Redefining the Reconstructive Ladder in Vulvoperineal Reconstruction: The Role of Pedicled Perforator Flaps

Abstract

Background Gynecological reconstruction is difficult, particularly in cases with recurrence and received previous surgeries and/or radiotherapy and necessitate secondary reconstruction. Perforator flaps can preserve other donor sites for potential later reconstruction, and they also can be better tailored to the defect. We hypothesized that the use of perforator-based flaps can better restore the defect with less complications. Methods A retrospective review was conducted of all patients who underwent vulvar–perineum reconstruction between 2011 and 2018 by the senior author, and oncologic and reconstructive outcomes and complications were analyzed. Results Thirty-three patients underwent 55 soft tissue reconstructions for vulvar–perineum defects during the study period. The mean follow-up time was 27.6 ± 28.9 months. Squamous cell carcinoma was the most common cancer (45.5%). For 11 patients (33.3%), the procedures were performed for the treatment of recurrent cancer. The average defect size was 39.8 ± 34.3 cm2. The overall survival rate was 90.3%. Profunda artery perforator flaps were the most commonly applied flap for reconstruction in both the primary and recurrent groups. Poor wound healing was the most common complication which occurred in 10 of the 55 flaps (18.2%). Perforator flaps presented fewer complications than myocutaneous flaps or traditional random flaps. Similarly, Island pedicle flap design also presented fewer complications than traditional rotation flaps. With proper reconstruction, previous surgery or radiotherapy did not contribute to an increase in complications. Conclusion In our experience, perforator flaps can provide satisfactory reconstruction for perineum reconstruction with low postoperative complications while preserving other donor sites in the event of disease recurrence for repeat resection and reconstruction. Previous surgery or radiotherapy did not increase the complications or preclude its usage. A redefined reconstructive ladder was created to help selecting the best state-of-the-art technique for reconstruction to achieve better results.

A Simplified Algorithmic Approach to Vulvar Reconstruction According to Various Types of Vulvar Defects

“…The traditional use of pedicled, distally based vertical rectus abdominis myocutaneous flap, gracilis flap, and anterolateral thigh flap have been reported. 4,5,9,13 Cordeiro et al 5 used a rectus flap to cover the posterior wall of the vagina. Salgarello et al 4 reported using a VRAM flap for larger and deep tissue coverage for extensive vulvectomy.…”

“…There have been numerous articles on the various methods of vulvar reconstruction using different types of flaps. 4,[6][7][8][9][10][11]13,[18][19][20][21][22] Several reports introduced their selection algorithm based on numerous reconstruction methods. 4,6 The surgical method of choice has mainly been described to be dependent on the size, shape, and location of the defect.…”

“…Previous studies reported that the recurrence rate of vulvar cancer ranged from 14.5% to 21.2%, whereas the complication rate was 7.7% to 57.4% after vulvar reconstruction. 11,13,18,24,25 Because of the reconstruction uses the surrounding tissue, vulvar cancer showed a relatively higher recurrence rate in vulvar reconstruction. In addition, it showed a high surgical complication rate because the surgical site was a weight bearing site in the sitting position and a site where urine and feces is discharged.…”

“…Several previous reports introduced the selection methods for vulvar reconstruction after wide vulvar excision. 6,[11][12][13][14] However, the selection of algorithm methods was also complicated. Therefore, simplifying the algorithm using recently reported simple and low-complication surgical methods is needed.…”

Experience with flap repair after vulvar carcinoma resection: a retrospective observational study of 26 cases

“…If necessary, kiss-flap technology or a combination of multiple flaps can be used to repair the defect and perform vulvoplasty. A Study have shown that the incidences of poor wound healing requiring debridement for perforator flaps and myocutaneous flaps are 22.4% and 25%, respectively ( 14 ). Compared to myocutaneous flaps, thinner perforator flaps are a better choice for treating some defects.…”