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

Gender-specific Anatomical Distribution of Internal Pudendal Artery Perforator: A Radiographic Study for Perineal Reconstruction

Cancer, trauma, infection, or radiation can cause perineal defects. Fasciocutaneous flaps based on perforator vessels (PV) from the internal pudendal artery (IPA) provide an ideal reconstructive option for moderate defects. We hypothesized that, due to gender differences in the pelvic–perineal region, the anatomical distribution of PV differs between genders.

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.

Outcomes of Immediate Internal Pudendal Artery Perforator Flap Reconstruction for Irradiated Abdominoperineal Resection Defects

BACKGROUND

There are many previous reports for using the internal pudendal artery perforator flap in vulvovaginal reconstruction; however, reports of this flap for perineal reconstruction after abdominoperineal excision of the rectum are scarce.

OBJECTIVE

The purpose of this study was to evaluate the outcomes of immediate internal pudendal artery perforator flap reconstruction for irradiated abdominoperineal resection defects.

DESIGN

This was a prospective case series.

SETTINGS

This flap could represent a step forward over other perineal flap approaches or primary closure.

PATIENTS

A total of 73 consecutive patients with anorectal tumors were included.

INTERVENTIONS

The study included immediate perineal reconstruction using 122 internal pudendal artery perforator flaps after abdominoperineal excision of the rectum.

MAIN OUTCOME MEASURES

Dimensions of the perineal defect (in centimeters squared), hospital stay (days), healing time (days), and postoperative complications (Clavien-Dindo grades) were measured.

RESULTS

The means of the perineal defect, hospital stay, and healing time were 51.62 cm, 15.94 days, and 38.52 days. The higher the patient BMI, the longer healing time (p = 0.02); Clavien-Dindo complications grades III to IV were greater in patients with perineal defect ≥60 cm (p = 0.03; OR = 10.56); postoperative complications were higher both in patients with anal squamous cell carcinoma (p = 0.005; OR = 6.09) and in patients with comorbidities (p = 0.04; OR = 2.78); hospital stay (p= 0.001) and healing time (p < 0.001) were higher in patients who had postoperative complications. The complete perineal wound healing at 12 weeks was achieved by 95% of patients, and our 30-day mortality rate was 4%.

LIMITATIONS

As a nonrandomized study, our results have to be interpreted with caution.

CONCLUSIONS

Multiple previously described advantages associated with internal pudendal artery perforator flap were also observed here, reinforcing the idea that it is reliable, versatile, and a useful option for perineal reconstruction after abdominoperineal excision of the rectum. Therefore, we propose that this flap could be considered as the first choice for perineal reconstruction in selected patients with moderate and some large defects after abdominoperineal excision of the rectum. See Video Abstract at http://links.lww.com/DCR/A367.

Modified Gluteal Fold V-Y Advancement Flap for Reconstruction After Radical Vulvectomy

Objective

To describe the surgical technique of the V-Y cutaneous supra-fascial (modified) gluteal advancement flaps for reconstruction after radical vulvectomy and to assess the outcome of patients according to their clinical characteristics.

Methods

Between January 2006 and July 2012, 36 V-Y flaps were performed in 21 patients to cover the defect after radical surgery of primary vulvar cancers. Surgery duration, blood loss, hospital stay, and wound healing were assessed according to patient age, body mass index (BMI), American Society of Anesthesiologists (ASA) score, and the initial defect size.

Results

Median patient age, BMI, and ASA score were 80 (range, 31–91), 28 (range, 18–36), 3 (range, 1–3), respectively. Median surgery duration and blood loss were 180 minutes (range, 60–275) and 400 mL (range, 100–1000), respectively. Median operating time was higher in patients ASA3 than ASA less than 3, 200 versus 120 minutes (P = 0.038). Median initial defect size was higher in patients with BMI greater than 28 than 28 or less, 92 versus 55 cm2 (P = 0.004). Local scar defect was observed in 16 patients (76%), mild, less than 10 cm2 in 10 patients. Median wound healing duration was higher in patients with bilateral than unilateral flap, 16 versus 9.5 days (P = 0.034).

Conclusions

The V-Y cutaneous suprafascial gluteal advancement flap for vulvar reconstruction after vulvectomy is an easy, safe, and reliable procedure. However, even mild local scar defect after bilateral flap may impact on wound healing and hospital stay, in elderly and ASA3 patients.

Fasciocutaneous Lotus Petal Flap for Perineal Wound Reconstruction after Extralevator Abdominoperineal Excision: Application for Reconstruction of the Pelvic Floor and Creation of a Neovagina

BACKGROUND

The extralevator abdominoperineal excision (ELAPE) procedure creates an extensive soft tissue defect of the pelvic floor. It has been suggested that primary reconstruction reduces the risk of wound infection and delayed wound healing in this high-risk area. Use of myocutaneous flaps or omentoplasty are associated with functional limitations and complications. We performed the perineal variant of the lotus petal flap, which was originally described for vulvar reconstruction. We aimed to verify if application of the lotus petal flap in pelvic floor reconstruction after ELAPE meets the goals of an ideal reconstruction.

METHODS

We performed a retrospective study of 28 patients who underwent the lotus petal flap procedure for pelvic floor reconstruction after ELAPE between January 2011 and March 2014.

RESULTS

Median age was 62.1 years and 78.6 % of patients were female. In most patients the tumor was preoperatively irradiated (89.3 %) and in 28.6 % of the reconstructions a biological mesh was applied. No total flap loss occurred. Six (21.4 %) patients had no complications, while 13 (46.4 %) patients had minor complications (Clavien-Dindo grade I-II). Reoperation (Clavien-Dindo grade IIIb) was performed in nine patients (32.1 %), three of whom required a second lotus petal flap reconstruction. Median time until wound healing was 14 weeks. No additional surgery was performed for aesthetic problems.

CONCLUSIONS

Reconstruction of the pelvic floor after ELAPE using the fasciocutaneous lotus petal flap has limited major complications, but still with a high incidence of minor wound complications. This retrospective cohort study shows limited consequences on form and function.

Vulvar reconstruction should be performed using gluteal-fold perforator flap because of less morbidities and complications

The authors present a case of bilateral vulvar defects after abrasion of malignant skin neoplasm, reconstructed with a gluteal-fold perforator flap, resulting in a successful outcome.

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.

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

OBJECTIVE

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.

METHODS

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.

RESULTS

All the 16 flaps prepared survived without major complications. Walking and sitting positions were restored in few post-operative days. Length of hospitalisation was 2-3 weeks. The flaps restored sensitivity few months after surgery. In no case the surgical scars needed being revised.

CONCLUSIONS

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.