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Skin Grafts, Omental Flaps, Advancement and Rotational Flaps

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BACKGROUND

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The condition and appearance of a woman’s genitalia strike at the core of her identity. Many patients experience severe sexual dysfunction, disturbed body image, and deranged pelvic anatomy after pelvic cancer surgery that compromise quality of life. Despite these important concerns, vulvovaginal reconstruction after pelvic cancer resection is not currently considered standard therapy.

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Competent, safe, and functional vulvovaginal reconstructions are essential components of the care of patients with pelvic malignancies. The reconstruction cannot be achieved by doing a few standard procedures; it requires specialists familiar with general principles of reconstructive surgery to select the most appropriate among many possible techniques for each individual patient. To this end, the plastic and reconstructive surgeon should play an integral role in the care of the patient with pelvic cancer.

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The surgeon and patient’s therapeutic partnership is central to the outcome of the reconstruction. Operations in this anatomic region have a significant bearing on quality of life, and patients and families should be involved in decision making when appropriate. Patients must be educated about their disease, prognosis, treatment options, and the likely deficits in structure and function that can result from their cancer operation. Reconstructive options must be thoroughly described along with reasonable expectations about future sensibility, function, and aesthetic outcome. It cannot be overemphasized that joint oncologic-reconstructive endeavors are first and foremost for cancer treatment; barring unique circumstances, oncologic resection should never be compromised to facilitate reconstructive efforts.

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The overarching goal of vulvovaginal reconstruction is the anatomic and functional restoration of these structures in an oncologically safe fashion that minimizes the risk of morbidity while optimizing the cosmetic outcome. Improved integration of reconstruction with primary treatment will improve aesthetic and functional results, and, thus, the ­quality of life of patients with pelvic neoplastic diseases. In this chapter, we explore the role of 3 essential tools in the armamentarium of plastic and reconstructive surgeons; skin grafts, omental flaps, and advancement and rotational flaps in vulvar and vaginal reconstructive surgery.

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INDICATIONS AND CLINICAL APPLICATIONS

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Squamous cell carcinoma is the most common histologic type of vulvar malignancy and the most frequent setting in which vulvar reconstruction occurs. It is diagnosed in 2 women per 100,000 every year in developed countries, and the age at diagnosis is most commonly in the sixth and seventh decades of life. Vulvar intraepithelial neoplasia (VIN) grade III represents a precursor lesion characterized by cellular atypia and abnormal maturation of the vulvar epithelium; it is typically found in a much younger patient population (around the fourth decade). VIN grade III is a surgical diagnosis, given that a 9% incidence of invasive carcinoma has been observed in untreated patients.

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Primary carcinoma of the vagina is rare, accounting for about 1% of reproductive cancers in women, with squamous cell carcinoma being the most common histologic ...

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