The introduction of radical vulvar surgery and pelvic exenteration in 1950s allowed for the treatment of locally advanced or recurrent cancer with improved survival outcomes.1,2 Unfortunately, the large defects accompanying radical vulvar surgery were often complicated by significant infections and poor wound healing. In light of the significant risk of postoperative morbidity, the quality of life following radical surgery has been of great concern to both patients and surgeons. To improve these outcomes, advances in reconstructive procedures have evolved to provide coverage of defects, enhance cosmetic results, and preserve quality of life.3
A thorough understanding of anatomy and surgical technique is a prerequisite for reconstruction of surgical defects of the vulva and pelvic floor. When selecting the appropriate closure technique, the simplest method is usually preferred. In many cases, extensive prior treatment (eg, radiation therapy), will make primary closure impractical and require the use of myocutaneous flaps for reconstruction of the pelvic floor. The use of myocutaneous flaps has become more popular over the past several decades and may include (1) transposition flaps, which pass over a portion of normal tissue to reach the defect, (2) rotational flaps, which are turned on an arc onto the defect, and (3) advancement flaps, which are moved onto the defect along a straight axis. Myocutaneous flaps are defined by the musculature, but also include the skin, subcutaneous tissue, and fascia and receive their blood supply from a predominant subcutaneous artery. The overlying skin typically receives its blood supply from perforators coming off the axial vessels within the muscle. Appropriate flap design allows for the placement of healthy, well-vascularized tissue into a surgical defect achieving the elimination of “dead-space” and defect closure.
Although reconstruction of the pelvic floor was introduced in the nineteenth century for congenital absence of the vagina, advances in surgical understanding and techniques have led to improved outcomes. Since the 1970s, the use of myocutaneous flaps derived from the upper portion of the lower extremity have been described for reconstructive purposes. Initially, pelvic defects resulting from radical vulvovaginal surgery were repaired in a 2-step process or left to heal by secondary intention. However, over the last 2 decades, immediate reconstruction of pelvic floor defects has become the standard and resulted in favorable outcomes.4,5 Once a decision has been made to perform reconstructive surgery, the selection of the specific procedure should be based on the principles of restoring normal anatomy, optimizing function, and minimizing the risk of postoperative morbidity. Patients and providers need to be aware of the affect of reconstructive surgery on both the transfer site and the donor site.
Vulvovaginal reconstruction following radical extirpative surgery results in superior outcomes in quality of life measures, particularly sexual function. Furthermore, when compared with patients who have not undergone reconstructive surgery, those who have undergone reconstruction have shown reduced complications such as infection and fistula formation.6 As a ...