w n d J Plast Reconstr Hand Surg 26: 327-329, 1992

VULVAR RECONSTRUCTWN WITH AN ABDOMINAL FLAP Nebojsa Rajacic, Mohammed K . Ebrahim and Abdul-Reda Lari From the Deparirneni of Plastic and Reconstructive Surgery, Mubarak AI- Kabeer Hospital, Kuwait University, Kuwait

(Submitted for publication September 5, 1991)

Abstrrict. There are many procedures for vulvar reconstruction after excision for cancer. The aim of which is to provide cosmetic and functional results with minimal secondary deformity. A patient presented with gross fibrous contracture and vaginal ectropion after radical vulvectomy and groin dissection for cancer. We used the pendulous lower abdominal tissue to reconstruct the vulva and mons pubis. There was no secondary deformity. Key words: vulvar reconstruction. abdominal flap.

Radical vulvectomy for cancer entails extensive tissue excision and creates a large skin defect. In the past these wounds were either closed primarily under considerable tension, or, more often, left to heal by secondary intention. Such practice resulted in a flat perineum with two physiological apertures, the urethra and the vagina. Excessive fibrosis can cause an abnormal urinary stream and vaginal ectropion. It was not until 1963 that Johanson and Lewin (5) followed by Rutledge and Sinclair (8) covered the defect with a skin graft. Primary skin grafting was also used by Bartholdson et al. in 1982 ( I ) . Julian et a/. (6) in 1971 used local flaps to close the defect, and later, several other authors reported the use of various local flaps including the bilateral gracilis flap (7). the tensor fascia lata myocutaneous flap (3), the superomedial thigh flap (4), the medial thigh fasciocutaneous flap ( lo), the distal rectus abdominis myocutaneous flap (9) and, most recently, the bilateral groin island flap (2). CASE REPORT A 38 year old multigravida patient presented having had a radical vulvectomy and groin dissection two years previously in a neighbouring country. There was no medical report with the patient. who was illiterate and knew little about the disease or the operation. Her main complaint was that of upward direction of the urinary stream and a tight painful contracture across and above the vagina

which made squatting during defaecation difficult and interfered with sexual activity (Fig. 1 a ) . On examination there was severe fibrosis and scarring across the mons pubis. There were multiple scars indicating the site of bilateral groin dissection as well as scars on the posterior aspect of the vagina where some local flaps had been raised. The wound looked as if it had been left to heal by secondary intention, and the history that she gave supported this assumption. At operation, she was put in lithotomy position and catheterised. The contracture was released all around the vulva and mons pubis. showing an extensive defect (Fig. 1 b). An abdominal apron flap was raised through a groin incision rather than a low abdominal incision. The apron flap was drawn downwards and slit in the middle so that it went on either side of the vulva to simulate the labia majora. The apron flap was hitched to the 0s pubis with a non-absorbable suture. As there was an ample tissue anteriorly, the upper thigh skin was mobilised to cover the posterior defect (Fig. 1 c). A suction drain was inserted and left in for five days. She made an uneventful postoperative recovery. There was no vascular compromise of the flap. She was discharged after eight days, and the condition of the wound was good at her two week check up when the stitches were removed (Fig. 1 d ) . Six weeks after operation she resumed normal sexual activity and had no complaints about micturition.

DISCUSSION The surgical aim of reconstructing the vulva is to restore a soft tissue pad around the vagina which defines the entrance for sexual intercourse, and this has been accomplished in several ways. Some of these operations are difficult, either because of damage caused by previous operation or because of multiple scars which make thigh fasciocutaneous and gracilis flaps unreliable. Another disadvantage of these flaps (with the exception of the groin island flap) is the scars that they themselves leave, which are difficult to hide. Our method of using the lower abdominal apron flap has many advantages. It provides the same Scond J Plosr Reronstr Hund Surg 26

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Fig. I . ( ( / ) The patient in lithotomy position. Note the severe fibrosis and contracture across the groin, mon pubis, and around the vagina. There is upward pull and ectropion of the vagina. There are many surgical scars in the posterior aspect of the vagina. ( h ) The extensive defect, which was created after surgical release of the contracture. (c) The defect covered by the apron flap. The flap is split to go on either side of the vagina. ( d ) The patient supine two weeks after the operation. Note the groin crease and normal contouring of the mons pubis and labia majorae.

quality of skin and subcutaneous tissue as the vulva with its hair bearing skin. The scars are completely hidden in the groin. It is simple and quick to do, and can be done when other local flaps are not feasible. The disadvantages are that the operation can only be done in patients with excessive lower abdominal skin, and there should be no abdominal incisions that could compromise the viability of the tip of the apron flap. Si,(inil J Pkisf Reconstr H(md Surg 26

Although we did not do an umbilical transposition, we are convinced that it would be possible to drag the apron flap further down if necessary. However, to overcome the possible poor vascularity of the apron’s tip especially after slitting it in the midline, we propose to limit the lateral extension of the incision and to leave the dog ears, which can be corrected at a later date. As the operation can provide ample skin to cover the anterior

Vulvar reconstruction with an abdominal p a p p a r t of t h e vulva, we a d v o c a t e t h a t some of t h e upper thigh skin should be mobilised t o cover the most posterior p a r t of t h e defect. The secondary defect should be covered with t h e apron flap, as in our case.

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REFERENCES

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Bartholdson L. Eldh J. Eriksson E. Peterson L-E. Surgical treatment of carcinoma of the vulva. Surg Gynecol Obstet 1982; 155: 655. Bertani A, Riccio M, Belligolli A. Vulvar reconstruction after cancer excision: the island groin flap technique. Br J Plast Surg 1990; 43: 159. Bostwick J 111. Hill HL, Nahai F. Repairs in the lower abdomen. groin or perineum with myocutaneous or omental flaps. Plast Reconstr Surg 1979; 63: 186. Hirshowitz B, Peretz BA. Bilateral superomedial thigh

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flaps for primary reconstruction of scrotum and vulva. Ann Plast Surg 1982; 8: 390. Johanson B, Lewin E. Cancer of the vulva. Vulvectomy. primary skin grafting and regional gland excision. Acta Chir Scand 1963; 126: 483. Julian C G , Callison J, Woodruff JD. Plastic management of extensive vulvar defects. Obstet Gynecol 1971; 38: 193. McCraw JB. Massey FM, Shanklin KD, Horton CE. Vaginal reconstruction with gracilis myocutaneous flaps. Plast Reconstr Surg 1976; 58: 176. Rutledge F, Sinclair M. Treatment of intraepithelial carcinoma of the vulva by skin excision and graft. Am J Obstet Gynecol 1968; 102: 807. Tobin G R , Day TG. Vaginal and pelvic reconstruction with distally rectus abdominis myocutaneous flaps. Plast Reconstr Surg 1988; 81: 62. Want T N , Whetzel T, Mathes SR, Vasconez LO. A fasciocutaneous flap for vaginal and perineal reconstruction. Plast Reconstr Surg 1987; 80: 95.

Scund J Plast Rrconstr Hund Surg 26

Vulvar reconstruction with an abdominal flap.

There are many procedures for vulvar reconstruction after excision for cancer. The aim of which is to provide cosmetic and functional results with min...
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