Experience with flap repair after vulvar carcinoma resection: a retrospective observational study of 26 cases

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.

Use of Rectus Flaps in Reconstructive Surgery for Gynecologic Cancer

The aim of this study was to explore the outcomes of pelvic reconstruction with a rectus abdominis myocutaneous (RAM) or rectus abdominis myoperitoneal (RAMP) flap following radical surgery for gynecologic malignancy. This is a retrospective case series of all pelvic reconstructions with RAM or RAMP flap performed in a gynecologic oncology service between 1998 and 2023. Reconstructions with other flaps were excluded. A total of 28 patients were included. Most patients had vulvar cancer (n = 15, 53.6%) and the majority had disease recurrence (n = 20, 71.4%). Exenteration was the most common procedure, being carried out in 20 (71.4%) patients. Pelvic reconstruction was carried out with a RAM flap in 24 (85.7%) cases and a RAMP flap in 4 (14.3%) cases. Flap-specific complications included cellulitis (14.3%), partial breakdown (17.9%), and necrosis (17.9%). Donor site complications included surgical site infection and necrosis occurring in seven (25.0%) and three (10.7%) patients, respectively. Neovaginal reconstruction was performed in 14 patients. Out of those, two (14.3%) had neovaginal stenosis and three (21.4%) had rectovaginal fistula. In total, 50% of patients were disease-free at the time of the last follow up. In conclusion, pelvic reconstruction with RAM/RAMP flaps, at the time of radical surgery for gynecologic cancer, is an uncommon procedure. In our case series, we had a significant complication rate with the most common being infection and necrosis. The development of a team approach, with input from services including Gynecologic Oncology and Plastic Surgery should be developed to decrease post-operative complications and improve patient outcomes.