Transverse Internal Pudendal (TIP) Flap in Vulvo-Vaginal Reconstruction

Abstract

Vulvar and vaginal reconstruction after radical extirpative resections remains a complex surgical problem. The gracilis musculocutaneous flap and its variants have been previously used with variable success. However, these flaps may be too bulky, are not always reliable, and the resultant scars can be objectionable. The fasciocutaneous flaps such as the pudendal thigh flaps by Wee and Joseph may obviate some of the problems but the tips of these flaps may extend into the inguinal region which may be involved with the tumor. We therefore sought out alternative sources of donor flap tissue. The internal pudendal artery as a source vessel was investigated for a new flap design. The purpose of this paper is to report our anatomic investigation of a transversely oriented fasciocutaneous flap which is based on an internal pudendal neurovascular pedicle, and to discuss our clinical experience with vulvar and vaginal reconstruction using this flap following oncological resection procedures. Preserved cadavers were dissected to confirm the clinically observed internal pudendal neurovascular bundle which appeared to supply the gluteal fold region, Next, fresh cadavers were used for acrylic-latex injection studies of the cutaneous territory supplied by the internal pudendal vessels. The transverse internal pudendal (TIP) flap was demonstrated to be based on a single neurovascular pedicle. Four patients were reconstructed using the bilateral transverse internal pudendal (TIP) flaps. Details of the procedure are given. We demonstrated that bilateral TIP flaps can be utilized safely in immediate gynecological oncologic reconstructions to provide a sensate and potentially functional vagina with cosmetically acceptable donor site scars. This new fasciocutaneous flap offers advantages over other musculocutaneous and fasciocutaneous flaps and may have applications to other areas of perineal reconstruction, including congenital and acquired deformities and chronic perineal wounds.