Asia-Oceania J . Obstet. Gynaecol. Vol. 18, No. 7: 23-29 1992
Reconstruction of Surgical Defects Using the Gluteus Maximus Myocutaneous Flap Following Radical Vulvectomy
Masahiro Ogino, Takako Sakamoto, Jun Inoue, Kazuyoshi Dobashi, Shoichi Okinaga, and Kiyoshi Arai Department of Obstetricsand Gynecology, Teikyo University School of Medicine, Tokyo, Japan
Abstract Radical vulvectomy is often complicated by problems associated with insufficient closure of large skin defects involving postoperative necrosis of the suture line over the mons pubis and the inguinal areas. To resolve these problems, the present study compared radical vulvectomy (RV, 7 cases) with radical vulvectomy followed by reconstructive operation using the gluteus maximus myocutaneous flap (RVR, 5 cases). There was no significant difference in operation time and blood loss between the two groups. Three of the 7 RV patients had wound separations requiring reoperation, while only 1 patient in the RVR group did. The average hospital stay was 86 days in the RV group and 38 days in the RVR. Risks of postoperative infection and wound breakdown were reduced with the flap technique, and ambulation and rehabilitation could begin earlier in this group. Surgical wounds were stable and the quality of life after operation was improved dramatically using the flap technique.
Key words : vulva cancer, reconstruction, operation Introduction Squamous cell carcinomas of the vulva account for approximately 3 4 % of all malignancies of the female genital, tract. Surgery for vulvar cancer should include wide removal of the primary lesion and excision of the regional lymph nodes. Recently, radical vulvectomy and bilateral groin node dissection (RV) have become the standard method of therapy for almost all operable stages of squamous cell carcinoma of the vulva.1) Although
survival is improved by RV, wound closure is often difficult, resulting in postoperativewound breakdown and prolonged hospitalization. Various methods have therefore been employed to improve wound healing and to shorten postoperative hospitalization.*-e) McCraw et aZ.7) demonstrated that viability of the isolated gracilis muscule with overlying skin and subcutaneous tissue could be maintained by preserving its vascular pedicle. This myocutaneous flap can be mobilized to reconstruct an area with large tissue defect and has been used to
Received: May 20, 1991 Reprint request to: Dr. Masahiro Ogino, Department of Obstetrics and Gynecology, Teikyo University School of Medicine, Kaga 2-11-1, Itabashi-ku, Tokyo 173, Japan
23
M. OGINO ET AL.
Fig. 1. Radical vulvectomy with bilateral inguinal node dissection has been completed.
Fig. 2. The left myocutanepus flap has been mobilized and being rotated into position.
cover the groin and vulva. The primary goals of this radical vulvectomy with reconstruction (RVR) are (a) to promote recovery,from RV, (b) to minimize technical difficulties and shorten operating time and (c) to minimize injury to the donor site. In this report we review the reconstruction of the vulva using the gluteus maximus myocutaneous flap following RV. The operative and perioperative morbidity of patients undergoing RV is compared with that of patients who underwent RVR at the time of the initial radical surgery. 24
Surgical Technique The patient was placed on the operating table in a lithotomy position with her legs in stirrups and the thigh abducted 45" and flexed 15". Conventional surgical procedures for advanced carcinoma of the vulva were then performed with inguinal and/or pelvic lymphadenectomy (Fig. 1). The defect area was carefully measured. The skin overlying the gluteus maximum muscle was prepared for the flap by outlining it with a sterile marking pen. This flap had to be sufficient in length and width to c h e r the defect area; in particular its
RECONSTRUCTION OF THE VLlLVA
Fig. 3. T h e flaps have been moved into position and sututred into place.
Fig. 4. T h e vulvar reconstruction 30 days postoperatively.
length had to be sufficient to assure no tension. Suture of the wound under too much tension needed to be avoided otherwise it would result in soft tissue necrosis and breakdown, ultimately requiring secondary skin grafting. The skin incision was then made sharply down through the fascia lata, with the full thickness of the subcutaneous tissue, and the vascular bed was included in the graft. The size of the flap was usually from 14 to 18 cm in length and 6 to 8 c m in width. The gluteus maximum muscle with attached skin and subcutaneous tissue was then elevated and freed from all adjacent tissue except its vas-
cular pedicle. The donor site was then closed (Fig. 2). Once in place, the flap could be fixed to the surrounding skin by sutures, and a hemovac drain brought out through a separate stab wound8*O) (Fig. 3). The drain was removed after about 48-72 hours, and the sutures were removed between the tenth and fourteenth postoperative days (Fig. 4).
Patients From 1978 to 1984, 7 patients with invasive squamous cell carcinoma of the vulva underwent RV at Teikyo University Hospital. These fitients were used as the control group. Since 25
M. OGINO ET AL.
Table 1. Clinical characteristics of study patients Patient
Age
Stage
Pathology
Radical vulvectomy
1 2 3 4 5 6 7*
75 87 72 47 65 45 68
Radical vulvectomy with reconstruction 1 85 2 65 3 74 4 79 5* 73
11 (T*NoMo) 111 (TzNoMo) 11 (T*NoM,) 111 (TsNaMo) 11 (TzNiMo) 111 (TZNIMO) 11 (TsNoMo)
Squamous cell Squamous cell Squamous cell Squamous cell Squamous cell Squamous cell Squamous cell
111 (TzN1Mo) 11 (T*NIMO) 111 (T*"o) 11 (TSNOMO) recurrence
Paget's disease Squamous cell carcinoma Paget's disease Squamous cell carcinoma Sauamous cell carcinoma
carcinoma carcinoma carcinoma carcinoma carcinoma carcinoma carcinoma
* Same patient the beginning of 1987 we have undertaken RVR on 5 patients, including 3 patients with invasive squamous cell carcinoma 1 of which was recurring and 2 patients with Paget's disease of the vulva. Ages of the patients ranged from 45 to 87 years, with a mean of 70 years. One patient had previously been given a radical vulvectomy with groin lymphadenectomy and received irradiation in 1972, but 7 years later she developed a recurrent lesion at the junction of the perineal skin and vaginal mucosa. This was treated by wide excision, reconstruction operation. These 11 patients were evaluated to assess differences in operating times, amount of blood loss, postoperative complications and hospitalization periods. Distribution by stages for each treatment group was similar in almost half of the patients with stage I1 disease. Table 1 shows clinical characteristics of 7 patients who had RV, and 5 patients who underwent RVR. Statistical Analysis Differences in the mean of operation times, amount of blood loss, incidence of breakdown or flap loss, walking practice, and postoperative hospitalization periods between RV and RVR groups were compared using the Student's t-test and xa. P values less than 0.05 were considered significant. 26
Results Operative and postoperative complications associated with the method of surgery are shown in Tables 2 and 3. The (a) mean operating time and (b) amount of blood loss in the two groups are as follows: (a) (M2S.D.); 196282 (minutes) for RV group vs. 218276 (minutes) for RVR group, and (b) 3672184 (ml) for the RV group vs. 319262 (mZ) for the RVR group. There were no significant differences in these two indices between the groups. Complications were evaluated in the immediate postoperative period for breakdown, wound infection, and flap loss. All the patients who had undergone RV developed breakdown and 3 of 7 patients were reoperated on for suturing. Only one patient developed breakdown due to the infection by methicillin resistant S t u p h y h c m aweus (MRSA) in the RVR group. This patient had to be resutured. In general, the RVR group had significantly fewer breakdowns as compared with the RV group (Table 3). One patient in the RV group developed necrosis; no patient did in the RVR group. Comparison of the postoperative ambulatory time in the two groups was as follows; 16+6 (9-27) days in the RV group vs. 12k4 (7-17) days in the RVR group. There was no significant difference between the two groups. Pa-
RECONSTRUCTION OF THE VULVA
Table 2. Operative and postoperative results Patient
(9)
Practice for walking (day)
Postoperative* hospitalization (day)
82 600 364 400 239 583 304 367f184
9 19 10 27 13 17 17 16f6
98 64 49 102 64 101 126 86f28
387 300 381 274 253 319f62
7 13 17
32 25 53 51 28 38f13
Operation time (min)
Blood loss
93 120 180 235 215 345 180 196f82
Radical vulvectomy
1 2 3 4 5 6 7 (MfS.D)
Radical vulvectomy with reconstruction
1 2 3 4 5 (M fS.D)
205 245 335 150 155 218f76
11 11 12f4
~
*
1 Postoperative hospitalization calculated from the operation date of discharge or the starting date
at radiation. p
Reconstruction of Surgical Defects Using the Gluteus Maximus Myocutaneous Flap Following Radical Vulvectomy
Masahiro Ogino, Takako Sakamoto, Jun Inoue, Kazuyoshi Dobashi, Shoichi Okinaga, and Kiyoshi Arai Department of Obstetricsand Gynecology, Teikyo University School of Medicine, Tokyo, Japan
Abstract Radical vulvectomy is often complicated by problems associated with insufficient closure of large skin defects involving postoperative necrosis of the suture line over the mons pubis and the inguinal areas. To resolve these problems, the present study compared radical vulvectomy (RV, 7 cases) with radical vulvectomy followed by reconstructive operation using the gluteus maximus myocutaneous flap (RVR, 5 cases). There was no significant difference in operation time and blood loss between the two groups. Three of the 7 RV patients had wound separations requiring reoperation, while only 1 patient in the RVR group did. The average hospital stay was 86 days in the RV group and 38 days in the RVR. Risks of postoperative infection and wound breakdown were reduced with the flap technique, and ambulation and rehabilitation could begin earlier in this group. Surgical wounds were stable and the quality of life after operation was improved dramatically using the flap technique.
Key words : vulva cancer, reconstruction, operation Introduction Squamous cell carcinomas of the vulva account for approximately 3 4 % of all malignancies of the female genital, tract. Surgery for vulvar cancer should include wide removal of the primary lesion and excision of the regional lymph nodes. Recently, radical vulvectomy and bilateral groin node dissection (RV) have become the standard method of therapy for almost all operable stages of squamous cell carcinoma of the vulva.1) Although
survival is improved by RV, wound closure is often difficult, resulting in postoperativewound breakdown and prolonged hospitalization. Various methods have therefore been employed to improve wound healing and to shorten postoperative hospitalization.*-e) McCraw et aZ.7) demonstrated that viability of the isolated gracilis muscule with overlying skin and subcutaneous tissue could be maintained by preserving its vascular pedicle. This myocutaneous flap can be mobilized to reconstruct an area with large tissue defect and has been used to
Received: May 20, 1991 Reprint request to: Dr. Masahiro Ogino, Department of Obstetrics and Gynecology, Teikyo University School of Medicine, Kaga 2-11-1, Itabashi-ku, Tokyo 173, Japan
23
M. OGINO ET AL.
Fig. 1. Radical vulvectomy with bilateral inguinal node dissection has been completed.
Fig. 2. The left myocutanepus flap has been mobilized and being rotated into position.
cover the groin and vulva. The primary goals of this radical vulvectomy with reconstruction (RVR) are (a) to promote recovery,from RV, (b) to minimize technical difficulties and shorten operating time and (c) to minimize injury to the donor site. In this report we review the reconstruction of the vulva using the gluteus maximus myocutaneous flap following RV. The operative and perioperative morbidity of patients undergoing RV is compared with that of patients who underwent RVR at the time of the initial radical surgery. 24
Surgical Technique The patient was placed on the operating table in a lithotomy position with her legs in stirrups and the thigh abducted 45" and flexed 15". Conventional surgical procedures for advanced carcinoma of the vulva were then performed with inguinal and/or pelvic lymphadenectomy (Fig. 1). The defect area was carefully measured. The skin overlying the gluteus maximum muscle was prepared for the flap by outlining it with a sterile marking pen. This flap had to be sufficient in length and width to c h e r the defect area; in particular its
RECONSTRUCTION OF THE VLlLVA
Fig. 3. T h e flaps have been moved into position and sututred into place.
Fig. 4. T h e vulvar reconstruction 30 days postoperatively.
length had to be sufficient to assure no tension. Suture of the wound under too much tension needed to be avoided otherwise it would result in soft tissue necrosis and breakdown, ultimately requiring secondary skin grafting. The skin incision was then made sharply down through the fascia lata, with the full thickness of the subcutaneous tissue, and the vascular bed was included in the graft. The size of the flap was usually from 14 to 18 cm in length and 6 to 8 c m in width. The gluteus maximum muscle with attached skin and subcutaneous tissue was then elevated and freed from all adjacent tissue except its vas-
cular pedicle. The donor site was then closed (Fig. 2). Once in place, the flap could be fixed to the surrounding skin by sutures, and a hemovac drain brought out through a separate stab wound8*O) (Fig. 3). The drain was removed after about 48-72 hours, and the sutures were removed between the tenth and fourteenth postoperative days (Fig. 4).
Patients From 1978 to 1984, 7 patients with invasive squamous cell carcinoma of the vulva underwent RV at Teikyo University Hospital. These fitients were used as the control group. Since 25
M. OGINO ET AL.
Table 1. Clinical characteristics of study patients Patient
Age
Stage
Pathology
Radical vulvectomy
1 2 3 4 5 6 7*
75 87 72 47 65 45 68
Radical vulvectomy with reconstruction 1 85 2 65 3 74 4 79 5* 73
11 (T*NoMo) 111 (TzNoMo) 11 (T*NoM,) 111 (TsNaMo) 11 (TzNiMo) 111 (TZNIMO) 11 (TsNoMo)
Squamous cell Squamous cell Squamous cell Squamous cell Squamous cell Squamous cell Squamous cell
111 (TzN1Mo) 11 (T*NIMO) 111 (T*"o) 11 (TSNOMO) recurrence
Paget's disease Squamous cell carcinoma Paget's disease Squamous cell carcinoma Sauamous cell carcinoma
carcinoma carcinoma carcinoma carcinoma carcinoma carcinoma carcinoma
* Same patient the beginning of 1987 we have undertaken RVR on 5 patients, including 3 patients with invasive squamous cell carcinoma 1 of which was recurring and 2 patients with Paget's disease of the vulva. Ages of the patients ranged from 45 to 87 years, with a mean of 70 years. One patient had previously been given a radical vulvectomy with groin lymphadenectomy and received irradiation in 1972, but 7 years later she developed a recurrent lesion at the junction of the perineal skin and vaginal mucosa. This was treated by wide excision, reconstruction operation. These 11 patients were evaluated to assess differences in operating times, amount of blood loss, postoperative complications and hospitalization periods. Distribution by stages for each treatment group was similar in almost half of the patients with stage I1 disease. Table 1 shows clinical characteristics of 7 patients who had RV, and 5 patients who underwent RVR. Statistical Analysis Differences in the mean of operation times, amount of blood loss, incidence of breakdown or flap loss, walking practice, and postoperative hospitalization periods between RV and RVR groups were compared using the Student's t-test and xa. P values less than 0.05 were considered significant. 26
Results Operative and postoperative complications associated with the method of surgery are shown in Tables 2 and 3. The (a) mean operating time and (b) amount of blood loss in the two groups are as follows: (a) (M2S.D.); 196282 (minutes) for RV group vs. 218276 (minutes) for RVR group, and (b) 3672184 (ml) for the RV group vs. 319262 (mZ) for the RVR group. There were no significant differences in these two indices between the groups. Complications were evaluated in the immediate postoperative period for breakdown, wound infection, and flap loss. All the patients who had undergone RV developed breakdown and 3 of 7 patients were reoperated on for suturing. Only one patient developed breakdown due to the infection by methicillin resistant S t u p h y h c m aweus (MRSA) in the RVR group. This patient had to be resutured. In general, the RVR group had significantly fewer breakdowns as compared with the RV group (Table 3). One patient in the RV group developed necrosis; no patient did in the RVR group. Comparison of the postoperative ambulatory time in the two groups was as follows; 16+6 (9-27) days in the RV group vs. 12k4 (7-17) days in the RVR group. There was no significant difference between the two groups. Pa-
RECONSTRUCTION OF THE VULVA
Table 2. Operative and postoperative results Patient
(9)
Practice for walking (day)
Postoperative* hospitalization (day)
82 600 364 400 239 583 304 367f184
9 19 10 27 13 17 17 16f6
98 64 49 102 64 101 126 86f28
387 300 381 274 253 319f62
7 13 17
32 25 53 51 28 38f13
Operation time (min)
Blood loss
93 120 180 235 215 345 180 196f82
Radical vulvectomy
1 2 3 4 5 6 7 (MfS.D)
Radical vulvectomy with reconstruction
1 2 3 4 5 (M fS.D)
205 245 335 150 155 218f76
11 11 12f4
~
*
1 Postoperative hospitalization calculated from the operation date of discharge or the starting date
at radiation. p
