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RECONSTRUCTIVE
Gluteal Fold V-Y Advancement Flap for Vulvarand Vaginal
Reconstruction: A New FlapPaik-Kwon Lee, M.D., Ph.D.
Moon-Seop Choi, M.D.Sang-Tae Ahn, M.D., Ph.D.
Deuk-Young Oh, M.D.Jong-Won Rhie, M.D., Ph.D.
Ki-Taik Han, M.D., Ph.D.Seoul, Korea
Background: Soft-tissue reconstruction following vulvar cancer
resection is adifficult challenge because of the functional,
locational, and cosmetic impor-tance of this region. Although
numerous flaps have been designed for vulvarreconstruction, each
has its disadvantages.Methods: The authors introduce the gluteal
fold fasciocutaneous V-Y advance-ment flap for vulvovaginoperineal
reconstruction after vulva cancer resection.This flap is supplied
by underlying fascial plexus derived from perforators of
theinternal pudendal artery and musculocutaneous perforators of
underlying mus-cle. The sensory supply of this flap comes from the
posterior cutaneous nerveof the thigh and the pudendal nerve. An
axis of V-shaped triangular flap isaligned to the gluteal fold. A
total of 17 flaps were performed in nine patients.Results: All
flaps survived completely, with no complications except for
smallperineal wound disruption in three patients.Conclusions: This
flap is thin, reliable, sensate, easy to perform, and hasmatched
local skin quality and concealed donor-site scar on the gluteal
fold. Inaddition, it can cover large vulvovaginal defects because
it can be advancedfarther as a result of the character of the
gluteal fold area. In our experience,the gluteal fold
fasciocutaneous V-Y advancement flap has proven very useful
forvulvar reconstruction, especially at the point of donor-site
scar, flap thickness,and degree of flap advancement. (Plast.
Reconstr. Surg. 118: 401, 2006.)
Vulvar cancer accounts for 5 percent of allfemale genital
cancers and 1 percent of allmalignancies in women. It can be
ob-served more frequently after the fifth or sixthdecade of life.
Recently, there has been an in-crease in the incidence of vulvar
cancer. Vulvarcancer is a diffusing disease that permeates
intoregional lymphatics, requiring radical resectionwith inguinal
lymph node dissection fortreatment.1 Characteristically, this area
is easilycontaminated by secretions from the vaginalexocrine gland
and vulnerable to infection afterflap surgery. Furthermore,
soft-tissue reconstruc-tion following vulvar cancer surgery
presents adifficult challenge.The ideal flap for vulvar defects
should be
sensate and thin with a reliable blood supply,and should present
a less conspicuous donor-sitescar. A large vulvovaginoperineal
defect is oftencreated by radical excision of cancer because of
the nature of vulvar cancer. Therefore, unlessthe flap is
adequate for mobilization, scar con-tracture and tension may result
in cosmetic andfunctional impairment, such as vaginal exposureand
deviation of the urinary stream.We used the V-Y advancement flap
from the
medial thigh and gluteal fold island flap forvulvar
reconstruction. However, there are somedisadvantages associated
with each one.In this article, to overcome these disadvan-
tages, we present a new gluteal fold fasciocuta-neous V-Y
advancement flap that (1) is sensateand thin with a reliable blood
supply, (2) can beadvanced easily, (3) presents a concealed scar
onthe gluteal fold and groin area, and (4) can beperformed in a
single-stage procedure.
PATIENTS AND METHODSThis flap can be used to cover extensive
vulvar
defects, which include the anterior commissure,perianus, vaginal
inner wall, and the labia majoraand minora. The apex of the
triangular flap ismarked on the gluteal fold and the base of this
flapis an open wound margin (Fig. 1).
The skin is incised down to the underlyingmuscle fascia with
meticulous electrocauteriza-tion. The flap is mobilized by
elevating the un-
From the Department of Plastic Surgery, The Catholic Uni-versity
of Korea College of Medicine.Received for publication October 28,
2004; accepted May 8,2006.Copyright 2006 by the American Society of
Plastic SurgeonsDOI: 10.1097/01.prs.0000227683.47836.28
www.PRSJournal.com 401
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derlying muscular fascia proximally and distally.The amount of
mobilization can be determinedaccording to defect size. Caution is
required to
avoid injury to perforators as much as possible.This flap is
advanced in a V-Y fashion and is se-cured to the recipient site,
reaching the vaginalinner wall with no tension. After the dog-ear
isremoved, the skin is closed layer by layer. Water-tight closure
should be performed on the vaginalmucosa. Finally, we apply
Dermabond (EthiconInc., Somerville, N.J.) to lower the risk of
postop-erative infections from the bacterial contamina-tion and
vaginal discharge.
RESULTSFrom April of 2003 to March of 2004, we per-
formed 17 gluteal fold V-Y advancement flaps forvulvoperineal
defects in nine patients after vulvec-tomy with or without inguinal
lymph node dissec-tion. The age of the patients ranged from 23 to
70years, averaging 56 years (Table 1).
Of the nine patients, six had squamous cellcarcinoma and radical
vulvectomy with inguinallymph node dissection, and three had vulvar
in-traepithelial neoplasia and simple vulvectomywithout inguinal
lymph node dissection. All pa-tients underwent reconstruction using
gluteal foldV-Y advancement flaps. Follow-up after operationranged
from 6 months to 1 year, with a mean of8.6 months.
All flaps survivedwithoutmajor complications.In three patients,
partial dehiscence occurred atthe junction of the two advanced
flaps and peri-neal skin, which were healed by conservative
treat-ment. All patients had sensation on the flap.
To assess flap sensation, we performed sensorytests such as
two-point discrimination, superficialpain, superficial touch,
temperature, and vibra-tion on the triangular flap of five patients
(cases 2,3, 5, 8, and 9) after surgery. The triangular flapswere
divided into three zones: proximal, center,and distal. Follow-up
for sensory testing rangedfrom 11 months to 1 year 10 months after
surgery.The results showed that all flaps had good sensa-tion (all
five modalities) in three zones. The prox-
Fig. 1. Schematic diagram of the flap. (Above) Preoperative
de-sign. The apex of the triangular flap ismarked on the gluteal
foldand the base of this flap is on the open wound margin.
(Below)After insetting of the flap. This flap is advanced in a V-Y
fashion.
Table 1. Summary of Patients
Patient Age (yr) Sex Diagnosis and Site Operation
Complications
1 70 F SCC, vulva RV/LD/bilateral V-Y Partial dehiscence2 40 F
VIN, vulva SV/bilateral V-Y None3 70 F SCC, vulva RV/LD/bilateral
V-Y None4 68 F SCC, vulva RV/LD/bilateral V-Y Partial dehiscence5
58 F SCC, vulva RV/LD/bilateral V-Y Partial dehiscence6 65 F SCC,
vulva RV/LD/bilateral V-Y None7 23 F VIN, vulva SV/bilateral V-Y
None8 37 F VIN, vulva SV/unilateral V-Y None9 53 F SCC, vulva
RV/LD/bilateral V-Y Partial dehiscenceSCC, squamous cell carcinoma;
VIN, vulvar intraepithelial neoplasia; RV, radical vulvectomy; SV,
simple vulvectomy; LD, inguinal lymph nodedissection.
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imal zone in three patients, the distal zone in onepatient, and
the center zone in one patient hadslightly decreased sensation
compared with theother zones. In a unilateral case (case 8),
12months after surgery, static two-point discrimina-tion using
Semmes-Weinstein monofilamentshowed 6 cm in the proximal, 4 cm in
the center,and 4 cm in the distal zone, which was comparableto that
of the unaffected side; 2.5 cm in the vulvararea, 4 cm in the groin
area, and 4 cm in thegluteal fold area. The proximal zone of the
flapshowed a markedly decreased sensation (two-point
discrimination) compared with the oppositevulvar area. However, a
less significant decrease insensation (two-point discrimination)
was observedwhen compared with the opposite groin and glu-teal fold
area, which corresponded to the flapcomponents. The other four
sensory modalitiesshowed similar results with two-point
discrimina-tion, which implies that the proximal zone showsslightly
decreased sensation compared with theother zones.
As a temporary side effect, all patients sufferedfromdeviated
urinary stream, but this was resolvedspontaneously with time.
Postoperative scarringwas natural in the groin and gluteal fold
area.Furthermore, revision for aesthetic or functionalproblems was
not necessary for any of the patients.
CASE REPORTSCase 2
A 40-year-old woman was diagnosed with vulvar in-traepithelial
neoplasia by excisional biopsy. Two glutealfold V-Y advancement
flaps for the vulvovaginoperinealdefect were performed.
Reconstruction was satisfac-tory, with no major complications. The
donor-site scarwas concealed on the gluteal fold line and was
aesthet-ically acceptable (Fig. 2).Case 8
A 37-year-old woman was diagnosed with vulvar intra-epithelial
neoplasia by excisional biopsy. We designed agluteal foldV-Y
advancement flap after simple vulvectomywithout inguinal lymph node
dissection. The flap waselevatedwith fascia and advanced to the
vulva defect area.The donor-site scar was concealed on the gluteal
fold andwas aesthetically acceptable (Fig. 3).
DISCUSSIONIn the past, radical vulvectomy defects had
been reconstructed using two bilateral longitudi-nal incisions
and repaired by primary closure, skingrafts,2 local flaps,3 or
myocutaneous flaps basedon gracilis,4 tensor fasciae latae,5 or
rectusabdominis.6 There is no doubt that flaps are su-perior to
skin grafting or direct closure in terms of
the aesthetic and functional aspects of reconstruc-tion.
Recently, the fasciocutaneous flap has be-come the preferred choice
in reconstruction ofvulvar defects, becausemyocutaneous flaps are
toobulky and leave an unsightly scar on the legs orabdomen.
In the 1990s, a perineal blood supply from theinternal pudendal
artery received more attention.Thus, numerous fasciocutaneous flaps
have beenintroduced by plastic surgeons. For example, pu-dendal
thigh flaps for vaginal reconstruction,7,8perineal artery axial
flaps,9 vulvoperineal fascio-cutaneous flaps,10 V-Y advancement
flaps from themedial thigh,1113 and gluteal fold island
flaps1416have been used for vulvovaginal reconstruction.Recent
advances in the knowledge of the cutane-ous and fascial vascular
anatomy have resulted inthe widespread use of those flaps. However,
thepudendal thigh and vulvoperineal flaps are ap-plied only to
vaginal reconstruction,7,8 and theperineal artery flap is suitable
for moderate sizedvulvar defects after vulvectomy.9 Among
theseflaps, the V-Y advancement flap from the medialthigh or
gluteal fold island flap has been widelyused for vulvovaginal
reconstruction by many sur-geons. The latter is supplied by the
superficialperineal artery, the terminal branch of the inter-nal
pudendal artery,14 and the former is based onthe suprafascial
vascular plexus from the superfi-cial and deep femoral
arteries.
Until 2002, we hadusedV-Y advancement flapsfrom the medial thigh
or gluteal fold island flapsfor vulvar defects as well. Fromour
experience, V-Yadvancement flaps from themedial thigh are
thin,reliable, and relatively easily elevated and havematched local
skin quality. However, the vaginalwall is exposed because of
limited advancementand tension of the flaps, and a conspicuous
donor-site scar is left on the medial thigh. Gluteal foldisland
flaps are similar to the labia majora andshow a concealed
donor-site scar on the glutealfold, but are bulky, requiring a
secondary debulk-ing procedure.
To overcome these disadvantages, we modifythe axis of the V-Y
advancement flap from themedial thigh to the gluteal fold. In
particular, thelong axis of the V-shaped triangular flap is
locatedat the gluteal fold and its base shares the marginof the
vulvar defect. This flap can be advancedfarther because of the
redundant soft tissue of thegluteal fold area and profuse blood
supply fromperforators of the internal pudendal artery. Inaddition,
this flapmaintains sensation bymeans ofthe posterior cutaneous
nerve of the thigh and thepudendal nerve. Our surgical procedure
does not
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involve dissection of the perforators of the inter-nal pudendal
artery, and the rami of the pudendalnerve, the main sensory supply
of our flap, whichare paired with perforators of the internal
puden-
dal artery, are not injured; thus, the sensation ofthe flap is
preserved.
We assessed postoperative flap sensation byconventional methods
of sensory testing, such as
Fig. 2. The patient in case 2, a 40-year-old woman with vulvar
intraepithelial neoplasia, underwent simple vulvectomy andbilateral
gluteal fold V-Y advancement flap surgery. (Above, left) Vulvar
defect and flap design. The apex of the triangular flapis marked on
the gluteal fold. (Above, right) The flap is elevated as a
fasciocutaneous flap. (Center, left) The flap is advanced inV-Y
fashion and the skin is closed. (Center, right, and below) Anterior
and posterior views 6 months after surgery. The scar
isaesthetically acceptable and the vagina inner wall is minimally
exposed.
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two-point discrimination, superficial pain, super-ficial touch,
temperature, and vibration, not forthe purpose of demonstrating an
ideal sensoryflap for the vulvar area but to suggest that our
flap
has sensation. Unfortunately, it was not possible
toretrospectively obtain preoperative values as a con-trol, and
only five of nine patients were availablefor follow-up sensory
testing postoperatively. The
Fig. 3. The patient in case 8, a 37-year-old woman with vulvar
intraepithelial neoplasia, underwent simple vulvectomy
andunilateral gluteal foldV-Yadvancementflapsurgery. (Above,
left)Unilateral vulvardefect andflapdesign. (Above, right)
Theflapis elevated as a fasciocutaneous flap. (Center, left) The
flap is advanced in V-Y fashion and the skin is closed. (Center,
right, andbelow) Anterior andposterior views6months after
theoperation. The scar is aesthetically acceptable and the vagina
innerwallis minimally exposed.
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results of sensory testing showed that all flaps hadgood
sensation. Even though the results are notconsistent in all five
patients, the decreased sen-sation in the proximal zone of the flap
may berelated to the surgical dissection of the proximalportion of
the flap to enhance the advancement ofthe flap for covering a large
defect. None of thepatients experienced any discomfort or
problemsin carrying out normal activities, including sexualactivity
at long-term follow-up of over 1 year.
This flap is thin, sensate, reliable, easy to ele-vate, has
matched local skin quality, and createsconcealed scars on the groin
area and gluteal fold.All operation scars are confined to the
vulvoperi-neal area and reconstruction can be performed ina single
stage. The only problem is the introduc-tion of hairy skin of the
remaining labium majorainto the vaginal wall in most cases.
However, thehairy skin portion is narrow and sparse in
density,producing no sexual disturbance or cosmeticproblems.
CONCLUSIONBased on the donor-site scar, thickness of flap,
and degree of flap advancement, we suggest thatthe gluteal fold
fasciocutaneous V-Y advancementflap is a better method for
reconstruction of vul-vovaginoperineal defects after
vulvectomy.
Paik-Kwon Lee, M.D., Ph.D.Department of Plastic SurgeryKangnam
St. Marys Hospital
The Catholic University of Korea College of Medicine505
Banpo-dong, Seocho-guSeoul 137-040, South Korea
[email protected]
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