Reconstructive Flaps for the Vulva

Kenneth D. Hatch

GENERAL PRINCIPLES

The surgical treatment of cancer of the vulva requires wide excision of the tumor. If the resulting defect is not closed, the patient is at risk for infection, stricture, and pain. Immediate reconstruction using musculocutaneous, fasciocutaneous, or cutaneous flaps has decreased postoperative infection and improved healing rates and body image.

Anatomic Considerations

The defect remaining after radical excision of vulva cancer is often difficult to close without tension on the suture lines. The wound edges separate and the defect heals by granulation and scarring. This leads to stricture around the vagina and/or anus (Fig. 5.1). The goal of flap reconstruction is to protect the vagina, urethra, and anal openings from this stricture. To do so requires the surgeon to select the skin flap that will leave the least tension on the suture lines so that separation does not occur. If epithelium stays attached to epithelium, then secondary healing and contracted scarring can be avoided (Fig. 5.2).
Flaps may be local or regional. They may have a random blood supply or an axial blood supply.
The random vascular pattern flaps depend on the microcirculatory system of the skin to survive until neovascularization occurs in 3 to 7 days (Fig. 5.3).
In the axial pattern flap, the direct cutaneous artery supplies this plexus. The length of this flap can be as long as the direct cutaneous artery.
For the random pattern flap, the dermal-subdermal plexus relies on the anastomotic connections in the plexus. This limits the length to two times the width of the flap.
Flaps may be local or regional. The majority of vulva flaps is local and has a random blood supply. These include the V-Y advancement flap, the transposition flap, and the rhomboid flaps.
The gluteal fold flap is a transposition flap and may be cutaneous or fasciocutaneous. The blood supply is from the perineal branches of the internal pudendal artery. This is a transposition flap with an axial blood supply at its base and random blood supply at the tip.
The gracilis flap is musculocutaneous. It is a regional flap, has an axial blood supply from the profunda femoris artery, and can be rotated on that vascular pedicle to create a neovagina or to cover large defects of the vulva.

PREOPERATIVE PLANNING

The patient should be counseled during the clinic visit about the changes in appearance that the surgery will bring. She should be aware of the possible incisions of the medial thigh or gluteus, if these flaps are used. There will be altered sensation to the new vulva skin.

SURGICAL MANAGEMENT

The type of flap used will be determined by the size and location of the defect. Perineal defects are best closed by the rhomboid transposition flap shown in Chapter 1. The V-Y flap is most often used for lateral defects (Fig. 5.4).
The gluteal fold flap can be used for lateral, anterior, and posterior defects (Video 5.1 ).
The gracilis myocutaneous flap is used when there is a very large defect that removes the entire vulva, mons, and medial thigh skin. Such large excisions remove the skin that V-Y would need and the branches of the internal pudendal artery that the gluteal fold would need (Video 5.2 , Fig. 5.5).

Positioning

Lithotomy with leg-support stirrups.

Figure 5.1. A: The preoperative markings for an en block resection of the groin nodes and vulva commonly performed prior to 1990. B: The defect is closed with lots of tension on the suture lines around the vagina and urethra. C: After the incisions separated and healed by granulation she has severe stricture of the vagina and urethra.

Figure 5.2. A: After 1990 most patients had separate groin and vulva incisions. This cancer was located on the perineum and rhomboid flaps will be used. B: The appearance of the vulva and perineum after the rhomboid flaps. C: Six months after the surgery the vaginal opening is normal and the rhomboid flaps have provided normal separation of the anus and vagina.

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