The use of rectus abdominis myocutaneous flaps following excision of vulvar cancer

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.

Subunit principle of vulvar reconstruction: algorithm and outcomes

BACKGROUND

Vulvar defects result chiefly from oncologic resection of vulvar tumors. Reconstruction of vulvar defects restores form and function for the purpose of coitus, micturition, and defecation. Many surgical options exist for vulvar reconstruction. The purpose of this article is to present our experience with vulvar reconstruction.

METHODS

From 2007 to 2013, 43 women presented to us with vulvar defects for reconstruction. Their mean age at the time of reconstruction was 61.1 years. The most common cause of vulvar defect was from resection of vulvar carcinoma and extramammary Paget's disease of the vulva. Method s of reconstruction ranged from primary closure to skin grafting to the use of pedicled flaps.

RESULTS

The main complications were that of long term hypertrophic and/or unaesthetic scarring of the donor site in 4 patients. Twenty-two patients (51%) were able to resume sexual intercourse. There were no complications of flap loss, wound dehiscence, and urethral stenosis.

CONCLUSIONS

We present a subunit algorithmic approach to vulvar reconstruction based on defect location within the vulva, dimension of the defect, and patient age and comorbidity. The gracilis and gluteal fold flaps are particularly versatile and aesthetically suited for reconstruction of a variety of vulvar defects. From an aesthetic viewpoint the gluteal fold flap was superior because of the well-concealed donor scar. We advocate the routine use of these 2 flaps for vulvar reconstruction.

Postablative reconstruction of vulvar defects with local fasciocutaneous flaps and superficial fascial system repair

INTRODUCTION

Postablative reconstruction of vulvar defects is a difficult challenge because of the functional, locational and cosmetic importance of this region. Local flaps carry a high incidence of delayed wound healing as local flaps may redistribute but not eliminate local wound tension. Repair of the superficial fascial system may avert local complications by minimising tension to the skin and increasing the initial biomechanical strength of wound. The aim of this study was to determine the clinical outcome of local fasciocutaneous flaps used for postablative reconstruction of vulvar defects in which the superficial fascial system was repaired.

METHODS

A retrospective analysis was conducted of patients with vulvar carcinoma in situ or vulvar carcinoma, who underwent ablation and immediate reconstruction with local fasciocutaneous flaps and superficial fascial system repair. Postoperative complications were recorded and clinical outcomes were evaluated.

RESULTS

Twelve of the 13 flaps healed primarily. Complications included 2 superficial wound infections, both of which were treated successfully with antibiotic therapy. One flap was complicated by minor wound dehiscence, which healed with conservative treatment.

DISCUSSION

Local fasciocutaneous flaps with superficial fascial system repair provide excellent design flexibility and can be designed and tailored to reconstruct postablative vulvar defects with good outcomes and minimal morbidity.

Reconstructive plastic surgery in the treatment of vulvar carcinomas

OBJECTIVE

The results obtained using plastic surgery reconstruction in 207 patients with a primary or recurrent vulvar carcinoma were analyzed with regard to the surgical procedures applied, pre-treatment and post-operative findings, along with the long-term oncological disease course.

STUDY DESIGN

Standardized data concerning the surgical procedures applied and clinical factors were collected in a databank and statistically analyzed.

RESULTS

The flaps employed were termed either 'local' (cutaneous or fasciocutaneous; n=84) or 'regional' (myocutaneous, n=123). For local flaps, the rate of secondary healing was 31%, dropping to 20% for regional flaps. Such healing disturbances often affected the donor region and did not lead to lasting clinical problems such as stenosis or distortion. Severe disturbances of wound healing (loss of more than 10%) were not observed in local flaps, whereas such problems were encountered in 5.9% of regional flaps. Gluteal thigh flaps were most frequently applied and were also the most successful type of myocutaneous reconstruction. Therapy was selected on an individual basis according to tumor status.

CONCLUSION

Plastic surgery reconstruction broadens the range of operative therapies available for the treatment of vulvar carcinomas, especially those at an advanced stage or recurrent tumors, and leads to a favorable oncological disease course as well as improved cosmetic results.

Surgical therapy of recurrent vulvar cancer

OBJECTIVE

The success of various surgical interventions in 201 cases with recurrent vulvar carcinoma was examined in the light of patients' pretreatment, surgical therapy, plastic reconstruction, and postoperative disease course.

STUDY DESIGN

A databank of standardized clinical data was analyzed using statistical procedures.

RESULTS

Therapy was selected on an individual basis according to tumor status. Recurrence at a site distant from the primary tumor, particularly in the inguinal region, indicated a markedly unfavorable prognosis. In contrast, tumors recurring locally did not exhibit any significant differences. Plastic surgery reconstruction led to improvements with respect to operability, wound healing, and survival.

CONCLUSION

Individualized reconstructive surgery of the vulva leads to good results in patients with recurrent vulvar cancer. To an even greater extent than is the case for primary therapy, plastic surgery enlarges the spectrum of feasible surgical alternatives so that a more favorable oncological outcome and excellent cosmetic results may be expected.

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

BACKGROUND

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.

METHODS

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.

RESULTS

All flaps survived completely, with no complications except for small perineal wound disruption in three patients.

CONCLUSIONS

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.

Reconstructive surgery following resection of primary vulvar cancers

OBJECTIVE

This study describes the surgical treatment and follow-up of 213 patients with primary vulvar cancer; particular attention is given to reconstructive surgical procedures.

METHODS

The clinical and pathological parameters of the patients were recorded according to standardized procedures, and the data concerning type of operation, surgical reconstruction and postoperative course of disease (recurrence-free and overall survival) were analyzed.

RESULTS

In about one-third of the cases, plastic surgery reconstruction involving skin-flaps was performed. In the present group of patients, plastic surgery procedures led to an elevated degree of operability as well as to more satisfactory results in terms of wound healing. For minor cosmetic defects, local (fasciocutaneous) skin-flaps resulted in excellent wound healing and short periods of in-patient treatment, even in patients with larger tumors. In cases exhibiting more severe wounds extending over larger areas of the vulva and its surrounding regions, similarly encouraging results were achieved using regional (myocutaneous) skin-flaps.

CONCLUSION

The present study shows that reconstructive surgery of the vulva leads to good results in patients with vulvar cancer. Plastic surgery enlarges the spectrum of available operative therapy in vulvar cancer, especially in large tumors, and its application leads to a favorable oncological outcome as well as excellent cosmetic results in patients with vulvar cancer.

Immediate vulvar and vaginal reconstruction using the gluteal-fold flap: long-term results

The gluteal-fold flap was used to reconstruct vulvar and posterior vaginal wall defects in 40 patients. This is a fasciocutaneous, islanded flap based on the internal pudendal artery and vein perforators. The flap is robust and has the advantage of being away from the pathway of carcinoma spread. In addition it has minimal donor-site morbidity as the scar is hidden in a natural crease.

Changes in the management of vulval cancer

Vulval carcinoma is relatively rare. The disease spreads from the vulva through embolization to the locoregional lymphatic station, the inguinofemoral nodes. Prior to this event cure can be achieved, but rarely predicted with certainty. This chapter reviews current therapeutic knowledge and recognizes the increasing importance of individualization of a treatment plan. The adoption of these principles will hopefully evolve a pattern of care that leads to a decrease in morbidity for those women with early tumours and less morbid but more effective strategies for those with advanced disease.

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.

V--Y flap for perineal reconstruction following modified approach to vulvectomy in vulvar cancer

OBJECTIVE

To evaluate a simple reconstructive procedure used in combination with a modified oncological approach to the treatment of invasive vulvar cancer. Local and systemic morbidity, length of hospital stay, local recurrence, and mortality were evaluated.

METHODS

Between September 1995 and January 1997, 19 patients underwent radical vulvectomy and inguinal lymphadenectomy with a modified oncological approach. The modified approach consisted of a triple incision: two inguinal incisions, shorter and following force lines of the groin, and a third incision around the vulvar lesion. Vulvectomy included a 2-cm safety margin around the tumor, based on clinical examination and anatomical-pathological frozen sections of the specimen. This procedure was always followed by perineal reconstruction with V-Y flaps by the plastic surgery team. Median follow-up was 12 months. The complication rate and lengths of hospital stay were evaluated and compared with those in a similar group in which radical vulvectomy was performed associated with two long longitudinal incisions in the groin. The data were statistically analyzed.

RESULTS

The perineal and inguinal dehiscence rates in group A (traditional approach) were 68.4% and 78.94%, respectively. The same rates in group B (modified approach), were 10.5% and 36.84%, respectively. Mean hospital stay was 39.5 days in group A (traditional) vs. 14.0 days in group B (modified). At 30 months' median follow-up, the rate of local recurrence in group A (traditional) was 42.0%; at 12 months' median follow-up, local recurrence in group B (modified) was 26.3%.

CONCLUSIONS

In this study, the use of V-Y flaps in combination with a modified oncological approach significantly reduced local complication rates and lengths of hospital stay, while observing oncological principles.

Epithelioid sarcoma of the vulva

We report a case of a 23-year-old woman diagnosed as having an epithelioid sarcoma of the vulva. She was treated by a clitoris-sparing hemivulvectomy and lymph node sampling of the ipsilateral groin. Vulvar reconstruction was performed with a rectus abdominis myocutaneous flap. Four years after the operation there is no evidence of disease and the patient has a normal sex life. The English literature on this subject is reviewed with special attention to the biological behavior and therapeutic approach.

The rectus abdominis myocutaneous flap: modifications, complications, and sexual function

BACKGROUND

Vaginal, perineal, and pelvic floor reconstruction is being performed with increasing frequency in conjunction with radical pelvic surgery. Although the vertical rectus abdominis myocutaneous flap is ideally suited to such procedures, little information exists regarding risks or complications associated with it.

METHODS

A chart review of all patients who underwent this procedure at two institutions was performed, and the results were compared with existing series. Surviving patients were asked to describe their satisfaction with the procedure and their sexual function.

RESULTS

Between 1990 and 1997, 22 patients underwent placement of a rectus abdominis myocutaneous flap for vaginal/pelvic floor reconstruction, 21 (95.5%) at the time of pelvic exenteration. Attachment of the graft was complete in 20 patients (90.9%) and partial in 1 (4.5%), and 1 patient experienced complete loss that resulted in total vaginal stenosis. Four patients (18.2%) developed mild vaginal stenosis that was corrected with dilators. Donor site complications included wound separation (above the fascia) in three patients and one delayed abdominal closure. There were no cases of bowel obstruction, dehiscence, hernia, or death. The only statistically significant identifiable risk factors for graft necrosis included prior abdominal surgery and operative time. Thirteen of 22 (59.1%) of the patients are cancer free (median progression free interval, 42.2 months), 11 (84.6%) of whom reported having had vaginal intercourse since surgery.

CONCLUSIONS

The rectus abdominis myocutaneous flap can be safely used with excellent results and acceptable morbidity, and in this series it restored sexual function in the majority of cancer survivors. Because previous abdominal surgery (transverse incisions or colostomy) may compromise blood supply to the flap, alternative sites should be considered in such cases.

Lotus petal flaps in vulvo-vaginal reconstruction

The perineum is an area of rich blood supply with multiple arterial anastomoses. Flaps raised on perforators around the perineum resemble the petals of the lotus and can be used to reconstruct a variety of vulvo-vaginal defects. Thirteen such flaps have been used successfully without any loss of flaps in eight patients. Eight flaps in four patients were used for vulvar reconstruction following radical vulvectomy.