Vulvar defects result chiefly from oncologic resection of vulvar tumors. Reconstruction of vulvar defects restores form and function for the purpose of coitus, micturition, and defecation. Many surgical options exist for vulvar reconstruction. The purpose of this article is to present our experience with vulvar reconstruction.
From to43 women presented to us with vulvar defects for reconstruction. Their mean age at the time of reconstruction was The most common cause of vulvar defect was from resection of vulvar carcinoma and extramammary Paget's disease of the vulva. Method s of reconstruction ranged from primary closure to skin grafting to the use of pedicled flaps. There were no complications of flap loss, wound dehiscence, and urethral stenosis. We present a subunit algorithmic approach to vulvar reconstruction based on defect location within the vulva, dimension of the defect, and patient age and comorbidity.
The gracilis and gluteal fold flaps are particularly versatile and aesthetically suited for reconstruction of a variety of vulvar defects.
From an aesthetic viewpoint the gluteal fold flap was superior because of the well-concealed donor scar. We advocate the routine use of these 2 flaps for vulvar reconstruction.
Vulvar defects result chiefly from oncologic resection. The worldwide incidence of vulvar tncremo manual peaks at 65 to 70 years of age and has been increasing in developed countries [ 1 ].
In Singapore, squamous cell carcinoma and vulvar intraepithelial neoplasia are the most common histological types of vulvar cancer [ 2 ]. The mainstay of treatment for vulvar cancer is wide surgical resection and radiation if necessary. Extramammary Paget's disease of the vulva vulvar intraepithelial adenocarcinoma is another common vulvar tumor treated with wide local excision [ 3 ]. Without reconstruction, surgical resection would result in mutilation and poor wound healing of the perineum, delaying delivery of any requisite adjuvant radiotherapy.
Reconstruction aims to restore anatomy and function of the external female genitalia, facilitating preservation of normal body image, sexual function, and micturition and defecation functions. The purpose of this paper is to describe our experience in 43 consecutive patients and to propose an algorithmic approach to vulvar reconstruction based on our experience.
Forty-three patients underwent vulvar defect reconstruction between and Their mean age at time of surgery was The underlying vulvar conditions are summarized in Table 1. There were 22 unilateral and 21 bilateral defects Table 1. Defects were empirically classified as small defects those which may be closed directly with undermining or with local flapsmedium defects primary closure of these would lead to severe distortion of the perineumand large defects these cannot be closed directly without risk of dehiscence.
Among unilateral defects there were 7 small defects 64 to 84 cm 210 medium defects to cm 2and 5 large defects to cm 2. Among bilateral defects there were 2 medium defects to cm 2 and 19 large defects to cm 2. Fifty per cent of patients who had large defects required groin node dissection. The mean follow-up period was DermNet provides Google Translate, a free machine translation service.
Note that this may not provide an exact translation in all languages. Author: Vanessa Ngan, Staff Writer, Vulvodynia is a term used to describe pain affecting the vulva when the cause of the pain is unknown. Vulvodynia is defined by the International Society for the Study of Vulvovaginal Diseases ISSVD as vulvar pain of at least 3 months duration, without a clear identifiable cause, which may have potential associated factors.
It may be provoked by sexual intercourse or other non-sexual factors insertion of tampons, tight clothing etcor spontaneous, or mixed provoked and spontaneous. Its onset can be primary or secondary, and temporal pattern intermittent, persistentconstant, immediate or delayed. Refer to DermNet's page on genital skin problems for conditions that may cause vulvar burning, stinging, irritation and rawness. In males, similar symptoms are called scrotodynia and male genital dysaesthesia.
Vulvodynia generally occurs in adult women between the mid-'20s to late '60s. These women are usually healthy active women with no history of chronic health problems or sexually transmitted diseases. Vulvodynia is no more or less common in women who have had one or more sexual partners.
Research indicates that hormonal factors and inflammation are not related to vulvodynia. Psychosocial and psychosexual factors may precede or follow the onset of vulvodynia. Vulval pain and discomfort can have a profound effect on the quality of life.
Perineal Flap Reconstruction after Oncologic Resection
Simple activities such as sitting at a desk, bicycle riding, social events and maintaining a sexual relationship, are impacted upon. A woman's self-image is negatively affected and may lead to depression and women that are depressed are more likely to suffer from vulvodynia. Because by definition, the cause of vulvodynia is unknown, treatment may be challenging. Treatment of vulvodynia usually requires a multidisciplinary approach that may include:. Specific treatment of vulvodynia is described under each subtype.
However, regardless of the type of vulvodynia, treatment for all must encompass a holistic approach taking into account the woman's physical and psychological needs. See smartphone apps to check your skin. DermNet NZ does not provide an online consultation service. If you have any concerns with your skin or its treatment, see a dermatologist for advice.
Vulvodynia — codes and concepts open. Vulval pain. Age site specific. Localised vulvodynia, Generalised vulvodynia, Provoked vulvodynia, Spontaneous vulvodynia, Mixed vulvodynia, Primary vulvodynia, Secondary vulvodynia, Vestibulodynia, Clitorodynia, Dysaesthetic vulvodynia, Associations with vulvodynia, Treatment of vulvodynia.Document publishing platform How it works.
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Documents Uncategorized. Update in Vulvovaginal and Perineal Reconstruction Scientific Information Vulvovaginal and perineal reconstruction is becoming fashionable, and is managed by different surgical specialties.
Gynecologists, general and plastic surgeons, and urologists are the physicians usually involved in managing the wide spectrum of clinical situations requiring reconstruction. Nevertheless, no consensus agreement exists among the different international societies regarding a standardized approach in this field.
The complexity of this topic brings together contributions from many disciplines, each sharing a unique perspective. This meeting represents a multidisciplinary multinational sounding board in which physicians with proven experience, coming from different european countries, try to improve the care and management of women requiring vulvovaginal and perineal reconstruction.
Faculty P. Bert apell e Bertapell apelle F. Bogliatt o Bogliatto F. Bor ghi Borghi R. Carone H. Dal Corso M. Giana J. Hage M. Karim R. Laan E. Le wis Lewis M. Sideri N.The prevailing treatment methods for some malignant diseases affecting the female genital tract are invasive to that body segment and in many instances result in compromise of physical function. Initial treatment planning for many years detailed the occurrence of morbidity and encouraged the acceptance of occasional residual physical deficit as sequelae for curative treatment of a dreaded disease.
Advances in the delivery of cancer care led to a decrease in surgical morbidity, increased survival after surgery, radiation therapy and chemotherapy, and greater life expectancy with a good quality of life.
With these advances, contemporary treatment planning began to emphasize full and complete return to normal functioning of the patient and in particular the body segment undergoing reconstruction.
The era of better informed consent with patient understanding of treatment options and outcome plays an important role in treatment planning and in the recovery process. Other reasons for emphasizing restoration to full functioning include the following:.
Among current-day trends for reconstructive procedures on the female genital tract, underlying dogma include the following:. The surgical techniques used in reconstructive procedures on the female genital tract range from simple procedures involving the application of split-thickness skin grafts to very complicated procedures in which large segments of skin and underlying tissue, including muscle, are used as flaps to cover gaping defects created at the time of radical or ultraradical surgery.
These techniques include grafting procedures, realignment of standard incisions, the use of vascular pedicle flaps, and organ substitution. Among the conditions that lead to complications when performing reconstructive procedures are: 1 decreased blood supply, 2 fibrosis at the operative site, 3 age older patients have more problemsand 4 unrecognized infection.
The aim of reconstruction should be to return the anatomic site to normal appearance and function. Split-Thickness Skin Grafting The establishment and easy applicability of split-thickness skin grafts have enhanced the gynecologists' role in reconstruction of the vulva. When wide local excision of vulvar lesions creates large defects, a segmental skin graft can be applied so that skin approximation without tension will ensure a better cosmetic result.
Primary closure and segmental grafting can be used at the same surgical sitting. The presence of multifocal vulvar, perineal, and perianal lesions occasionally necessitates the removal of multiple areas of skin.
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Reapproximation is difficult. The technique of removing just the vulvar skin i. Although operative time and hospital stay are lengthened when skinning vulvectomy and grafting are performed, better cosmetic results with few residual sequelae are obtained.
The mons pubis is a potential graft selection site. A skin graft has been applied to the vulva. Walton LA: Carcinoma in situ of the vulva.
A Self Instructional Program. Chapel Hill, Health Sciences Consortium, Vacuum assisted closure of complex perineal wounds. Dis Colon Rectum ; 47 10 Lotus petal flaps for scrotal reconstruction combined with Integra resurfacing of the penis and anterior abdominal wall following necrotizing fasciitis. J Plast Reconstr Aesthet Surg ; 62 3 Outcomes of immediate vertical rectus abdominis myocutanous flap reconstruction for irradiated abdominoperineal defects.
J Am Coll Surg ; Reconstruction of the pelvis and perineum with a free latissimus dorsi myocutaneous flap: a case report. Ann R Coll Surg Engl ; 94 8 : e—e Reconstruction of acquired defects of the vagina and perineum. Semin Plast Surg ; — The gluteal fold flap: A versatile option for perineal reconstruction following anorectal cancer resection J Plast, Reconstr Aesthet Surg ; e Weinstock MA. Malignant melanoma of the vulva and vagina in the United States: Patterns of incidence and population-based estimates of survival.
Am J Obstet Gynecol ; Cancer ; Melanoma of the vulva: An update. Gynecol Oncol ; Malignant melanoma of the vulva: evaluation of prognostic factors with emphasis on DNA poloidy in 75 patients. Conservative therapy for melanoma of the vulva. Malignant melanoma of the vulva: A clinicopathological study of 50 women. Br J Obstet Gynecol ; A clinicopathological study of 30 melanomas of the vulva. Malignant melanoma of the vulva treated by radical hemivulvectomy: A prospective study of the Gynecologic Oncology Group.
Primary melanoma of the vagina: A clinicopathologic analysis. Obstet Gynecol ; Veronesi U, Cascinelli N. Narrow excision 1 cm margin : A safe procedure for thin cutaneous melanoma.
Arch Surg ; DTIC therapy in metastatic malignant melanoma: A simplified dose schedule. Cancer Treat Rep ; Reconstruction of perineal defects. Ann R Coll Surg Engl ; Colleague's E-mail is Invalid. Your message has been successfully sent to your colleague. Save my selection. Disclosure: The authors have no financial interest to declare in relation to the content of this article. Simon G. The work cannot be changed in any way or used commercially without permission from the journal.
Perineal wounds are one of the more challenging plastic surgical defects to reconstruct.
Gracilis Flap for Perineal and Vaginal Reconstruction
Resections in the perineum vary in size and are frequently complicated by radiation, chemotherapy, and contamination. Furthermore, the awkward location and potential need to maintain function of the anus, urethra, and vagina and to allow comfortable sitting all contribute to the complexity of these reconstructions.
In light of this complex nature, many options are available for flap coverage. In this paper, we discuss the properties of perineal defects that make each option appropriate. Causes of perineal defects Fig. Perineal reconstruction options range from simple to complex. Often direct closure is possible, but may be inappropriate when the wound is under significant tension, and should only be undertaken judiciously in those with significant risk factors for wound breakdown such as radiated skin, chemotherapy, or active nicotine use.
Closure by secondary intent is sometimes appropriate, especially for small or contaminated wounds. This is, however, a difficult location for patients to tolerate packing and—especially for more complex wounds—may be prolonged. Simple techniques including wide undermining, z-plasties, rotation flaps, transposition flaps, and advancement flaps may be appropriate for smaller superficial defects.
Larger defects typically require both additional tissue to fill dead space and potentially resurface wounds and may include flaps based on the rectus muscle, gracilis muscle, omentum, or internal pudendal arteries. In addition to systemic factors that may affect perineal healing, flap choice may be dictated by the availability of donor sites.
It is not uncommon for the abdomen to be relatively unavailable. This may be due to the presence of significant hernias, morbid obesity Fig.Skip to search form Skip to main content You are currently offline. Some features of the site may not work correctly. DOI: We include all the patients who could not be repaired by direct closure due to excessive skin tension. We assessed the different flaps used, the surgical complications rate, wound healing, or the progression to chronic wounds.
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References Publications referenced by this paper. Pedicled thinned deep inferior epigastric artery perforator flap for perineal reconstruction: a preliminary report. Algorithmic approach to lower abdominal, perineal, and groin reconstruction using anterolateral thigh flaps. The propeller flap concept used in vaginal wall reconstruction. Lotus petal flaps in vulvo-vaginal reconstruction. Ngi Wieh YiiNiri S.
Niranjan Medicine British journal of plastic surgery Related Papers. Abstract Topics 6 References Related Papers.