Singapore Flap Research Articles

Abbe McIndoe Procedure Vs Singapore Flap for Neovaginal Reconstruction in MayerRokitansky-Küster-Hauser Syndrome: A Prospective Interventional Study

Introduction: Congenital uterovaginal agenesis is a condition wherein, although the secondary sexual traits usually develop, the lack of a uterus and vagina leaves the patients unable to conceive and experience sexual fulfillment. A well-done neovaginal repair is essential for enhancing the psychological and social effects on women. Aim: To compare the Abbe McIndoe technique and the Singapore flap, which are frequently used for vaginal reconstruction. Materials and Methods: This prospective interventional study was conducted over three years at the Department of Plastic Surgery, SRM Medical College Hospital and Research Center, Kattankulathur, Tamil Nadu, India. Twelve patients with MayerRokitansky-Küster-Hauser (MRKH) syndrome were included, with six undergoing the Abbe McIndoe procedure and six undergoing the Singapore flap procedure. This study assessed operative time, hospital stay, neovaginal length, complications, mould use, donor site morbidity, and sexual satisfaction. Data were analysed using Statistical Package for the Social Sciences (SPSS) version 26.0, with a p-value of <0.05 considered statistically significant. Results: The mean±SD age of participants was 22.6±4.16 years in both groups. The mean±SD operative time was slightly longer for the Singapore flap (127±8.37 minutes) compared to the Abbe McIndoe procedure (123±13.03 minutes). The Singapore flap group had a more extended hospital stay (11.17±1.32 days vs. 9.17±1.94 days) but achieved a greater mean neovaginal length (9.28±0.25 cm vs. 8.88±0.61 cm). The Singapore flap group experienced fewer complications, with no late complications and only one immediate complication, compared to the Abbe McIndoe group, which had two late and two immediate complications. Mould use was not required in the Singapore flap group, while it was variable in the Abbe McIndoe group. The Singapore flap group had no donor site morbidity compared to four cases in the Abbe McIndoe group. Sexual satisfaction was higher in the Singapore flap group, with five patients reporting ‘good’ outcomes than three in the Abbe McIndoe group. Conclusion: The Singapore flap technique demonstrated superior outcomes in neovaginal reconstruction for MRKH syndrome, with fewer complications, no need for postoperative moulds, no donor site morbidity, and higher sexual satisfaction. These findings suggest that the Singapore flap may be a preferred technique for neovaginal reconstruction in appropriate clinical settings.

Repair of radiation-induced rectovaginal fistula with rectal stricture by a combined Tuttle, Turnbull-Cutait and Singapore flap approach.

Radiation-induced rectovaginal fistula (RI-RVF) with associated rectal stricture represents a challenging problem in management. The aim of the present technical note is to describe a surgical technique aimed at minimizing disease recurrence by avoiding radiated tissue in the reconstruction: 1. Tuttle longitudinal incision of posterior vaginal wall with sharp excision of proximally located fistula; 2. Resection of strictured rectum via a combined transvaginal/laparotomy access, reconstruction with Turnbull-Cutait colon pull-through, and delayed handsewn coloanal anastomosis with loop ileostomy; 3. Bridge closure of the posterior vaginal wall by the interposition of a Singapore flap. This approach resulted in a favorable outcome at the 1-year follow-up in one patient with a medical history of gynecological carcinoma status after hystero-salpingo-oophorectomy followed by adjuvant radiation.

Vaginoplasty using the Singapore flap for congenital vaginal atresia: A case report

Vaginoplasty using the Singapore flap for congenital vaginal atresia: A case report

V09-07 HOW TO USE A MESH SLING SAFELY AFTER THE POST-VESICOVAGINAL FISTULA REPAIR REPAIR PATIENT WITH STRESS URINARY INCONTINENCE

You have accessJournal of UrologyCME1 Apr 2023V09-07 HOW TO USE A MESH SLING SAFELY AFTER THE POST-VESICOVAGINAL FISTULA REPAIR REPAIR PATIENT WITH STRESS URINARY INCONTINENCE Micheal Breen Tamatave, Madagascar, Ly Hoang Roberts, and Larry Sirls Micheal Breen Tamatave, MadagascarMicheal Breen Tamatave, Madagascar More articles by this author , Ly Hoang RobertsLy Hoang Roberts More articles by this author , and Larry SirlsLarry Sirls More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003317.07AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Patients with complicated obstetric fistulas may have stress urinary incontinence (SUI) after vesicovaginal fistula repair (VVF), especially if the urethra in involved. Various techniques to treat post-VVF SUI have low success rates or is technically challenging due to thin and scarred peri-urethral tissue. We describe a technique to place a midurethral mesh sling outside of the pre-existing vaginal mucosa. METHODS: With the patient in dorsal lithotomy under spinal anesthesia, a foley catheter is placed into the bladder and the labial majora is retracted for adequate exposure. A rectangular area of the same size as the mesh sling (3x1cm) at the midurethra is marked. A number 15 scalpel is used to incise the vaginal mucosa at the marked lines, and Metzenbaum scissors are used to dissect and mobilize the edges. The dissection is then carried out laterally to be behind the inferior pubic bone. This is done on both sides. The island of vaginal mucosa is then superficially scored using low power bovie cauterization to allow for mesh adhesion and tissue ingrowth. The mesh is sutured to the island of skin using a 3-0 Chromic or vicryl suture at the mesh edges in 4 areas. 0- prolen sutures are then placed on each lateral edge of the mesh in a running stitch. The Metzenbaum scissors are then used to enter into the endopelvic fascia behind the pubic bone to develop the retropubic space. Next, a suprapubic incision is made 1cm cranial to the pubic bone down to the rectus fascia. The Stamey needle is passed in a top-down approach approximately 2cm from midline and end delivered into the vaginal incision. To check for bladder perforation, a metal catheter is placed into the bladder and swept laterally to evaluate for any metallic noise indicative of contact. The prolene suture is passed up to the suprapubic incision and the same is done contralaterally. Bladder is backfilled with sterile saline with methylene blue by gravity and foley removed. Sutures are tied together midline with the sling tension adjusted while patient performs a Valsalva. Suprapubic incision is then closed in multiple layers. The vaginal incision is closed with mobilization of the proximal vaginal mucosa and reapproximation to the distal edge. For larger incisions, a Singapore flap can be done for adequate coverage. RESULTS: Successful managment of SUI. CONCLUSIONS: For challenging cases of SUI after a post-VVF repair, this technique can be an option. Further investigation is needed for clinical outcomes. Source of Funding: None © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e839 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Micheal Breen Tamatave, Madagascar More articles by this author Ly Hoang Roberts More articles by this author Larry Sirls More articles by this author Expand All Advertisement PDF downloadLoading ...

Vaginal reconstruction with Singapore flaps in Mayer-Rokitansky-Küster-Hauser syndrome

Vaginal reconstruction with Singapore flaps in Mayer-Rokitansky-Küster-Hauser syndrome

Surgical treatment of deep-lying ano-/rectovaginal fistulas using a de-epithelialized “Singapore flap” (pudendal thigh flap)

Summary Background Rectovaginal fistulas represent 5% of all anorectal fistulas. For affected women, this pathology is associated with a reduction in quality of life (QoL) and self-esteem. Most commonly used methods of surgical closure have high recurrence rates or permanent perineal complaints, which in turn lead to negative effects on QoL and self-esteem. A fistula closure, using the “de-epithelialized Singapore flap” (SF), can be a good alternative therapy strategy. Method Our retrospective case series processes the long-term results of seven patients who were operated on for ano-/rectovaginal fistula using the SF. All patients underwent surgery at the University Hospital Graz, between May 2012 and July 2015. The data of the surgical follow-up examinations were collected and an additional telephone survey was carried out. The procedure is presented based on a structured description. All procedures were performed jointly by the Department of General Surgery and the Department of Plastic Surgery. Results The average age of the seven patients was 46.14 years (23–72 a). Five patients had a total of 12 previous operations with frustrating results. Of the seven patients treated, six had a permanent fistula closure (85.7%). The results of the telephone survey (n = 6) showed a high level of patient satisfaction (100%), and an improvement in QoL (83.3%), through our surgical method. In our cohort, neither urinary nor fecal incontinence occurred. Conclusion The treatment of an ano-/rectovaginal fistula using the “de-epithelialized pudendal thigh flap” (Singapore flap) is a promising treatment alternative. In particular, patients who have had previous proctological interventions show a benefit from this procedure.

Common Modalities of Reconstruction for Scrotal Defects at a Tertiary Care Hospital in Eastern India: An Observational Study

Introduction: Scrotal reconstruction remains a challenging problem to the surgeons. The various techniques used for scrotal reconstruction includes residual tissue re-arrangement, skin grafts, pedicled and free tissue transfer. There is lack of unified approach to deal with the issue. Aim: To discuss the surgical techniques performed for scrotal reconstruction in a tertiary care centre along with its epidemiological factors. Materials and Methods: This observational descriptive study was conducted on 33 cases in a tertiary care centre located in Eastern India over a period of three years. Scrotal reconstruction was planned according to aetiology, defect size, associated co-morbidity and age of the patient. Evaluation to assess the efficacy of each procedure was done with patient’s satisfaction scoring. At the time of discharge, with simple four level Likert scale, patient’s satisfaction was assessed. Descriptive statistics was used and results were expressed in terms of frequency and percentage. Results: The mean age of the patients with scrotal defects was 48±15.98 years. Fournier’s gangrene (n=21) was the leading cause of scrotal defects followed by trauma (n=8). The most common scrotal defect size was 50-75% (n=12). The most common scrotal reconstruction performed was Pudendal artery flap (Singapore flap) (n=12). Donor site scar was limited and acceptable. Wound related complications detected clinically as partial tissue necrosis, was observed in two cases. Most patients were satisfied with the final outcome, assessed by Likert scale. Conclusion: Scrotal reconstruction should be performed taking in account its aetiology, associated comorbidity, age and the scrotal defect size. Aesthetically and psychologically, well planned flap is reliable and better in comparison to Split-Thickness Skin Graft (STSG) and most of the complications can be managed conservatively.

Clinical and functional outcome of surgery for posttraumatic cloacal deformity.

Cloacal deformity is a disabling condition that severely affects a patient's quality of life. Surgery to repair cloacal deformity remains the mainstay of treatment. The aim of this study is to assess the clinical and functional outcome of patients treated for traumatic cloacal deformity by three different techniques. A retrospective multicentre study was carried out using data from women operated on for cloacal deformity between 2015 and 2019. Demographic characteristics, the presence of urinary and/or faecal incontinence and manometric findings were collected. The main outcome measures were represented by St Mark's and Rockwood faecal incontinence quality of life scores. Thirty eight women with a median age of 34years [interquartile range (IQR) 31-39years] were enrolled. Perineoplasty was performed in 23 patients by direct suture of the rectovaginal septum, in five using the X-flap and in 10 by the Singapore flap. Median resting and squeezing pressures increased significantly from 28.15 (IQR 23-32.7)cmH2 O to 45 (IQR 31-60.7) cmH2 O (p=0.0001) and from 47 (IQR 41.2-54.7)cmH2 O to 97.2 (IQR 80-118)cmH2 O (p=0.0001), respectively. Maximum tolerable volume improved from 120 (IQR 90-137.5)ml to 137.5 (IQR 120-150)ml (p=0.002). The St Mark's score decreased from 18 (IQR 14-20) to 4.5 (IQR 2-8) after 20months (p=0001). Sexual activity was confirmed by 16 patients preoperatively and by 27 postoperatively. A diverting stoma was performed in three patients after X-flap perineoplasty and in 14 treated by direct closure. No significant differences were found pre- and postoperatively between the three groups. Regardless of the technique used, surgical repair significantly improves both clinical and functional outcomes irrespective of the presence of a covering stoma.

Penile and scrotal defects post-Fournier gangrene: reconstructive options and challenges in resource limited settings

Introduction: Penile and scrotal defects following necrotizing fasciitis (Fournier gangrene) of the perineum in males can be a source of great morbidity and psychological concern to the patients inflicted with such a problem. In severe cases, it can result in mortality. Reconstruction of extensive defects/ulcers can be challenging in resource limited settings due to limited availability of tools such as doppler ultrasound/stethoscope, loupes, and operating microscopes for microsurgical procedures. Fournier gangrene is usually managed by the urologists in most centers in collaboration with the plastic surgeons for reconstruction of more extensive defects. Objective: The aim of the study was to review the penile and reconstructive options deployed for post-Fournier gangrene patients over a 3-year period (April 2017 to March 2020) in a tertiary hospital setting highlighting options utilized, indications for the respective options, and challenges encountered. Methodology: Case notes of Fournier gangrene patients offered penoscrotal reconstruction by the urology and plastic surgical teams within the period were retrieved, reviewed, and relevant data useful in achieving the above objectives extracted for analysis. Clinical photographs of some of the patients were included for illustration. Results: Twenty patients (20) that met the inclusion criteria were reviewed. Fourteen (70%) had defects involving both the scrotum and the penis, five (25%) involved the scrotum alone, while one (5%) had defect on the penis alone. Four (20%) had diabetes mellitus, three (15%) had HIV infection, and two (10%) had hypertension. Seventy percent (14) of the patients had secondary wound repair by direct closure, 5% (one) had split skin grafting alone, 5% (one) had a combination of split skin grafting and local advancement flap, and 20% (four) required the use of available locoregional flap [three being bilateral scrotal advancement flaps and one being bilateral pudendal thigh (Singapore) flap]. Healing was satisfactory in all the patients although two of them (10%) had surgical site infection whereas one (5%) had mild wound dehiscence, but all healed within 2 weeks. Conclusion: Post-Fournier gangrene defects can be reconstructed using several options, the choice of which is dependent on the size of the defect, elasticity of residual scrotal skin, status of defined locoregional pedicles, availability of modern diagnostic and operating equipment, and expertise of the surgeon. Collaboration between the urologists and the plastic surgeons is recommended for optimal outcome.

Interposition of a unilateral singapore posteriorly based fasciocutaneous axial flap for treating rectoneovaginal fistula in a male-to-female trans-sexual patient

Rectoneovaginal fistula (RnVF) is one of the major complications for the gender reassignment surgery. Closure of the RnVF with interposition of a pedicled tissue flap is a useful surgical approach to reconstruct the perineal space and provide neovascularization. Martius flap, gracilis muscle flap, and Singapore flap are the options of pedicled tissue flap. An HIV-positive 37-year-old male-to-female trans-sexual patient presented with a large RnVF (8–9 cm × 4 cm) after penile inversion vaginoplasty. A modified Singapore flap was performed to repair RnVF and to reconstruct the perineal space. Vaginal reconstruction with a fasciocutaneous Singapore flap can be considered for male-to-female trans-sexual patients with a complex RnVF as it provides excellent neovascularization with a sensate flap and desirable cosmetic outcome.

A retrospective review to identify criteria for incorporating the Singapore flap and gracilis muscle flap into obstetric fistula repair.

ObjectiveTo identify criteria to guide surgeons regarding indications for use of the Singapore and gracilis muscle flaps in obstetric fistula repair.MethodsThis is a retrospective case series. Obstetric fistula surgeons in Lilongwe, Malawi, have been incorporating plastic surgery techniques with the Singapore and gracilis muscle flaps since collaborating with plastic surgeons in 2016. We describe the surgical outcomes of procedures utilizing each flap individually and those using both.ResultsBetween February 2016 and June 2019, 69 patients received a flap at the time of obstetric fistula repair at the Fistula Care Center in Lilongwe, Malawi. A total of 32 (46.4%) received a Singapore flap, 20 (29.0%) received a gracilis flap, and 17 (24.6%) received both types of flap.ConclusionBased on our outcomes, we note the possible advantage of incorporating the gracilis flap even when it is thought that the Singapore flap is sufficient. However, more data are needed.

Island singapore flap vaginoplasty of two adult cases of Mayer– Rokitansky–Küster–Hauser Syndrome Type I

Mayer–Rokitansky–Kuster–Hauser Syndrome Type I is an emotionally distressful rare condition that limits normal sexual functioning and relationships. First described in 1989 by Wee and Joseph, the neurovascular island pudendal thigh flap (Singapore flap) has been variously utilized and modified for use in vaginal reconstruction. We report two adult cases of vaginal agenesis who underwent vaginal reconstruction using the Singapore flap. Both patients reported improved sexual lifestyle. Keywords: Island Singapore flap, Vaginoplasty, Mayer–Rokitansky–Kuster–Hauser syndrome Type I

Plastic Surgery Techniques for the Improvement of Outcomes of Complex Obstetric Fistula Repairs

Background: As part of a larger study on the outcomes of obstetric fistula surgery, a review on patient outcomes when using gracilis muscle and/or Singapore flaps was conducted.
 Methods: The database queried includes over 1700 patients. Fifty-five cases were identified having had either a gracilis muscle and or a Singapore flap as part of the repair.
 Results: Twenty-one patients had a Singapore flap only. Median age was 26 years (19-55), four had one prior repair and two had two prior repair attempts. Nine cases were Goh type 3 and nine were Goh type 4 indicating urethral involvement. 71% (n=15) were >3 centimeters in diameter. Median estimated blood loss (ebl) was 200 ml and average OR time was 2.5 hours. Median catheter duration 17 days (13-25). 81% (n=17) were dye test negative, with an average pad weight of 19.2 grams. 19 patients had a gracilis muscle flap alone with median age of 43 (23-70). Four had one previous repair, one had four previous repairs. Nine were Goh type 3 and eight were Goh type 4. 70% (n=12) had a fistula >3 cm in diameter and 88% (n=15) had type iii considerations (previous repair attempt, circumferential, or severe scarring). Median ebl was 250 ml and average operative time was two hours and 30 minutes. Median catheter duration was 17 days (14-31). 82% (n=14) had negative dye tests, with average pad weight of 19 grams. 16 patients had both a Singapore and a gracilis. Median age was 31 (15-70), nine were Goh type 3, seven were Goh type 4. 87.5% (n=14) had a fistula that was more than 3 cm in diameter and 87.5% (n=14) were type iii. Median ebl was 300 ml (250-1000 ml), and average operative time was 3 hours and 45 minutes. 81% (n=13) had a negative dye test, with two patients going home positive and returning negative over the course of four months. Average pad weight was 18.9 grams.
 Conclusion: For large fistulas with a significant amount of vaginal tissue loss, the Singapore flap is a potential option for improved outcomes. For recurrent cases and those with poor quality tissue, the gracilis muscle may lead to overall improved outcomes. Overall, these techniques are useful for complex obstetric fistula cases where outcomes are generally less favorable. Further prospective studies are needed.

Plastic Surgery Techniques for the Improvement of Outcomes of Complex Obstetric Fistula Repairs

Aims: As part of a larger study on the outcomes of obstetric fistula surgery, a review on patient outcomes when using gracilis muscle and/or Singapore flaps was conducted.
 Methods: The database queried includes over 1700 patients. Fifty-six cases were identified having had either a gracilis muscle and or a Singapore flap as part of the repair.
 Results: Twenty-one patients had a Singapore flap only. Median age was 26 years (19-55), four had one prior repair and two had two prior repair attempts. Nine cases were Goh type 3 and nine were Goh type 4 indicating urethral involvement. 71% (n=15) were >3 centimeters in diameter. Median estimated blood loss (ebl) was 200 ml and average OR time was 2.5 hours. Median catheter duration 17 days (13-25). 81% (n=17) were dye test negative, with an average pad weight of 19.2 grams. 19 patients had a gracilis muscle flap alone with median age of 43 (23-70). Four had one previous repair, one had four previous repairs. Nine were Goh type 3 and eight were Goh type 4. 70% (n=12) had a fistula >3 cm in diameter and 88% (n=15) had type iii considerations (previous repair attempt, circumferential, or severe scarring). Median ebl was 250 ml and average operative time was two hours and 30 minutes. Median catheter duration was 17 days (14-31). 82% (n=14) had negative dye tests, with average pad weight of 19 grams. 16 patients had both a Singapore and a gracilis. Median age was 31 (15-70), nine were Goh type 3, seven were Goh type 4. 87.5% (n=14) had a fistula that was more than 3 cm in diameter and 87.5% (n=14) were type iii. Median ebl was 300 ml (250-1000 ml), and average operative time was 3 hours and 45 minutes. 81% (n=13) had a negative dye test, with two patients going home positive and returning negative over the course of four months. Average pad weight was 18.9 grams. 
 Conclusions: For large fistulas with a significant amount of vaginal tissue loss, the Singapore flap is a potential option for improved outcomes. For recurrent cases and those with poor quality tissue, the gracilis muscle may lead to overall improved outcomes. Overall, these techniques are useful for complex obstetric fistula cases where outcomes are generally less favorable. Further prospective studies are needed.

Sondanın Üretrada Şişirilmesine Bağlı Gelişen Fournier Gangreni-Singapur Flebi ve Safen Veniyle Üretroplasti

Sondanın Üretrada Şişirilmesine Bağlı Gelişen Fournier Gangreni-Singapur Flebi ve Safen Veniyle Üretroplasti

Vaginal reconstruction with rectus abdominis myocutaneous flaps after abdominoplasty

Sir,Invaginal reconstruction,autologousflapscanprovide coverageof a critical wound and return of function, which significantlyimproves psychological well-being and quality of life. Manypatients will have multiple reconstructive options for a vaginaldefect; however, there are some cases where an ideal flap existsand the alternatives are either suboptimal or infeasible. Wepresent a case to demonstrate the viability of performing avertical rectus abdominis myocutaneous flap (VRAM) for vag-inal reconstruction in a patient with a prior abdominoplasty.A 61-year-old female with a history of recurrent vaginalcancer after primary resection and radiation therapy presentedfor functional vaginal reconstruction after total pelvic exentera-tion. The patient’s surgical history was significant for a fullabdominoplastywithrectusplicationandumbilicaltransposition10yearspriortopresentation.Theconsiderabledefectcreatedbythe pelvic exenteration (Fig. 1)requiredalargeflaptofillthepelvicdeadspaceandalargeskinpaddletocreatetheneovaginalvault. Given the patient ’s ample abdominal subcutaneous tissue,apedicledVRAMwaschosentorepairthedefect.Askinpaddlewas designed such that the neovaginal vault would have a depthof 11 cm and a diameter of 3 cm. Using the equationcircumference ¼ pi diameter;a width of 9 cm was chosen for the skin paddle. Replacementof perineal skin loss required additional vertical length on theflap. Due to the length of skin needed, the skin paddle wasdesigned beyond the rectus abdominis onto the chest wall.Dissection was carried out in standard fashion with theexception that the entire width and length of fascia under theskinpaddlewasincludedwiththeflap.Thiswasdoneinorderto capture as manymusculocutaneousperforators as possible,maximizing perfusion to the skin paddle. After elevation, theflapmaintainednormalcapillaryrefillanddemonstratedgoodbleeding throughout the entire length of the skin paddle (Fig.2a).Theflapwasthenfoldedonitselftocreatetheneovaginalvault (Fig. 2b) and inset into the pelvis after dissection of thedeep inferior epigastric artery (Fig. 3).The patient was discharged in good condition 3 days later. Ather 6-week follow-up evaluation, the flap revealed a soft andfunctional vaginal opening and no recipient or donor site mor-bidity. The patient was last seen in follow-up 1-year postopera-tively and reported that she was able to have sexual intercourse.There are a number of options for vaginal reconstructionincluding Singapore flaps, posteri or thigh flaps, gracilis flaps,VRAM, colon, and jejunum. In our patient, the size of theperinealdefect,sizeofthedeadspacewithinthepelvis,andneedfor total circumferential reconstruction made the VRAM theoptimal flap for reconstruction. Its perforating myocutaneousvessels concentrated in the periumbilical area allow the utiliza-tion of a large skin paddle [ 1, 2]. Other reconstructive optionswere considered, such as bilater al gracilis flaps. However, therewas concern that they would not be able to provide the requiredsoft tissue and skin needed for the reconstruction. Failure toprovide reliable skin paddles for critical wound coverage couldhave resulted in devastating complications.There is considerable controversy concerning whether it issafe to use an abdominal myocutaneous flap after disruptionof the blood supply to the skin. The principles of flap perfu-sion suggest the possibility of revascularization of the skinfrom the undermined surface. However, the extent and reli-ability of this neovascularization is disputed [ 3].Manyplasticsurgeons would recommend against using abdominally basedflaps after abdominoplasty or liposuction [4, 5]. In addition,some authors recommend consent forms for abdominoplastyto include as a risk the loss of reconstructive options [6].

The propeller flap concept used in vaginal wall reconstruction

Most posterior vaginal wall defects are due to abdominoperineal resection for colorectal carcinoma involving the posterior vaginal wall or resection of local malignancies. The rectus abdominis myocutaneous flap, the modified Singapore flap and the gracilis myocutaneous flap remain workhorse solutions for this type of vaginal reconstruction. The introduction of the perforator concept has introduced new therapeutic options using the gluteal donor site region. Recently, perforator-based gluteal flaps have been described as a reliable solution for reconstruction of posterior vaginal wall defects, with low donor site morbidity. Here, we present a new technique to optimise results and minimise morbidity to the patient.

Reconstrução vaginal pelo retalho neurovascular pudendo crural na síndrome de Rokitansky

INTRODUÇÃO: Agenesia vaginal relacionada à síndrome de Mayer-Rokitansky-Kuster-Hauser (MRKH) ocorre na proporção de 1 para cada 4000 ou 5000 nascimentos femininos, causando grande limitação à vida afetiva da paciente. O manejo da agenesia vaginal inclui acompanhamento psicológico e reconstrução vaginal. OBJETIVO: Mostrar a experiência do Serviço com a técnica do retalho neurovascular pudendo crural para reconstrução vaginal no tratamento de 8 pacientes com síndrome de Rokitansky. MÉTODO: Apresentam-se oito casos de síndrome de Rokitansky em que a reconstrução vaginal foi realizada pelo retalho neurovascular pudendo crural, chamado retalho de Cingapura. O período de acompanhamento pós-operatório variou de 6 meses e 3 anos. RESULTADOS: Uma neovagina funcional de, no mínimo, 10 cm de profundidade e 5 cm de diâmetro foi criada em todos os casos. Apesar da queixa de dor local de moderada intensidade no pós-operatório imediato, as pacientes apresentaram-se satisfeitas com os resultados. As relações sexuais foram liberadas no 40º dia de pós-operatório, sem relatos de sangramento ou dor. Três pacientes apresentaram crescimento de pêlo no intróito vaginal. CONCLUSÃO: A técnica do retalho de Cingapura permitiu a reconstrução vaginal sem a necessidade de dilatação pós-operatória, mantendo a inervação do períneo e com cicatrizes pouco perceptíveis.

Defektdeckung an der Vulva mit plastisch-rekonstruktiven Verfahren – Indikationen, Techniken und Ergebnisse

Fragestellung: Die zunehmende Inzidenz an Vulvakarzinomen in den letzten Jahren lässt die Anzahl an Patientinnen, die mit plastisch-rekonstruktiven Verfahren an der Vulva versorgt werden müssen, ansteigen. Material und Methodik: Zwischen 2004 und 2009 wurden 20 Frauen mit primären bzw. rezidivierten Vulva-/Vaginalkarzinomen, ausgedehnter VIN/AIN, großen Defekten nach Wundheilungsstörungen oder Scheidenstenose mit 24 Lappenplastiken operiert. Dazu wurden 9 distante (6 VRAM, 2 M. gracilis und ein M. tensor fasciae latae) und 15 regionäre Lappen eingesetzt (8 Gluteal Fold, 4 Transpositionslappen, 3 Singapore-Flaps). Bei den distanten Lappen war die Indikation in der Regel ein großer Defekt nach Rezidiventfernung, bei den lokoregionären Lappen kleinere Defekte und Erhalt der Vita sexualis bei jungen Patientinnen mit Vulvakarzinom der hinteren Kommissur. Ergebnisse: Der VRAM-Lappen erwies sich als sehr verlässlicher Lappen zur Defektdeckung im Mons-pubis-Bereich und bei großen Defekten im gesamten Vulvabereich, der Gluteal-Fold-Flap wurde zur Rekonstruktion größerer Defekte lateral und dorsal verwendet, der Singapore-Flap zur Rekonstruktion der Vagina und bei periurethralen Defekten. Transpositionslappen helfen, Introitusverengungen bei Läsionen an der hinteren Kommissur zu verhindern. Ein individualisiertes Vorgehen nach Einzelbefund ist ausschlaggebend für den Erfolg. Die Rate schwerer Komplikationen in unserer Serie war sehr gering. Schlussfolgerung: Wir schlussfolgern, dass die individualisierte Lappendeckung an der Vulva in der Hand von plastisch-rekonstruktiv erfahrenen operativ tätigen Gynäkologen ein sicherer Eingriff zum Erhalt der Sexualfunktion und Deckung von großen Defekten nach Rezidiventfernung von Malignomen darstellt.

Transverse Singapore Flap for Reconstruction of a Congenital Rectovaginal Fistula in an 18-Month-Old Infant

Many different types of flaps have been used for reconstruction of rectovaginal fistulae. This is the first report of using a transverse Singapore flap for repairing a large 3 cm by 3-cm complex congenital rectovaginal fistula in an 18-month-old infant with VATER syndrome. A right transverse Singapore flap was used to reconstruct both the posterior wall of the vagina and the anterior wall of the rectum while simultaneously joining the 2 structures to the perineum. Despite minor postoperative delayed healing which resolved, the patient has maintained a functionally and cosmetically satisfactory result at 20-month follow-up. For complex rectovaginal fistulae reconstruction in the pediatric patient, the transverse Singapore flap is a reliable and viable option for the reconstructive surgeon.