Modified Lotus Petal Flap for Vulvo-Vaginal Reconstruction after Resection for Vulvar Cancer − A Single Institution Experience

Redefining the Reconstructive Ladder in Vulvoperineal Reconstruction: The Role of Pedicled Perforator Flaps

BACKGROUND

 Gynecological reconstruction is difficult, particularly in cases with recurrence and received previous surgeries and/or radiotherapy and necessitate secondary reconstruction. Perforator flaps can preserve other donor sites for potential later reconstruction, and they also can be better tailored to the defect. We hypothesized that the use of perforator-based flaps can better restore the defect with less complications.

METHODS

 A retrospective review was conducted of all patients who underwent vulvar-perineum reconstruction between 2011 and 2018 by the senior author, and oncologic and reconstructive outcomes and complications were analyzed.

RESULTS

 Thirty-three patients underwent 55 soft tissue reconstructions for vulvar-perineum defects during the study period. The mean follow-up time was 27.6 ± 28.9 months. Squamous cell carcinoma was the most common cancer (45.5%). For 11 patients (33.3%), the procedures were performed for the treatment of recurrent cancer. The average defect size was 39.8 ± 34.3 cm². The overall survival rate was 90.3%. Profunda artery perforator flaps were the most commonly applied flap for reconstruction in both the primary and recurrent groups. Poor wound healing was the most common complication which occurred in 10 of the 55 flaps (18.2%). Perforator flaps presented fewer complications than myocutaneous flaps or traditional random flaps. Similarly, Island pedicle flap design also presented fewer complications than traditional rotation flaps. With proper reconstruction, previous surgery or radiotherapy did not contribute to an increase in complications.

CONCLUSION

 In our experience, perforator flaps can provide satisfactory reconstruction for perineum reconstruction with low postoperative complications while preserving other donor sites in the event of disease recurrence for repeat resection and reconstruction. Previous surgery or radiotherapy did not increase the complications or preclude its usage. A redefined reconstructive ladder was created to help selecting the best state-of-the-art technique for reconstruction to achieve better results.

Lotus petal flap and vertical rectus abdominis myocutaneous flap in vulvoperineal reconstruction: a systematic review of differences in complications

BACKGROUND

Vulvoperineal defects resulting from surgical treatment of (pre)malignancies may result in reconstructive challenges. The vertical rectus abdominis muscle flap and, more recently, the fasciocutaneous lotus petal flap are often used for reconstruction in this area. The goal of this review is to compare the postoperative complications of application of these flaps. Methods: A comprehensive literature search of the PubMed, MEDLINE and Cochrane Library databases was performed until 6 June 2020. Search terms included the lotus petal flap, vertical rectus abdominis muscle flap and the vulvoperineal area. Articles were independently screened by two researchers according to the PRISMA-guidelines. Results: A total of 1074 citations were retrieved and reviewed, of which 55 were included for full text analysis. Following lotus petal flap reconstructions, the complication rate varied from 0.0% to 69.9%, with more complications concerning the recipient site compared with the donor site complications (26.0% versus 4.5%). Following vertical rectus abdominis muscle flap reconstructions the complication rate varied between 0.0% and 85.7% with almost twice the number of recipient site complications compared to donor site complications (37.1% versus 17.8%). Conclusions: Overall, the lotus petal flap has lower complication rates at both the donor and the recipient site compared with the vertical rectus abdominis muscle flap. When both options seem viable, the lotus petal flap procedure may be preferred on the basis of the reported lower complication rates. Abbreviations: APE: abdominoperineal excision; ELAPE: extra levator abdominoperineal excision; LP flap: lotus petal flap; NIH: National Institute of Health; NR: not reported; RCT: randomized controlled trial; VRAM flap: vertical rectus abdominis myocutaneous flap.