YGYNO-975500; No. of pages: 9; 4C: 4, 5, 6, 7 Gynecologic Oncology xxx (2014) xxx–xxx

Contents lists available at ScienceDirect

Gynecologic Oncology journal homepage: www.elsevier.com/locate/ygyno

1

Review

4Q1

Albert H. Chao a,⁎, Georgia A. McCann b, Jeffrey M. Fowler c a

9

H I G H L I G H T S

The Ohio State University, Department of Plastic Surgery, Columbus, OH 43212, USA University Of Texas Health Science Center, Department of Obstetrics and Gynecology, San Antonio, TX 78229, USA The Ohio State University, Department of Obstetrics and Gynecology, Columbus, OH 43210, USA

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Keywords: Flap Reconstruction

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Objectives. 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. Methods. A review of the literature was performed on soft tissue reconstruction in patients with gynecologic malignancies. Results. 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. Conclusions. 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. © 2014 Elsevier Inc. All rights reserved.

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Article history: Received 16 April 2014 Accepted 30 April 2014 Available online xxxx

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• Many clinical scenarios exist where commonly used reconstructive options are suboptimal or unavailable. • Alternatives to skin grafts, local skin flaps, and rectus abdominis/gracilis flaps are reviewed. • Patient selection, indications, surgical technique, clinical uses and outcomes for these alternative reconstructive options are discussed.

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Contents

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Alternatives to commonly used pelvic reconstruction procedures in gynecologic oncology

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Introduction . . . . . . . . . . . . . . . . . . . Limitations of commonly used reconstructive options General considerations . . . . . . . . . . . . . . Defect sites . . . . . . . . . . . . . . . . . . . Groin/suprapubic . . . . . . . . . . . Pelvic cavity . . . . . . . . . . . . . Perineum . . . . . . . . . . . . . . Vagina . . . . . . . . . . . . . . . .

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⁎ Corresponding author at: 915 Olentangy River Road, Suite 2100, Columbus, OH 43212, USA. Fax: +1 614 293 9024. E-mail address: [email protected] (A.H. Chao).

http://dx.doi.org/10.1016/j.ygyno.2014.04.059 0090-8258/© 2014 Elsevier Inc. All rights reserved.

Please cite this article as: Chao AH, et al, Alternatives to commonly used pelvic reconstruction procedures in gynecologic oncology, Gynecol Oncol (2014), http://dx.doi.org/10.1016/j.ygyno.2014.04.059

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Introduction

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Surgical treatment of gynecologic malignancies may require soft tissue reconstruction under several circumstances. Reconstructive needs can be present in the immediate setting following primary tumor extirpations, delayed settings including postradiation wound breakdown, and in the salvage of patients who have developed disease recurrence. Treatment of these defects can be further complicated by previously performed reconstructive procedures, and prior or planned multimodality therapy. The “workhorses” of reconstruction in women with gynecologic malignancies have largely been flaps based on the rectus abdominis and gracilis muscles [1–5]. While these are suitable options in many cases, there are several situations where these flaps may be suboptimal or unavailable, and where the ability to select and perform alternative techniques becomes essential. In this article, alternative techniques for the reconstruction of defects encountered in patients with gynecologic malignancies are reviewed. Points of discussion include patient selection, indications, surgical technique, clinical uses and outcomes.

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Flap options . . . . . . . . . . . . . . Anterolateral thigh (ALT) flap . Anatomy . . . . . . Surgical technique . Donor site . . . . . Clinical uses . . . . Gluteal flap . . . . . . . . . Anatomy . . . . . . Surgical technique . Donor site . . . . . Clinical uses . . . . Omental flap . . . . . . . . Anatomy . . . . . . Surgical technique . Donor site . . . . . Clinical uses . . . . Posterior thigh flap . . . . . Anatomy . . . . . . Surgical technique . Donor site . . . . . Clinical uses . . . . Pudendal thigh (Singapore) flap Anatomy . . . . . . Surgical technique . Donor site . . . . . Clinical uses . . . . Rectus femoris flap . . . . . Anatomy . . . . . . Surgical technique . Donor site . . . . . Clinical uses . . . . Sartorius flap . . . . . . . . Anatomy . . . . . . Surgical technique . Donor site . . . . . Clinical uses . . . . Tensor fascia lata flap . . . . Anatomy . . . . . . Surgical technique . Donor site . . . . . Clinical uses . . . . Vastus lateralis flap . . . . . Conclusion . . . . . . . . . . . . . . . Conflict of interest . . . . . . . . . . . References . . . . . . . . . . . . . . .

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Limitations of commonly used reconstructive options

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Commonly used reconstructive options include skin grafts, local skin flaps, and myocutaneous/muscle flaps based primarily on the rectus abdominis and gracilis muscles [3]. Skin grafts are most suitable for superficial defects that have a well-vascularized bed, and are therefore relatively limited in patients undergoing major resections (e.g., perineal defects that communicate with the pelvic cavity) and in patients with poorly vascularized wounds (e.g., radiation injury). Similarly, there is a minimal role for local skin flaps such as rhomboid flaps in these situations. These flaps are based on random pattern blood supply and therefore lack the robust vascularity of axial pattern flaps such as muscle flaps, and are also of limited size/bulk. Rectus abdominis muscle/myocutaneous flaps have been widely used to reconstruct a variety of gynecologic defects including the creation of a neovagina, perineal wound coverage, and obliteration of pelvic dead space following exenteration [1,6,7]. Certain situations limit or preclude the use of rectus abdominis flaps [8]. The deep inferior epigastric vessels may in some instances be part of a surgical resection or within the field of prior irradiation. If both fecal and urinary diversions are

123

Please cite this article as: Chao AH, et al, Alternatives to commonly used pelvic reconstruction procedures in gynecologic oncology, Gynecol Oncol (2014), http://dx.doi.org/10.1016/j.ygyno.2014.04.059

124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140

A.H. Chao et al. / Gynecologic Oncology xxx (2014) xxx–xxx

Patients in whom a reconstructive need is anticipated often will be undergoing a major surgical resection, and may have had prior treatments that must be taken into account when formulating a reconstructive plan. The ability to achieve successful healing without complications is critical both in regard to minimizing patient morbidity and in ensuring that patients receive any indicated adjuvant therapies without delay. Surgical planning in advance of these complicated procedures is necessary and often involves multidisciplinary input. Many factors must be considered when selecting the appropriate method of reconstruction:

169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203

Perineum

Vagina

used for reconstruction should be outside of the field of radiation when possible. In patients who have undergone prior surgery, operative reports should be reviewed to confirm preservation of vascular pedicles. A preoperative CT angiogram can be useful [12], although ultimately intraoperative identification of a flap's blood supply should be made prior to flap elevation. Prior surgical scars should also be taken into consideration and reused when possible. Creating additional incisions in close proximity to old scars may result in skin territories with a narrow base of vascular supply. (4) Timing of reconstruction. In general, immediate reconstruction at the time of surgical resection is preferable to delayed reconstruction. At the time of tumor extirpation, the surgeon has a wide exposure that allows for accurate assessment of reconstructive options (including blood supply), as well as of the defect itself, and potentially obviates the need for the patient to undergo additional operations. Returning for reconstruction at later time requires dissection through scarred wounds, a distorted surgical field with compromised vascular supply, and may underestimate the true extent of the defect.

D

167 168

t1:4 t1:5 t1:6 t1:7 t1:8 t1:9 t1:10 t1:11 t1:12 t1:13 t1:14 t1:15 t1:16 t1:17 t1:18 t1:19 t1:20

Pelvic cavity

T

160 161

C

158 159

E

156 157

(1) Goals of reconstruction. The goals of reconstruction should be clearly defined and can include achieving cutaneous wound closure, obliterating dead space, coverage of critical structures (e.g., neurovascular structures in the groin), restoring anatomic form, or any combination of these objectives. For example, a defect that requires only skin coverage may be appropriately reconstructed with a fasciocutaneous flap alone, which obviates the sacrifice of a muscle. On the other hand, a defect that requires only dead space obliteration may be restored with a muscle flap alone, which minimizes morbidity by allowing a tension-free closure of the donor site. The overarching goal in all cases is to achieve healing without complications while restoring form and function. (2) Defect size and location. The specific location and size of the defect should be anticipated preoperatively, with formulation of a tentative plan for the flaps that may be needed to ensure inclusion of donor sites within the surgical field and appropriate informed consent (Table 1). Final committal to a reconstructive technique should be made only after completion of the surgical resection. Intraoperative use of a template of the defect with emulation of flap transposition can aid surgical planning prior to commencement of flap elevation. For very large defects, consideration should be given toward skin grafting of the donor site so that a large skin paddle can be harvested, which may be used for cutaneous coverage and/or deepithelialized for additional flap bulk [11]. (3) Previous treatments. History of prior cancer treatments and surgery should be carefully reviewed in all patients. In patients who have received prior radiation therapy, flap tissues and vascular supply

R

154 155

R

152 153

N C O

150 151

U

148 149

t1:3

Anterolateral thigh flap [30] Sartorius flap [59] Rectus femoris flap [56] Tensor fascia lata flap [62] Vastus lateralis flap [30] Anterolateral thigh flap [39] Omental flap [42–46] Posterior thigh flap [49] Vastus lateralis flap [39] Anterolateral thigh flap [38] Gluteal flap [40,41] Posterior thigh flap [49] Rectus femoris flap [55] Anterolateral thigh flap [38] Gluteal flap [41] Posterior thigh flap [49] Pudendal thigh flap [50,51]

F

165 166

147

Options

Groin/suprapubic

O

General considerations

145 146

t1:1 t1:2

Anatomic site

R O

164

143 144

Table 1 Overview of alternatives to commonly used reconstructive options.

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162 163

planned, placement of both stomas through a single rectus abdominis muscle or through the flap donor site is not ideal. Prior surgery where elevation of abdominal subcutaneous tissues has been performed (e.g., hernia repair) limits use of the rectus abdominis to a muscle only flap. In addition, cesarean sections or other surgeries that require the use of a Maylard incision may also preclude the use of the rectus abdominis flap. Furthermore, it is important to note that a laparotomy is typically required to transfer a rectus abdominis-based flap. This becomes a significant consideration in patients who otherwise would not be undergoing a laparotomy as part of their surgical resection, or in patients who present with a delayed soft tissue defect. The gracilis flap has been widely used as both a muscle and myocutaneous flap for pelvic reconstruction [5]. One of the primary limitations of this flap is its relatively small bulk that may be insufficient to fill pelvic dead space, even when performed bilaterally. In addition, since its vascular pedicle is located several centimeters below the pubic symphysis, the flap has a limited arc of rotation for transfer into the pelvic cavity. Although the gracilis flap has been described as a myocutaneous flap, the skin paddle overlying the muscle tends to be unreliable when designed vertically along the longitudinal axis of the muscle [2,9]. While a transverse skin paddle design is more reliable, this ordinarily must be designed over the proximal flap that generally will not reach pelvic defects [10].

E

141 142

3

204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222

Defect sites

223

In the gynecologic oncology patient, defects for reconstruction can be broadly classified into those of the groin/suprapubic area, pelvic cavity, perineum, and vagina. In many cases, defects will be composite defects involving portions of more than one anatomic area. In these situations it may be advantageous to select reconstructive options that can address more than one anatomic area simultaneously, or consider performing more than one reconstructive technique.

224 225

Groin/suprapubic

231

Defects of the groin are commonly encountered following inguinofemoral lymphadenectomy, where the rate of wound complications has been reported to be as high as 70% [13–16]. Anatomic factors contribute to groin wound problems, including devascularization of skin flaps, disruption of lymphatic channels during lymphadenectomy, proximity to the groin crease/perineum as sources of bacterial contamination, and shear forces. Furthermore, radiation therapy may also further predispose to wound healing problems [17]. Exposure of the neurovascular structures of the groin may favor performance of a soft tissue flap [18,19]. Reconstruction of groin wounds typically involves transposition of a soft tissue flap with a cutaneous component, which decreases tension across the closure. In cases where a significant dead space results due to the extent of the resection, a myocutaneous flap may be preferable in order to fill this dead space and prevent seroma formation.

232 233

Please cite this article as: Chao AH, et al, Alternatives to commonly used pelvic reconstruction procedures in gynecologic oncology, Gynecol Oncol (2014), http://dx.doi.org/10.1016/j.ygyno.2014.04.059

226 227 228 229 230

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269

Defects of the perineum typically require primarily skin coverage. Although technically skin grafts can be considered in some cases, certain anatomic considerations may favor use of a soft tissue flap instead. The perineum experiences relatively greater shear forces, and is at higher risk for bacterial contamination, to which skin grafts are more vulnerable. Perineal defects may also often communicate with a concurrent pelvic defect, in which case skin grafting is precluded and a soft tissue flap is necessary.

270

Vagina

271

284 285

Vaginal defects can be categorized according to their anatomic location and extent of the resulting defect. They can be partial, involving the anterior/lateral or posterior wall, or circumferential. The latter are further classified into those that involve only the upper two-thirds of the vagina or the entire vagina [23,24]. The type of defect typically largely dictates the options for vaginal reconstruction. In addition to reconstructing a defect, vaginal reconstruction also promotes healing by healthy tissues to treatment fields that have often been previously irradiated. It is also used to restore anatomic form and function, provide pelvic floor support, protect the small intestine, and prevent fistula formation and herniation [24]. Though patients who undergo vaginal reconstruction often have postoperative psychological and physical issues, studies have shown improved quality of life in these women compared to those who have not undergone reconstruction [25,26].

286

Flap options

287

Anterolateral thigh (ALT) flap

288 289

The anterolateral thigh (ALT) flap was first described for use as a free microvascular flap [27]. Since that time, the ALT flap has gained widespread popularity as a reconstructive technique because of improved understanding of its anatomy, reliability, and versatility [28,29]. As a pedicled flap, its wide arc of rotation allows it to be used for the reconstruction of a variety of defects including of the abdominal wall, groin, perineum, and posterior trunk [30].

276 277 278 279 280 281 282 283

290 291 292 293 294 295 296 297 298 299 300 301 302 303

C

274 275

E

272 273

R

267 268

R

265 266

O

263 264

C

257 258

Donor site Use of the ALT flap is associated with minimal donor site morbidity, even when the VL muscle is harvested in its entirety [29,34]. Typically, a skin paddle width of approximately 9–10 cm can be used while still being able to achieve primary donor site closure; wider flaps may require skin grafting.

335 336

Clinical uses There have been relatively few descriptions of the ALT flap for reconstruction in patients with gynecologic malignancies, mostly consisting of case reports [35–37]. In one of the largest studies, Zeng et al. described their experience with 11 patients who underwent ALT flap reconstruction of oncologic vulvar defects [38]. A low rate of complications was observed, and the authors also describe their technique for reconstructing bilateral vulvar defects using a single flap, either by fenestrating the flap

341 342

N

255 256

U

253 254

307

F

Perineum

252

Surgical technique In designing an ALT flap, the two key anatomic landmarks are the anterior superior iliac spine (ASIS) and the superolateral patella, as a line adjoining these two points or slightly lateral to it approximates the interval between the VL and RF muscles. The majority of cutaneous perforator vessels are concentrated within a 5 cm radius of the midpoint of this line [32], and therefore the ALT flap is typically tentatively centered on this point, with an elliptical skin design oriented with its long axis parallel to this line (S1). The flap is raised from a supine position with the medial incision made first, and then a subfascial dissection is performed from medial to lateral to identify cutaneous perforator vessels, after which the final flap skin paddle position may be shifted proximally/distally if necessary to ensure their inclusion within the flap. In most cases, a single perforator vessel is sufficient to supply an entire flap [33]. If the ALT flap will be performed as a skin only flap, then the lateral incision is made and subfascial dissection performed from lateral to medial to join the previous medial dissection. The cutaneous perforators are then dissected proximally to the descending branch, which is in turn dissected proximally to its origin to increase pedicle length. If the ALT flap will be performed as a myocutaneous flap with inclusion of the VL, then the muscle is circumferentially freed and no perforator vessel dissection is necessary. When used for groin and pelvic cavity reconstruction, an inguinal route is typically used for transposition (S2, Fig. 1), where consideration may need to be given to division of the inguinal ligament lateral to the femoral vessels to prevent kinking of the flap. When used for perineal reconstruction, the flap is tunneled subcutaneously. In both scenarios, transferring the flap deep to the sartorius and RF muscles can increase the reach of the flap (S3).

O

261

250 251

R O

259 260

When surgical resections result in substantial dead space within the pelvic cavity, placement of a soft tissue flap to obliterate this space can be beneficial. This may especially be true in patients who have received prior radiation therapy, where subsequent surgical resection exposes poorly vascularized and non-collapsible radiated wound surfaces [20, 21]. The benefits of soft tissue flap reconstruction in patients with pelvic defects have been well demonstrated. They introduce healthy wellvascularized tissue from outside the radiated field, and reduce the incidence of wound healing problems and fluid collections [7,22]. Muscle flaps alone are sometimes adequate to reconstruct these defects. However, pelvic cavity defects frequently coexist with vaginal and/or perineal defects, in which case a myocutaneous flap, or sometimes two separate flaps may be necessary.

P

248 249

ALT flap can be harvested either as a myocutaneous flap, or as a perfora- 304 tor flap that includes skin only. Furthermore, in cases where only a mus- 305 cle flap is needed, a VL muscle only flap may be performed. 306

D

Pelvic cavity

T

247

E

4

Anatomy The vascular supply to the ALT flap is the descending branch of the lateral circumflex femoral artery (LCFA), which originates from the profunda femoris. In the proximal thigh, the descending branch travels between the vastus lateralis (VL) and rectus femoris (RF) muscles, and then enters the substance of the VL in the distal thigh. As it traverses the thigh, the descending branch gives rise to numerous perforator vessels that supply the skin of the anterolateral thigh [31]. Since the VL and the skin of the anterolateral thigh share a common blood supply, the

Fig. 1. Final inset of an anterolateral thigh flap reconstruction of bilateral groin defects.

Please cite this article as: Chao AH, et al, Alternatives to commonly used pelvic reconstruction procedures in gynecologic oncology, Gynecol Oncol (2014), http://dx.doi.org/10.1016/j.ygyno.2014.04.059

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A.H. Chao et al. / Gynecologic Oncology xxx (2014) xxx–xxx

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Surgical technique For a SGAP flap, preoperatively a line is marked from the (PSIS) to the greater trochanter, as the SGA and its cutaneous branches are located predominantly along the medial two-thirds of this line [40]. For an IGAP flap, a vertical line is dropped from the PSIS, as the IGA and its cutaneous branches are located predominantly in a horizontal strip located along the middle third of this line [40]. A handheld Doppler is

Donor site Since SGAP/IGAP flaps are fasciocutaneous and therefore spare the GM muscle, there is minimal associated donor site morbidity. Relatively wide flaps (approximately 10 cm) can be harvested in many patients while still allowing for primary donor site, particularly when performed as a V–Y advancement where the lateral aspect of the flap is partially inset into to the donor site.

400 401

F

T

373 374

Anatomy The GM muscle originates from the posterior superior iliac spine (PSIS), coccyx, and sacrum, from which it inserts onto the greater trochanter and iliotibial tract. The vascular supply to the superior half of the muscle is the superior gluteal artery (SGA), and that to the inferior half is the inferior gluteal artery (IGA). Both vessels originate from the internal iliac system, where the SGA emerges medially superior to the piriformis muscle, while the IGA emerges medially inferior to the piriformis muscle. Each of these vessels can independently perfuse half of the muscle and overlying skin, with both ultimately giving rise to cutaneous perforator vessels after traveling through the GM muscle.

C

372

E

370 371

R

368 369

R

366 367

N C O

360 361

U

358 359

O

Gluteal flaps utilize the gluteus maximus (GM) muscle and/or overlying skin for soft tissue reconstruction, which shares a common blood supply. In cancer patients, gluteal flaps are frequently performed as fasciocutaneous flaps without muscle, since the GM is not generally considered expendable in an ambulatory patient. In these cases, flaps utilize the skin territory overlying either the superior or inferior aspect of the GM, referred to as superior gluteal artery perforator (SGAP) or inferior gluteal artery perforator (IGAP) flaps, respectively.

356 357

R O

364 365

355

392 393 394 395 396 397 398 399

402 403 404 405 406

Clinical uses With the popularization of perforator flaps, where cutaneous perforator vessels of a flap are dissected through the muscle rather than taken with the muscle, SGAP/IGAP flaps have recently been used to reconstruct perineal defects in cancer patients. In 2009, Wagstaff et al. presented one of the largest series of these cases involving 14 patients with concurrent perineal and posterior vaginal defects following cancer resections [41]. They performed 11 SGAP and 3 IGAP flaps, with no flap losses and all patients resuming sexual intercourse. In that study, the authors utilized preoperative CT angiography to aid selection of SGAP versus IGAP flaps, and performed the flaps in rotational fashion where the lateral apex of the flap was inset into the posterior cephalad vagina. Another series was reported by Cheon et al., who described 10 patients who underwent 9 SGAP and 1 IGAP flaps for the treatment of radiated sacral ulcers and osteoradionecrosis in cancer patients [40]. They experienced one major complication involving partial flap loss, which was salvaged with a contralateral SGAP flap.

407 408

Omental flap

424

Anatomy The greater omentum is a double sheet of peritoneum comprised of two leaflets. The anterior leaf attaches to the greater curvature of the stomach, proximal duodenum, and gastrosplenic ligament. The omentum then drapes a variable distance anterior to the small and large intestines before folding to form its posterior leaf, which ascends to join the transverse colon and gastrocolic ligament. The omental flap possesses two dominant blood supplies from the right and left gastroepiploic arteries, which course within the anterior leaf of the omentum approximately 1.5 cm inferior to the greater curvature of the stomach.

425

Surgical technique Open harvest of the omental flap is most common, and typically begins with reflection cranially to expose its attachments to the transverse colon, which are taken down to isolate the flap on only its anterior attachments. Usually the flap is based on either the right or left gastroepiploic artery, and the other is ligated, as are the short gastric branches between the stomach and gastroepiploic arcade.

435

P

Gluteal flap

353 354

390 391

D

363

351 352

then used to further refine the location of the SGA/IGA and its perforators for designing the skin paddle, which is usually elliptically shaped and with its long axis horizontally oriented (S4–S5). SGAP/IGAP flaps are most easily raised from a prone position. The skin is incised and dissection carried down to a subfascial plane. Typically, dissection is then performed from lateral to medial in this plane until the cutaneous perforating vessels are identified, which are then dissected apart from the GM muscle in order to gain additional vascular pedicle length (S6). The flap can then be transferred into the defect either as a rotational or V–Y advancement flap (Fig. 2).

E

362

(excising the central portion of the flap for inset of the vagina), or by dividing the flap in half if 2 separate cutaneous perforating vessels are present. In another study, Wong et al. presented a series of 18 patients who underwent ALT–VL myocutaneous flap reconstruction following pelvic exenteration for dead space obliteration and external wound õcoverage of the perineum and vagina [39]. The most commonly encountered complications were minor perineal wound dehiscences that healed spontaneously. In cases where only dead space obliteration was needed, the skin paddle of the ALT–VL flap was removed with transfer of only the VL as a muscle flap. No studies to date have examined sexual function following ALT flap reconstruction of vaginal/vulvar defects. Although few reports of the ALT flap exist in the gynecologic oncology literature, many studies support its use for similar oncologic defects of the groin, pelvis, and perineum [28,30].

349 350

5

409 410 411 412 413 414 415 416 417 418 419 420 421 422 423

426 427 428 429 430 431 432 433 434

436 437 438 439 440 441

Donor site 442 The donor site morbidity associated with omental flap harvest is 443 similar to laparotomy alone. 444

Fig. 2. Final inset of a left superior gluteal artery perforator flap performed in V–Y advancement fashion to reconstruct a sacral defect.

Clinical uses The omental flap has been widely used in gynecologic oncology. Previously described uses include in the prevention of postoperative complications such as following radical abdominal hysterectomy and

Please cite this article as: Chao AH, et al, Alternatives to commonly used pelvic reconstruction procedures in gynecologic oncology, Gynecol Oncol (2014), http://dx.doi.org/10.1016/j.ygyno.2014.04.059

445 446 447 Q4 448

451

pelvic lymphadenectomy, repair of vaginal fistulas, pelvic floor reconstruction following exenteration, and vaginal reconstruction when combined with skin grafting [42–46].

452

Posterior thigh flap

453

The posterior thigh (PTF) flap, also known as the gluteal thigh flap, is a superiorly based fasciocutaneous flap derived from the posterior aspect of the thigh. While gluteal flaps are located in the territory of the GM and based on the SGA or IGA, gluteal thigh flaps are located along the posterior thigh and based on the descending branch of the IGA. Descriptions of use of the PTF in patients with gynecologic malignancies date back to the 1980s, where it was used for both pelvic cavity and vaginal reconstruction [47,48]. Subsequently, reports of its use include in the reconstruction of defects involving the perineum, vagina, and pelvic cavity [49].

472 473 474 475 476 477 478 479 480 481 482 483 484 485 486 487 488 489 490 491 492 493 494 495 496 497 498 499 500 501 502 503 504 505 506 507 508

Surgical technique Preoperative markings are preferably made with patients in a standing position, and include the gluteal fold, a line between the ischial tuberosity and greater trochanter, and its midline. A handheld Doppler is useful to help identify the course of the descending branch of the IGA as it travels down the posterior thigh. A triangular skin paddle is then designed, with its base at the gluteal crease (S7). While very large flap may be reliably perfused, skin paddles generally must be less than 9 cm in width in order to close the donor site primarily, and should stop a few centimeters above the popliteal fossa to minimize the risk of a scar contracture at the knee joint. The patient is positioned in lithotomy for perineal and vaginal reconstruction. Flap elevation starts inferiorly, where a subfascial plane is entered. The PTF is then raised from inferior to superior up to the level of the gluteal crease (S8). The flap may then be transferred to the defect by creating a subcutaneous tunnel and deepithelializing the portion of the flap that traverses in the tunnel, or by excising the native intervening thigh tissue and replacing it with flap tissues (Fig. 3).

R O P D

471

E

469 470

T

467 468

C

465 466

Anatomy The blood supply to the PTF is the descending branch of the IGA, which in turn derives from the internal iliac system. The descending branch exits from beneath the GM at the gluteal crease at a point approximated by the midpoint of a line between the ischial tuberosity and greater trochanter. From there, it continues subcutaneously approximately along the midline of the posterior thigh. The skin paddle territory involves the surface of the posterior thigh, from gluteal crease to popliteal fossa, up to 34 cm long × 15 cm wide [49].

E

463 464

R

462

R

460 Q5 461

O

458 459

Donor site As a fasciocutaneous flap, very little donor site morbidity is associated with use of the PTF [49]. For skin paddles 9 cm or less in maximal width, primary closure is usually possible, but larger flaps may require skin grafting.

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N

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U

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A.H. Chao et al. / Gynecologic Oncology xxx (2014) xxx–xxx

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6

Clinical uses In one of the earliest descriptions (1984) of the PTF in patients with gynecologic cancer, Achauer et al. presented a series of 7 patients who underwent immediate vaginal reconstruction [47]. They achieved primary healing and satisfactory sexual function in the majority of cases. Since their report, there have been relatively few subsequent studies of the PTF in gynecologic reconstruction. One of the largest and most recent (2010) series was reported by Friedman et al. who performed 27 flaps in 19 patients for a variety of defects including after pelvic exenteration, vulvectomy, and vaginectomy [49]. The authors experienced a low complication rate, including only 1 instance of flap failure, which they attribute to attempting to perform the flap as an island flap where the cutaneous component of the flap base was divided. They therefore recommend preserving the skin at the superiorly located

Fig. 3. Long-term postoperative result of bilateral posterior thigh flap reconstruction of a perineal and vaginal defect.

flap base. In cases where both pelvic dead space needs to be filled as well as reconstruction of external soft tissues, the authors perform bilateral flaps, with one deepithelialized and used for the pelvic cavity, and the other used for external skin coverage.

509

Pudendal thigh (Singapore) flap

513

Wee and Joseph from Singapore originally described the “Singapore” flap in 1989 as a useful option for vaginal reconstruction [50]. It was originally described as an island flap and has since been modified by Woods. This modification involves the creation of a peninsular instead of an island flap, which may increase flap blood supply [51]. The pudendal thigh flap is readily harvested, reliable, and may be favorable for shallow defects.

514 515

Anatomy The pudendal thigh flap derives its blood supply from the posterior labial arteries, which are branches of the perineal, and ultimately the internal pudendal arteries. The posterior labial arteries possess anastomotic connections with branches of the deep external pudendal, medial femoral circumflex and anterior branch of the obturator arteries over the proximal portion of the adductor muscle. The posterior aspect

521 522

Please cite this article as: Chao AH, et al, Alternatives to commonly used pelvic reconstruction procedures in gynecologic oncology, Gynecol Oncol (2014), http://dx.doi.org/10.1016/j.ygyno.2014.04.059

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Donor site There is minimal donor site morbidity associated with pudendal thigh flaps. The donor site defect is typically closed primarily and is often inconspicuous once healed (Fig. 4).

O

F

Anatomy The RF muscle originates on the ASIS and upper acetabulum, and inserts onto the patella. Its dominant blood supply is via the LCFA, which branches off the lateral aspect of the profunda femoris in the proximal thigh and enters the muscle along its deep surface.

Clinical uses The pudendal thigh flap may be performed as a unilateral flap for posterior vaginal defects or to augment a myocutaneous flap in cases of total vaginal reconstruction, and performed bilaterally for creation of a neovagina. The original island flap can be advantageous in that it does not disrupt the labia, and therefore allows for a more anatomic appearance of the external genitalia. However, flap failure can result from compression of the vascular supply at the tunneled area. The modification by Woods may be more reliable and should be considered in

569 570

574 575 576 577 578

Surgical technique The RF flap can be performed as either a muscle only or myocutaneous flap. When performed as a myocutaneous flap, the skin paddle is elliptical and centered with its long axis along a line between the ASIS and patella. In either case, the distal insertion of the muscle is divided, and dissection performed from inferior to superior along its deep surface.

579 580

Donor site When performed as a myocutaneous flap, primary closure of the donor site is usually possible when the skin paddle is no wider than approximately 9 cm. Although the RF is involved in terminal knee extension, existing studies suggest that there is minimal associated functional donor site morbidity [53,54].

585 586

R O

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571

P

544 545

Rectus femoris flap

D

542 543

567 568

E

540 541

women who have been heavily pre-treated and at risk for wound healing complications. Woods described their experience with the modified (peninsular) flap in 31 patients, of which there was only one flap failure, which occurred in a patient who was heavily pre-treated.

The RF muscle is one of four muscles in the quadriceps group, and 572 functions both in hip flexion and knee extension. 573

T

538 539

C

536 537

E

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Surgical technique 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 modification described by Woods involves dividing the labia posteriorly and allowing it to retract anteriorly, allowing the flap to be performed as an inferiorly based fasciocutaneous flap, which may be easier to inset and has additional cutaneous vascular supply (S10). If flaps are raised bilaterally for total vaginal reconstruction, they are sutured together with absorbable suture first, which creates a pouch that is subsequently inserted and inset into the defect. When performed concurrently with an abdominal procedure such as pelvic exenteration, a non-absorbable suture is placed at the apex of the pouch and subsequently secured to internal structures such as the sacrum. A Vaseline-coated pack is then placed in the vagina and a binder was used to hold it in place. 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.

R

533

R

532

N C O

530 531

of this flap often times retains sensation from the posterior labial branches of the pudendal nerve and perineal rami of the posterior cutaneous nerve of the thigh. Including the deep fascia and epimysium of the adductor muscles in this flap prevents inadvertent damage to its neurovascular supply.

U

528 529

7

581 582 583 584

587 588 589 590

Clinical uses There are very few reports of the RF flap in patients with gynecologic cancers. Cardosi et al. described a case of use of a RF myocutaneous flap to reconstruct a vulvoperineal defect following anterior exenteration where rectus abdominis and gracilis flaps were not feasible [55]. The RF flap has been widely used for reconstruction of groin defects of both oncologic and other etiologies [56,57]. Use of the RF flap has largely been replaced by the ALT flap.

591 592

Sartorius flap

599

593 594 595 596 597 598

The sartorius is a long thin muscle that assists in hip flexion, abduc- 600 tion, and lateral rotation, as well as knee flexion. 601 Anatomy The sartorius muscle originates on the ASIS and inserts onto the medial tibial condyle. It receives a segmental blood supply from the superficial femoral artery, which gives rise to approximately 6–7 branches to the muscle that enters the flap along its deep and medial surface.

602

Surgical technique Dissection usually begins in a subcutaneous plane to expose the superficial surface of the muscle. This is followed by careful dissection along its deep aspect where its segmental blood supply is located. The superior and/or inferior muscle substance may be divided to facilitate mobility, and then the muscle either advanced or turned over into the groin defect.

607 608

603 604 605 606

609 610 611 612 613

Donor site 614 There is minimal donor site morbidity associated with use of the sar- 615 torius muscle. 616

Fig. 4. Final inset of a left pudendal thigh flap into a posterior vaginal defect with donor site closure.

Clinical uses 617 The sartorius flap has been widely used in the reconstruction of 618 groin defects of both oncologic and other etiologies [57–59]. 619

Please cite this article as: Chao AH, et al, Alternatives to commonly used pelvic reconstruction procedures in gynecologic oncology, Gynecol Oncol (2014), http://dx.doi.org/10.1016/j.ygyno.2014.04.059

A.H. Chao et al. / Gynecologic Oncology xxx (2014) xxx–xxx

Anatomy The TFL muscle originates on the iliac crest/ASIS and inserts onto the tibial condyle. The dominant blood supply to the TFL is via the LCFA, which gives rise to multiple branches that enter the deep surface of the muscle approximately 7–12 cm inferior to the ASIS.

625 626 627 628 629 630 631 632 633 634 635 636 637 638 639 640 641 642

Surgical technique Preoperatively, the ASIS and lateral condyle of the tibia are marked. A line adjoining these two points approximates the anterior border of the muscle. Based on the dimensions of the defect, the width of the flap is then marked posterior to this line. Beyond the two-thirds point of the thigh, the skin paddle of the TFL flap becomes less reliable, and therefore myocutaneous flaps generally are not designed past this point. Flap elevation begins inferiorly, where the insertion of the TFL is identified and divided, and then the flap is raised off of its deep surface from inferior to superior, where ultimately the vascular pedicle will be identified entering its deep surface. Donor site Harvest of the TFL flap is associated with minimal functional morbidity.

651

Vastus lateralis flap

652

C

E

647 648

R

645 646

See section on Anterolateral thigh flap. Conclusion

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The field of gynecologic oncology is unique in its breadth, where practitioners are intimately involved with and orchestrate the comprehensive care of women with gynecologic malignancies from diagnosis to surgery, adjuvant chemotherapy and surveillance. In addition, procedures such as pelvic exenteration have required the gynecologic oncologist to also be proficient in reconstructive procedures in order to improve surgical outcomes and quality of life. As more treatment options have become available, the complexity of treating recurrences has increased, where radical surgery may be necessary in patients who have been heavily pre-treated, which in turn complicates any reconstructive procedures that may be necessary. Fortunately, options for reconstruction have also evolved, and now include a wide spectrum of techniques suitable for the various clinical scenarios encountered by the gynecologic oncologist. Given the continued evolution of these alternative techniques, an integrated multi-disciplinary approach may be indicated in many cases. Consultation with a plastic surgeon can help with preoperative planning as well as intraoperative decision-making. Current evidence supports use of the alternative methods of reconstruction reviewed in this article. However, further larger scale and comparative studies are necessary in order to refine surgical decision-making. As therapy for primary and recurrent gynecologic cancers continues to evolve, so will the complexity of reconstruction. Thus, it is imperative that the gynecologic oncologist, who is ultimately the orchestrator of

662 663 664 665 666 667 668 669 670 671 672 673 674 675 676

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The authors have no commercial associations or financial disclosures 682 that might pose or create a conflict of interest with information present- 683 ed in this manuscript. No funding was received for this work. 684 References

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[1] Carlson JW, Carter JR, Saltzman AK, Carson LF, Fowler JM, Twiggs LB. Gynecologic reconstruction with a rectus abdominis myocutaneous flap: an update. Gynecol Oncol 1996;61:364–8. [2] Copeland LJ, Hancock KC, Gershenson DM, Stringer CA, Atkinson EN, Edwards CL. Gracilis myocutaneous vaginal reconstruction concurrent with total pelvic exenteration. Am J Obstet Gynecol 1989;160:1095–101. [3] Fowler JM. Incorporating pelvic/vaginal reconstruction into radical pelvic surgery. Gynecol Oncol 2009;115:154–63. [4] Jurado M, Bazán A, Elejabeitia J, et al. Primary vaginal and pelvic floor reconstruction at the time of pelvic exenteration: a study of morbidity. Gynecol Oncol 2000;77:293–7. [5] Soper JT, Rodriguez G, Berchuck A, Clarke-Pearson DL. Long and short gracilis myocutaneous flaps for vulvovaginal reconstruction after radical pelvic surgery: comparison of flap-specific complications. Gynecol Oncol 1995;56:271–5. [6] Casey III WJ, Tran NV, Petty PM, Stulak JM, Woods JE. A comparison of 99 consecutive vaginal reconstructions: an outcome study. Ann Plast Surg 2004;52:27–30. [7] Goldberg GL, Sukumvanich P, Einstein MH, Smith HO, Anderson PS, Fields AL. Total pelvic exenteration: the Albert Einstein College of Medicine/Montefiore Medical Center Experience (1987 to 2003). Gynecol Oncol 2006;101:261–8. [8] Nelson RA, Butler CE. Surgical outcomes of VRAM versus thigh flaps for immediate reconstruction of pelvic and perineal cancer resection defects. Plast Reconstr Surg 2009;123:175–83. [9] Lacey CG, Stern JL, Feigenbaum S, Hill EC, Braga CA. Vaginal reconstruction after exenteration with use of gracilis myocutaneous flaps: the University of California, San Francisco experience. Am J Obstet Gynecol 1988;158:1278–84. [10] Fansa H, Schirmer S, Warnecke IC, Cervelli A, Frerichs O. The transverse myocutaneous gracilis muscle flap: a fast and reliable method for breast reconstruction. Plast Reconstr Surg 2008;122:1326–33. [11] Campbell CA, Butler CE. Use of adjuvant techniques improves surgical outcomes of complex vertical rectus abdominis myocutaneous flap reconstructions of pelvic cancer defects. Plast Reconstr Surg 2011;128:447–58. [12] Rosich-Medina A, Ariyaratnam J, Koo B, et al. The utility of CT angiography in planning perineal flap reconstruction following radical pelvic surgery. Int J Surg 2012;10:217–20. [13] Gaarenstroom KN, Kenter GG, Trimbos JB, et al. Postoperative complications after vulvectomy and inguinofemoral lymphadenectomy using separate groin incisions. Int J Gynecol Cancer 2003;13:522–7. [14] Hinten F, van den Einden LC, Hendriks JC, et al. Risk factors for short- and long-term complications after groin surgery in vulvar cancer. Br J Cancer 2011;105:1279–87. [15] Paley PJ, Johnson PR, Adcock LL, et al. The effect of sartorius transposition on wound morbidity following inguinal–femoral lymphadenectomy. Gynecol Oncol 1997;64:237–41. [16] Zhang SH, Sood AK, Sorosky JI, Anderson B, Buller RE. Preservation of the saphenous vein during inguinal lymphadenectomy decreases morbidity in patients with carcinoma of the vulva. Cancer 2000;89:1520–5. [17] Montana GS, Thomas GM, Moore DH, et al. Preoperative chemo-radiation for carcinoma of the vulva with N2/N3 nodes: a gynecologic oncology group study. Int J Radiat Oncol Biol Phys 2000;48:1007–13. [18] Gravvanis A, Caulfield RH, Mathur B, Ramakrishnan V. Management of inguinal lymphadenopathy: immediate sartorius transposition and reconstruction of recurrence with pedicled ALT flap. Ann Plast Surg 2009;63:307–10. [19] Nirmal TJ, Gupta AK, Kumar S, Devasia A, Chacko N, Kekre NS. Tensor fascia lata flap reconstruction following groin dissection: is it worthwhile? World J Urol 2011;29:555–9. [20] Butler CE, Gündeslioglu AO, Rodriguez-Bigas MA. Outcomes of immediate vertical rectus abdominis myocutaneous flap reconstruction for irradiated abdominoperineal resection defects. J Am Coll Surg 2008;206:694–703. [21] Hinojosa MW, Parikh DA, Menon R, Wirth GA, Stamos MJ, Mills S. Recent experience with abdominal perineal resection with vertical rectus abdominis myocutaneous flap reconstruction after preoperative pelvic radiation. Am Surg 2009;75:995–9. [22] Berger JL, Westin SN, Fellman B, et al. Modified vertical rectus abdominis myocutaneous flap vaginal reconstruction: an analysis of surgical outcomes. Gynecol Oncol 2012;125:252–5. [23] Cordeiro PG, Pusic AL, Disa JJ. A classification system and reconstructive algorithm for acquired vaginal defects. Plast Reconstr Surg 2002;110:1058–65. [24] Pusic AL, Mehrara BJ. Vaginal reconstruction: an algorithm approach to defect classification and flap reconstruction. J Surg Oncol 2006;94:515–21. [25] Hawighorst-Knapstein S, Schönefussrs G, Hoffmann SO, Knapstein PG. Pelvic exenteration: effects of surgery on quality of life and body image—a prospective longitudinal study. Gynecol Oncol 1997;66:495–500.

686 Q7 687 688 689 690 691 692 693 694 695 696 697 698 699 700 701 702 703 704 705 706 707 708 709 710 711 712 713 714 715 716 717 718 719 720 721 722 723 724 725 726 727 728 729 730 731 732 733 734 735 736 737 738 739 740 741 742 743 744 745 746 747 748 749 750 751 752 753 754

T

649 650

Clinical uses In patients with gynecologic malignancies, the TFL flap is most often used to reconstruct defects of the groin and suprapubic area, although it has also been described for use in the perineum [60]. Most descriptions of the TFL flap in this patient population date back to the 1980s [61–63], with the majority consisting of case reports and limited case series. Due to its arc of rotation, the TFL flap is generally not suitable for defects of the perineum or pelvic cavity. Use of the TFL flap has largely been replaced by the more versatile ALT flap.

643 644

Conflict of interest

F

623 624

O

The tensor fascia lata (TFL) muscle is located on the lateral aspect of the thigh and functions in knee stabilization.

677 678

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621 622

these lengthy and complex extirpative procedures, be familiar with the full spectrum of reconstructive options. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ygyno.2014.04.059.

P

Tensor fascia lata flap

D

620

E

8

Please cite this article as: Chao AH, et al, Alternatives to commonly used pelvic reconstruction procedures in gynecologic oncology, Gynecol Oncol (2014), http://dx.doi.org/10.1016/j.ygyno.2014.04.059

A.H. Chao et al. / Gynecologic Oncology xxx (2014) xxx–xxx

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[45] Patsner B, Hackett TE. Use of the omental J-flap for prevention of postoperative complications following radical abdominal hysterectomy: report of 140 cases and literature review. Gynecol Oncol 1997;65:405–7. [46] Schloericke E, Hoffmann M, Zimmermann M, et al. Transperineal omentum flap for the anatomic reconstruction of the rectovaginal space in the therapy of rectovaginal fistulas. Colorectal Dis 2012;14:604–10. [47] Achauer BM, Braly P, Berman ML, DiSaia PJ. Immediate vaginal reconstruction following resection for malignancy using the gluteal thigh flap. Gynecol Oncol 1984;19:79–89. [48] Hurwitz DJ, Swartz WM, Mathes SJ. The gluteal thigh flap: a reliable, sensate flap for the closure of buttock and perineal wounds. Plast Reconstr Surg 1981;68:521–32. [49] Friedman JD, Reece GR, Eldor L. The utility of the posterior thigh flap for complex pelvic and perineal reconstruction. Plast Reconstr Surg 2010;126:146–55. [50] Wee JT, Joseph VT. A new technique of vaginal reconstruction using neurovascular pudendal-thigh flaps: a preliminary report. Plast Reconstr Surg 1989;83:701–9. [51] Woods JE, Alter G, Meland B, Podratz K. Experience with vaginal reconstruction utilizing the modified Singapore flap. Plast Reconstr Surg 1992;90:270–4. [52] Gleeson NC, Baile W, Roberts WS, et al. Pudendal thigh fasciocutaneous flaps for vaginal reconstruction in gynecologic oncology. Gynecol Oncol 1994;54:269–74. [53] Daigeler A, Dodic T, Awiszus F, Schneider W, Fansa H. Donor-site morbidity of the pedicled rectus femoris muscle flap. Plast Reconstr Surg 2005;115:786–92. [54] Gardetto A, Raschner Ch, Schoeller T, Pavelka ML, Wechselberger G. Rectus femoris muscle flap donor-site morbidity. Br J Plast Surg 2005;58:175–82. [55] Cardosi RJ, Hoffman MS, Greenwald D. Rectus femoris myocutaneous flap for vulvoperineal reconstruction. Gynecol Oncol 2002;85:188–91. [56] Alkon JD, Smith A, Losee JE, Illig KA, Green RM, Serletti JM. Management of complex groin wounds: preferred use of the rectus femoris muscle flap. Plast Reconstr Surg 2005;115:776–83. [57] Fischer JP, Mirzabeigi MN, Sieber BA, et al. Outcome analysis of 244 consecutive flaps for managing complex groin wounds. J Plast Reconstr Aesthet Surg 2013;66:1396–404. [58] Bartlett EK, Meise C, Bansal N, et al. Sartorius transposition during inguinal lymphadenectomy for melanoma. J Surg Res 2013;184:209–15. [59] Wu LC, Djohan RS, Liu TS, Chao AH, Lohman RF, Song DH. Proximal vascular pedicle preservation for sartorius muscle flap transposition. Plast Reconstr Surg 2006;117:253–8. [60] Chafe W, Fowler WC, Walton LA, Currie JL. Radical vulvectomy with use of tensor fascia lata myocutaneous flap. Am J Obstet Gynecol 1983;145:207–13. [61] Cronjé HS, Van Zyl JS. Resurfacing the vulva and vagina. Int J Gynaecol Obstet 1988;27:113–8. [62] Goldberg MI, Rothfleisch S. The tensor fascia lata myocutaneous flap in gynecologic oncology. Gynecol Oncol 1981;12:41–50. [63] Staiano JJ, Wong L, Butler J, Searle AE, Barton DP, Harris PA. Flap reconstruction following gynaecological tumour resection for advanced and recurrent disease—a 12 year experience. J Plast Reconstr Aesthet Surg 2009;62:346–51.

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[26] Ratliff CR, Gershenson DM, Morris M, et al. Sexual adjustment of patients undergoing gracilis myocutaneous flap vaginal reconstruction in conjunction with pelvic exenteration. Cancer 1996;78:2229–35. [27] Song YG, Chen GZ, Song YL. The free thigh flap: a new free flap concept based on the septocutaneous artery. Br J Plast Surg 1984;37:149–59. [28] Ali RS, Bluebond-Langner R, Rodriguez ED, Cheng MH. The versatility of the anterolateral thigh flap. Plast Reconstr Surg 2009;124:e395–407. [29] Hanasono MM, Skoracki RJ, Yu P. A prospective study of donor-site morbidity after anterolateral thigh fasciocutaneous and myocutaneous free flap harvest in 220 patients. Plast Reconstr Surg 2010;125:209–14. [30] Lannon DA, Ross GL, Addison PD, Novak CB, Lipa JE, Neligan PC. Versatility of the proximally pedicled anterolateral thigh flap and its use in complex abdominal and pelvic reconstruction. Plast Reconstr Surg 2011;127:677–88. [31] Wei FC, Jain V, Celik N, Chen HC, Chuang DC, Lin CH. Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps. Plast Reconstr Surg 2002;109:2219–26. [32] Yu P. Characteristics of the anterolateral thigh flap in a Western population and its application in head and neck reconstruction. Head Neck 2004;26:759–69. [33] Saint-Cyr M, Schaverien M, Wong C, et al. The extended anterolateral thigh flap: anatomical basis and clinical experience. Plast Reconstr Surg 2009;123:1245–55. [34] Collins J, Ayeni O, Thoma A. A systematic review of anterolateral thigh flap donor site morbidity. Can J Plast Surg 2012;20:17–23. [35] Chao AH, McCann GA, Fowler JM. Bilateral groin reconstruction with a single anterolateral thigh perforator flap as an alternative to traditional myocutaneous flaps. Gynecol Oncol Case Rep 2014 [in press]. [36] Huang LY, Lin H, Liu YT, ChangChien CC, Chang SY. Anterolateral thigh vastus lateralis myocutaneous flap for vulvar reconstruction after radical vulvectomy: a preliminary experience. Gynecol Oncol 2000;78:391–3. [37] Luo S, Raffoul W, Piaget F, Egloff DV. Anterolateral thigh fasciocutaneous flap in the difficult perineogenital reconstruction. Plast Reconstr Surg 2000;105:171–3. [38] Zeng A, Qiao Q, Zhao R, Song K, Long X. Anterolateral thigh flap-based reconstruction for oncologic vulvar defects. Plast Reconstr Surg 2011;127:1939–45. [39] Wong S, Garvey P, Skibber J, Yu P. Reconstruction of pelvic exenteration defects with anterolateral thigh–vastus lateralis muscle flaps. Plast Reconstr Surg 2009;124:1177–85. [40] Cheon YW, Lee MC, Kim YS, Rah DK, Lee WJ. Gluteal artery perforator flap: a viable alternative for sacral radiation ulcer and osteoradionecrosis. J Plast Reconstr Aesthet Surg 2010;63:642–7. [41] Wagstaff MJ, Rozen WM, Whitaker IS, Enajat M, Audolfsson T, Acosta R. Perineal and posterior vaginal wall reconstruction with superior and inferior gluteal artery perforator flaps. Microsurgery 2009;29:626–9. [42] Fujiwara K, Kigawa J, Hasegawa K, et al. Effect of simple omentoplasty and omentopexy in the prevention of complications after pelvic lymphadenectomy. Int J Gynecol Cancer 2003;13:61–6. [43] Kusiak JF, Rosenblum NG. Neovaginal reconstruction after exenteration using an omental flap and split-thickness skin graft. Plast Reconstr Surg 1996;97:775–81. [44] Hultman CS, Sherrill MA, Halvorson EG, et al. Utility of the omentum in pelvic floor reconstruction following resection of anorectal malignancy: patient selection, technical caveats, and clinical outcomes. Ann Plast Surg 2010;64:559–62.

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Please cite this article as: Chao AH, et al, Alternatives to commonly used pelvic reconstruction procedures in gynecologic oncology, Gynecol Oncol (2014), http://dx.doi.org/10.1016/j.ygyno.2014.04.059

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