GYNECOLOGIC
ONCOLOGY
8,
Perineal
78-83 (1979)
Reconstruction following Radical Vulvectomy
Extended
MELVYN I. DINNER, M. B., B. CH., FRCS,* R. PETERS, M. D., FACS,* PIERRE W. MARTIMBEAU, M. D., FRCS (C),? AND RICHARD L. DOLSKY, M. D.*
CALVIN
*Department of Plastic and Reconstructive Surgery, tSection of Gynecologic Oncology, Cleveland Clinic Foundation, Cleveland, Ohio 44106 Received
September 5, 1978
Extended radical vulvectomy frequently leaves a large perineal defect. Myocutaneous flaps allow a single stage reconstruction of a functional perineum and vagina.
The availability of healthy, vascularized, full-thickness skin, subcutaneous tissue, and muscle to repair surgical defects of the perineum has enabled the gynecologic oncologist to perform extensive resections without the fear of a prolonged debilitating postoperative period of convalescence. The recent addition of the axial pattern myocutaneous element to the reconstructive armamentarium of the plastic surgeon [I] has provided for one-stage bilateral gracilis myocutaneous flaps to reconstruct such defects. The gracilis myocutaneous flap for vaginal cavity reconstruction as described by McGraw and associates [2] has provided the means for safely importing skin, subcutaneous tissue, and muscle into these defects as a one-stage procedure. This flap based on an arteriovenous pedicle is vascularized by branches of the obturator artery (Fig. 1). We report two such recent cases in which extensive and potentially crippling surgical defects of the vulva and perineum were repaired. CASE 1
A 3%year-old woman with extensive infiltrating squamous cell carcinoma of the vulva, Stage III (T3N2M0, Fig. 2), was submitted after thorough evaluation to extended radical vulvectomy and bilateral en bloc groin lymphadenectomy (Fig. 3). The operation included bilateral pelvic lymphadenectomy, resection of rectosigmoid, rectum, and anus, and formation of end-descending colostomy. With the patient in lithotomy position, the pubic tubercle and site of insertion of the semitendinous muscles were marked and a line joining these areas was demarcated. The gracilis myocutaneous element was dissected after transecting the gracilis muscle inferiorly and exposing the neurovascular island pedicle which enters that muscle three finger-breadths inferior to the pubic tubercle (Fig. 1). The entire flap was rotated through 180” and inserted into the defect to cover 78 009@8258/79/040078-06$01.00/O Copyright All rights
@ 1979 by Academic Press. Inc. of reproduction in any form reserved.
PERINEAL
FIG.
FIG.
FIG.
3.
79
RECONSTRUCTION
I.
Neurovascular
2.
Squamous
cell cancer
Surgical
defect
and design
pedicle.
of vulva
of gracilis
and perineum.
myocutaneous
flap.
80
DINNER
ET AL.
FIG. 4. Gracilis myocutaneous flap.
FIG. 5. Flap transposed into defect.
FIG.
6.
Donor defect, closed primarily.
PERINEAL
RECONSTRUCTION
81
perineum, introitus, and the ischiorectal fossa on one side (Figs. I, 4-6). The procedure was repeated on the contralateral surface (Fig. 7). The margins of the donor defect were undermined and closed by direct approximation, leaving vertical incisions on the medial aspect of both thighs. The postoperative course was interrupted by minor posterior wound dehiscence, necessitating minimal debridement and the application of a split-thickness skin graft. CASE 2
A 27-year-old mother of two presented with infiltrating squamous cell carcinoma involving the rectum and posterior vaginal wall and surrounding tissues. Exenteration of the entire perineal area and hysterectomy were performed following permanent colostomy. Two gracilis myocutaneous flaps were developed and rotated into the defect (Figs. 8-11).
FIG. 7.
Bilateral gracilis myocutaneous flaps in .s;~~~
FIG. 8. Operative defect.
82
DINNER
FIG.
9.
FIG.
FIG.
Bilateral
10.
1 I.
Flaps
Immediate
ET AL.
gracilis
myocutaneous
transposed
postoperative
into
flap.
defect.
appearance.
PERINEAL
FIG.
12.
83
RECONSTRUCTION
Six-month
follow-up.
case
I.
DISCUSSION
Extended radical ablation for tumors of the vagina, vulva, and perineal area may result in formidable defects predisposing the patient to a prolonged postoperative period of debility and severe functional deficit [3-51. In the past, many of these wounds have been allowed to granulate and contract and heal by secondary intention, or were repaired by the application of split-thickness skin grafts. In many cases the result has been scar contraction and poor functional perineal status. The recently described concept of myocutaneous flaps, including the gracilis myocutaneous flap has provided the reconstructive surgeon the wherewithal to reconstruct in a single stage a functional, sensitive perineum and vagina. McGraw it ul. [2] have reported two cases of partial vaginal and total perineal reconstruction using simultaneous bilateral gracilis myocutaneous flaps. REFERENCES I. McGraw, J. B., and Dibbell, D. G. Experimental definition of independent myocutaneous vascular territories, P/~sr. Reconstr. Surg. 60, 212-220 (1977). 2. McGraw. J. B., Massey, F. M., Shanklin, K. D., and Horton, C. E. Vaginal reconstruction with gracilis myocuraneous flaps, Pht. Rrcousrr. Sup. 58, 176-183 (1976). 3. Krupp, P. J., Lee, F. V., Barson, H. W. K., et ~1. Carcinoma of the vulva, Gvnecol. Onto/. 1, 345-362 (1973). 4. Kaplan, A. L., and Kaufman, R. H. Management of advanced carcinoma of the vulva, Gynecol. Oncol. 3, 220-232 (1975). 5. Boronow, R. C. Therapeutic alternative to primary exenteration for advanced vulva-vaginal cancer, C;vnc~ol. Ot~(,ol. 1, 233-255 (1973).
ONCOLOGY
8,
Perineal
78-83 (1979)
Reconstruction following Radical Vulvectomy
Extended
MELVYN I. DINNER, M. B., B. CH., FRCS,* R. PETERS, M. D., FACS,* PIERRE W. MARTIMBEAU, M. D., FRCS (C),? AND RICHARD L. DOLSKY, M. D.*
CALVIN
*Department of Plastic and Reconstructive Surgery, tSection of Gynecologic Oncology, Cleveland Clinic Foundation, Cleveland, Ohio 44106 Received
September 5, 1978
Extended radical vulvectomy frequently leaves a large perineal defect. Myocutaneous flaps allow a single stage reconstruction of a functional perineum and vagina.
The availability of healthy, vascularized, full-thickness skin, subcutaneous tissue, and muscle to repair surgical defects of the perineum has enabled the gynecologic oncologist to perform extensive resections without the fear of a prolonged debilitating postoperative period of convalescence. The recent addition of the axial pattern myocutaneous element to the reconstructive armamentarium of the plastic surgeon [I] has provided for one-stage bilateral gracilis myocutaneous flaps to reconstruct such defects. The gracilis myocutaneous flap for vaginal cavity reconstruction as described by McGraw and associates [2] has provided the means for safely importing skin, subcutaneous tissue, and muscle into these defects as a one-stage procedure. This flap based on an arteriovenous pedicle is vascularized by branches of the obturator artery (Fig. 1). We report two such recent cases in which extensive and potentially crippling surgical defects of the vulva and perineum were repaired. CASE 1
A 3%year-old woman with extensive infiltrating squamous cell carcinoma of the vulva, Stage III (T3N2M0, Fig. 2), was submitted after thorough evaluation to extended radical vulvectomy and bilateral en bloc groin lymphadenectomy (Fig. 3). The operation included bilateral pelvic lymphadenectomy, resection of rectosigmoid, rectum, and anus, and formation of end-descending colostomy. With the patient in lithotomy position, the pubic tubercle and site of insertion of the semitendinous muscles were marked and a line joining these areas was demarcated. The gracilis myocutaneous element was dissected after transecting the gracilis muscle inferiorly and exposing the neurovascular island pedicle which enters that muscle three finger-breadths inferior to the pubic tubercle (Fig. 1). The entire flap was rotated through 180” and inserted into the defect to cover 78 009@8258/79/040078-06$01.00/O Copyright All rights
@ 1979 by Academic Press. Inc. of reproduction in any form reserved.
PERINEAL
FIG.
FIG.
FIG.
3.
79
RECONSTRUCTION
I.
Neurovascular
2.
Squamous
cell cancer
Surgical
defect
and design
pedicle.
of vulva
of gracilis
and perineum.
myocutaneous
flap.
80
DINNER
ET AL.
FIG. 4. Gracilis myocutaneous flap.
FIG. 5. Flap transposed into defect.
FIG.
6.
Donor defect, closed primarily.
PERINEAL
RECONSTRUCTION
81
perineum, introitus, and the ischiorectal fossa on one side (Figs. I, 4-6). The procedure was repeated on the contralateral surface (Fig. 7). The margins of the donor defect were undermined and closed by direct approximation, leaving vertical incisions on the medial aspect of both thighs. The postoperative course was interrupted by minor posterior wound dehiscence, necessitating minimal debridement and the application of a split-thickness skin graft. CASE 2
A 27-year-old mother of two presented with infiltrating squamous cell carcinoma involving the rectum and posterior vaginal wall and surrounding tissues. Exenteration of the entire perineal area and hysterectomy were performed following permanent colostomy. Two gracilis myocutaneous flaps were developed and rotated into the defect (Figs. 8-11).
FIG. 7.
Bilateral gracilis myocutaneous flaps in .s;~~~
FIG. 8. Operative defect.
82
DINNER
FIG.
9.
FIG.
FIG.
Bilateral
10.
1 I.
Flaps
Immediate
ET AL.
gracilis
myocutaneous
transposed
postoperative
into
flap.
defect.
appearance.
PERINEAL
FIG.
12.
83
RECONSTRUCTION
Six-month
follow-up.
case
I.
DISCUSSION
Extended radical ablation for tumors of the vagina, vulva, and perineal area may result in formidable defects predisposing the patient to a prolonged postoperative period of debility and severe functional deficit [3-51. In the past, many of these wounds have been allowed to granulate and contract and heal by secondary intention, or were repaired by the application of split-thickness skin grafts. In many cases the result has been scar contraction and poor functional perineal status. The recently described concept of myocutaneous flaps, including the gracilis myocutaneous flap has provided the reconstructive surgeon the wherewithal to reconstruct in a single stage a functional, sensitive perineum and vagina. McGraw it ul. [2] have reported two cases of partial vaginal and total perineal reconstruction using simultaneous bilateral gracilis myocutaneous flaps. REFERENCES I. McGraw, J. B., and Dibbell, D. G. Experimental definition of independent myocutaneous vascular territories, P/~sr. Reconstr. Surg. 60, 212-220 (1977). 2. McGraw. J. B., Massey, F. M., Shanklin, K. D., and Horton, C. E. Vaginal reconstruction with gracilis myocuraneous flaps, Pht. Rrcousrr. Sup. 58, 176-183 (1976). 3. Krupp, P. J., Lee, F. V., Barson, H. W. K., et ~1. Carcinoma of the vulva, Gvnecol. Onto/. 1, 345-362 (1973). 4. Kaplan, A. L., and Kaufman, R. H. Management of advanced carcinoma of the vulva, Gynecol. Oncol. 3, 220-232 (1975). 5. Boronow, R. C. Therapeutic alternative to primary exenteration for advanced vulva-vaginal cancer, C;vnc~ol. Ot~(,ol. 1, 233-255 (1973).
