Subunit principle of vulvar reconstruction: algorithm and outcomes

Abstract

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.

Keywords: Carcinoma; Surgical flaps; Vulvar.

Fig. 1

Algorithm for reconstruction of vulvar defect

Fig. 2

Intraoperative positioning for vulvar reconstruction Intraoperative positioning of patient on Allen Yellofin stirrups. The knees are extended and stirrups hinged in a manner that allows adduction of the hips to reduce tension on the flaps during inset. The buttocks are exposed for the elevation of gluteal fold flaps in this case.

Fig. 3

A case of myocutaneous gracilis transposition flap Right vulvar squamous cell cancer in a 61-year-old (case 18). (A) Hemivulvectomy defect with pubic bone exposed and dead space to fill. (B) Right myocutaneous gracilis flap with its slender distal muscular end. (C) Flap was transposed and inset with distal muscle filling deep bony cavity; donor site was closed primarily; the result shown at one year postoperatively.

Fig. 4

A case of myocutaneous gracilis transposition flap Vulvar cancer in a 74-year-old (case 2). (A) Vulvectomy defect. (B) Left myocutaneous gracilis flap. (C) Flap was transposed and inset into defect and donor site was closed primarily; the result shown at one year postoperatively.

Fig. 5

A case of bilateral gracilis VY-advancement flaps Paget's disease of the vulva in a 60-year-old (case 36). Bilateral gracilis VY-advancement flap reconstruction one year postoperatively showing a patent well-centered urethral meatus as a result of careful periurethral inset of the flaps.

Fig. 6

A case of vertical rectus myocutaneous flap Post-reconstruction with left vertical rectus myocutaneous flap at 6 months follow-up in a 45-year-old patient who had sarcoma (case 22). Note colostomy was sited to the right (instead of usual left) to facilitate optimal wound coverage with an ipsilateral rectus flap.

Fig. 7

A case of gluteal fold transposition flap Paget's disease of the right vulva in a 63-year-old (case 11). (A) Vulvectomy defect with perforators dopplered. (B) Right gluteal fold flap. (C) Flap was transposed and inset into defect and donor site was closed primarily; the result shown at one year postoperatively with a well-concealed donor-site in the gluteal crease.

Fig. 8

A case of bilateral gluteal fold VY-advancement flaps Post-reconstruction with bilateral gluteal fold VY-advancement flaps at 1 year follow-up in a 51-year-old patient (case 24) who had bilateral Paget's disease of the vulva.

Fig. 9

A case of gracilis muscle flap and skin grafting An 83-year-old patient (case 17) who had vulvar carcinoma. Post-reconstruction with a right gracilis muscle flap and skin grafting; at one year follow-up showing a patent introitus and vaginal vault.