Vulvar Malignancies Research Articles

Noninfectious genital ulcers.

Noninfectious genital ulcers are much more common than ulcers arising from infections. Still, it is important to take a thorough history of sexual activity and a sexual abuse screen. A physical exam should include skin, oral mucosa, nails, hair, vulva, and vaginal mucosa if needed. The differential diagnosis of noninfectious genital ulcers includes: lipschütz ulcers, complex aphthosis, Behçet's syndrome, vulvar metastatic Crohn's disease, hidradenitis suppurativa, pyoderma gangrenosum, pressure ulcers, and malignancies. It is important to come to the correct diagnosis to avoid undue testing, stress, and anxiety in patients experiencing genital ulcerations.

Outcome of vulvar reconstruction in patients with advanced and recurrent vulvar malignancies.

BackgroundThe 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.MethodsPatients 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.ResultsThirty-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 %.ConclusionSoft 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.

Outcome of vulvar reconstruction by anterolateral thigh flap in patients with advanced and recurrent vulvar malignancy.

To evaluate the outcomes of vulvar reconstruction using anterolateral thigh (ALT) flaps in patients with advanced and recurrent vulvar malignancies. Totally 24 patients who received ALT-based vulvar reconstruction were retrospectively reviewed to evaluate the outcome focusing on quality of life and prognosis. Four patients received vulvar reconstruction at the time of primary surgery due to advanced stage, and 20 patients underwent vulvar reconstruction after recurrence. No patient experienced complete flap loss. Major complications happened in five patients (20.83%). Minor complications occurred in three patients (12.5%). All wounds healed favorable after appropriate treatment. The mean scale of verbal rating scale (VRS-4) was 1.58 before reconstruction while decreased to 0.13 after surgery (P < 0.0001). Mean performance status was 1.67 before surgery compared to 0.13 after surgery (P < 0.0001). Fourteen patients (58.33%) developed recurrence with a median interval of recurrence of 5 months after vulvar reconstruction. Ten patients (41.67%) are living with disease free in a median follow-up of 19.5 months. Overall 5 years survival was 56.4%. ALT flap based vulvar reconstruction method can improve the quality of life and might be considered as an appropriate option for reconstructing the vulvar defects in patients with advanced or recurrent vulvar malignancy.

Vulvar cancer: a review for dermatologists.

Vulvar malignancies are important tumors of the female reproductive system. They represent a serious health issue with an incidence between 2 and 7 per 100,000 and year. We provide a review about most important cancer entities, i.e., melanoma, squamous cell carcinoma, basal cell carcinoma, neuroendocrine cancer, and skin adnexal malignancies.Squamous cell carcinoma is the most common vulvar malignancy that can develop from vulvar intraepithelial neoplasia or de novo. Basal cell carcinoma represents only 2% of all vulvar cancers. Melanoma of the vulva exists in two major types-superficial spreading and acral lentiginous. A special feature is the occurrence of multiple vulvar melanomas. Of the adnexal cancer types Paget's disease and carcinoma are seen more frequently than other adnexal malignancies. The dermatologist should be aware of this problem, since he might be the first to be consulted by patients for vulvar disease. Treatment should be interdisciplinary in close association to gynecologists, oncologists, and radiologists.

Sentinel lymph node mapping in patients with vulvar malignancies using indocyanine green and near-infrared imaging: Preliminary detection rate experience

Sentinel lymph node mapping in patients with vulvar malignancies using indocyanine green and near-infrared imaging: Preliminary detection rate experience

Investigation of the clinicopathological features of squamous cell carcinoma of the vulva: a retrospective survey of the Tohoku Gynecologic Cancer Unit.

This multi-institutional study was conducted to clarify the clinicopathological features of squamous cell carcinomas of the vulva. The medical records of vulvar cancer patients treated between 2002 and 2012 were retrospectively reviewed following approval by the Institutional Review Board of each institution. One hundred and eleven patients with vulvar malignancies were included. Of these, 63 patients had squamous cell carcinoma (57 %). Initial treatment was surgery, radiation therapy (RT), and concurrent chemoradiotherapy (CCRT) in 34 (54 %), 15 (24 %), and 11 (17 %) patients, respectively. Nineteen, 11, 26, and 7 patients had stage I, II, III, and IV disease, respectively. Of the 34 patients who had surgical treatment, 50 % had stage I disease, while 74 % of those who received CCRT had stage III or IV disease. Complete response (CR) rates for the surgery, RT, and CCRT groups were 73, 60, and 64 %, respectively. The 5-year survival rates for stage I/II and III/IV disease were 64 and 39 %, respectively (P = 0.019). The 5-year survival rates for the surgery, RT, and CCRT groups were 53, 38, and 50 %, respectively, and the prognosis of patients treated with surgery or CCRT was significantly better than that of patients who received RT (P < 0.05). In multivariate analysis, clinical response to initial treatment was an independent prognostic factor (P < 0.001). Although many patients had advanced-stage disease in the CCRT group, the therapeutic outcome for the surgery and CCRT groups was similar. Thus, CCRT may be a promising treatment for squamous cell carcinoma of the vulva.

Gynaecological Screening for Cervical and Vulvar Malignancies in a Cohort of Systemic Sclerosis Patients: Our Experience and Review of the Literature

Background. Increased incidence of cancer was frequently reported in scleroderma (SSc), but no association with gynaecological malignancies was described in literature. Objectives. To investigate gynaecological neoplasms in SSc patients. Methods. In this cross-sectional analysis, we evaluated 80 SSc patients, living in the same geographical area. We considered all patients undergoing gynaecological evaluation, including pap test as screening for cervical cancer, between January 2008 and December 2014. Results. 55 (68.7%) patients were negative and 20 (25%) presented inflammatory alterations, while cancer or precancerous lesions were found in 5 (6.2%) cases (2 showed cervical cancer (one of them in situ), 1 vulvar melanoma, 1 vulvar intraepithelial neoplasia, and 1 endocervical polyp with immature squamous metaplasia). The frequency of cervical cancer in our series seems higher in comparison to the incidence registered in the same geographical area. The presence of atypical cytological findings correlated with anti-Scl70 autoantibodies (p = 0.022); moreover, the patients with these alterations tended to be older (median 65, range 46–67), if compared to the whole series (p = 0.052). Conclusions. A relatively high frequency of gynaecological malignancies was found in our SSc series. In general, gynaecological evaluation for SSc women needs to be included in the routine patients' surveillance.

Osseous Metastases in Gynaecological Epithelial Malignancies: A Retrospective Institutional Study and Review of Literature.

Osseous metastasis in gynaecological epithelial tumours is an extremely rare phenomenon occurring in less than 1% of these cancers. To analyse the clinical characteristics and prognosis in patients with gynaecological epithelial cancers with bone metastases. This was a single institutional retrospective study done with the data available from January 2008 to January 2015. Out of 1686 patients with epithelial gynaecological malignancies there were a total 18 (1.07%) patients with osseous metastasis. Clinico-pathologic characteristics were tabulated in Microsoft Excel 2013 and data were analysed using SPSS software Version 21. A p-value< 0.05 was taken to be statistically significant. Survival analysis was done by using Kaplan-Meier method and log-rank test was used to find out the difference in survivals. Out of the 18 gynaecological epithelial cancer patients with bone metastases, 12 had cervical cancer, three had ovarian cancer, two had endometrial carcinoma and one patient had vulvar malignancy. Twelve patients had squamous cell histology, while the rest had adenocarcinoma. The mean interval from primary diagnosis of cancer to the detection of bone metastases was 31.9 months (range, 1 - 60 months). Solitary bone lesion was present in seven patients. The most common site of bone metastasis was lumbar vertebra. Extra-osseous metastasis was present in 12 patients. The mean follow-up period was 8.3 months. During the follow-up period 12 out of the 18 patients died. There was significant difference in survival (p = 0.005) between patients with solitary bone metastasis and patients with multiple osseous metastases. Near significant survival difference (p = 0.056) was also noted in patients with extra-osseous metastases when compared to the patients without. Improved survival was also found in patients with controlled local disease (p = 0.003) when compared to patients with local failure. Bone metastasis in gynaecological epithelial malignancies is a rare phenomenon, but with grave prognosis. Multiple sites of bone involvement, recurrence at the primary tumour site and presence of other non-osseous metastases are poor prognostic indicators. Treatment in these patients should be tailored according to the patient's need.

Delayed Presentation of Patients with Gynaecological Malignancies in Kano, North-Western Nigeria

The diagnosis and management of gynaecological cancers are still challenging in low- and middle-income countries. In patients with gynaecological malignancies delay at any point increases morbidity and mortality. This study evaluated the factors that may delay presentation, diagnosis and treatment of patients with malignant gynaecological cancers, and described the duration of each delay. It was a prospective cross-sectional study. A total number of 96 patients diagnosed to have gynaecological malignancy were enrolled in the study between the April 2014 and April 2015. The median age was 47.5 years (range of 18 - 84 years). The diagnoses on admission were cervical malignancy 34 (35.42%), ovarian malignancy 32 (33.33%), chorio carcinoma 15 (15.63%), cancers of uterine body (endometrial and leiomyosarcoma) 10 (10.42%) and vulval malignancies 5 (5.2%). Majority of the patients 65 (67.7%) presented late at either stage III or IV. At presentation, 36 patients (37.5%) had severe anaemia; 10 patients (10.41%) had obstructive uropathy; 3 (3.13%) developed fistula; 19 (19.79%) died on admission from complication of their disease. Most patients 61 (63.54%) had delayed presentation of more than 90 days (“patients delay”). Time in decision ranged between 3 days to maximum of 2920 days and median of 150 days. 58 (60.42%) gave a reason for such delay as lack of knowledge of their presenting symptoms, as a warning sign of possible malignancy; 80 (83.33%) had delay in diagnosis (“doctor delay”); 40 (41.67%) reported that the medical practitioner did not make referral to the center with available gynaecological services; “hospital delay” was observed in 66 (68.75%) of patients. The reason for delayed treatment in 35 (36.46%) of patients was severe patients condition that warrant stabilization (blood transfusion and dialysis) and 29 (30.21%) could not afford the treatment. Late presentation is a great problem in the management of oncological patients in this environment. High cost of care is the major challenge for the patients and gynaecologist in north-western part of Nigeria.

Computed tomography, magnetic resonance imaging and FDG positron emission tomography in the management of vulvar malignancies.

To prospectively evaluate the value of CT or MRI (CT/MRI) and PET in the management of vulvar malignancies. Abdominal and pelvic CT/MRI and whole-body (18) F-FDG (fluorodeoxyglucose) PET or PET/CT (collectively designated PET hereafter) were performed. Lesion status was determined by the pathological findings or clinical follow-up. The diagnostic efficacy was evaluated by receiver operating characteristic (ROC) curve analysis. The clinical impact of PET was determined on a per scan basis. Twenty-three patients were enrolled, and 38 PET examinations were performed. CT/MRI and PET studies were used for primary staging (n = 17), monitoring the response (n = 7) and restaging after recurrence (n = 14). In primary staging, there was no significant difference between CT/MRI and PET in detecting metastatic inguinal lymph nodes (ILN). CT/MRI was significantly more efficacious than PET in detecting pelvic lymph node (PLN) or distant metastasis (p = 0.007 by ROC per patient basis). PET findings resulted in two positive impacts and one negative impact for both primary staging and restaging. False-positive PLN or distant metastasis PET findings are not uncommon, and hence should be interpreted with caution. PET can be supportive when metastatic ILN/PLN or distant metastasis is suspected on CT/MRI. • False-positive metastatic PLN or distant metastasis PET findings are not uncommon. • CT/MRI has value in the management of vulvar malignancies. • PET can be supportive when metastasis is suspected by CT/MRI.

Carcinoma espinocelular de la vulva: caso clínico

SUMMARY Background: Squamous cell carcinoma (SCC) is a malignant epithelial neoplasm. SCC can be divided into 4 groups: non-melanoma skin cancer (NMSC), head and neck, esophageal and lung cancer. The risk for metastasis of SCC is 0.3-3.7%. Vulvar SCC is approximately 3-5% of all gynecological cancers. Case report: An 86-year old woman with a history of several years of genital pruritus and many consultations for this reason, prior treatments included valacyclovir for genital herpes; topical corticosteroids and tachrolymus for lichen sclerosus et atrophicus (LEA) with poor response. She presented with pruritus and new vulvar lesions. Physical examination showed two ulcerated nodules on the left periclitorid region and the introitus. The biopsy confirmed an infiltrating well-differentiated SCC. CT-scans discarded metastases. She received 7 weeks of radiotherapy. Due to persistence of the tumor the patient entered palliative care. Two years afterwards the patient is in good condition. Discussion: SCC represents 95% of vulvar malignancies. There are 2 types: SCC in young women, associated with high-risk human papilloma virus infection and SCC in elder women associated to the preexistence of LEA. 45-61% of vulvar SCC is associated in with preexisting

Importance of the physical exam and in-office tests in the evaluation of vulvovaginal irritation

Background: Vulvovaginal irritation is a common gynecologic complaint. A number of factors may lead to a trial of therapy without undertaking a physical exam or diagnostic testing. Case Report: A 45 year-old woman presented to our colposcopy clinic for evaluation of an abnormal Papanicolaou (Pap) test. She reported a one month history of vulvovaginal irritation, for which Premarin vaginal cream had been empirically prescribed. Examination of the external genitalia showed ulcers and erythema of the labia minora. Speculum exam was deferred because of the patient’s discomfort. Wet mount microscopy from a vaginal swab revealed evidence of Trichomonas vaginalis, bacterial vaginosis (BV), and yeast. A swab of the ulcers was sent for herpes simplex virus (HSV) polymerase chain reaction (PCR); this confirmed HSV-2. Treatment was initiated for each of these conditions, and the patient returned for colposcopy 21 days later. Conclusion: This case illustrates the importance of the physical exam when evaluating a complaint of vulvovaginal irritation. In many cases, the cause(s) of vulvovaginal irritation can be identified based on physical exam findings and in-office testing with wet mount microscopy, vaginal pH, and the amine “whiff” test. In some cases, additional testing may be required to establish or confirm a diagnosis. Accurate diagnosis is essential not only to initiate appropriate therapy, but also to prevent the transmission of sexually transmitted infections. In some cases, this may decrease the delay in diagnosing vulvar gynecologic malignancies.

Misdiagnosed Rhabdomyosarcoma of the Vulva

Vulvar carcinoma is a rare disease that accounts for 5% of gynecologic cancers. Sarcomas of the vulva are extremely rare, and account for only 1% to 3% of all vulvar malignancies. We report of a case of a 26 years woman with a vulva mass. Excision was done and histopathologic result showed rhabdomyosarcoma.

The role of regional anaesthesia in the surgical management of vulval malignancy

Surgical excision is the management of choice in vulval cancer however, the patient population are typically elderly and comorbid, for whom general anaesthesia (GA) carries considerable risk. The outcome of 107 procedures were reviewed in order investigate the postoperative complication rates associated with general and regional anaesthesia for the surgical management of vulval cancer. GA was used in 78 (72.9%) cases; 27 (22.9%) had a regional anaesthetic (spinal/epidural/ileoinguinal) and two women had a GA following a failed spinal anaesthetic. Women having a regional anaesthetic were significantly older (p = 0.0198), had a higher ACE (p = 0.0001) and ASA score (p < 0.0001) than those having a GA. There was an association between GA and grade II+ complications, compared with regional techniques (odds ratio, OR 2.72) but this was not significant due to the small number of events. Regional anaesthetic techniques are safe, well-tolerated alternatives to GA for the surgical management of vulval cancer, especially in an elderly and comorbid population.

Isolated sentinel lymph node biopsy with conservative management in women diagnosed with vulvar cancer

Objectives: Sentinel lymph node (SLN) dissection is a reliable method for evaluation of the inguinal lymph nodes in patients with vulvar malignancies. The objective of this study was to examine SLN evaluation alone in women with squamous cell carcinoma (SCC) of the vulva and evaluate the inguinal recurrence and complication rates.

A Thirty-year Review of Vulvar Cancer in Jamaica, 1978 to 2007.

To evaluate the trends in vulvar cancer between 1978 and 2007 in Kingston and St Andrew, Jamaica, with respect to age-standardized rates and histologic types. All cases of vulvar cancer recorded in the Jamaica Cancer Registry from 1978 to 2007 were extracted and analysed for age distribution and histologic type. There were 78 cases (one person of unknown age) of vulvar cancer recorded over the 30-year period. Sixty per cent of the affected patients were between 50 and 80 years old. The most common histologic type of vulvar malignancy was squamous cell carcinoma (82%). There was a decline in age-standardized incidence rates of both vulvar cancers overall and vulvar squamous cell carcinoma over the 30-year period. Squamous cell carcinoma is the most common vulvar malignancy in the Jamaican population, and affects primarily older women. Despite high prevalence rates of high-risk human papillomavirus infection, no increase in the age-standardized incidence of vulvar squamous cell carcinoma was identified.

Increased risk and pattern of secondary malignancies in patients with invasive extramammary Paget disease

Extramammary Paget disease (EMPD) is often associated with underlying or distant synchronous malignancies. The prognosis for affected patients is generally favourable; however, the risk of secondary malignancies is unknown. The goal of the study was to analyse the incidence, prognosis and pattern of secondary malignancies for patients with invasive EMPD using data from the Surveillance, Epidemiology and End Results (SEER) Program. We searched the SEER Program database for patients diagnosed with invasive EMPD between 1973 and 2008. Demographic data, outcome and secondary malignancies more than 1 year after the initial diagnosis of invasive EMPD were included in the analysis. We calculated the standardized incidence ratio (SIR) and estimated the excess absolute risk (EAR) per 10,000 person-years (PY). There were 1439 patients who were diagnosed with invasive EMPD. Most patients (80.4%) had localized disease, while 17.1% had locoregional spread and 2.5% presented with distant disease. The SIR for secondary malignancies in patients with invasive EMPD was significantly elevated with an EAR of 97.4 additional malignancies per 10,000 PY. The excess risk was mostly due to a significantly increased incidence of colorectal and anal malignancies. The initial site of disease predicted the site of the secondary malignancies, with patients with colorectal, anal, vulvar and scrotal disease showing an increased risk of colorectal, anal, vulvar and scrotal malignancies, respectively. Our study identified a long-term increased risk of developing secondary malignancies in patients with invasive EMPD that are mainly related to the site of origin of this disease. Patients with invasive EMPD require prolonged follow-up and screening for these malignancies.

Exenterative surgery for recurrent gynaecological malignancies

Cancer is a leading cause of death worldwide. Gynaecological cancers (i.e. cancers affecting the ovaries, uterus, cervix, vulva and vagina) are among the most common cancers in women. Unfortunately, given the nature of the disease, cancer can recur or progress in some patients. Although the management of early-stage cancers is relatively straightforward, with lower associated morbidity and mortality, the surgical management of advanced and recurrent cancers (including persistent or progressive cancers) is significantly more complicated, often requiring very extensive procedures. Pelvic exenterative surgery involves removal of some or all of the pelvic organs. Exenterative surgery for persistent or recurrent cancer after initial treatment is difficult and is usually associated with significant perioperative morbidity and mortality. However, it provides women with a chance of cure that otherwise may not be possible. In carefully selected patients, it may also have a place in palliation of symptoms. The biology of recurrent ovarian cancer differs from that of other gynaecological cancers; it is often responsive to chemotherapy and is not included in this review. To evaluate the effectiveness and safety of exenterative surgery versus other treatment modalities for women with recurrent gynaecological cancer, excluding recurrent ovarian cancer (this is covered in a separate review). We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE up to February 2013. We also searched registers of clinical trials, abstracts of scientific meetings and reference lists of clinical guidelines and review articles and contacted experts in the field. Randomised controlled trials (RCTs) or non-randomised studies with concurrent comparison groups that included multivariate analyses of exenterative surgery versus medical management in women with recurrent gynaecological malignancies. Two review authors independently assessed whether potentially relevant studies met the inclusion criteria. No studies were found; therefore no data were analysed. The search strategy identified 1311 unique references, of which seven were retrieved in full, as they appeared to be potentially relevant on the basis of title and abstract. However, all were excluded, as they did not meet the inclusion criteria of the review. We found no evidence to inform decisions about exenterative surgery for women with recurrent cervical, endometrial, vaginal or vulvar malignancies. Ideally, a large RCT or, at the very least, well-designed non-randomised studies that use multivariate analysis to adjust for baseline imbalances are needed to compare exenterative surgery versus medical management, including palliative care.

Psychologic, Relational, and Sexual Functioning in Women After Surgical Treatment of Vulvar Malignancy: A Prospective Controlled Study

Vulvectomy for vulvar malignancy can affect sexual functioning based on anatomic, physiologic, psychologic, and relational mechanisms. The aims of this study were to prospectively investigate sexual adjustment of women with vulvar malignancy during a follow-up period of 1 year after vulvectomy and to compare the results with healthy control women. In this prospective controlled study, participants completed the Beck Depression Inventory scale, World Health Organization-5 Well-being scale, Dyadic Adjustment Scale, Short Sexual Functioning Scale, and Specific Sexual Problems Questionnaire to assess various aspects of psychosocial and sexual functioning just before surgery, 6 months, and 1 year after treatment. Twenty-nine women with vulvar malignancy and 29 healthy controls completed the survey. Compared with the presurgery status, no significant differences were found in psychologic, relational, and sexual functioning in women after surgery for vulvar malignancy. Compared with healthy control women, women with vulvar malignancy reported significantly lower psychologic well-being and quality of partner relationship, both before and after treatment. Moreover, significantly more patients with vulvar malignancy reported preoperative and postoperatively sexual dysfunctions than healthy controls, including entry and deep dyspareunia, abdominal pain during intercourse, reduced ability to achieve orgasm, and reduced intensity of orgasm. This prospective study yielded no differences in psychosocial and sexual functioning for women with vulvar malignancy before and after vulvectomy. However, when compared with healthy controls, patients with vulvar malignancy are at high risk for sexual dysfunctions, both before and after surgical treatment.

Modified gluteal fold advancement V-Y flap for vulvar reconstruction after surgery for vulvar malignancies

ObjectiveThe aim of the study is to assess the feasibility and complications of the modified V-Y advancement gluteal flap in the vulvo-perineal reconstruction among women operated for vulvar malignancies. MethodsFrom December 2008 to April 2012 women who underwent radical surgery for invasive vulvar cancer were considered for the study. Patients after demolitive procedure were submitted to reconstructive step (Group A) consisting of bilateral or monolateral V-Y advancement fascio-cutaneous flap, from gluteal fold. Surgical results were compared to those of a historical group of patients (Group B) with the same characteristics but not submitted to the reconstructive step. ResultsTwenty-nine patients were considered for the study and submitted to radical surgery followed by V-Y flap. Surgical results were compared to those of 78 patients submitted to demolitive surgery only. There were no differences in terms of clinical characteristics between the two groups. The average length of hospital stay was 7 and 10days, respectively for Groups A and B (P=0.0067). Mean operating time was higher in Group A, 210 vs 120min (P<0.00001). Among women with tumor size larger than 4cm (27 Group A, 30 Group B), Group A had lower complication rate (dehiscence 11% vs 40%; P=0.0172). ConclusionsModified gluteal fold advancement V-Y flap is a safe and simple procedure and can be harvested in a single surgery session. It could be able to reduce hospital stay and in patients with large loss of substance could reduce rate of complications.