. P values were set at 5% for all comparisons.

RESULTS

There were 65 patients with VRAM flaps identified during the review period. Mean defect size was 204.71 cm2. Mean age was 63.97, and mean BMI was 27.18. History of prior radiation was noted in 90.77% of patients (n = 59). When adjusted for age and BMI, mean defect area was significantly different for patients with minor or major wounds. Larger perineal defects were associated with increased risk of major wound complications (odds ratio, 1.012; 95% confidence interval, 1.003-1.022).

CONCLUSIONS

The vertical rectus abdominis flap has been a workhorse flap for perineal reconstruction. Defect size does not affect risk of partial flap necrosis, complete flap loss, infection, abdominal fascial dehiscence, ventral hernia, or seroma, which supports the utility of VRAM flap for perineal reconstruction. Larger perineal defects are associated with increased risk for major wound complications, which required reoperation, regardless of age or BMI. Future studies should be performed to determine if there is a maximum defect size cutoff that limits the utility of VRAM flap reconstruction or to develop a predictive model to assess the risk of major wound complications based on defect size.

Pelvic/Perineal Reconstruction: Time to Consider the Anterolateral Thigh Flap as a First-line Option?

Background:

Abdominoperineal resection (APR) and pelvic exenteration continue to be common procedures for the treatment of colorectal malignancy. The workhorse flap for reconstruction in these instances has been the vertical rectus abdominis myocutaneous flap. The associated donor site morbidity, however, cannot be ignored. Here, we provide a review of the literature and present the senior author’s (A.M.) experience using the pedicled anterolateral thigh (ALT) flap for reconstruction of soft tissue defects following APR and pelvic exenteration.

Methods:

Patients who underwent pelvic/perineal reconstruction with pedicled ALT flaps between 2017 and 2019 were included in the study. Parameters of interest included age, gender, body mass index, comorbidities, history of radiation, extent of ablative surgery, and postoperative complication rate.

Results:

A total of 23 patients (16 men and 7 women) with a median age and body mass index of 66 years (inter-quartile range [IQR]: 49–71 years) and 24.9 kg/m² (IQR: 24.2–26.7 kg/m²) were included in the study, respectively. Thirteen (56.5%) patients presented with rectal cancer, 5 (21.7%) with anal squamous cell carcinoma (SCC), 4 (17.4%) with Crohn’s disease, and 1 (4.3%) with Paget’s disease. Nineteen patients (82.6%) received neoadjuvant radiation. Nine (39.1%) patients experienced 11 complications (2 major and 9 minor). The most common complication was partial perineal wound dehiscence (N = 6 [26.1%]). Stable soft tissue coverage was achieved in all but one patient.

Conclusions:

The ALT flap allows for stable soft tissue coverage following APR and pelvic exenteration without being associated with abdominal donor site morbidity. Consideration to its use as a first-line reconstructive option should be given in pelvic/perineal reconstruction.

[Reconstruction of abdo-perineal resection by Taylor flap: About 68 patients]

PURPOSES

Healing after abdomino-perineal resection is often difficult, especially in patients who have undergone radiation therapy. Vaginal reconstruction is also an important issue for the women who undergo this surgery. We describe and analyze here our series of perineal reconstructions with modified Taylor flaps. Between 2010 and 2016, 68 patients (52 women, 16 men) with cancer of the anal canal (53), adenocarcinoma of the lower rectum (9), or other malignant neoplasms of the perineum underwent reconstruction with a rectus abdominis myocutaneous (RAM) flap with an inferior pedicle and an oblique skin paddle.

RESULTS

This review of records showed that all patients healed, with a median of 30 days. The reoperation rate was 11.7% including 1 for eventration. The principal causes for delayed healing were scar dehiscence, abscess, and partial necrosis. No flap required removal, however. The mean duration of hospitalization was 23.7 days.

CONCLUSION

Modified Taylor flaps substantially improved the reconstruction of defects resulting from abdomino-perineal resection. They enabled complete and rapid healing with low comorbidity.

An Algorithmic Anatomical Subunit Approach to Pelvic Wound Reconstruction

BACKGROUND

Prior radiation therapy, pelvic dead space, and a dependent location contribute to perineal dehiscence rates as high as 66 percent after primary closure of pelvic wounds. Various regional flaps have been described to reconstruct pelvic defects, but an algorithmic pairing of individual flaps to specific anatomical regions has not been described.

METHODS

A retrospective review of a prospectively maintained database was performed to identify consecutive pelvic reconstructions from 2010 to 2013 with at least 6 months' follow-up. Pelvic defects and resulting flaps were described by anatomical subunits involved: anterolateral thigh flap for mons, gracilis flap for labia majora and introitus, vertical rectus abdominis myocutaneous flap for vagina and/or perineal raphe, and gluteus musculocutaneous flap for isolated perianal defects.

RESULTS

Twenty-seven women and three men underwent consecutive pelvic reconstruction with a mean age of 60 years (range, 26 to 83 years) and a mean body mass index of 28 kg/m(2) (range, 17 to 40 kg/m(2)). Twenty-one patients (70 percent) had prior radiation therapy. In total, 45 flaps were performed according to the subunit principle. Three patients had a minor dehiscence (<5 cm), one patient had a major dehiscence, and one required reoperation for abscess. There were two partial flap losses necessitating débridement and readvancement of the flap. Twenty-five percent of female patients were sexually active after vaginal reconstruction.

CONCLUSIONS

The pelvic subunit principle provides an effective algorithm for choosing the ideal pedicled flap for each region involved in acquired pelvic defects. This algorithm is based on individual attributes that make each flap most appropriate for each subunit. Complications were minimal and patient satisfaction with appearance and function was excellent.

Outcome of vulvar reconstruction in patients with advanced and recurrent vulvar malignancies

Background

The use of flaps in vulvar cancer-related reconstruction has been increasing, but few studies have evaluated the outcome and quality of life of patients after this surgery. The purpose of this study was to evaluate the outcomes of vulvar reconstruction using musculocutaneous/skin flaps in patients with advanced and recurrent vulvar malignancies.

Methods

Patients with vulvar malignancies who underwent vulvar reconstruction using different types of flaps were retrospectively reviewed. Patient outcomes were evaluated with a focus on quality of life and prognosis.

Results

Thirty-six patients were enrolled, 58.33 % of them used anterolateral thigh flap (ALT), 16.67 % of them used pudendal thigh flap (PTF), 11.11 % of them used deep omferior epigastric perforator (DIEP) and gracilis myocutaneous flap were used in 2.78 % of the patients, the other 11.11 % patients used two types of flaps. Eleven patients (30.56 %) developed complications, including 5 patients (13.89 %) with partial necrosis, 5 (13.89 %) with minimal wound dehiscence and 1 (2.78 %) with flap cellulitis. All patients who developed partial necrosis (13.89 %) underwent reoperation. The mean verbal rating scale score was 1.44 before reconstruction and 0.17 after surgery (P < 0.0001). The mean performance status was 1.67 before surgery and improved to 0.31 after surgery (P < 0.0001). The median overall follow-up time after vulvar reconstruction was 9 months. Twenty-one patients (58.3 %) developed recurrence at a median interval of 5 months after vulvar reconstruction. After a median follow-up time of 14 months, 41.7 % of the patients were living and disease-free. The 5-year survival of the 36 patients was 53.8 %.

Conclusion

Soft tissue reconstruction in patients undergoing resection of advanced/recurrent vulvar malignances is associated with a low rate of postoperative complications, decreased pain, and improved functional status. Although the recurrence rate in this patient population is high, a reasonable proportion of patients who undergo resection for advanced/recurrent vulvar cancer and reconstructive surgery appear to benefit.

Comparison of vertical and oblique rectus abdominis myocutaneous flaps for pelvic, perineal, and groin reconstruction

BACKGROUND

Wound complications after perineal and groin obliterative procedures are a significant cause of morbidity, particularly following chemoradiation therapy. Vertical and, increasingly, oblique rectus abdominis myocutaneous flaps have been used to fill potential dead space and bring healthy, vascularized tissue into the defect. The authors compared the complications and outcomes of patients undergoing perineal or groin reconstruction with vertical or oblique rectus abdominis myocutaneous flaps. They hypothesized that the oblique flap offers outcomes similar to those of the vertical flap, without an increased risk of complications.

METHODS

All patients who underwent immediate reconstruction of perineal, pelvic, or groin defects using vertical (n=49) or oblique rectus abdominis myocutaneous (n=22) flaps over the past 10 years at the University of Washington Medical Center were reviewed retrospectively. Patient, disease, and obliterative procedure characteristics and donor- and recipient-site complications were compared. Statistical analysis was performed using the t test for continuous variables and Fisher's exact test for categorical variables.

RESULTS

There were no statistically significant differences in major or minor donor- or recipient-site complication rates, need for augmented fascial closure, need for additional flaps, flap loss, readmission, or reoperation rate between the two groups.

CONCLUSIONS

Immediate reconstruction of perineal or groin defects with oblique rectus abdominis myocutaneous flaps results in complication rates similar to those with reconstruction using with vertical flaps. Oblique flap reconstruction is a reasonable and safe alternative, providing several distinct advantages over the vertical flap, including greater arc of rotation, thinner skin paddle, less bulk, and limited fascial harvest.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Reconstruction of acquired perineovulvar defects: a proposal of sequence

Acquired perineovulvar defects are usually the result of excision of vulvar intraepithelial neoplasia (VIN) or invasive squamous cell carcinoma. Because both VIN and vulvar carcinoma have a tendency toward local recurrence, future reconstructive options should be reckoned with during treatment of the primary and all subsequent (pre-) malignant perineovulvar lesions. Hence, a proposal of sequence of reconstructive options for these defects is called for. In cases where local skin flaps suffice, these are preferably designed in such a fashion as not to sever the branches of the internal pudendal vascular system. In cases where either a pudendal thigh flap or an infragluteal flap may be used to close the perineovulvar defect, the pudendal thigh flap is to be preferred to preserve the infragluteal flap for future use. Only when these flaps no longer are available or sufficient to cover the defect should the gluteal thigh flap be applied. The use of myocutaneous flaps is rarely indicated to close isolated superficial perineovulvar defects.

Local Fasciocutaneous Infragluteal (FCI) Flap for Vulvar and Vaginal Reconstruction: A New Technique in Cancer Surgery

Introduction

Soft tissue reconstruction after vulvar, vaginal, or anal cancer resection poses a formidable task for reconstructive surgeons because of the functional, locational, and cosmetic importance of this region. Although numerous flaps have been designed for vulvar reconstruction, each has its disadvantages.

Methods

The authors introduce the local fasciocutaneous infragluteal (FCI) flap for vulvar and vaginal reconstruction after tumor resection, vaginal scar obliteration, and vulvar ulceration in 15 patients operated on between 1999 and 2007. The FCI flap is supplied by the cutaneous branch of the descending branch of the inferior gluteal artery. The sensory supply of this flap comes from side branches of the posterior cutaneous nerve of the thigh. A total of 17 flaps were performed in 15 patients.

Results

Except for one, all flaps survived. One flap necrosis occurred because of false postoperative position with compression and tension to the vascular pedicle. In the remaining patients, we found one local cancer recurrence with necessity of a second flap from the contralateral side. The patients report satisfaction with reconstruction, without one having pain at donor site and recurrent vaginal ulceration.

Conclusions

This article discusses the expanding indications of this versatile flap and the operative technique of the local FCI flap for reconstruction of vulvar and partial vaginal defects. It can be raised in different volume and dimension out of possible irradiated area with an inconspicuous scar.

The anterior Obturator Artery Perforator (aOAP) flap: surgical anatomy and application of a method for vulvar reconstruction

OBJECTIVE

Vulvar reconstruction following oncologic resection is challenging. Some flaps used for reconstruction can show adverse characteristics such as excessive tissue bulk or increased distance to the defect. Region of the sulcus genitofemoralis is of thin and pliable tissue proximate to the vulva. Vasculature and suitability of that region used for vulvar reconstruction were focused in this work.

METHODS

Vascular architecture of the region comprising the sulcus genitofemoralis was examined bilaterally on 10 female corpses (n = 20 specimens). In addition, tissue characteristics and suitability of that region to form a fasciocutaneous flap for vulvar reconstruction were anatomically examined and clinically proven.

RESULTS

Vasculature of the sulcus genitofemoralis is reflected by either a musculocutaneous perforator (80%, 16/20) piercing the gracilis muscle or a septocutaneous perforator (20%, 4/20) passing the posterior border of the gracilis muscle 1.3 ± 0.3 [cm] laterally to the inferior pubic ramus. Both types of perforators derive from the anterior branch of the obturator artery and accompanying vein. This perforator, the anterior obturator artery perforator (aOAP), supplies a skin territory of about 7 × 15 [cm] centered on the sulcus genitofemoralis. The aOAP flap proved its suitability and versatility for vulvar reconstruction.

CONCLUSIONS

The sulcus genitofemoralis is of a constant vascular anatomy reflected by the aOAP vessel. Especially the tunneled aOAP island flap offers outstanding characteristics beneficial for reconstruction of a more anatomically normal vulva. Scars are limited within anatomic borders of the urogenital region improving self-image. The aOAP flap clearly enlarges the surgical options available to restore the form and function of the vulva.

Reconstruction of an extensive perineal defect using two modified V-Y flaps based on perforators from the gluteus maximus muscle

SUMMARY

We report the case of a women with severe perineal defect secondary to a perianal cancer that required reconstruction from the posterior wall of the urinary bladder to the coccyx, and which laterally surpassed both ischial tuberosities. For this reconstructive work, we used two V-Y advanced flaps taken from the gluteal region. On the basis of these flaps, we modified the final position in the advance of the lateral ends, crossing the tips of each flap over each other to provide a greater volume of tissue in the central area, with no signs of vascular injury. We believe that the use of V-Y flaps, based on the perforating arteries of the gluteus maximus, allows the reconstruction of especially extensive defects in the perineal region. The technique is rapid and easy perform, and produces acceptable clinical outcome and minimum morbidity.

Reconstructive plastic surgery in the treatment of vulvar carcinomas

OBJECTIVE

The results obtained using plastic surgery reconstruction in 207 patients with a primary or recurrent vulvar carcinoma were analyzed with regard to the surgical procedures applied, pre-treatment and post-operative findings, along with the long-term oncological disease course.

STUDY DESIGN

Standardized data concerning the surgical procedures applied and clinical factors were collected in a databank and statistically analyzed.

RESULTS

The flaps employed were termed either 'local' (cutaneous or fasciocutaneous; n=84) or 'regional' (myocutaneous, n=123). For local flaps, the rate of secondary healing was 31%, dropping to 20% for regional flaps. Such healing disturbances often affected the donor region and did not lead to lasting clinical problems such as stenosis or distortion. Severe disturbances of wound healing (loss of more than 10%) were not observed in local flaps, whereas such problems were encountered in 5.9% of regional flaps. Gluteal thigh flaps were most frequently applied and were also the most successful type of myocutaneous reconstruction. Therapy was selected on an individual basis according to tumor status.

CONCLUSION

Plastic surgery reconstruction broadens the range of operative therapies available for the treatment of vulvar carcinomas, especially those at an advanced stage or recurrent tumors, and leads to a favorable oncological disease course as well as improved cosmetic results.

Surgical therapy of recurrent vulvar cancer

OBJECTIVE

The success of various surgical interventions in 201 cases with recurrent vulvar carcinoma was examined in the light of patients' pretreatment, surgical therapy, plastic reconstruction, and postoperative disease course.

STUDY DESIGN

A databank of standardized clinical data was analyzed using statistical procedures.

RESULTS

Therapy was selected on an individual basis according to tumor status. Recurrence at a site distant from the primary tumor, particularly in the inguinal region, indicated a markedly unfavorable prognosis. In contrast, tumors recurring locally did not exhibit any significant differences. Plastic surgery reconstruction led to improvements with respect to operability, wound healing, and survival.

CONCLUSION

Individualized reconstructive surgery of the vulva leads to good results in patients with recurrent vulvar cancer. To an even greater extent than is the case for primary therapy, plastic surgery enlarges the spectrum of feasible surgical alternatives so that a more favorable oncological outcome and excellent cosmetic results may be expected.

[Vulvoperineoplasty for vulvar pain in the posterior fourchette (15 cases)]

BACKGROUND

Vulvar pain is a common presenting complaint in dermatology consultations arising from numerous possible causes. Where such pain is mechanical, resulting from stretching of the vulva, particularly during sexual intercourse, the patient should be checked for anatomical features that could account for the pain, localised anatomical adhesions or sclerosis of the fourchette, and amenable to treatment by vulvoperineoplasty.

PATIENTS AND METHODS

A retrospective study of all patients undergoing vulvoperineoplasty for vulvar pain in the fourchette was carried out between 1.1.1993 and 1.1.2003.

RESULTS

Fifteen successive patients were included in the study. The mean rate of sexual intercourse doubled between the pre-operative period and the post-operative period, rising from 5 (0 to 30) to 9.8 (3 to 30). Mean pain intensity during intercourse on a scale of 1 to 10 fell from 7.6 (5 to 9) before surgery to 1.6 (0 to 5) after surgery. None of the patients experienced any sequelae. All patients except one (who was no longer sexually active), expressed willingness to undergo vulvoperineoplasty again if necessary.

DISCUSSION

Vulvoperineoplasty is a simple procedure and proved useful for female patients presenting vulvar pain and adhesions or sclerosis of the fourchette.

The Extended Approach to the Vascular Pedicle of the Anterolateral Thigh Perforator Flap: Anatomical and Clinical Study

BACKGROUND

The anterolateral thigh perforator flap is a well-described and versatile flap that has specific advantages. However, the variable anatomy makes flap elevation challenging. Furthermore, the dissection of the proximal part of the pedicle that runs underneath the rectus femoris muscle demands continuous pull by an assistant and is inconvenient and tiring for the surgeon. A technique that facilitates dissection of the proximal pedicle part is suggested. It is useful in both pedicled and free flap transfer, when maximum pedicle length is crucial.

METHODS

Five anterolateral thigh perforator flaps were dissected using the extended technique. Four were transferred as free flaps and one as an island pedicled flap. In addition, anatomical cadaver studies were performed bilaterally in five fresh cadavers to further clarify the relevant anatomy.

RESULTS

All flaps survived well. One patient suffered from donor-site infection caused by inadequate drainage. Conservative treatment with daily dressing changes resulted in satisfactory healing. Two patients suffered from hypesthesia of part of the lateral thigh area. No patient experienced any difficulty in daily activities and none suffered from knee extension lag.

CONCLUSIONS

An extended approach for dissection of the anterolateral thigh perforator flap is described that is useful in both pedicled and free flap transfers. Cautious tunnel creation is a prerequisite for avoidance of complications.

Perineum Reconstruction With Pedicled Anterolateral Thigh Fasciocutaneous Flap

Eighteen pedicled anterolateral thigh perforator island flaps were used for complex perineal reconstructions between May 2003 and May 2005. The patients' average age was 48.6 years (range, 32 to 64 years), and the average follow-up period was 8 months (range, 2 to 13). In 7 cases, the perforator was septocutaneous and in 11 it was intramuscular. The application of the pedicled anterolateral thigh fasciocutaneous flap is described perineum reconstruction. The size of the perineum defects ranged from 6 x 9 cm to 16 x 17 cm, and the size of the transferred flap ranged from 8 x 11 cm to 18 x 20 cm. All flaps survived. One patient developed minor wound dehiscence in the posterior aspect of the perineal wound because of fecal contamination and skin maceration. The esthetic appearance of the reconstructed perineum was good. Despite a variable vascular anatomy that can give rise to some surgical challenge in raising the flap, the authors conclude that this is a safe and reliable flap for perineal reconstruction.

Reconstructive surgery following resection of primary vulvar cancers

OBJECTIVE

This study describes the surgical treatment and follow-up of 213 patients with primary vulvar cancer; particular attention is given to reconstructive surgical procedures.

METHODS

The clinical and pathological parameters of the patients were recorded according to standardized procedures, and the data concerning type of operation, surgical reconstruction and postoperative course of disease (recurrence-free and overall survival) were analyzed.

RESULTS

In about one-third of the cases, plastic surgery reconstruction involving skin-flaps was performed. In the present group of patients, plastic surgery procedures led to an elevated degree of operability as well as to more satisfactory results in terms of wound healing. For minor cosmetic defects, local (fasciocutaneous) skin-flaps resulted in excellent wound healing and short periods of in-patient treatment, even in patients with larger tumors. In cases exhibiting more severe wounds extending over larger areas of the vulva and its surrounding regions, similarly encouraging results were achieved using regional (myocutaneous) skin-flaps.

CONCLUSION

The present study shows that reconstructive surgery of the vulva leads to good results in patients with vulvar cancer. Plastic surgery enlarges the spectrum of available operative therapy in vulvar cancer, especially in large tumors, and its application leads to a favorable oncological outcome as well as excellent cosmetic results in patients with vulvar cancer.

Deep Inferior Epigastric Perforator (DIEP) Flap for Vulvar Reconstruction After Radical Vulvectomy

For vulvar reconstruction following radical vulvectomy in a 71-year-old woman with a large vulvar cancer, we applied the deep inferior epigastric perforator flap (DIEP flap), a typical perforator flap, which could be performed by utilizing an abdominal incision wound without producing another surgical scar and had less donor site morbidity because of a minimal sacrifice of muscles. The surgical procedures were less invasive and simple, and morphologically and functionally satisfactory results were obtained: no recurrence of cancer, a well-preserved vulvar morphology with less donor site scarring, and no functional disturbance such as dysuria and abdominal hernia. We consider that the DIEP flap is the first choice for vulvar reconstruction following radical vulvectomy. Even in radical vulvectomy without an abdominal incision wound, the DIEP flap with an anatomically reliable vascular pedicle can be an effective option.

Flap algorithm in vulvar reconstruction after radical, extensive vulvectomy

The objective of this study was to assess the reconstructive options after radical, extensive vulvectomy; relate them to tumor characteristics; and select a choice of flaps able to correct every remaining defect. This study is a retrospective review of a 4-year experience with 31 flaps in 20 consecutive vulvar reconstructions. Three of the 31 flaps presented nonsignificant delayed healing at their tips and 3 other flaps developed a major breakdown related to an infection or an error in flap planning. According to the authors, the size of the defect is the main issue that must be taken into consideration during the establishment of reconstructive needs. Closure of vulvar defects is preferably performed using fasciocutaneous flaps, which are very reliable flaps and can be raised with different techniques to meet different needs. A flap is then chosen with the fewest potential complications. An algorithm has been thus established: Small to medium-size defects are closed with island V-Y flaps, island gluteal fold flaps, or pedicled pudendal thigh flaps. Among them, the island V-Y flap is the workhorse flap for vulvar reconstruction because of its versatility, reliability, and technical simplicity compared with its very low complication rate. If the vulvar defect is large and/or reaches the vulva-crural fold, V-Y flaps are also preferred to close these large and posteriorly extended excisions. If the vulvar defect is very large, extending both anteriorly and posteriorly, the use of a distally based, vertically oriented rectus abdominis muscle flap is recommended. Using this algorithm, immediate vulvar reconstruction with pedicled local or regional flaps can be performed easily and reliably.

Cecal pelvic transposition following total pelvic exenteration

BACKGROUND

Multiple techniques have been utilized in an attempt to prevent small bowel obstructions following total pelvic exenteration. Pelvic transposition of the cecum may be an effective way to reduce the incidence of this serious complication.

CASES

We present three women who underwent total pelvic exenteration and cecal pelvic transposition to exclude the small bowel from the "empty pelvis". All three patients did well without any postoperative small bowel complications.

CONCLUSION

Cecal pelvic transposition precludes the small bowel from entering the pelvis. This procedure can be performed relatively easily by a gynecologic oncologist experienced with bowel surgery. A larger patient series is needed to assess the efficacy of this previously unpublished procedure.

Reconstruction of an extensive vulvectomy defect using the gluteus maximus fasciocutaneous V-Y advancement flap

Effective management of a vulvar wound resulting from oncological ablative surgery poses a formidable task for the reconstructive surgeon. During the past two decades, numerous procedures have been described in an effort to provide stable, sensate coverage that minimizes deformity and preserves function, often in the setting of concomitant radiation. At the authors' institution, a fasciocutaneous V-Y advancement flap based on the gluteus maximus has been adopted as a common approach to this problem. They present their institutional experience with this procedure. A 10-year chart review (1991-2001) yielded a series of 20 vulvectomy patients, all of whom were reconstructed by the same surgeon using ischial fasciocutaneous V-Y flaps based on perforators from the inferior border of the gluteus maximus muscle. Patients underwent vulvectomy for recurrent or advance-stage vulvar cancer, or extensive carcinoma in situ. Squamous cell carcinoma was the most common pathology (N = 13). Fifteen patients had bilateral V-Y flaps; the remainder had unilateral procedures. Six patients underwent prior radiation therapy. Two patients had delayed reconstruction for vaginal stenosis. Flap survival was 100%. There were no major complications, early or late. Minor complications were limited to localized areas of delayed healing, all of which responded to conservative measures. Functional outcome was excellent in all patients. At an average follow-up of 44 months, there were five episodes of recurrent disease necessitating surgical intervention. Based on this series, the gluteus maximus V-Y advancement flap provides a straightforward and reliable method to recruit local tissue for stable coverage of these often difficult-to-manage wounds.

Vaginal reconstruction after extended radical pelvic surgery for cancer: comparison of two techniques

An immediate partial or total vaginal reconstruction is frequently proposed in cases of exenterative or extended radical pelvic surgery for cancer treatment. One of the main complications after this reconstruction is the vagina obliteration caused by the healing process. This study compares the results of two different reconstructive techniques, particularly focusing on general complications and the risk of vaginal occlusion. A transversus rectus abdominis musculoperitoneal (TRAMP) composite flap has been performed in five cases, and an inverted inferior transverse rectus abdominis musculocutaneous flap (TRAM) has been used in another five cases. Recovery was uneventful in eight cases. One patient (case 5) developed an aortofemoral embolism requiring a bilateral transfemoral embolectomy and heparin administration. Another patient (case 9) experienced severe peritonitis because of the partial leak of the rectal anastomosis, and therefore a Mikulicz's colostomy was performed. Four patients who underwent the TRAMP flap developed a complete closure of the neovagina. In one patient with a TRAMP flap, a severe shortening (2 cm) of the neovagina occurred. Five patients out of five who underwent a reconstruction with a TRAM flap had a stable length of the neovagina (6 to 12 cm) and no shrinkage in diameter occurred, even though a vaginal stent was not used. The conventional inferior TRAM flap with a skin paddle seems to better maintain a stable length of the neovagina than the TRAMP composite flap with peritoneum.

Innervated island flaps in morphofunctional vulvar reconstruction

In this article, the authors present their own experience in vulvar reconstruction following vulvectomy using two different innervated island flaps according to the size and site of the defect. Island-flap mobilization is possible thanks to the rich blood supply of the perineal region. The methods described are a "V-Y amplified sliding flap from the pubis" and a "fasciocutaneous island flap" raised from one or both gluteal folds. The V-Y amplified sliding flap from the pubis is indicated when the defect is symmetric and located anteriorly. This flap is harvested from the pubis and vascularized by the deep arterial network of the pubis. Sensory innervation is provided by branches of the ileo-inguinal nerve. The fasciocutaneous island flap, raised from one or both gluteal folds, can be used following hemivulvectomy or radical vulvectomy, respectively, to cover posteriorly located defects. Vascularization is provided by the musculocutaneous perforating branches of the pudendal artery, whereas sensory innervation is maintained through the perineal branches of the pudendal nerve. Twenty-two patients have undergone reconstructive surgery of the vulvar region from 1989 to date. On 14 patients, a V-Y amplified sliding flap was used; on 7 patients, reconstruction was carried out by island flaps raised from the gluteal fold. Both techniques are compatible with inguino-femoral lymphadenectomy, and they allow for a correct morphofunctional reconstruction and provide good local sensibility. The final result is aesthetically satisfactory, as all final scars are hidden in natural folds.

Anterolateral thigh fasciocutaneous flap in the difficult perineogenital reconstruction

A pedicled anterolateral thigh fasciocutaneous flap that was used to cover a complicated perineogenital defect after bilateral gracilis myocutaneous flap for perineal reconstruction is presented. The indications and advantages of this approach are outlined. This technique offers to the plastic surgeon and gynecologic oncologist a new option in the armamentarium for reconstruction of the perineum, and it offers the patient reduced donor-site morbidity.