Pudendal Thigh Fasciocutaneous Flaps for Vaginal Reconstruction in Gynecologic Oncology

doi:10.1006/gyno.1994.1209

Gynecologic Oncology

Volume 54, Issue 3, September 1994, Pages 269-274

https://doi.org/10.1006/gyno.1994.1209 Get rights and content

Abstract

The pudendal thigh is a sensate fasciocutaneous flap supplied by the posterior labial artery. We report on the results of pudendal thigh flaps used for vaginal reconstruction in eight patients at the time of pelvic exenteration (6) and radical vaginectomy (2). Patients were interviewed and results were assessed 5 to 19 months after surgery. The flaps were raised in the thigh creases just lateral to the hair bearing area of the labia majora and included skin, subcutaneous tissues, deep fascia of the thigh, and the epimysium of the adductor muscles. Flap sizes varied from 9 × 4 cm to 15 × 6 cm. Bilateral flaps were used in seven patients. The flaps were technically easy to perform. Partial (apical) flap necrosis occurred in four patients. One patient developed complete necrosis of bilateral flaps, followed by an enterovaginal fistula. One patient whose flaps did not necrose developed a rectovaginal fistula at the site of rectal reanastomosis. The functional results are disappointing. The only patient having successful vaginal intercourse had a unilateral flap reconstruction following lower vaginectomy in a nonirradiated pelvis. No patient with bilateral flaps or prior pelvic irradiation has had successful coitus. Other long-term sequelae include vulvar pain (2), chronic vaginal discharge (2), hair growth (4), and protrusion of the flaps (2). These vulvovaginal symptoms discourage patients and their partners from genital contact. Breaching the integrity of the vulva to construct a neovagina that is likely to be unsuitable for sexual intercourse may deprive women of their only potential for normal genital sexual responsiveness. Techniques of vaginoplasty require continued assessment.

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Cited by (35)

Vulvar and vaginal reconstruction using the angel wing perforator-based island flap
2015, Gynecologic Oncology
Vulvar and vaginal reconstruction can be challenging for the reconstructive surgeon. The reconstructive goal is to provide wound healing, adequate function, and acceptable appearance. In the present study, we introduce a new design called the “angel wing” flap, which is a modification of a transposition flap and is based on the perforator concept for vulvar and vaginal reconstruction.
From January 2002 to December 2013, 23 women underwent reconstruction of vulvar and vaginal defects. Causative factors were vulvar cancer in 14 patients, extramammary Paget's disease in 2, vulvar dysplasia in 5, and combined vulvar and vaginal cancer in 2 patients.
A total of 41 flaps were applied. All patients underwent surgical reconstruction in a single step using the “angel wing” flap. Flap size ranged from 4 × 7 to 13 × 6 cm² and the operative duration for reconstructive surgery ranged from 30 to 100 min. All the flaps survived with good coverage of the defect. Mean follow-up time after the procedure was 16.1 months (range, 6–30 months).
In this article, we introduce a simple and easy reconstructive procedure of the “angel wing” flap. For restoring function, as well as for esthetic purposes, the flap was designed in accordance with the defect since the natural contour of the vulva and vagina is three-dimensional.
Alternatives to commonly used pelvic reconstruction procedures in gynecologic oncology
2014, Gynecologic Oncology
Citation Excerpt :
When the apex is not secured to internal pelvic structures, the binder should be used for several weeks postoperatively to minimize the risk of prolapse. The flap is harvested from the groin crease just lateral to the labia majora and is usually designed to measure approximately 9 × 4 cm to 15 × 6 cm [52], with the base of the flap at the level of the posterior fourchette (S9). In the original Singapore flap, the flap is islandized with an incision made posteriorly through the skin and subcutaneous tissue, and then rotated 90° and tunneled under the labia majora.
The objective of this review is to discuss alternatives to commonly used methods of soft tissue reconstruction in patients with gynecologic malignancies, and in particular alternatives to skin grafts, local skin flaps, and rectus abdominis/gracilis flaps.
A review of the literature was performed on soft tissue reconstruction in patients with gynecologic malignancies.
Soft tissue reconstruction is often necessary to achieve successful wound healing, minimize complications, and to restore anatomic form and function. Commonly used methods such as skin grafts, local skin flaps, and rectus abdominis/gracilis flaps are effective, but many scenarios exist where they may be suboptimal or unavailable for use. Situations faced by the gynecologic oncologist where this may be the case include patients in whom prior treatments and/or tumor involvement have affected the vascular supply and tissues of commonly used options, those with disease recurrence who have previously undergone tumor extirpation and reconstruction, and patients undergoing radical surgery where commonly used options alone are inadequate. Under these circumstances, there are several alternative options, and an understanding of the full spectrum of reconstructive techniques is essential.
Many clinical scenarios exist where commonly used options for soft tissue reconstruction are suboptimal or unavailable. Current evidence supports use of alternative methods of reconstruction in these situations. However, further larger scale and comparative studies are needed to refine surgical decision-making.
Vulvar reconstruction using the "lotus petal" fascio-cutaneous flap
2013, Gynecologic Oncology
Citation Excerpt :
Further, in the absence of a need for bulk, the fascio-cutaneous flaps provide a more anatomically appropriate thickness for coverage of the vulvar and perineum than myocutaneous flaps. Though multiple advancement flaps are suitable for vulvo-perineal reconstruction, including the gluteus flap [12], the V to Y advancement [13], and the pudendal thigh flap [14], the gluteal fold version of the lotus petal flap best respects a natural anatomic fold at the donor site leading to the most cosmetic donor site closure (Fig. 1D). Additionally, the lotus petal flap can be based some distance from even a wide radical excision, allowing use when more proximal flap bases have been excised [15].
Vulvar reconstruction using the “lotus petal” fascio-cutaneous flap offers a relatively novel means to restore symmetry and functionality after extirpative gynecologic or oncologic procedures. We sought to assess the success rates and morbidity in a large series of consecutively treated patients.
We performed a retrospective review of 59 consecutive cases of lotus petal flaps performed at a single institution to more accurately assess success and complication rates.
We identified 80 flaps performed among the 59 patients between September 1, 2008 and March 30, 2013. The median (range) age was 59 years (24–89) and the median (range) BMI was 27 kg/m² (19–34). The indications for vulvar/perineal excision were as follows: 39 (66.1%) vulvar carcinoma or melanoma, 12 (20.3%) vulvar dysplasia, 5 (8.5%) colorectal disease and 3 (5.1%) cases of hidradenitis suppurativa. The mean defect area, determined by post-fixation pathology specimen was 29 cm². Medical or surgical complications occurred in 36% of patients of which superficial wound separation was the most common (15%). There were no cases of complete flap loss, but partial loss occurred in 7 (8.8%) cases. 3 (5.1%) patients required re-operation prior to discharge with one case requiring skin grafting. Delayed surgical revision was required in 4 patients for partial flap loss (2) or stricture/stenosis (2).
The lotus petal flap is safe for use in gynecologic reconstruction, with acceptable short- and long-term complication rates. Previous reports of smaller series likely underestimate the risk of complications through case selection.
Reconstruction of the irradiated perineum following extended abdomino-perineal excision for cancer: An algorithmic approach
2012, Journal of Plastic, Reconstructive and Aesthetic Surgery
Citation Excerpt :
Alone, this fascio-cutaneous flap does not provide sufficient bulk for extended APER defects, and is used more frequently for vaginal defects. Unfortunately this flap has proved inconsistent in survival.26 A recent study has improved the understanding of the vascular anatomy of this flap, however this is yet to be clinically corroborated.27
Our unit has implemented an algorithm for irradiated perineal reconstruction incorporating current evidence and a new technique in line with the advent of laparoscopic tumour excision. Our approach attempts to maintain the benefits patients derive from minimally invasive oncological surgery.
Four consecutive patients had uterine retroversion to obturate pelvic deadspace and reconstruct the posterior vaginal wall. Age range was 41–84 years and mean follow-up of 21 months with mean in-patient stay of 7 days. All patients had neoadjuvant radiotherapy or chemoradiation for low rectal/anorectal adenocarcinoma. All patients had laparoscopic Extended APER and contiguous posterior vaginal wall excision and reconstruction with uterine retroversion and z-plasty skin closure. One patient required ultrasound aspiration of a pre-sacral seroma at two months. No patients returned to theatre for major complications. We highlight one minor and no major complications associated with an algorithmic approach incorporating our method of uterine retroversion and z-plasty parallel to traditional flap reconstruction methods.
Penoscrotal reconstruction with gracilis muscle flap and internal pudendal artery perforator flap transposition
2012, Urology
Citation Excerpt :
These problems in versatility could cause difficulty in controlling inflammation in patients with Fournier's gangrene. Fasciocutaneous flaps, such as a medial thigh flap, a gluteal thigh flap, and a superomedial thigh flap were also used widely in the past.3,5,16 These flaps provided a pliable local flap without being bulky, and good protection of superficial defects and donor site scar could be concealed.
Extensive defects of the perineal area, with exposure of the testes, are difficult to reconstruct. For the reconstruction of these defects, we applied gracilis muscle flap combined with pudendal artery perforator fasciocutaneous flap, which provided us a reliable cutaneous flap and allowed us to cover exposed testes with sufficient muscular volume.
We retrospectively analyzed 7 patients from 2004-2011 whose penoscrotal defects had been reconstructed using gracilis muscle flap and an internal pudendal artery perforator flap. Six had Fournier's gangrene and 1 had extramammary Paget's disease. We examined characteristics of the patients, preoperative management, operative procedure, and their clinical courses.
All flaps survived during the entire follow-up periods. The mean width of the defects was 10.14 cm and the mean length was 9.29 cm. The width of the fasciocutaneous flap was approximately 6-10 cm, whereas the length ranged from 10-15 cm. The reconstructed areas were in good functional and esthetic conditions.
The combination of the gracilis muscle flap and the internal pudendal artery perforator fasciocutaneous flap provides pliable and reliable soft tissue coverage for extensive penoscrotal defects with adequate bulkiness and minimal donor site morbidity.
The pudendal thigh flap for vaginal reconstruction: Optimising flap survival
2010, Journal of Plastic, Reconstructive and Aesthetic Surgery
The pudendal thigh fasciocutaneous (PTF) flap is a useful flap in perineal reconstruction, that is reliable when small but is traditionally unreliable when large flaps are raised. Large flaps in particular, are associated with an increased incidence of apical necrosis. Thorough descriptions of the vascular anatomy of this flap have been lacking from the literature, with the current study evaluating this anatomy, aiming to provide the anatomical basis for vascular problems and for techniques to maximise its survival.
Five unembalmed human cadaveric pelvis specimens were studied. Lead oxide injectant enabled radiographic and dissection analysis of the arterial anatomy of the integument of the perineum.
A consistent pattern of vascular supply was found in all specimens. 1: the blood supply to the pelvic floor was supplied sequentially by the posterior labial/scrotal arteries, cutaneous branches from the anterior branch of the obturator artery, and branches from the external pudendal arteries. 2: these vessels ran close to the midline, medial to the PTF flap. 3: the posterior labial/scrotal arteries were deep to the Colles' fascia and the branches from the obturator artery and external pudendal arteries were located superficial to the Colles' fascia.
This study has demonstrated that the PTF flap is a three vascular territory flap and that the pedicle is situated close to the midline. This may explain why regions of the PTF flap may have a potentially precarious blood supply, and suggests that the PTF flap should be designed more medially. Given the third territory of supply to the apex of the flap, a delay procedure may help to avoid flap necrosis.

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Regular ArticlePudendal Thigh Fasciocutaneous Flaps for Vaginal Reconstruction in Gynecologic Oncology

Abstract

Regular Article
Pudendal Thigh Fasciocutaneous Flaps for Vaginal Reconstruction in Gynecologic Oncology