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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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Arcieri M, Restaino S, Rosati A, Granese R, Martinelli C, Caretto AA, Cianci S, Driul L, Gentileschi S, Scambia G, Vizzielli G, Ercoli A. Primary flap closure of perineal defects to avoid empty pelvis syndrome after pelvic exenteration in gynecologic malignancies: An old question to explore a new answer. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:107278. [PMID: 38134482 DOI: 10.1016/j.ejso.2023.107278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 11/05/2023] [Accepted: 11/14/2023] [Indexed: 12/24/2023]
Abstract
Pelvic exenteration (PE) is a radical oncological surgical procedure proposed in patients with recurrent or persistent gynecological cancers. The radical alteration of pelvic anatomy and of pelvic floor integrity can cause major postoperative complications. Fortunately, PE can be combined with reconstructive procedures to decrease complications and functional and support problems of pelvic floor, reducing morbility and mortality and increasing quality of life. Many options for reconstructive surgery have been described, especially a wide spectrum of surgical flaps. Different selection criteria have been proposed to select patients for primary perineal defect flap closure without achieving any strict indication of the best option. The aim of this review is to focus on technical aspects and the advantages and disadvantages of each technique, providing an overview of those most frequently used for the treatment of pelvic floor defects after PE. Flaps based on the deep inferior epigastric artery, especially vertical rectus abdominis musculocutaneous (VRAM) flaps, and gracilis flaps, based on the gracilis muscle, are the most common reconstructive techniques used for pelvic floor and vaginal reconstruction. In our opinion, reconstructive surgery may be considered in case of total PE or type II/III PE and in patients submitted to prior pelvic irradiation. VRAM could be used to close extended defects at the time of PE, while gracilis flaps can be used in case of VRAM complications. Fortunately, numerous choices for reconstructive surgery have been devised. As these techniques continue to evolve, it is advisable to adopt an integrated, multi-disciplinary approach within a tertiary medical center.
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Affiliation(s)
- M Arcieri
- Department of Biomedical, Dental, Morphological and Functional Imaging Science, University of Messina, Messina, Italy; Department of Maternal and Child Health, Obstetrics and Gynecology Clinic, University Hospital of Udine, Udine, Italy.
| | - S Restaino
- Department of Maternal and Child Health, Obstetrics and Gynecology Clinic, University Hospital of Udine, Udine, Italy
| | - A Rosati
- Department of Woman, Child, and Public Health, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - R Granese
- Department of Biomedical, Dental, Morphological and Functional Imaging Science, University of Messina, Messina, Italy
| | - C Martinelli
- Department of Human Pathology of Adult and Childhood "G. Barresi", Unit of Gynecology and Obstetrics, University of Messina, Messina, Italy
| | - A A Caretto
- Department of Plastic Surgery, Catholic University of Sacred Heart, Rome, Italy
| | - S Cianci
- Department of Human Pathology of Adult and Childhood "G. Barresi", Unit of Gynecology and Obstetrics, University of Messina, Messina, Italy
| | - L Driul
- Department of Maternal and Child Health, Obstetrics and Gynecology Clinic, University Hospital of Udine, Udine, Italy; Medical Area Department (DAME), University of Udine, Udine, Italy
| | - S Gentileschi
- Plastic Surgery, Lymphedema Center Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - G Scambia
- Department of Woman, Child, and Public Health, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy; Department of Woman, Child and Public Health, Catholic University of Sacred Heart, Rome, Italy
| | - G Vizzielli
- Department of Maternal and Child Health, Obstetrics and Gynecology Clinic, University Hospital of Udine, Udine, Italy; Medical Area Department (DAME), University of Udine, Udine, Italy
| | - A Ercoli
- Department of Human Pathology of Adult and Childhood "G. Barresi", Unit of Gynecology and Obstetrics, University of Messina, Messina, Italy
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Shin J, Kim SA, Rhie JW. Perineal perforator switch flap for three-dimensional vulvovaginal reconstruction. J Plast Reconstr Aesthet Surg 2022; 75:3208-3216. [PMID: 35717498 DOI: 10.1016/j.bjps.2022.04.052] [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: 09/12/2021] [Revised: 01/12/2022] [Accepted: 04/12/2022] [Indexed: 10/18/2022]
Abstract
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.
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Affiliation(s)
- Jongweon Shin
- Department of Plastic and Reconstructive Surgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Tongil-ro 1021, Eunpyeong-gu, Seoul, Republic of Korea.
| | - Seong Ae Kim
- Department of Plastic and Reconstructive Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jong-Won Rhie
- Department of Plastic and Reconstructive Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Abstract
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.
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Secondary Vulvar Reconstruction Using Bilateral Gluteal Fold Flaps after Radical Vulvectomy with Direct Closure. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3550. [PMID: 33889476 PMCID: PMC8057754 DOI: 10.1097/gox.0000000000003550] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 03/02/2021] [Indexed: 11/26/2022]
Abstract
Although primary vulvovaginal reconstruction after vulvectomy has high potential to improve patients’ outcomes, flap reconstruction is not an established part of the current standard treatment for vulvar cancer. We report a patient with successful secondary vulvar reconstruction 3 years after radical vulvectomy with direct wound closure. A 69-year-old woman presented with chronic, burning vulvar pain 3 years after radical vulvectomy without reconstruction for stage IB vulvar cancer. Her urethral orifice had everted because of the direct wound closure, which resulted in severe pain on contact. We performed secondary vulvar reconstruction using bilateral 14 × 5 cm2 gluteal fold flaps. Postoperative pain management and overall aesthetic outcomes were satisfactory. Secondary vulvar reconstruction with gluteal fold flaps can avoid the sequelae resulting from inadequate direct wound closure after radical vulvectomy. Thus, we strongly advocate immediate vulvar reconstruction to prevent such situations.
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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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O'Brien AL, Jadallah E, Chao AH. Reconstruction of a radical total vulvectomy defect with a single split anterolateral thigh perforator flap: A case report and review of the literature. Microsurgery 2020; 41:70-74. [PMID: 32339351 DOI: 10.1002/micr.30592] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 02/22/2020] [Accepted: 04/10/2020] [Indexed: 11/08/2022]
Abstract
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.
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Affiliation(s)
- Andrew L O'Brien
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Erin Jadallah
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Albert H Chao
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Outcomes Analysis of Gynecologic Oncologic Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2015. [PMID: 30859025 PMCID: PMC6382220 DOI: 10.1097/gox.0000000000002015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 09/18/2018] [Indexed: 11/26/2022]
Abstract
Background: Defects resulting from gynecologic oncology resections can range from small external defects to total exenterations, requiring complex pelvic reconstruction. We aim to investigate the patient and surgical factors that influence complication rates, reoperation rates, and length of stay. We hypothesize that this patient cohort will have high complication and reoperation rates that are likely most affected by their medical and extirpative surgery factors, with less direct impact from their reconstructive surgery procedures. Methods: All cases of reconstruction following resection of a gynecological oncology tumor at the University of Wisconsin Hospital over the last 14 years were reviewed. Forty-three patients were identified who required 66 flaps for reconstruction. Results: Mean follow-up period was 19 months. Overall complication rate was 65% and reoperation rate was 33%. Plastic surgery flap-specific complication and reoperation rates were 47% and 19%, respectively, and were not significantly associated with any patient risk factors. Flap reconstruction subtype was not associated with time to complete healing, complication rate, or reoperation. Prior chemotherapy was significantly correlated with increased rate of overall complication (P = 0.0253) and reoperation (P = 0.0448), but prior radiation was not. Mean hospital stay was 11 days (SD ± 9 d). Factors found to be significantly associated with an increase in hospitalization length were increasing number of comorbidities (P = 0.021), exenteration defects (P = 0.0122), myocutaneous flap reconstruction (P = 0.0003), radiation (P = 0.0004), and chemotherapy P = 0.0035). Conclusion: This patient cohort has an overall high complication and reoperation rate; however, increasingly complex reconstruction is not associated with significant differences in complication rates or reoperation.
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Deng C, Chang S, Wei Z, Jin W, Li H, Nie K, Tang X, Wang D. Alternative Design for Anterolateral Thigh Multi-Paddled Flaps: The 3-5 System. Med Sci Monit 2018; 24:9102-9109. [PMID: 30552758 PMCID: PMC6319140 DOI: 10.12659/msm.911883] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The design and harvest of the anterolateral thigh (ALT) multi-paddled flap is a critical step in reconstructive surgeries. However, limited perforator distribution patterns of traditional design methods have gradually emerged in clinical practice. The aim of this study was to investigate the effect of a new technique (the 3-5 system) on ALT multi-paddled flap design. MATERIAL AND METHODS A total of 151 ALT flaps were harvested from 149 patients over a 26-month period. Among them, 100 ALT flaps were examined preoperatively using a handheld Doppler device to localize vascular perforators. RESULTS By detecting perforator penetration points through the vastus lateral muscle (VLM) or the intermuscular septum and perforator entry points to the deep fascia, precise ALT flap perforator distribution patterns were found. Meanwhile, a 3-5 system was developed to design ALT flaps based on these findings. The remaining 51 ALT flaps from 49 patients during a 9-month period did not require the use of preoperative handheld Doppler. In addition, preoperative handheld Doppler and intraoperative findings demonstrated that all ALT flap penetration points through the VLM or intermuscular septum and the perforator entry point in the deep fascia were closely related based on 3 longitudinal lines and 5 horizontal lines. CONCLUSIONS ALT flaps were successfully harvested using a 3-5 system without the need for preoperative handheld Doppler analysis. Moreover, the 3-5 system is a simple and practical approach for preoperative ALT multi-paddled flap design.
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Affiliation(s)
- Chengliang Deng
- Department of Plastic Surgery, Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou, China (mainland)
| | - Shusen Chang
- Department of Plastic Surgery, Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou, China (mainland)
| | - Zairong Wei
- Department of Plastic Surgery, Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou, China (mainland)
| | - Wenhu Jin
- Department of Plastic Surgery, Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou, China (mainland)
| | - Hai Li
- Department of Plastic Surgery, Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou, China (mainland)
| | - Kaiyu Nie
- Department of Plastic Surgery, Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou, China (mainland)
| | - Xiujun Tang
- Department of Plastic Surgery, Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou, China (mainland)
| | - Dali Wang
- Department of Plastic Surgery, Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou, China (mainland)
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Di Donato V, Bracchi C, Cigna E, Domenici L, Musella A, Giannini A, Lecce F, Marchetti C, Benedetti Panici P. Vulvo-vaginal reconstruction after radical excision for treatment of vulvar cancer: Evaluation of feasibility and morbidity of different surgical techniques. Surg Oncol 2017; 26:511-521. [DOI: 10.1016/j.suronc.2017.10.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 09/28/2017] [Accepted: 10/03/2017] [Indexed: 10/18/2022]
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12
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Abstract
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.
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13
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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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14
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Zhang W, Zeng A, Yang J, Cao D, He X, Wang X, You Y, Chen J, Lang J, Shen K. Outcome of vulvar reconstruction in patients with advanced and recurrent vulvar malignancies. BMC Cancer 2015; 15:851. [PMID: 26542779 PMCID: PMC4635970 DOI: 10.1186/s12885-015-1792-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2015] [Accepted: 10/15/2015] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Wei Zhang
- Departments of Obstetrics and Gynecology, Peking Union Medical College (PUMC) Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Shuaifuyuan No.1,Dongcheng District, Beijing, 100730, China.
| | - Ang Zeng
- Departments of Plastic Surgery, Peking Union Medical College (PUMC) Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.
| | - Jiaxin Yang
- Departments of Obstetrics and Gynecology, Peking Union Medical College (PUMC) Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Shuaifuyuan No.1,Dongcheng District, Beijing, 100730, China.
| | - Dongyan Cao
- Departments of Obstetrics and Gynecology, Peking Union Medical College (PUMC) Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Shuaifuyuan No.1,Dongcheng District, Beijing, 100730, China.
| | - Xiaodong He
- Departments of General Surgery, Peking Union Medical College (PUMC) Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.
| | - Xiaojun Wang
- Departments of Plastic Surgery, Peking Union Medical College (PUMC) Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.
| | - Yan You
- Departments of Pathology,
- Peking Union Medical College (PUMC) Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.
| | - Jie Chen
- Departments of Pathology,
- Peking Union Medical College (PUMC) Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.
| | - Jinghe Lang
- Departments of Obstetrics and Gynecology, Peking Union Medical College (PUMC) Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Shuaifuyuan No.1,Dongcheng District, Beijing, 100730, China.
| | - Keng Shen
- Departments of Obstetrics and Gynecology, Peking Union Medical College (PUMC) Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Shuaifuyuan No.1,Dongcheng District, Beijing, 100730, China.
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15
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Zhang W, Zeng A, Yang J, Cao D, Huang H, Wang X, You Y, Chen J, Lang J, Shen K. Outcome of vulvar reconstruction by anterolateral thigh flap in patients with advanced and recurrent vulvar malignancy. J Surg Oncol 2015; 111:985-91. [PMID: 25974742 DOI: 10.1002/jso.23908] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Accepted: 03/03/2015] [Indexed: 11/10/2022]
Affiliation(s)
- Wei Zhang
- Department of Obstetrics and Gynecology; Peking Union Medical College (PUMC) Hospital; Chinese Academy of Medical Sciences & Peking Union Medical College; Beijing China
| | - Ang Zeng
- Department of Plastic Surgery; Peking Union Medical College (PUMC) Hospital; Chinese Academy of Medical Sciences & Peking Union Medical College; Beijing China
| | - Jiaxin Yang
- Department of Obstetrics and Gynecology; Peking Union Medical College (PUMC) Hospital; Chinese Academy of Medical Sciences & Peking Union Medical College; Beijing China
| | - Dongyan Cao
- Department of Obstetrics and Gynecology; Peking Union Medical College (PUMC) Hospital; Chinese Academy of Medical Sciences & Peking Union Medical College; Beijing China
| | - Huifang Huang
- Department of Obstetrics and Gynecology; Peking Union Medical College (PUMC) Hospital; Chinese Academy of Medical Sciences & Peking Union Medical College; Beijing China
| | - Xiaojun Wang
- Department of Plastic Surgery; Peking Union Medical College (PUMC) Hospital; Chinese Academy of Medical Sciences & Peking Union Medical College; Beijing China
| | - Yan You
- Department of Pathology; Peking Union Medical College (PUMC) Hospital; Chinese Academy of Medical Sciences & Peking Union Medical College; Beijing China
| | - Jie Chen
- Department of Pathology; Peking Union Medical College (PUMC) Hospital; Chinese Academy of Medical Sciences & Peking Union Medical College; Beijing China
| | - Jinghe Lang
- Department of Obstetrics and Gynecology; Peking Union Medical College (PUMC) Hospital; Chinese Academy of Medical Sciences & Peking Union Medical College; Beijing China
| | - Keng Shen
- Department of Obstetrics and Gynecology; Peking Union Medical College (PUMC) Hospital; Chinese Academy of Medical Sciences & Peking Union Medical College; Beijing China
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16
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Huang JJ, Chang NJ, Chou HH, Wu CW, Abdelrahman M, Chen HY, Cheng MH. Pedicle perforator flaps for vulvar reconstruction — New generation of less invasive vulvar reconstruction with favorable results. Gynecol Oncol 2015; 137:66-72. [DOI: 10.1016/j.ygyno.2015.01.526] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Revised: 12/31/2014] [Accepted: 01/07/2015] [Indexed: 11/29/2022]
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17
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Sirimahachaiyakul P, Orfaniotis G, Gesakis K, Kiranantawat K, Ciudad P, Nicoli F, Maruccia M, Sacak B, Chen HC. Keyhole anterolateral thigh flap: A special way of partition for reconstruction around a protruding structure or cavity/tunnel. Microsurgery 2015; 35:356-63. [PMID: 25597746 DOI: 10.1002/micr.22377] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Revised: 12/15/2014] [Accepted: 12/19/2014] [Indexed: 11/06/2022]
Affiliation(s)
- Pornthep Sirimahachaiyakul
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
- Division of Plastic Surgery; Department of Surgery; Faculty of Medicine Vajira Hospital; Navamindradhiraj University; Bangkok Thailand
| | - Georgios Orfaniotis
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Kanellos Gesakis
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Kidakorn Kiranantawat
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
- Department of Plastic and Maxillofacial Surgery; Faculty of Medicine Ramathibodi Hospital; Mahidol University; Bangkok Thailand
| | - Pedro Ciudad
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Fabio Nicoli
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Michele Maruccia
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
- Department of Plastic and Reconstructive Surgery; Sapienza University; Rome Italy
| | - Bulent Sacak
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
| | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery; China Medical University Hospital; Taichung Taiwan
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18
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Pedicled Perforator Flaps for Vulvar Reconstruction – A Versatile, Less Invasive and Simple Way with Favorable Results. Plast Reconstr Surg 2014. [DOI: 10.1097/01.prs.0000455528.46291.f5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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19
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Alternatives to commonly used pelvic reconstruction procedures in gynecologic oncology. Gynecol Oncol 2014; 134:172-80. [DOI: 10.1016/j.ygyno.2014.04.059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 04/26/2014] [Accepted: 04/30/2014] [Indexed: 11/23/2022]
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20
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Filobbos G, Chapman T, Khan U. Split anterolateral thigh (ALT) free flap for vulva reconstruction: A case report. J Plast Reconstr Aesthet Surg 2012; 65:525-6. [DOI: 10.1016/j.bjps.2011.08.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2011] [Accepted: 08/07/2011] [Indexed: 11/24/2022]
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