Vulvar Reconstruction Research Articles

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

Objective: To assess the feasibility and complications of the modified V-Y advancement gluteal flap in vulvoperineal reconstruction among women operated for vulvar malignancies.

Perineal reconstruction with an extrapelvic vertical rectus abdominis myocutaneous flap.

Extensive perineal resections often require autologous tissue reconstruction, especially in wide oncological resections. Local and regional pedicled flaps from the lower extremity and abdominal sites have been described. Defects of the pelvis and perineum rarely require free-tissue transfer. The vertical rectus abdominis myocutaneous (VRAM) flap, traditionally delivered to the perineum through an intraperitoneal transpelvic route, is a workhorse flap for combined pelvic and perineal defects because of its ability to provide substantial coverage of the perineum, reliable vascular supply, and larger volume to obliterate dead space. We propose and describe an extended VRAM flap for vulvar reconstruction delivered to the perineum in an extrapelvic fashion. A 54-year-old woman with a prior history of anal squamous cell carcinoma underwent neoadjuvant chemoradiotherapy followed by abdominoperineal resection, total abdominal hysterectomy, and bilateral salpingo-oophorectomy. Three years later, she developed vulvar squamous cell carcinoma with vascular and lymphatic invasion and underwent radical vulvectomy and distal urethrectomy. The resection defect was 10 × 15 cm, including the distal 1 cm of the urethra, distal vaginal orifice, and wide exposure of the pubic bone. An extrapelvic extended VRAM flap was used for reconstruction. The flap was harvested and transposed into the defect via a wide suprapubic subcutaneous tunnel. A neovaginal and urethral orifice was created in the flap by splitting the muscle in the direction of its fibers, taking care to protect the vascular pedicle, and inset to the vaginal orifice. There were no postoperative complications. She has maintained urinary continence with follow-up of 38 months. Introduction of a rectus abdominis flap to the perineum through an extrapelvic route is preferred if laparotomy is not used for the resection. We successfully report and advocate the use of an extended VRAM flap for vulvar reconstruction delivered to the perineum in an extrapelvic fashion.

Reconstruction of the Vulva with Sensate Gluteal Fold Flaps

Soft-tissue reconstruction of the vulva following resection of malignancies is challenging. The function of perineal organs should be preserved and the reconstructed area should maintain an acceptable cosmetic appearance. Reconstruction with local flaps is usually sufficient in the primary phase after a radical vulvectomy. Numerous flaps have been designed for vulvar reconstruction usually based on circulation from the internal pudendal artery branches. In this paper we introduce our modification of the gluteal fold V-Y advancement flap as a primary reconstruction after a radical vulvectomy. Twenty-two patients were operated with a radical vulvectomy because of vulvar malignancies. The operation was primary in eight and secondary in 14 patients. The reconstruction of the vulva was performed in the same operation for each patient. All flaps survived completely. Wound complications were registered in three patients. Late problems with urinary stream were corrected in two patients. A local recurrence of the malignancy was observed in six patients during the follow-up period. Gluteal fold flap is easy to perform, has a low rate of complications and gives good functional results. Even a large defect can be reconstructed reliably with this method. A gluteal fold V-Y advancement flap is sensate and our modification allows the flap to be transposed with lesser dissection as presented before.

Vulvar reconstruction by a “supra-fascial” lotus petal flap after surgery for malignancies

ObjectiveThe aim of this study is to report on our experience with the supra-fascial lotus petal flap following the resection of vulvar cancer. MethodsThe original lotus petal flap or gluteal-fold flap technique was initially described with fascial elevation. However, flap harvesting in a supra-fascial plane is feasible. Between 2008 and 2011, we performed and evaluated this modified flap technique for labia majora reconstruction on five elderly females (mean age: 72years). ResultsResection and reconstruction were performed in the same operative time with a median time procedure of 118min. We observed neither flap failure nor partial necrosis. Functional evaluation beyond six months showed low donor site morbidity and good aesthetic results. ConclusionImmediate vulvar reconstruction with supra-fascial lotus petal flap is a fast, easy and reliable procedure. It enables wide resection and safety margin following tumor removal with free tension suture, good aesthetic results and a favourable functional outcome.

Local Fasciocutaneous Infragluteal (FCI) Flap for Vulvar and Vaginal Reconstruction: A New Technique in Cancer Surgery

Soft tissue reconstruction after vulvar, vaginal, or anal cancer resection poses a formidable task for reconstructive surgeons because of the functional, locational, and cosmetic importance of this region. Although numerous flaps have been designed for vulvar reconstruction, each has its disadvantages. The authors introduce the local fasciocutaneous infragluteal (FCI) flap for vulvar and vaginal reconstruction after tumor resection, vaginal scar obliteration, and vulvar ulceration in 15 patients operated on between 1999 and 2007. The FCI flap is supplied by the cutaneous branch of the descending branch of the inferior gluteal artery. The sensory supply of this flap comes from side branches of the posterior cutaneous nerve of the thigh. A total of 17 flaps were performed in 15 patients. Except for one, all flaps survived. One flap necrosis occurred because of false postoperative position with compression and tension to the vascular pedicle. In the remaining patients, we found one local cancer recurrence with necessity of a second flap from the contralateral side. The patients report satisfaction with reconstruction, without one having pain at donor site and recurrent vaginal ulceration. This article discusses the expanding indications of this versatile flap and the operative technique of the local FCI flap for reconstruction of vulvar and partial vaginal defects. It can be raised in different volume and dimension out of possible irradiated area with an inconspicuous scar.

Anterolateral Thigh Flap–Based Reconstruction for Oncologic Vulvar Defects

Vulvar defects after tumor extirpation always require immediate reconstruction. Transferring a skin flap from a distant region may be required for large defects. Although the anterolateral thigh flap has gained popularity in other types of oncoplastic surgery, it has rarely been reported for vulvar reconstruction. The aims of this retrospective study were to evaluate the outcome of anterolateral thigh flap-based vulvar reconstruction and to develop an operative strategy. Eleven patients with vulvar carcinoma underwent resection and immediate reconstruction with the anterolateral thigh flap between 2005 and 2009. Based on defect type and local soft-tissue quality, four types of anterolateral thigh flap-based reconstructions were performed: unilateral anterolateral thigh flap, ipsilateral anterolateral thigh flap combined with contralateral advancement flap or local flap, fenestrated anterolateral thigh flap, and split anterolateral thigh flap. Postoperative complications were recorded and clinical outcomes were evaluated. Partial flap necrosis occurred in one patient with a fenestrated anterolateral thigh flap for bilateral reconstruction. One wound dehiscence occurred in the contralateral local flap. Two patients had prolonged serous drainage. Mean follow-up was 8 months. One patient developed stricture of the urethral meatus and another had regional metastasis. With careful design, the anterolateral thigh flap may provide reliable and durable soft-tissue coverage for various vulvar defects with good outcomes and minimal donor-site morbidity.

Vulvar reconstruction. The exploitation of an ignorance

At the very end of the 20th century, the clinical reconstruction of the morphology of the vulva became a widespread fashion. Going well beyond the context of classic dysmorphophobia, requests to practitioners have to do with submission to a stereotypical concept: recreating general appearance of the female genital organs as there are in childhood. Based on ignorance as well as on very old justifications – rejection of animality and the depreciation of the female body –, such submission, dismissive of the adult state of these organs, is a trespass against elementary ethical imperatives. Moreover, this moral issue poses two types of problems. On the one hand, there are medical ethics considerations for practitioners. On the other, and more broadly, it is a cultural issue that reaches down into the foundations of Western civilization.

The anterior Obturator Artery Perforator (aOAP) flap: Surgical anatomy and application of a method for vulvar reconstruction

Objective Vulvar reconstruction following oncologic resection is challenging. Some flaps used for reconstruction can show adverse characteristics such as excessive tissue bulk or increased distance to the defect. Region of the sulcus genitofemoralis is of thin and pliable tissue proximate to the vulva. Vasculature and suitability of that region used for vulvar reconstruction were focused in this work. Methods Vascular architecture of the region comprising the sulcus genitofemoralis was examined bilaterally on 10 female corpses ( n = 20 specimens). In addition, tissue characteristics and suitability of that region to form a fasciocutaneous flap for vulvar reconstruction were anatomically examined and clinically proven. Results Vasculature of the sulcus genitofemoralis is reflected by either a musculocutaneous perforator (80%, 16/20) piercing the gracilis muscle or a septocutaneous perforator (20%, 4/20) passing the posterior border of the gracilis muscle 1.3 ± 0.3 [cm] laterally to the inferior pubic ramus. Both types of perforators derive from the anterior branch of the obturator artery and accompanying vein. This perforator, the anterior obturator artery perforator (aOAP), supplies a skin territory of about 7 × 15 [cm] centered on the sulcus genitofemoralis. The aOAP flap proved its suitability and versatility for vulvar reconstruction. Conclusions The sulcus genitofemoralis is of a constant vascular anatomy reflected by the aOAP vessel. Especially the tunneled aOAP island flap offers outstanding characteristics beneficial for reconstruction of a more anatomically normal vulva. Scars are limited within anatomic borders of the urogenital region improving self-image. The aOAP flap clearly enlarges the surgical options available to restore the form and function of the vulva.

Vulvar reconstruction using a “V-Y” fascio-cutaneous gluteal flap: a valid reconstructive alternative in post-oncological loss of substance

We will present our experience in vulvar reconstruction using a local fascio-cutaneous flap, in order to get an easier intra-operative management and a good post-operative outcome. Between May 2006 and December 2008, eight patients with vulvar carcinomas underwent a vulvar reconstruction, using a V-Y advancement flap of the gluteal fold. This fascio-cutaneous flap, based on the perforator vessels originated from the internal pudendal artery, was used for the reconstructive treatment of patients who had undergone a vulvectomy with medium-size defects. All the 16 flaps prepared survived without major complications. Walking and sitting positions were restored in few post-operative days. Length of hospitalisation was 2-3weeks. The flaps restored sensitivity few months after surgery. In no case the surgical scars needed being revised. The follow-up results proved satisfactory in terms of patients' compliance and morphological results. The flap appeared to be thin, well vascularised and very flexible in its advancement. The post-operative follow-up is characterised by a rapid healing and a low incidence of short- and long-term complications.

Gluteal fold VY advancement flapに基づく再建を行った外陰癌の1症例

Gluteal fold VY advancement flapに基づく再建を行った外陰癌の1症例

The gluteal fold fascio-cutaneous flap for reconstruction after radical excision of primary vulvar cancers

Objectives Reconstructive surgery plays an important role in cosmetic and functional results of major excisional surgery performed as a treatment for invasive vulvar cancer. Traditional techniques – gracilis myocutaneous o rectus abdominis flaps – have several limits. We describe here a different surgical approach that we have used since 1998 in an effort to obtain better results in vulvar reconstruction. Methods From January 1998 to June 2007, thirty three patients who underwent excisional radical surgery for invasive vulvar tumors, were treated with vulvar reconstruction using the gluteal fold fascio-cutaneous local flap. Flaps were designed along the gluteal fold in adequate length and size. They were oval or triangular in shape depending on the defect they were supposed to cover. The flaps – which always included the fascial layer – were raised up to identify a perforator branch of the internal pudendal artery and then harvested as an island flap to achieve better mobility. Results We had no major complications, only two patients presented marginal necrosis and eight patients experienced significant seromas. Advantages over the alternative techniques included reduced dimensions of scars, absence of flap liponecrosis, no need of modifying patient's position on the surgical table, and very limited blood loss. Conclusions We conclude that gluteal fold flap offers excellent cosmetic and functional results with a low complication rate. Therefore we support the gluteal fold flap as a valid surgical option whenever reconstruction is needed after radical excision of vulvar neoplasms.

Primary Vulvar Nocardiosis

Nocardiosis is an uncommon disease, and the primary skin infection is usually at the site of a recent injury. Nocardia is a saprophytic bacterium of the soil belonging to the order Actinomycetales. A 68-year-old woman presented with a painful, hard, dark reddish lesion located in the right hemivulva. She had been treated by radiotherapy for a vulvar leiomyosarcoma arising from the left Bartholin gland at the age of 45. Pathology results demonstrated nocardial infection, initially advanced despite antibiotic therapy. The necrosis extended to and involved the ischiopubic bone, requiring extensive surgical treatment. We performed a radical vulvectomy with partial pubic bone excision to remove the necrotic tissue. A transverse gracilis-myocutaneous free flap was used for vulvar reconstruction. Wound necrosis recurrence required a rectus abdominis myocutaneous flap reconstruction, with an excellent final result. This is the first report of primary vulvar nocardiosis. This infection may simulate advanced vulvar carcinoma requiring extensive surgical treatment.

Gluteal Fold V-Y Advancement Flap for Vulvar and Vaginal Reconstruction: A New Flap

Soft-tissue reconstruction following vulvar cancer resection is a difficult challenge because of the functional, locational, and cosmetic importance of this region. Although numerous flaps have been designed for vulvar reconstruction, each has its disadvantages. The authors introduce the gluteal fold fasciocutaneous V-Y advancement flap for vulvovaginoperineal reconstruction after vulva cancer resection. This flap is supplied by underlying fascial plexus derived from perforators of the internal pudendal artery and musculocutaneous perforators of underlying muscle. The sensory supply of this flap comes from the posterior cutaneous nerve of the thigh and the pudendal nerve. An axis of V-shaped triangular flap is aligned to the gluteal fold. A total of 17 flaps were performed in nine patients. All flaps survived completely, with no complications except for small perineal wound disruption in three patients. This flap is thin, reliable, sensate, easy to perform, and has matched local skin quality and concealed donor-site scar on the gluteal fold. In addition, it can cover large vulvovaginal defects because it can be advanced farther as a result of the character of the gluteal fold area. In our experience, the gluteal fold fasciocutaneous V-Y advancement flap has proven very useful for vulvar reconstruction, especially at the point of donor-site scar, flap thickness, and degree of flap advancement.

Flap Algorithm in Vulvar Reconstruction After Radical, Extensive Vulvectomy

Flap Algorithm in Vulvar Reconstruction After Radical, Extensive Vulvectomy

Immediate Vulvar and Vaginal Reconstruction Using the Gluteal-Fold Flap: Long-term Results

Immediate Vulvar and Vaginal Reconstruction Using the Gluteal-Fold Flap: Long-term Results

Deep Inferior Epigastric Perforator (DIEP) Flap for Vulvar Reconstruction After Radical Vulvectomy

For vulvar reconstruction following radical vulvectomy in a 71-year-old woman with a large vulvar cancer, we applied the deep inferior epigastric perforator flap (DIEP flap), a typical perforator flap, which could be performed by utilizing an abdominal incision wound without producing another surgical scar and had less donor site morbidity because of a minimal sacrifice of muscles. The surgical procedures were less invasive and simple, and morphologically and functionally satisfactory results were obtained: no recurrence of cancer, a well-preserved vulvar morphology with less donor site scarring, and no functional disturbance such as dysuria and abdominal hernia. We consider that the DIEP flap is the first choice for vulvar reconstruction following radical vulvectomy. Even in radical vulvectomy without an abdominal incision wound, the DIEP flap with an anatomically reliable vascular pedicle can be an effective option.

Flap Algorithm in Vulvar Reconstruction After Radical, Extensive Vulvectomy

The objective of this study was to assess the reconstructive options after radical, extensive vulvectomy; relate them to tumor characteristics; and select a choice of flaps able to correct every remaining defect. This study is a retrospective review of a 4-year experience with 31 flaps in 20 consecutive vulvar reconstructions. Three of the 31 flaps presented nonsignificant delayed healing at their tips and 3 other flaps developed a major breakdown related to an infection or an error in flap planning. According to the authors, the size of the defect is the main issue that must be taken into consideration during the establishment of reconstructive needs. Closure of vulvar defects is preferably performed using fasciocutaneous flaps, which are very reliable flaps and can be raised with different techniques to meet different needs. A flap is then chosen with the fewest potential complications. An algorithm has been thus established: Small to medium-size defects are closed with island V-Y flaps, island gluteal fold flaps, or pedicled pudendal thigh flaps. Among them, the island V-Y flap is the workhorse flap for vulvar reconstruction because of its versatility, reliability, and technical simplicity compared with its very low complication rate. If the vulvar defect is large and/or reaches the vulva-crural fold, V-Y flaps are also preferred to close these large and posteriorly extended excisions. If the vulvar defect is very large, extending both anteriorly and posteriorly, the use of a distally based, vertically oriented rectus abdominis muscle flap is recommended. Using this algorithm, immediate vulvar reconstruction with pedicled local or regional flaps can be performed easily and reliably.

Rectus Femoris Myocutaneous Flap for Vulvoperineal Reconstruction

Background. Many reconstructive procedures for large vulvoperineal defects have been described. The present report describes the use of the rectus femoris myocutaneous flap, which has not previously been described for this purpose.Case. A 52-year-old woman suffered a local recurrence of a Bartholin's gland carcinoma after anterior exenteration and pubectomy. A palliative resection was performed which resulted in a large vulvoperineal defect with transpelvic herniation of the peritoneal contents. This was immediately reconstructed with a rectus femoris myocutaneous flap. Her postoperative course and healing were uneventful.Conclusion. This technique is an alternative method for vulvar reconstruction. It is especially useful for large defects when a gracilis or rectus abdominis flap is not available.

Anterolateral Thigh Vastus Lateralis Myocutaneous Flap for Vulvar Reconstruction after Radical Vulvectomy: A Preliminary Experience

Background. There are many myocutaneous flap methods which have been reported for the immediate reconstruction of large vulvar defects created by deforming radical cancer surgery in the female perineum except for the anterolateral thigh vastus lateralis myocutaneous flap. The present report describes our preliminary experience with the use of this flap in a patient who underwent radical vulvectomy for locally advanced squamous cell carcinoma of the vulva.Case. A 75-year-old woman underwent radical vulvectomy with bilateral inguinal lymphadenectomy due to right vulvar squamous cell carcinoma. The large vulvar defect was immediately reconstructed by using anterolateral thigh vastus lateralis myocutaneous flap. The postoperative course was uneventful. In addition to the expected primary healing, the neovulva had a relatively normal appearance with satisfactory sensation and function and the donor defect was found to be minimal both functionally and aesthetically.Conclusion. This technique can be used as an alternative method for vulvar reconstruction after radical vulvectomy. Further studies are warranted to prove the efficacy of this myocutaneous flap in reconstructing large vulvar defects.

Innervated island flaps in morphofunctional vulvar reconstruction.

In this article, the authors present their own experience in vulvar reconstruction following vulvectomy using two different innervated island flaps according to the size and site of the defect. Island-flap mobilization is possible thanks to the rich blood supply of the perineal region. The methods described are a "V-Y amplified sliding flap from the pubis" and a "fasciocutaneous island flap" raised from one or both gluteal folds. The V-Y amplified sliding flap from the pubis is indicated when the defect is symmetric and located anteriorly. This flap is harvested from the pubis and vascularized by the deep arterial network of the pubis. Sensory innervation is provided by branches of the ileo-inguinal nerve. The fasciocutaneous island flap, raised from one or both gluteal folds, can be used following hemivulvectomy or radical vulvectomy, respectively, to cover posteriorly located defects. Vascularization is provided by the musculocutaneous perforating branches of the pudendal artery, whereas sensory innervation is maintained through the perineal branches of the pudendal nerve. Twenty-two patients have undergone reconstructive surgery of the vulvar region from 1989 to date. On 14 patients, a V-Y amplified sliding flap was used; on 7 patients, reconstruction was carried out by island flaps raised from the gluteal fold. Both techniques are compatible with inguino-femoral lymphadenectomy, and they allow for a correct morphofunctional reconstruction and provide good local sensibility. The final result is aesthetically satisfactory, as all final scars are hidden in natural folds.