Leigh G. Seamon and Jay W. Carlson
Indications for Vaginal Reconstruction
Following the extirpative phase of radical pelvic surgery for gynecologic, urologic, or colorectal malignancies, neovaginal creation is an important aspect of pelvic floor reconstruction. In addition to optimizing potential sexual function, pelvic reconstruction serves to close anatomical dead space and introduce new vascular supply to an often previously irradiated and devascularized area. The reconstruction results in improved wound healing, decreased fistula formation, reduced postoperative seroma and abscess formation, and improved quality of life.1-8 Although surgical times may be longer in patients undergoing primary vaginal reconstruction, pelvic abscesses and small bowel fistulas are reduced compared to patients without neovaginal reconstruction (0%-7% vs. 20%-27% and 3% vs. 20%, respectively).2,3 Other authors report a reduction in intestinal fistula rates from 16% to 5% with reconstruction and no increase in operative time with the use of 2 surgical teams.1,9-11
Some patients may not desire a neovagina for intercourse; however, the reduced perioperative morbidity associated with myocutaneous flap neovascularization should be considered when counseling patients for reconstruction. A knowledge of various reconstructive techniques is an essential component in the gynecologic surgeon’s operative armamentarium.12 The main goals and principles of vaginal reconstruction are outlined in Table 32C-1.
Table 32C-1 Goals and Principles of Vaginal Reconstruction at the Time of Pelvic Exenteration
Classification of Vaginal Defects Following Exenteration
A formal classification system for vaginal defects following extirpative surgery was proposed by Cordeiro et al13 to facilitate an algorithm for vaginal reconstruction (Figure 32C-1). In this system, partial vaginal removal is considered a type I defect, whereas circumferential vaginal resection is a type II defect. Type I (partial) vaginal defects are further separated into type IA defects, described as anterior or lateral vaginal wall defects, and type IB defects, described as removal of only the posterior vaginal wall. Circumferential defects (type II) are subdivided into type IIA, removal of the upper two-thirds of the vagina, and type IIB, total vaginectomy.13
FIGURE 32C-1. Anatomical classification system for vaginal defects following extirpative surgery. (Redrawn, with permission, from Pusic AL, Mehrara BJ. Vaginal reconstruction: an algorithm approach to defect classification and flap reconstruction. J Surg Oncol. 2006;94(6):515-521.)
The surgeon must be prepared to perform the optimal procedure for the specific situation accounting for individual preoperative and postoperative variables.12 Rather than using a specific algorithm, we have used this anatomical classification system, acknowledging its limitations, to propose various methods for surgical reconstruction according to anatomical defect.
Classification of Surgical Procedures for Vulvovaginal Reconstruction
Reconstruction can be generally classified according to procedure type: grafts or flaps. Grafts are further subdivided into split-thickness, full-thickness, and anastomosed grafts. Flaps are usually named by the location of the donor site and are described as random skin flaps, axial pattern skin flaps, fasciocutaneous flaps, myocutaneous flaps, or intestinal flaps (Table 32C-2). Additionally, the procedures can be classified according to donor site (distant vs. local), blood supply (none, random, or a specific artery), and type of sensory innervation (sensate vs. nonsensate).
Table 32C-2 Classification of Reconstructive Vulvovaginal Procedures
General Preoperative Preparation for Vaginal Reconstruction
During the preoperative phase, the goals and objectives of vaginal reconstruction are reviewed with the patient. For the patient and the supporting family, a multidisciplinary approach with psychiatry, enterostomal therapy nurses, and a patient who has previously undergone a similar procedure may be beneficial.12,14 Consultation with anesthesia and reservation of a critical care bed are also essential steps in preoperative planning. Additionally, it is important to consult with radiation oncology regarding previous radiation doses and fields and discuss any planned intraoperative or postoperative radiation because this may have important implications for reconstruction and flap selection.14,15The gynecologic surgeon must have a well-thought-out approach to both the extirpative and reconstruction phases with contingency plans based on the operative events or surgical findings.
General preoperative preparation for vaginal reconstructive procedures is similar for vulvar surgeries. If the patient has undergone a previous abdominal procedure or has severe peripheral vascular disease and a rectus myocutaneous flap is planned, a review of the operative report or a preoperative arteriogram may be required to ensure the patency of the inferior epigastric artery. When reconstruction is performed immediately following an exenteration, we recommend preoperative stomal site marking. Given the radicality of exenterative procedures and the reconstruction, it is the authors’ preference to instruct the patient to undergo a chlorhexidine shower/wash and prepare the bowel. Patients are instructed to drink clear liquids the day prior to surgery and use a cathartic solution over 2 to 4 hours. Perioperative prophylactic antibiotic must include a spectrum of coverage for bowel organisms. In the preoperative holding area, the patient is given heparin 5000 units subcutaneously 2 hours prior to surgery. If vaginal reconstruction accompanies an exenterative procedure, the patient is typed and crossed for 4 units of packed red blood cells.
Positioning and Planning
The patient is placed in dorsal low lithotomy position with support of the lower leg (Allen stirrups; Hill-Rom Holdings, Inc., Batesville, IN) with the coccyx slightly overhanging the end of the operating room table. Positioning may be best accomplished with the patient in slight Trendelenburg to simulate perineal access for the extirpative and reconstructive phases because any slight intraoperative cephalad shift may impede exposure. The potential donor site(s) is (are) marked with a permanent pen. Regardless of the planned procedure, the entire abdomen is prepped from the midnipple line to the pubic symphysis, covering the midaxillary line, and inguinal regions. Prepping this area, as well as the lateral thigh and both legs from below the knee to the perineum, will allow for the preparation of multiple donor sites if required. Additionally, the perineum, including the anus, buttocks, and posterior anal/coccygeal area, is thoroughly prepped, and a Foley catheter is placed.
To expedite total operative length, a second surgical team is beneficial to concomitantly perform the vulvovaginal extirpative and reconstruction phases. If a rectus myocutaneous flap is planned, harvesting the flap and rotating it into the pelvis is typically the first reconstructive step initiated immediately after the resection is completed. This allows a second surgical team to tubularize the flap and suture the neovagina in place. This procedural order also prevents potential disruption of the urinary/fecal diversion as well as stomal site misplacement caused by flap harvesting and abdominal wall mobilization required to close the donor-site defect.
Reconstruction for Type I (Partial) Vaginal Defects
Skin Grafts With an Omental Flap
Free skin grafts are classified into 3 categories: split-thickness skin grafts (STSGs), full-thickness skin grafts (FTSGs), and anastomosed grafts. This chapter will focus only on STSGs and FTSGs. These 2 grafts depend on the spontaneous development of vascular supply and intimate contact between the graft and the recipient site. The host site should be free of infection and remain immobile until neovascularization occurs. This requires strict bed rest for 2 to 3 days postoperatively with the blood supply remaining tenuous until approximately 7 days postoperatively.
Split-Thickness Skin Grafts
Box 32C-1 Master Surgeon’s Corner
STSG with an omental flap is most useful for coverage of partial vaginal (type I) defects.
Meticulous hemostasis must be achieved.
The STSG must be well applied to the vaginal stent to ensure complete “take.”
After the pelvic extirpative phase, an STSG with an omental flap as its base can be used for partial vaginal removal (type IA or IB) or for circumferential defects (type IIA or IIB), particularly when the pelvis does not allow room for a myocutaneous flap, such as in an obese patient, or when a coloproctostomy (low rectal anastomosis) is performed (Figure 32C-2). This technique for neovaginal reconstruction following pelvic exenteration was first reported by Berek and colleagues, who modified the McIndoe-Banister vaginoplasty by using omentum to create the anterior and lateral vaginal walls.16,17 Wheeless modified Berek’s procedure by using the omentum as a cylindrical neovaginal wall lined by an STSG.18,19 Since these initial reports, other authors affirmed the feasibility of this procedure or further modified the technique by eliminating the STSG and substituting a polyglycolic acid mesh or an acellular dermal allograft for type IA (anterior wall) vaginal defects.20-23 Additionally, use of fibrin tissue adhesive (Tisseel VH fibrin sealant; Baxter, Deerfield, IL) with or without vacuum-assisted closure (V.A.C. Therapy System; KCI, San Antonio, TX) may improve STSG viability and is further described in the section on STSG for vulvar reconstruction.16,24-26 Although STSG combined with omental cylinder is feasible for type II defects following exenteration, we believe it is not well suited for large defects in previously irradiated fields, where we prefer a myocutaneous flap such as the rectus myocutaneous flap described later.
FIGURE 32C-2. Split-thickness skin graft with omental flap for neovaginal reconstruction.
Skin grafting requires careful selection of the donor site. The patient should be encouraged to wear shorts or other similar clothing to assist with defining donor-site concealment boundaries.27 For a more cosmetic result, several authors advocate using the inner thigh or the buttocks versus the lateral or anterior thigh as the donor site; however, the skin on the inner thigh is generally thinner (0.016 in) than skin on the buttocks or lateral/anterior thigh (0.018 in), and the dermatome should be adjusted accordingly.27
Preparing the Omental Flap for STSGs. First, the lesser sac is entered, as is done for an omentectomy. The omentum is freed from the transverse colon and colonic mesentery and harvested from the stomach’s greater curvature by securing the right gastroepiploic vessels and its gastric branches. The left gastroepiploic vessels are spared and supply blood to the omental flap. It is important to adequately mobilize the omentum in order to obtain the desired pedicle. The omental J-flap is placed out of the way until the reconstructive phase when it is placed lateral to the descending colon along the left colic gutter. It is recommended to delay suturing the proximal omentum to the gutter until the omental cylinder and graft with vaginal stent are placed in the pelvis. This maximizes manipulation and utilization of the omental flap.
Harvesting the STSG and Placing the Graft Over a Vaginal Stent. Prior to sterile prepping, the donor site is marked to allow a 10 × 20 cm STSG. A region at least this size is needed to accommodate the 20% passive contraction that is expected with STSG. A 10 × 20 cm STSG is harvested from the donor site using an air-powered dermatome set to 13 to 19/1000 of an inch (0.013-0.019) and the graft meshed in a ratio of 1.5:1. If the graft is taken from the buttocks, this is done prior to the laparotomy, and the graft is stored. A thin layer of thrombin spray (or diluted 100-fold Tisseel) is placed on the donor site and covered with a clear occlusive dressing such as Tegaderm (3M, St. Paul, MN) or petrolatum-impregnated gauze followed by a pressure dressing. The STSG is placed over a vaginal stent (Adjustable Vaginal Stent; Mentor Corporation, Santa Barbara, CA) with the dermis facing outward. The STSG is sutured together using undyed interrupted 3-0 polyglycolic acid suture (Figure 32C-3).
FIGURE 32C-3. Split-thickness skin graft with the dermis facing outward over a vaginal mold. (Adapted from Kusiak JF, Rosenblum NG. Neovaginal reconstruction after exenteration using an omental flap and split-thickness skin graft. Plast Reconstr Surg. 1996;97(4):775-781.)
Wrapping the STSG and Mold in the Distal Omental Flap and Placement in the Pelvis. The graft and mold are placed into the distal portion of the omental flap, which is made into a cylinder. The lateral rolled margins and apex/cephalad portion are sutured without compromising the vascular supply using interrupted and mattress 3-0 polyglycolic acid sutures, respectively. The apical sutures prevent the vaginal mold and graft from migrating deep into the pelvis. The STSG-covered stent and omental cylinder are placed in the pelvis, taking care not to distort the orientation of the omental cylinder. The distal omentum is sutured to the vaginal introitus.
The proximal omental flap is sutured along the left lateral gutter and to the iliopectineal line to create a “pelvic lid” preventing bowel prolapse into the pelvis. If there is not enough omentum to create the lid, the omental lid can be augmented with polyglycolic acid mesh. Transverse monofilament sutures (2-0 nylon) placed through the labia serve to secure the stent and prevent expulsion. It is recommended that the patient be taken back the operating room in 7 to 10 days for stent removal under sedation.
Box 32C-2 Complications and Morbidity
Graft “take” is re-evaluated on postoperative day 7 to 10 to assess viability.
Necrotic tissue should be resected at this time.
Total graft failure requires repeat skin grafting or use of a myocutaneous flap.
Vaginal stenting should continue until sexual activity or for a period of 1 year.
The patient should remain at complete bed rest for 2 to 3 days postoperatively. On day 7 to 10 following the procedure, the patient returns to the operating suite for vaginal stent removal, donor-site dressing change, and fitting of a soft Silastic vaginal mold. The mold is placed inside a condom, and the condom is changed daily. For patient comfort and to prevent expulsion, the length of the mold should not protrude from the introitus. The patient is instructed to insert the stent for 20 to 30 minutes 3 times a day and while asleep at night. The patient returns to the office 2 to 4 weeks after stent removal for inspection of the neovagina. Sexually active patients may discontinue the vaginal mold after 3 to 6 months and resume intercourse. Otherwise, it is recommended that the stenting continue for 1 year.
Full-Thickness Skin Grafts
FTSGs include the epidermal and dermal skin layer versus only the epidermal layer with STSG. The main advantage of FTSGs over STSGs is reduction in secondary contracture, which translates into decreased risk of neovaginal stenosis and less time required for vaginal stenting. Additionally, the donor site of FTSGs heals in a more cosmetic fashion due to primary closure, whereas the STSG requires secondary healing. However, the disadvantages of FTSG over STSG include hair growth, increased primary contraction rates (up to 50% vs. 20% with STSG), a potentially higher infection risk, and longer healing time (14 days vs. 7-10 days with STSG).27
The patient is prepared as described earlier for STSG. Prior to prepping the skin, an 8 × 16 to 17 cm hairless, elliptical donor site is marked in the groin region adhering to Langer’s lines (Figure 32C-4). Some authors recommend bilateral groin grafts measuring 7 × 15 cm each, whereas others recommend a graft that is 3 times longer than wide, allowing nice donor-site approximation.28 Consideration may be given to preoperative donor-site depilation to avoid hair growth.
FIGURE 32C-4. Donor site for a full-thickness skin graft for vaginal reconstruction. (Reproduced, with permission, from Hallberg H, Holmstrom H. Vaginal construction with skin grafts and vacuum-assisted closure. Scand J Plast Reconstr Surg Hand Surg. 2003;37(2):97-101.)
Operative Procedure and Postoperative Care
The previously marked donor site is incised, the graft is harvested and moistened with saline, and the subcutaneous adherent fat is removed with curved scissors. The FTSG is meshed if required, and the donor site is closed primarily. The graft is then sutured around a vaginal mold and placed into the pelvic cavity, and the free edges are sutured to the introitus. A suprapubic catheter will avoid potential urethral necrosis from the vaginal mold placing pressure on the Foley catheter. Postoperative care is similar to STSG; however, because the FTSG is less prone to secondary contracture, vaginal stenting is only needed for 3 to 6 months.
Mesh or Allograft Omental Flaps
Alternatives to using autologous grafts for vaginal reconstruction include use of polyglycolic acid mesh and acellular dermal allografts in combination with an omental flap. This technique is best suited for partial vaginal wall defects (type I defects). The advantages to this approach include that there is readily available material, decreasing the operative time and avoiding donor-site issues including potential infection, postoperative pain, and scar formation. The basic principles of the procedure are similar to STSG, as described earlier.
Patients should be informed that a skin substitute will help recreate the vaginal wall and that the possibility of an infection or reaction to this material exists. Materials used for neovagina reconstruction after exenteration includes a woven mesh (Vicryl; Ethicon Inc., Cornelia, GA) and a regenerative tissue matrix (AlloDerm; LifeCell Corp., The Woodlands, TX).21-23 Although Vicryl mesh is made from polyglycolic acid and is absorbable, AlloDerm is procured from human cadaver skin and processed to allow a foundation for neoangiogenesis and epithelialization without an inflammatory response.29 These acellular dermal allografts are generally 2.06 to 3.30 mm thick and meshed 1:1 (LifeCell).
Operative Procedure and Postoperative Care
The omental flap is prepared, and an acellular dermal allograft is selected (6 × 16 cm or 4 × 12 cm), rehydrated in sterile saline for 5 minutes, and trimmed to fit the defect. If used for a type II defect, the 6 × 16 cm piece is chosen and folded over a vaginal stent to create a cylinder. Alternatively, 2 pieces of 4 × 12 cm grafts are trimmed and sutured together. The allograft is placed over the vaginal mold, sutured to the omental bed (or cylinder for type II defects), and placed in the pelvis. The allograft is then sutured into the remaining vaginal wall or the introitus, if a total exenteration is performed.
Alternatively, for type I defects, a polyglycolic acid mesh with omental flap can be considered. The mesh is trimmed to size, fit over a vaginal stent, and sutured into the remaining vagina with a running 3-0 polyglycolic acid suture. The postoperative care is similar to STSGs.
Reconstruction for Type II (Circumferential) Vaginal Defects
Circumferential vaginal defects following exenterative procedures usually require reconstructive flaps. Flap selection will depend on the size of the defect, the functional effect on both the recipient and donor sites, and operator experience. Although no single flap is suitable in all situations for neovaginal reconstruction, we prefer the vertical rectus abdominis flap when feasible due to its bulk, reliability, and minimal donor-site morbidity and incorporation into the mid-line incision.9,30-32
Skin Flap Classification
Skin flaps include the epidermis, dermis, and subcutaneous tissue, whereas fasciocutaneous flaps incorporate the underlying fascia in addition to the epidermis, dermis, and subcutaneous tissue. A myocutaneous flap also incorporates the underlying muscle. Myocutaneous flaps that are supplied by a single artery (tensor fascia lata), a dominant pedicle plus 1 or more minor vessels (gracilis), or 2 dominant vessels (rectus abdominis) are considered type I, type II, or type III flaps, respectively.
A simplified classification divides flaps into groups according to blood supply: cutaneous/random pattern, arterial/axial pattern, island, and free flaps.33 Cutaneous flaps or random pattern skin flaps rely on subdermal vascularization, whereas a single subcutaneous vessel supplies arterial or axial pattern flaps. Flaps whose pedicle consists of only the vessels are termed island flaps. Free flaps are harvested from distant sites and require microvascular anastomoses compared to local flaps, which are derived from skin adjacent to the recipient site. Local flaps are further characterized by the manner in which the donor site arrives at the recipient site: transposition, rotation, or advancement. A transposition flap further describes that it has been tunneled under or passed over a normal tissue bridge. Flaps that are rotated in an arc to reach the recipient site are rotational flaps, whereas flaps that arrive at the recipient site by mobilization in a relatively straight line are called advancement flaps.
Posterior Labial Artery/Pudendal Thigh Fasciocutaneous/Singapore Flaps
Box 32C-3 Master Surgeon’s Corner
The pudendal thigh flap is a sensate, axial pattern, fasciocutaneous flap that is useful for covering vaginal defects or neovagina creation with bilateral flaps.
Flap size can be tailored to patient anatomy.
The underlying adductor fascia is raised with the flap, and labial “tunnel” pressure is avoided to ensure viability.
In 1989, Wee and Joseph34 from Singapore first described the neurovascular pudendal thigh fasciocutaneous flap for vaginal reconstruction. The pudendal thigh flap is a sensate, axial pattern, fasciocutaneous flap that is vascularized by the posterior labial artery, a terminal branch of the superficial perineal artery, which is derived from the internal pudendal artery. Anastomosis with the deep external pudendal artery, a branch of the femoral artery, provides additional blood supply. Because the main supply to the flap is the posterior labial artery, the Singapore flap may not be viable if hypogastric artery ligation is performed during the extirpative phase.
Posteriorly, the flap is innervated by both the pudendal nerve via its posterior labial branches and the perineal rami of the posterior cutaneous nerve of the thigh. Anteriorly, the genitofemoral and ilioinguinal nerves supply sensation; however, these nerves are often denervated on harvesting of the flap. Thus, there is only sensation in the lower neovagina.
The advantages of the Singapore flap include technical simplicity, hidden scars for enhanced cosmesis with minimal donor-site morbidity, less bulk than myocutaneous flaps, a natural vaginal angle, sensation similar to the inner thigh and perineum, and no requirement for postoperative vaginal stenting or use of dilators. A disadvantage with the flap is the limited experience with concurrent exenteration or for radiation necrosis. Bilateral flaps are required for neovaginal creation, and additional chronic problems with the Singapore flap include vulvar pain, vaginal discharge, hair growth, and flap prolapse. Thus, we do not favor this operation for reconstruction of type II vaginal defects following exenteration. Nonetheless, the Singapore flap is a useful tool in the surgical armamentarium as a single flap for complex rectovaginal fistula repair and vulvar and perineal reconstruction.
The patient is prepped for the operating room as previously described.
Marking the Pudendal Thigh Donor Site. The hair overlying the groin, perineum, and labia is shaved with clippers. The ischial tuberosity is located because this is where the flap’s vascular supply emerges. A bilateral horn-shaped 4 to 6 × 9 to 16.5 cm flap is marked with a permanent pen just lateral to the hair-bearing labia majora and to the medial corner of the femoral triangle (Figure 32C-5). The posterior skin margin is at the level of the fourchette, and the flap is centered on the groin crease. The flap width and length depend on defect size and the patient’s anatomy. Bilateral larger flaps are needed for neovaginal recreation following total pelvic exenteration, but a unilateral smaller flap may suffice for creating 1 vaginal wall following an anterior or posterior exenteration.
FIGURE 32C-5. Pudendal thigh myocutaneous flap. For neovaginal creation, a 5 to 6 × 14.5 to 16.5 cm flap is marked bilaterally centered on the groin crease. The flaps are harvested, tunneled under the labia, and sutured into place. (Reproduced, with permission, from Wee JT, Joseph VT. A new technique of vaginal reconstruction using neurovascular pudendal-thigh flaps: a preliminary report. Plast Reconstr Surg. 1989;83(4):701-709.)
Harvesting the Pudendal Thigh Flap. An incision is carried down on each side through the subcutaneous tissue to the deep fascia, except at the flap’s base. The underlying deep fascia and epimysium of the adductor muscle are incised and raised with the distal flap, but not at the base. The fascia is intermittently sutured to the skin flap to prevent inadvertent vessel shearing during manipulation.
To allow 70- to 90-degree transposition to meet the opposing flap, the posterior flap margin/base on each side is incised only through the dermis and subcutaneous tissue to a 1- to 1.5-cm depth and undermined 4 cm parallel to the skin. This creates a subcutaneous pedicle for rotation that contains the neurovascular supply. A suture is placed at the tip of the flap to assist with maneuvering the flap under the labia.
Tunneling the Pudendal Thigh Flap Versus Dividing the Labia. Once each flap is raised, the labia are mobilized off the pubic rami and perineal membrane. The labia should be elevated sufficiently to allow passage of the flap, creating a bridge. Each flap is transposed 70 to 80 degrees and passed under the labia to meet the contralateral flap. Some authors recommend removing the epidermis of the buried part of the flap.35 Alternatively, the labia are divided and the flaps rotated into place. This modification eliminates tunnel pressure on the vascular supply, potentially increasing flap viability, and is recommended if using this flap after exenteration.
Suturing the Pudendal Thigh Flap and Deep Fixation. In the midline, the flap is sutured to the contralateral flap creating a vaginal tube. The posterior flap junction is sutured first, followed by the anterior junction. The tube is invaginated and the apex fixed securely to the sacrum or retropubic/obturator fascia with a nonabsorbable suture, and the neovaginal opening is sutured to the introitus/labia minoral mucocutaneous junction. Drains are placed in the donor sites and the pelvis. Each donor site is closed primarily.
Box 32C-4 Complications and Morbidity
Vulvar pain, vaginal discharge, hair growth, and flap prolapse are potential complications.
Flap prolapse can be prevented by securing the neovaginal tube to the sacrum or obturator fascia.
Flap viability should be assessed daily.
The perineal area and lower vaginal tube are inspected for viability on daily rounds. Although no stents or dilators are required in the perioperative period for most fasciocutaneous or myocutaneous flaps, we prefer to leave a mold in place to prevent possible agglutination of the neovagina. The mold is removed on postoperative day 2 or 3.
Bulbocavernosus Myocutaneous Flap, or Martius Flap
In 1928, Martius first described a bulbocavernosus flap for large urethrovaginal and vesicovaginal fistulas in which the skin was left in situ.36 The bulbocavernosus flap can include the overlying dermis and epidermis and be used for partial neovaginal construction following supralevator exenteration. The flap is a sensate, axial pattern flap that can be mobilized as an island or transposition flap. This flap also works well as a secondary flap to augment another flap. The neurovascular supply of the bulbocavernosus flap is derived from the pudendal artery and nerve. Like the Singapore flap, the Martius flap may be nonviable if the internal iliac artery is sacrificed during the extirpative phase. The advantages include surgical simplicity, minimal and acceptable donor-site morbidity, minimal blood loss, and less disfigurement than other flaps. It is a sensate island flap and seems to have a minimal impact on vaginal intercourse; however, some patients will experience pain, loss of sensation, or paresthesias over the donor site. Due to the location of the flap, hair is retained and could be the source of chronic vaginal discharge.37 Another disadvantage is that the Martius flap is shorter than other myocutaneous flaps and requires compliance with postoperative dilation.38
Preoperative Preparation and Operative Procedure
Marking the Martius Donor Site. The patient is prepared for vaginal reconstructive surgery as previously described. The flap is marked for maximum width and length, yet still allowing for primary closure. The flap is designed overlying the bilateral labia majoral fat pad with the superior margin at the clitoral level or just slightly superiorly, while the inferior margin is marked at the perineal body. The medial and lateral margins are bounded by the sulcus between the labia minora and majora and the lateral edge of the labia majora, respectively. The patient’s anatomy determines the flap’s length (8-10 cm) and width (4-7 cm).
Harvesting the Martius Flap. The flap is harvested by sharply incising the medial margin, freeing the labia minora and introitus from the underlying labial fat pad. The subcutaneous tissue is dissected to the pubic ramus. Next, the tissue under the bulbocavernosus muscle is carefully undermined laterally mobilizing the bulbocavernosus pad. Note that the vascular supply, the perineal branch of the pudendal artery, is at risk at this point in the dissection as it enters the inferior margin of the pedicle. The skin along the lateral and superior margin is incised and the subcutaneous tissue is dissected. Finally, the flap is harvested by incising the posterior margin. The flap is mobilized on the inferior pedicle and ready for transposition. The same procedure is carried out on the opposite side.
Tunneling the Martius Flap. A bridge is made in the paravaginal tissue by elevating the remaining 3 to 4 cm of vagina away from the pubic ramus. The flap is passed through this window into the pelvis (Figure 32C-6). A stay suture at the tip of the flap may help transpose the flap into position and avoid shearing the cutaneous portion.
FIGURE 32C-6. Bulbocavernosus myocutaneous (Martius) flap for vaginal reconstruction. The bilateral flaps are marked, harvested, tunneled into position. (Adapted from Green AE, Escobar PF, Neubaurer N, Michener CM, Vongruenigen VE. The Martius flap neovagina revisited. Int J Gynecol Cancer. 2005;15(5):964-966.)
Suturing the Martius Flap. The flap is made into a vaginal tube using interrupted sutures. First, the posterior aspect of the neovagina is sutured onto the vaginal cuff. Next, the flaps are sewn together to complete the posterior wall of the neovagina. The anterior portion of the neovaginal flap is sutured to the anterior vaginal cuff as well as to the contralateral flap. The apex of the neovagina is closed with interrupted sutures, and an omental flap is placed in the pelvis (Figure 32C-7). For stabilization of the neovagina, the flap is secured laterally to the levator muscle pedicles. A vaginal mold is placed in the neovagina and removed on postoperative day 3 or 4, after which time a 3-cm Silastic rod is fitted. Drains are placed in the donor sites, and these sites are closed primarily.
FIGURE 32C-7. Bulbocavernosus myocutaneous (Martius) flap for vaginal reconstruction. The bilateral flaps are tabularized and sutured to the remaining vagina or introitus. (Adapted from Green AE, Escobar PF, Neubaurer N, Michener CM, Vongruenigen VE. The Martius flap neovagina revisited. Int J Gynecol Cancer. 2005;15(5):964-966.)
Postoperative care is similar to that for the pudendal thigh fasciocutaneous flap; however, the Martius flap is shorter than the pudendal thigh flap and requires meticulous use of a dilator as described for STSG.
Bilateral Gracilis Myocutaneous Flap
Box 32C-5 Master Surgeon’s Corner
Obesity and concurrent rectal anastomosis are relative contraindications to the gracilis flap because of its bulk.
The gracilis flap may be used to cover combination vulvovaginal defects with a single flap.
To ensure flap viability, the skin island should be shorter than the muscle length, and excessive rotation of the flap should be avoided.
McCraw originally developed the gracilis flap for vaginal reconstruction in 1976 with several modifications described by Berek and Copeland.10,18,39 Neovaginal creation after total exenteration (type II vaginal defect) requires bilateral gracilis flaps, whereas unilateral flaps may suffice following partial exenteration (type I vaginal defect). The long gracilis flap is considered a type II flap with 1 dominant pedicle, the medial circumflex femoral artery (a branch of the deep femoral artery), and 1 or 2 other minor vessels that are generally sacrificed when harvesting the full flap. In contrast, a short gracilis flap is supplied by the terminal branches of the obturator artery and may be used for vaginal reconstruction as long as the hypogastric and obturator arteries remain intact. The short gracilis is an excellent flap for vulvar reconstruction. Both the short and long gracilis flaps maintain good to fair pressure and touch sensibility as well as some muscle contractility via the intact obturator nerve.39
The advantages of gracilis myocutaneous neovaginal formation compared to no definitive reconstruction at the time of exenteration include an overall decrease in complication rate, prevention of bowel herniation, decreased fistulization rates, improved primary healing, reduced fluid loss from the denuded pelvic cavity, decrease in hospital stay, and an adequate portal for cancer surveillance. Due to the bulk of bilateral flaps, the gracilis is not suitable if a low rectal anastomosis is planned. Additionally, obesity is considered a relative contraindication to the procedure given the increased risk of flap necrosis.10
Unfortunately, bilateral flaps are required for neovaginal recreation, and they lead to unsightly scars and are associated with high rates of prolapse (18%), painful intercourse (18%), excessive vaginal secretions (28%) or dryness (33%), and complaints of neovaginal size.40 Although there are notable disadvantages to the gracilis over the rectus flap (see later section on vertical rectus abdominis myocutaneous flaps), the gracilis flap is preferred when the rectus cannot easily rotate into the defect such as those involving the lower vagina, introitus, or vulva, particularly with an intact vaginal apex.30
Preoperative Preparation and Operative Procedure
Marking the Gracilis Donor Site. The patient is placed in lithotomy, positioning the knee in less than 45 degrees of flexion and the hips at 45 degrees of abduction with 15 degrees of flexion. A line is drawn from the pubic tubercle at the adductor longus tendon insertion to the medial tibial condyle where the semitendinosus tendon inserts. The elliptical flap is outlined posterior to this line and is generally 12 cm (range, 8-14 cm) in length and 6 cm (range, 4-7 cm) in width.10 The cutaneous portion above this line is supplied by perforating branches of the sartorius muscle and is at risk for marginal skin necrosis if harvested with the gracilis.39 The gracilis can support a cutaneous island 2 cm above and 4 cm below the muscle. Although the size can be adjusted intraoperatively to fit the defect, the skin overlying the distal third of the gracilis (near the medial tibial condyle) is at highest risk for sloughing because the distal vascular pedicles are often sacrificed during flap mobilization. The entire gracilis muscle will remain viable, but harvesting the entire skin paddle should be avoided. After the flap is marked, the entire thigh must be prepped from below the knee to the perineum including the buttocks. The flap is harvested as an island flap.
To avoid harvesting the wrong flap, Morrow and Curtin27 prefer to design the skin island after anatomically locating the course of the gracilis. First, the semi-tendinosus tendon is easily palpable at the posterior medial tibial condyle and marked. Next, a 2- to 3-cm incision is made superior to the marked site and represents the area overlying the gracilis tendon insertion. Dissection is carried through the subcutaneous tissue and fascia lata until the gracilis tendon is isolated. An instrument is passed beneath the tendon, and the tendon is placed on tension clearly outlining the gracilis muscle’s path (Figure 32C-8). The skin paddle is then centered over the muscle.
FIGURE 32C-8. Identification of the gracilis tendon insertion at the medial tibial condyle.
Harvesting the Gracilis Flap. The dissection is begun by incising the skin along the anterior boundary down to the level of the fascia lata. The adductor longus tendon is identified immediately anterior to the incision. The adductor longus tendon fascia is incised, elevated with the gracilis flap, and retracted medially. This will expose the adductor brevis muscle and possibly the neurovascular pedicle. The vascular pedicle is invested in the facial layer emerging from the adductor longus and brevis muscles approximately 5 to 10 cm from the insertion of the gracilis on the pubic ramus.
Centering the skin paddle over the muscle is critical to avoiding skin necrosis. Dissection is continued to the distal apex taking care to harvest the gracilis muscle enveloped in its fascia. Exposure of the muscle without its facial envelope suggests the wrong plane.27 To prevent shearing, sutures are sequentially placed as the fascia is incised to secure the fascia to the skin (Figure 32C-9). Distally, the gracilis muscle is transected with electrocautery and elevated off the underlying fascia.
FIGURE 32C-9. The gracilis muscle is harvested, and the proximal portion remains attached to the pubic ramus. AB, adductor brevis muscle; AL, adductor longus muscle; AM, adductor magnus muscle.
Posteriorly, the dissection continues, exposing the bare abductor magnus and brevis, and is carried out to meet the apex of the skin island near the pubic ramus. During this dissection, the neurovascular pedicle is reidentified with a sterile Doppler. If shorter gracilis flaps are planed and mobilization is an issue, the vascular pedicle may be sacrificed with little or no flap necrosis due to primary vascularization from the obturator artery.10
Tunneling the Gracilis Flap for Vaginal Reconstruction. After the island flap is completely elevated, a capacious subcutaneous tunnel is developed forming a labial skin bridge between the flap incision and the pelvic cavity. The adequacy of this space cannot be overemphasized because the most common cause of flap failure is compression in the tunnel.41 The flap is rotated 180 degrees posterior on its pedicle, which is clockwise around the left pedicle and counterclockwise around the right pedicle, and placed gently through the tunnel into the pelvis. Alternatively, it can be rotated anteriorly 90 degrees to fill perineal defects.
Suturing the Gracilis Flap. Each flap margin and apex is sewn to its contralateral flap creating a vaginal tube with the flap’s skin forming the neovaginal walls (Figure 32C-10). The complex is gently lifted into the pelvis, and the skin edges are sutured to the introitus. We prefer to suture the neovagina to the levator and retropubic fascia when feasible to help reduce neovaginal prolapse. A vaginal mold is sutured to the labial folds and removed on postoperative day 2 or 3. An omental flap is harvested to form a pelvic lid and prevent bowel herniation into the pelvis. A pelvic drain is recommended to reduce fluid accumulation around the flap.
FIGURE 32C-10. The bilateral gracilis flaps are rotated into place, and the posterior wall of the neovagina is approximated with sutures.
The donor sites are carefully closed primarily with several vertical mattress sutures and multiple interrupted sutures or staples, avoiding compression of the gracilis vascular pedicle (Figure 32C-11). The legs are wrapped with bandages, again avoiding pressure in the proximal portion near the vascular pedicle.
FIGURE 32C-11. The tubularized gracilis flaps are situated within the pelvis and secured in place. Donor sites are closed primarily.
Box 32C-6 Complications and Morbidity
The gracilis flap may be subject to flap prolapse and result in vaginal secretion and painful intercourse.
Flap viability should be assessed daily.
The most common cause of flap necrosis is compromised vascular supply due to angulation during rotation.
The patient is not restricted in ambulation. The vaginal mold is removed on postoperative day number 2 or 3 without the further use of molds or dilators.
Vertical Rectus Abdominis Myocutaneous (VRAM) Flap and Extended VRAM Flap
Box 32C-7 Master Surgeon’s Corner
VRAM flap size and orientation can be tailored to the patient’s anatomy and reconstructive needs.
Viability of the ipsilateral inferior epigastric artery must be confirmed.
The VRAM flap should be harvested early in the reconstructive phase to facilitate planning of additional reconstructive procedures (urinary and bowel diversions).
A fascial substitute may be required to ensure a tension-free closure of the donor site.
Due to its reliability, single donor site with incorporation into the primary incision with minimal donor site morbidity, 360-degree arc of rotation, no requirement for postoperative dilation, and technical ease, the rectus abdominis myocutaneous flap is the preferred flap for neovaginal recreation. Tobin and Day first described the use of distally based rectus flaps for vulvar and vaginal reconstruction with several modifications described by others.9,31,42 It is a paralyzed, nonsensate flap due to motor and sensory denervation that occurs during harvesting. As a type III flap, the blood supply is reliable with 2 dominant arteries and other smaller musculocutaneous perforators. The dominant blood supply for the proximal and distal rectus flap is derived from the superior and inferior epigastric vessels, respectively. The inferior epigastric artery is a branch of the external iliac artery, whereas the superior epigastric artery is derived from the internal thoracic artery, a branch of the subclavian artery.
The rectus abdominis flap can be raised in a vertical, transverse, or diagonal fashion for complete vaginal reconstruction (type IIA or IIB defects), partial vaginal reconstruction (type IA or IB defects), or other inguinal or perineal defects. It is distally based and requires patent inferior epigastric vessels. Although raising a transverse rectus abdominis myocutaneous flap is suitable, this flap requires harvesting the skin island perpendicular to the previously made vertical midline skin incision. The diagonally extended vertical rectus abdominis myocutaneous (VRAM) flap (also known as the oblique rectus abdominis musculocutaneous [ORAM] flap) has the advantage of a longer skin island due to anastomoses between the epigastric perforators and the superficial intercostal arteries, which also communicate with the superficial epigastric artery and the cutaneous branches of the lateral deep and superficial circumflex iliac arteries. Based on our experience, the anticipated maximum width and length of the diagonally extended VRAM (ORAM) are 10 to 15 cm and 10 cm, respectively. We prefer the ORAM flap for neovaginal reconstruction due to its width, versatility, and ease of flap inset compared to the conventional VRAM.
We recommend harvesting the rectus flap as the first step of the reconstructive phase. After the flap is raised and rotated into the pelvis, the first surgical team can continue with other abdominal procedures, such as the ileal conduit formation and colostomy while the second surgical team completes the perineal reconstruction. Elevating the rectus flap first allows for optimal stomal placement and reduces potential disruption of the conduit and colostomy. These flaps may be harvested from either side.
The main advantages of the rectus flap over the gracilis flap for neovaginal reconstruction include a lower rate of flap necrosis (5%-9% vs. 10%-38%), single donor site incorporated into the primary incision compared to 2 donor sites with unpleasant scar formation, and perhaps a decreased rate of vaginal prolapse (1.5% vs. up to 18%). Although current sexual function studies regarding postexenterative vaginal reconstruction are limited, 50% to 85% of patients report intercourse after rectus neovaginal reconstruction.31
The rectus myocutaneous flap may not be well suited for morbidly obese patients or those with extremely thick abdominal walls. Other disadvantages include mild stenosis (up to 18% of patients) correctable with dilation, potential for difficult abdominal closure with up to 23% of patients requiring mesh closure, and a 3% fascial dehiscence rate.31 Absolute contraindications include occlusion of the ipsilateral inferior epigastric vessel and ipsilateral previous Maylard incision or stoma placement.31
We recommend a preoperative arteriogram in patients with severe peripheral vascular disease or previous abdominal surgery to ensure inferior epigastric patency and an intraoperative sterile Doppler to confirm patency prior to raising the flap.
Harvesting the VRAM Flap. The donor site for the rectus flap is outlined prior to prepping the patient, as shown in Figure 32C-12. The skin island is incised with the scalpel and the dissection carried down to the fascia. The lateral edge of the anterior rectus fascia is incised, and the lateral edge of the rectus muscle is identified and isolated. Care must be taken to harvest the entire rectus muscle. Next, the superior boundary of the flap and rectus is identified, and the rectus muscle is elevated from the posterior rectus sheath, clamped, transected, and suture ligated. The posterior rectus sheath is preserved.
FIGURE 32C-12. The rectus abdominis myocutaneous flap is outlined on a transverse (Flap A) or vertical (Flap B) axis.
The previously made anterior rectus sheath incision is continued in such a fashion to mirror a smaller version of the skin flap. Stay sutures are placed at 3- to 4-cm intervals between the anterior rectus fascial cut edge and the skin paddle to stabilize the flap and avoid shearing during manipulation. The dissection is continued to the arcuate line. Below the arcuate line, the muscle is raised with the peritoneum, and the entire rectus sheath is preserved. The inferior epigastric vessels enter the flap posteriorly and laterally at approximately 4 to 6 cm above the pubic symphysis. If additional length is required, the vascular pedicle can be skeletonized and the rectus muscle developed completely to its tendinous insertion.
Tunneling the VRAM Flap. With the flap sufficiently mobilized, the skin island is rotated directly into the hemostatic pelvis and placed under the pubic symphysis (Figure 32C-13). The skin island should easily reach the perineum without tension on the vascular pedicle or muscle or shearing the flap. If tension is noted, the rectus muscle should be further mobilized. At this point, the other surgical team can begin the urinary conduit, colostomy, or other planned reconstructive procedures.
FIGURE 32C-13. The rectus abdominis myocutaneous flap is harvested, tubularized, and rotated into position in the pelvis.
Suturing the VRAM Flap. The skin island is tubularized into a vaginal cone with the skin paddle facing the inside, forming the neovagina. The skin edges are sutured together with interrupted absorbable suture (Figure 32C-14). The neovagina subcutaneous tissue is secured to the levator ani and retropubic fascia. The neovaginal opening is sutured to the introital skin edge. A vaginal mold is sutured to the labial folds and removed on postoperative day 2 or 3. An omental flap is harvested to form a pelvic lid and to prevent bowel herniation into the pelvis.
FIGURE 32C-14. A vaginal mold is placed in the neovagina.
Attention is turned to closing the donor site. This occasionally requires bilateral mobilization of the subcutaneous tissue to the midaxillary line, vertical mattress sutures, or rarely a mesh. The donor site should be mobilized completely prior to finalizing stoma and drain sites to avoid misplacement. If a urinary conduit is performed, 2 drains are placed in the pelvis. One drain is placed above the neovagina flap, and another drain is placed near the conduit ureteral anastomosis. Additional drains may be placed in the subcutaneous tissue to drain the donor site.
Box 32C-8 Complications and Morbidity
The donor site should be monitored vigilantly to ensure its integrity.
Bowel or urinary diversion stomas placed in the reconstructed abdominal wall should be monitored for prolapsed or peristomal herniation.
The most common cause of flap necrosis is compromised vascular supply due to angulation during rotation.
The patient is not restricted in ambulation. The vaginal mold is removed on postoperative day 2 or 3 without the further use of molds or dilators.
Indications for Vulvar Reconstruction
The primary goal of the vulvar reconstructive effort is to maximize the healing at the surgical site. The cosmetic appearance, while extremely important, is a secondary goal of this reconstructive effort. Flaps can be used to obliterate dead space, bring new vascularity to an area that has frequently received radiation, and allow for primary closure while improving body self-image and allowing for sexual function. The success of the primary reconstructive procedure is inversely related to the complexity of deformity and the flap design.43 Age greater than 60 years, weight greater than 80 kg, tobacco abuse, and vascular disease also confound reconstructive efforts.44
Perioperative Considerations for Vulvar Reconstruction
Thromboembolic prevention should be used for all patients. Standard antibiotic prophylaxis can be prescribed for the abdominal or pelvic portion of the case, with consideration given for a redosing of the antibiotic at the time of the skin incisions for the reconstructive portion of the procedure.
In addition to the general anesthetic, the preoperative placement of an epidural may be helpful in providing excellent pain management for: (1) the primary surgical site, (2) the potential donor sites required during the reconstructive phase, and (3) the 48 to 72 hours of bed rest potentially required postoperatively.
The dorsal low lithotomy position using stirrups to support the heel and lower leg is the preferred position for most flaps. In general, the lower extremity should be partially abducted to provide adequate access to the perineal region.
The lower extremities should be prepped to below the knee to allow the option of using a combination of potential flaps for the reconstructive phase. Consider sewing the anus closed with a purse-string suture to minimize contamination during these procedures. If the bladder and urethra are retained, prolonged transurethral (> 24 hours) or suprapubic bladder drainage may be required for these patients given the extent of surgery performed and the localized periurethral swelling that may ensue.
STSG for Vulvar and Perineal Reconstruction
The principles of STSGs for vaginal reconstruction are identical for vulvar reconstruction.
Preoperative Care and Operative Procedure
Preoperative care and marking the donor site for STSGs are the same as previously described for vaginal reconstruction.
Harvesting the STSG and Placing on the Vulva
The STSG is usually harvested from the inner thighs or buttocks using an air-powered dermatome. The dermatome is set to a thickness of 13 to 19/1000 of an inch, and the graft is meshed (normally 1.5:1) and trimmed to fit the defect. Fibrin sealants such as Tisseel have been used to increase the graft success rate.
The graft is secured with 3-0 or 4-0 absorbable sutures. The recipient site is then covered with a pressure dressing over petrolatum-impregnated gauze, or a vacuum-assisted closure device (VAC) may be used (Figure 32C-15). If a wound VAC is used over an STSG, the recommended pressure is 100 mm Hg on an intermittent setting. The VAC is generally removed on postoperative day 3 or 4. A liquid diet is recommended until it is removed. The patient will be able to pass flatus with the VAC in place, but sometimes, it requires earlier removal for a bowel movement. The utilization of a hydrocolloid dressing (DuoDERM; ConvaTec, Skillman, NJ) around the anus and nongrafted areas may be helpful in facilitating a leak-free system.24
FIGURE 32C-15. Vacuum-assisted closure device (VAC) over the vulvar wound.
The patient remains at complete bed rest for 3 days postoperatively or while the VAC is in place. A Foley catheter is recommended. Activity should be restricted to walking for the first 2 weeks.
Rhomboid Transposition Flap
The rhomboid transposition flap is an extremely useful and versatile flap for vulvar reconstruction. The first description of this type of transposition flap is credited to Limberg, who in 1946 described closure of a parallelogram with 60- and 120-degree angles with a transposition flap named for him. This flap derives its vascular supply from the underlying subcutaneous tissue and does not require a myofascial incision. The underlying subcutaneous portion of the flap should be at least 1.0 to 1.5 cm thick. Because the flap derives its blood supply from the subcutaneous tissue, the flap base may be oriented posteriorly or anteriorly depending on the shape of the vulvar defect and the perceived best closure. In general, this flap is for a smaller defect, with the ideal flap being 4 to 6 cm across the base.45
The patient is prepped for the operating room as previously described. There are no unique requirements for this flap.
Marking the Donor Site for the Rhomboid Flap
The skin site next to the vulvar defect is marked and measured. The practical flap is limited to about 4 × 4 cm, with larger flaps being technically possible but associated with some breakdown and subsequent granulation. The origin of the incision should be slightly more posterior than the midpoint of the vulvar defect (Figure 32C-16). The flap should be 0.5 cm larger than the measured surgical defect because this allows for some normal contraction and closure with less tension. A similar-sized flap may be required on the opposite side depending on the vulvar defect.
FIGURE 32C-16. Bilateral rhomboid flaps are designed to cover a posterior vulvar defect. (Redrawn, with permission, from Burke TW, Morris M, Levenback C, Gershenson DM, Wharton JT. Closure of complex vulvar defects using local rhomboid flaps. Obstet Gynecol. 1994;84(6):1043-1047.)
Mobilizing the Rhomboid Flap
The original irregular defect is converted to a rhomboid with 60- and 120-degree angles. The parallelogram has a long diagonal and a short diagonal (Figure 32C-17). A line is drawn extending from the short diagonal with a length equal to the short diagonal. A line is then drawn from the end of the first line with a length equal to and parallel to one of the adjacent sides of the defect. Flap elevation should be in the subcutaneous plane to preserve the dermal-subdermal plexus of vessels. At least 1.0 to 1.5 cm of subcutaneous tissue must be attached to the flap. The flap is then transposed and the mucosal edge approximated to the edge of the flap with a 3-0 absorbable suture. The donor site edges are undermined and closed in layers with 3-0 absorbable suture for the deep dermal layer and 4-0 absorbable monofilament suture for the subcuticular closure.
FIGURE 32C-17. The defect is converted to a parallelogram with angles of 60 and 120 degrees, and the flap is designed accordingly. (Adapted from Morrow CP, Curtin JP. Reconstructive surgery. In: Morrow CP, Curtin JP, eds. Gynecologic Cancer Surgery. Philadelphia, PA: Churchill Livingstone; 1996:323-380.)
Securing the Rhomboid Flap in Place
The flap is secured with interrupted 3-0 absorbable sutures (Figure 32C-18). A single nonabsorbable 2-0 monofilament suture is used to secure the flap at the perineal body if there is any perceived tension. Given the extent of the undermining required, larger flaps may benefit from the placement of a subcutaneous drain for the first 3 postoperative days to help reduce the incidence of hematomas, seromas, and infection. Alternatively, a VAC may be placed over the vulvar area and removed on postoperative day 3.
FIGURE 32C-18. The rhomboid flap rotated and secured over the vulvar defect.
For a posterior flap in the perianal area, a liquid diet is recommended for the first 3 days. If a VAC was used, a liquid diet is also recommended until the device is removed. The patient will be able to pass flatus with the VAC in place, but it usually requires removal for a bowel movement.
V-Y Advancement Flap
Simple sliding V-Y or axial advancement flaps are very reliable primary flaps for smaller vulvar defects. Occasionally, these flaps may be used as secondary flaps to augment a primary flap. In general, the V-Y flaps can be used to primarily close more extensive vulvar defects than a rhomboid flap. V-Y advancement flap advantages include sensation, reliable blood supply, and concealed scars on the gluteal fold.
The general preoperative preparation is similar to that for the flaps described earlier. The unique requirement for this flap is to be sure the patient is positioned with the coccyx on the end of the table, giving partial exposure to the gluteus.
Marking the Donor Site for the V-Y Advancement Flap
The flap is marked with the apex of the “V” on the gluteal fold. The base of the triangular flap is centered on the vulvar wound (Figure 32C-19). The size is dependent on the defect, but may be 12 to 15 cm across the base. The length of this flap is usually between 10 and 15 cm (Figure 32C-20).
FIGURE 32C-19. The V-Y advancement flap centered on the wound with the apex in the gluteal fold. (Adapted, with permission, from Lee PK, Choi MS, Ahn ST, Oh DY, Rhie JW, Han KT. Gluteal fold V-Y advancement flap for vulvar and vaginal reconstruction: a new flap. Plast Reconstr Surg. 2006;118(2):401-406.)
FIGURE 32C-20. The V-Y advancement flap is marked for closure of a large posterior vulvar defect after resection of vulvar melanoma. (Photo contributed by Drs. Mark Morgan, Sara Kim, and Sameer Patel.)
Mobilizing the V-Y Flap
The incision is carried through the skin to the underlying muscle fascia. The flap mobilization is facilitated by incising and elevating the underlying muscular fascia both proximally and distally. The flap is advanced and the leading edge trimmed to fit the contour of the vulvovaginal defect.
Securing the V-Y Flap in Place
This flap is sutured into place with interrupted 2-0 or 3-0 absorbable sutures. The donor defect is closed in a linear fashion, forming the base of the “Y” (Figure 32C-21).
FIGURE 32C-21. The V-Y advancement flap is sutured into place. (Photo contributed by Drs. Mark Morgan, Sara Kim, and Sameer Patel.)
The postoperative care is similar to described earlier for other vulvar reconstructive procedures. If the flap is in close proximity to the anus, consider a liquid diet and bed rest for the first 3 postoperative days.
Pudendal Thigh Flap (Singapore Flap)
In addition to its utility for vaginal reconstruction, the pudendal thigh flap, or Singapore flap, is another potential option for vulvar, vaginal, or perineal reconstruction. The preoperative care and steps of marking and harvesting are reviewed earlier. To allow rotation to close the vulvar defect, the posterior medial base may require a minimal amount of triangular cutaneous excision. This avoids a pucker at the rotation base. The postoperative care is the same.
Myocutaneous Flaps for Vulvar and Perineal Reconstruction
Myocutaneous flaps are more complicated than cutaneous or fasciocutaneous flaps, but they have the advantage of covering large vulvoperineal defects with reliable reconstruction. In addition to the specific flaps described below, the rectus flap is another option for vulvar reconstruction. The rectus flap, harvested from the rectus abdominis muscle as described earlier for vaginal reconstruction, may be transposed under a mons skin bridge and used on the anterior or lateral vulva, or even in the inguinal area (Figure 32C-22).
FIGURE 32C-22. The rectus abdominis myocutaneous flap mobilized and secured over the left groin area.
The Martius transposition island skin flap may also be used to repair vulvar defects. The stalk is harvested to allow sufficient length to reach the defect. The paddle may be mobilized on an anterior base if the defect is in the anterior vulvar area or harvested with a posteriorly based stalk for posterior vulvar defects.
Gracilis Myocutaneous Flap
Whereas the long gracilis is frequently used for vaginal reconstruction, the short gracilis is an excellent flap for vulvar reconstruction. The short gracilis flap is supplied by the terminal branches of the obturator artery. The size of the short gracilis flap varies from 12 to 14 cm in length and 5 to 7 cm in width. A unilateral flap is primarily used in vulvar or perineal reconstruction in a patient with a recurrent lesion or a bulky primary lesion that is not amendable to more conservative resection.
Tensor Fascia Lata Flap
The tensor fascia lata flap was commonly used for vulvar reconstruction in the era of the en bloc radical vulvectomy with bilateral inguinal lymphadenectomy, or the butterfly incision. This radical resection was associated with an extremely high postoperative morbidity and wound separation. Now that most vulvectomies are performed through separate incisions, the utilization of this flap has declined. Nevertheless, it remains an option for inguinal, anterior, and lateral vulvar reconstruction. The tensor fascia lata muscle originates at the anterior superior iliac spine and extends distally down the lateral thigh into the fascia lata. This myocutaneous flap derives its vascular supply from the lateral femoral circumflex artery, which usually arises from the profunda femoral artery and enters the muscle approximately 6 to 8 cm caudal of the spine. The flap, with its unique blood supply, may support a pedicle up to 40 cm in length and 15 cm in width.46 The tensor fascia lata is innervated by the superior gluteal nerve that enters the muscle posteriorly and deep to the vascular pedicle. The cutaneous portion is innervated by the lateral cutaneous branch of the 12th thoracic nerve as well as the lateral cutaneous nerve of the thigh.
Marking the Tensor Fascia Lata Donor Site. The marking and measuring for this flap start at the site of vascular insertion, approximately 8 cm caudal to the superior iliac spine (Figure 32C-23). The measuring then extends medially to the most inferior aspect of the perineal defect to determine the length of the flap required. Next, the anterior border of the flap is defined by drawing a line from the anterior superior iliac spine to the lateral tibial condyle. The posterior border is determined from a line that extends from the greater trochanter to the knee, ending approximately 5 cm cephalad to the knee. The width is determined by the inguinal and vulvar defect size but is usually from 5 to 8 cm. The length is also based on the size of the defect plus an extra centimeter to allow for contraction during mobilization.
FIGURE 32C-23. Tensor fascia lata marked out preoperatively. (Reprinted, with permission, from Knapstein PG, Frieberg V. Reconstructive operations of the vulva and vagina. In: Knapstein PG, Frieberg V, Sevin BU, eds. Reconstructive Surgery in Gynecology. New York, NY: Thieme Medical Publishers; 1997:11-70.)
Mobilizing the Tensor Fascia Lata Flap. The outlined flap is incised to the fascia. The base of this flap should be wider than the cutaneous portion. Care should be taken to maintain the vascular pedicle as it enters the flap between the rectus femoris and vastus lateralis.
The skin should be secured to the fascia with interrupted 2-0 or 3-0 absorbable sutures to prevent shearing during mobilization.
Securing the Tensor Fascia Lata Flap. Once harvested, this flap is transposed medially along the groin and vulvar areas to fill the surgical defect. The flap is secured with interrupted 2-0 absorbable sutures (Figure 32C-24, A and B). Undermining the subcutaneous defect margins along the entire length is required to facilitate donor site closure. The donor site is closed with staples. A subcutaneous drain is placed in the donor site.
FIGURE 32C-24. (A and B) Tensor fascia lata mobilized and secured in defect. (Reprinted, with permission, from Knapstein PG, Frieberg V. Reconstructive operations of the vulva and vagina. In: Knapstein PG, Frieberg V, Sevin BU, eds. Reconstructive Surgery in Gynecology. New York, NY: Thieme Medical Publishers; 1997:11-70.)
Ice packs to the donor site may be helpful in reducing edema and surgical site pain for the first 48 hours. However, ice to the flap itself may compromise perfusion and increase morbidity. It is the authors’ preference to keep the vulvar wound as dry as possible.
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