Utilizing V-Y fasciocutaneous advancement flaps for vulvar reconstruction

Vulvar Reconstruction with Keystone Flaps after Radical Vulvectomy

Vulvar cancer is a rare oncologic pathology, accounting for only 3%-5% of all gynecologic neoplasms, with squamous cell carcinoma responsible for more than 90% of these cases; the remaining 10% includes Paget disease, lichen sclerosus, and vulvar melanoma. Radical vulvectomy has become the gold standard treatment due to the high recurrence rate and effective local control in patients with squamous cell carcinoma stages IB to IVA. To address these needs, various reconstructive options have been reported in the literature, each potentially offering different results due to their diverse nature. We present a series of patients who underwent vulvar reconstruction with the keystone flap, describing the surgical technique, complication rate, advantages over other techniques, and long-term follow-up.

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.

A Comprehensive Discussion in Vaginal Cancer Based on Mechanisms, Treatments, Risk Factors and Prevention

Vaginal cancer is a rare and uncommon disease that is rarely discussed. Although vaginal cancer traditionally occurs in older postmenopausal women, the incidence of high-risk human papillomavirus (HPV)-induced cancers is increasing in younger women. Cervical cancer cells contain high-risk human papillomavirus (HPV) E6 and E7 proteins and inhibiting HPV gene expression leads the cells to stop proliferating and enter senescence. As E6, and E7 protein promoted the carcinogenesis mechanism, and here not only regulate the cellular degradation of P53, and pRb but also enhances the cell proliferation along with E6 protein targets the p53 for breakdown and subsequently promote the apoptotic cell death, and DNA repair inhibition, that is indispensable to the continue the lifecycle of the HPV. As a synchronous or metachronous tumor, vaginal cancer is frequently found in combination with cervical cancer. It is uncertain what causes invasive female vaginal organ cancer. HPV type 16 is the most often isolated HPV type in female vaginal organ cancers. Due to cancer’s rarity, case studies have provided the majority of etiologic findings. Many findings demonstrate that ring pessaries, chronic vaginitis, sexual behavior, birth trauma, obesity, vaginal chemical exposure, and viruses are all risk factors. Because of insufficient understanding and disease findings, we are trying to find the disease’s mechanism with the available data. We also address different risk factors, therapy at various stages, diagnosis, and management of vaginal cancer in this review.

A Review of Reconstruction for Vulvar Cancer Surgery

Importance

Vulvar reconstruction may be required after vulvectomy or any vulvar surgery. Providers should be familiar with techniques for reconstruction to improve clinical outcomes.

Objective

This article reviews the different techniques for reconstruction after vulvectomy and describes the decision-making process for selection of appropriate techniques, postoperative care, and expected outcomes.

Evidence Acquisition

A literature search was conducted, focusing on the plastic surgery and gynecologic oncology literature, using the following search terms: "vulvar reconstruction," "perineal reconstruction," "vulvectomy," and "vulvar cancer." The search was limited to English publications.

Results

Reconstruction after vulvectomy can be performed using a variety of techniques ranging from simple or complex closure to adjacent tissue rearrangement to skin grafting, locoregional, and free flaps. The appropriate technique is best chosen based on the characteristics of the patient and postablative defect, as well as the reconstructive goals. Postoperative complications are usually minor.

Conclusions

Vulvar reconstruction techniques vary widely and offer patients improved outcomes.

Relevance

Knowledge of vulvar reconstruction techniques is necessary for gynecologists performing vulvar surgery to ensure optimal patient outcomes.

Subcutaneous Vulvar Flap Viability Evaluation With Near-Infrared Probe and Indocyanine Green for Vulvar Cancer Reconstructive Surgery: A Feasible Technique

Introduction: Vulvar cancer is a rare condition affecting older women and accounts for 3-5% of all gynecological cancers. Primary surgical treatment involves the removal of a large amount of tissue for which reconstructive surgery is often necessary with a high rate of postoperative complications. Despite several techniques for the evaluation of vulvar flap viability have been proposed, many methods cannot be performed during surgery and require expensive devices often missing in a gynecological clinic. This study aims to verify the feasibility and the safety of the vulvar flap viability evaluation through a near-infrared endoscopic probe and Indocyanine green (ICG) tracer in a small group of patients and to evaluate long-term vulvar flap outcomes. Methods: Patients with primary vulvar cancer who required surgical treatment and subsequent vulvar flap reconstructive surgery were prospectively included in the study. A 25 mg ICG vial diluted in 20 ml of saline solution was intravenously infused before closing the skin edges of the flaps. All patients were given 0.2 mg/kg body weight of intravenous ICG. After 10-15 min, a near-infrared endoscopic probe was used to evaluate the vulvar flap viability. Results: Of the 18 patients who underwent radical vulvectomy for vulvar cancer during the study period, 15 were included in the analysis. All packaged surgical flaps showed tracer uptake on the surgical margin. No intro-operative complications were recorded neither surgery-related nor to dye infusion. No surgical infection, dehiscence, or necrosis was recorded. Conclusions: Vulvar flap viability assessment using Indocyanine green and a laparoscopic infrared probe is a feasible method. All cases included in the analysis showed a dye uptake on the surgical edge of the flap. Further, prospective studies are needed to confirm the method in clinical practice and to evaluate its superiority over simple subjective clinical evaluation.

V-Y advancement flap to correct a perineal defect after an episiotomy dehiscence

INTRODUCTION AND HYPOTHESIS

Episiotomy scar may be the site of complications and result in wound dehiscence in the long term. The aim of this video article was to describe the surgical steps required to repair a right perineal defect after episiotomy using a V-Y advancement flap.

METHOD

Our patient had an episiotomy dehiscence that had already benefited from an end-to-end repair, but the perineal defect recurred. A V-Y advancement flap was performed. The first step of this surgery was to remove the episiotomy scar. A V-shaped flap was then created to fill the perineal defect. Upon advancement, the V flap was transformed in a Y shape and secured using tension-free absorbable sutures.

CONCLUSION

There was no flap necrosis, and the esthetic result was satisfactory.

The V-Y gluteal fold advancement flap: Outcomes following radical surgery for vulvar malignancies

OBJECTIVE

To evaluate the feasibility and complication rate of the V-Y gluteal fold flap in surgery for vulvar cancer.

METHODS

From June 2015 to June 2018, 62 patients surgically treated for vulvar cancer were included in the study. Twenty-three (37.1%) underwent plastic reconstructive surgery with V-Y advancement flaps.

RESULTS

The mean surgical time was longer for patients undergoing V-Y flap surgery. The margins were positive in six patients (9.7%), close (<8 mm) in 10 (16.1%), and adequate (>8 mm) in 46 (74.2%). Six (9.7%) patients had dehiscence and two (3.2%) patients suffered from necrosis. In patients undergoing V-Y flap reconstruction, two (8.7%) had a wound dehiscence, no patients had necrosis. In patients undergoing direct closure, four (10.3%) had wound dehiscence and two (5.1%) had necrosis.

CONCLUSIONS

V-Y gluteal fold advancement technique is a safe procedure, performed in a single surgical session with minimal increase in surgical time and low wound healing complications. Use of this technique was correlated with an increased rate of adequate surgical margins (<8 mm) and reduced need for adjuvant radiotherapy.

Reconstruction of a radical total vulvectomy defect with a single split anterolateral thigh perforator flap: A case report and review of the literature

Reconstruction following total vulvectomy is a reconstructive challenge. Previously described techniques typically require bilateral flaps and the associated donor site morbidity. We present a case of reconstruction after radical total vulvectomy using a single split anterolateral thigh (ALT) perforator flap with a design that optimizes perfusion while allowing for primary donor site closure. A 68-year-old female with a history of vulvar squamous cell carcinoma who had previously undergone vulvectomy and radiation therapy presented with local recurrence. The patient required a radical total vulvectomy, resulting in a 12 × 10 cm vulvar defect. A 2-perforator ALT flap (25 × 7 cm) was harvested, split transversely, and then inset in a circumferential manner around the vulva. This approach contrasts with previous reports, which split the ALT flap longitudinally or centrally, and can compromise perfusion and/or preclude primary donor site closure. The patient healed without complication with 6 months of follow-up. The described approach allows for total vulvectomy reconstruction using a single ALT flap with a perforator configuration that maximizes perfusion while obviating the need for donor site grafting.