Continuing Education Activity
The female perineum is at risk for distribution through a variety of etiologies, including trauma, sexual abuse, parturition, infections, and cancer. When it occurs, and deeper structures are involved, operative intervention is required. Vulvar-vaginal reconstruction is not an uncommon procedure, and understanding the reconstructive ladder is key. This activity reviews the relevant anatomy and equipment used and highlights the inter-professional team's role in evaluating and treating patients who undergo this procedure.
- Identify the indications for vulvar-vaginal reconstruction.
- Describe the equipment, personnel, preparation, and technique in regards to vulvar-vaginal reconstruction.
- Review appropriate evaluation of the potential complications and clinical significance of vulvar-vaginal reconstruction.
- Outline interprofessional team strategies for improving care coordination and communication to advance vulvar-vaginal reconstruction and improve outcomes.
According to the CDC, around 6500 women were diagnosed with Vulvar cancer in 2020 alone. While primary vaginal cancer is relatively uncommon and more likely the result of local invasion from surrounding structures, approximately 1:100,000 women will be diagnosed with invasive or in-situ cancer each year. With the average age of diagnosis for both vulvar and vaginal cancer being in the 60s, this is a disease of an older generation. The vast majority of primary vaginal and vulvar cancers will be of squamous cell origin. Risk factors for vulvar cancer include cigarette smoking, prior history of vulvar cancer, cervical intraepithelial neoplasia, lichen sclerosis, and immunodeficiency.
The most common risk factors for vaginal cancer include HPV, number of sexual partners, early age of first intercourse, and cigarette smoking. Most of the time, vulvar cancers are diagnosed early with disease confined to the primary location, while vaginal cancers are diagnosed later, with half of the patients presenting greater than stage II. Type of cancer, stage of the disease, the oncologist’s surgical approach, location of disease, and expectations of future function drive a plastic surgeon’s reconstructive algorithm.
Anatomy and Physiology
Pelvic anatomy and physiology are diverse and are treated by several subspecialists, including gynecologic oncologists, colorectal surgeons, urologists, and plastic surgeons. Most vulvar cancers are located superficially and are cured with wide local excision of the primary lesion. The vulva is a catch-all for the external female anatomy. This includes the labia majora and minora, vestibule, introitus, mons pubis, clitoris, Bartholin glands, Skene glands, and ureteral meatus. The vulva functions to protect a woman’s sexual organs and is the heart of much of the female sexual response. This area is supplied by the pudendal nerve, which exits the sacral spine and enters the pelvis just medial to the ischial spine. This nerve provides sensation to the vulva and is responsible for urination, defecation, and orgasm. It divides into three main branches: the inferior rectal nerve, perineal nerve, and the dorsal nerve to the clitoris. The internal pudendal artery, a branch of the internal iliac artery, supplies the vast majority of the external genitalia. The superficial external pudendal artery, a branch of the femoral artery, supplies the labia majora. Venous drainage follows the superficial and deep systems from which they came.
The vagina is an elastic, muscular tube that connects the vulva to the cervix. It is responsible for sexual intercourse and childbirth. It is supplied by the anterior branch of the internal iliac artery, which continues as the vaginal artery. The nerve supply is largely autonomic.
It is also important to understand the anatomic relation of these organs with the pelvic floor muscles, bladder (anterior), and rectum (posterior).
The primary indication of vaginal and vulvar reconstruction is to restore the structure, body image, sexual function, and integrity of the genitalia and pelvic floor. This most commonly happens after colorectal or gynecologic cancer resection. Treatment for these types of cancer varies from chemotherapy, radiation, and surgical excision.
Surgical treatments for these types of lesions include pelvic exoneration, abdominoperineal resection, vulvectomy, and vaginectomy. These complex wounds are often unable to heal on their own or after primary closure and benefit from flap reconstruction. Flap reconstruction of pelvic defects has been shown to decrease perineal wound morbidity secondary to the obliteration of dead space and the addition of a new healthy blood supply to the wound bed.
There are no absolute contraindications for vaginal or vulvar reconstruction. Age is not a risk factor for these procedures. ASA class III, increased operative times, smoking status, obesity, and preoperative radiation are all risk factors for complications, but no single risk factor has shown to be an absolute contraindication.
The required equipment is the same for any standard operation for external surgery. For internal surgery, including the vagina or introitus, spreading retractors such as a Gelpi or Weitlaner and Speculum will be necessary, as are deeply curved retractors like the Deaver. It is recommended to have variable sizes available. Positioning will likely require stirrups for lithotomy positioning.
Ideally, the scrub team should receive training at the hospital where these procedures are performed. The surgical or gynecological oncology team and the reconstructive team should be present at a time out. While in the hospital, nursing staff familiar with flap monitoring should be utilized. Appropriate training for staff is imperative for optimal outcomes.
As for all surgeries, a thorough history and physical are required. Risks and comorbidities are reviewed and optimized when appropriate. Appropriate pads are placed on bony prominences to decrease the risk of pressure sores. The patient is prepped and draped in the usual sterile fashion.
When appropriate, small superficial defects may be amenable to split-thickness skin grafting. This is reliant on a well-vascularized wound bed and in the absence of preoperative radiation.
Please refer to the basic flap design StatPearls for an overview before continuing.
The flap selected for perineal reconstruction depends on the size and location of the defect, functional goals of reconstruction, prior radiation field, and other coexisting factors such as previous abdominal surgery. We will discuss different defects and different ways to reconstruct them in this section. Regardless of defect and location, the chosen flap should have a reliable blood supply and provide enough tissue to close the defect.
Like any area on the body, reconstruction of the vulva depends on the location and depth of the defect. Small areas of excision may be closed primarily without loss of form or function, but larger areas will need adjacent tissue transfer or flap reconstruction. The vestibule of the vulva can be divided into three subunits, each with its own unique anatomy. The upper third consists of the mons and upper labia, the middle third is the labia proper, and the lower third consists of the vaginal orifice and perineum.
The perineum’s blood supply rivals that of the face, allowing the reconstructive surgeon many options for reconstruction with adjacent tissue transfer. The blood supply to the perineum was first described in 1889 by Car Manchot. The anterior portion of the vulva’s blood supply stems from the superficial external pudendal artery, while the posterior section is supplied by the deep external pudendal artery. The internal pudendal artery also supplies this area and gives rise to cutaneous perforators for which adjacent tissue transfer flaps are based on. These arteries have a vast anastomosis with each other and the contralateral side. Small to medium-sized shallow defects of the vulva and vagina may be reconstructed with rotational flaps. This has also been described as a lotus flap because the design of these flaps is similar to that of lotus leaves. The lotus flap is based on cutaneous perforators from the internal pudendal artery with the pivot point near the midline of the perineum. This allows for easy translocation of the flap to the defect. With a maximum size of 18x6 cm and mirrored anatomy, it can be used for unilateral or bilateral defects.
When designing the flap, suitable perforators of the internal pudendal artery are found using a pencil Doppler. The flap is then dissected from the tip to the base in either an adipocutaneous or fasciocutaneous manner. The flap is transposed into the defect, and the donor site is closed primarily.
Superior vulvar defects may be amenable to a mons pubis or suprapubic flap. These flaps obtain their blood supply from the Superficial external pudendal artery and the superficial inferior epigastric artery and their respective veins. These flaps have a maximum dimension of 10x4cm and are used primarily for defects of the superior, anterior vulva, anterior commissure, and labia minora/majora. The mons pubis flap may be used as a transposition flap or a V-Y advancement because of its reliable vascular pedicle. A line drawn from the anterior commissure of the labia provides guidance for the base of this flap. The flap is then drawn similar to the defect. An incision is made and dissected deep beneath the Scarpa fascia but superficial to the inguinal ligament. The flap is raised and transposed into the defect, with the donor site closed primarily. A V-Y advancement may also be created for superior oval defects of the anterior commissure.
Vaginal defects can be generally classified as partial (Type 1) or circumferential (Type 2). Type 1 defects can be further classified as anterior or lateral defects (Type 1A), which come from resection of primary vaginal or bladder cancers, and posterior defects (Type 1B), which usually arise from invading rectal or anal cancers and are more common than Type 1A. Type 2 circumferential defects can be further divided into upper two-thirds (Type 2A) or total vaginal defects (Type 2B). Type 2A defects are frequently caused by uterine or cervical cancers, while Type 2B is most commonly caused by total pelvic exoneration.
The majority of vaginal defects can be reconstructed using three different pedicled flaps: Pudendal (Singapore or lotus) flaps, gracilis flaps, and rectus flaps. Type 1A defects without a large amount of missing tissue are amenable to pudendal flaps, unilateral or bilateral myocutaneous gracilis flaps. Type 1B posterior wall defects are best reconstructed with rectus flaps. Type 2A upper two-thirds vaginal defects are best reconstructed with tubed rectus flaps, and Type 2B total vaginal defects are best reconstructed with bilateral myocutaneous gracilis flaps.
The myocutaneous gracilis flap used for vaginal or vulvar reconstruction can be unilateral or bilateral. The gracilis muscle is the most superficial of the adductor muscles originating from the pubic symphysis and inserts on the medial surface of the tibia within the pes anserinus. This flap is based on the descending branch of the medial femoral circumflex artery. The perforating vessel is found approximately 10cm inferior to the pubic tubercle in between the adductor longus and adductor magnus. After the muscle is divided from its insertion and origin, it may be translocated to the defect.
The rectus flap is an excellent choice for type 1B and 2B defects. It is based on the deep inferior epigastric artery, a branch of the external iliac artery. For open procedures, the skin paddle can be incorporated into the original incision, and the long pedicle length allows the reconstructive surgeon to reach the pelvic defect. The skin paddle can be designed for a multitude of defects and even tubed for circumferential defects. After designing the skin paddle over the rectus muscle, the superior epigastric artery and vein are ligated, and the flap is flipped through the abdomen into the pelvis. With the advent of minimally invasive robotic surgery, new techniques have arisen for rectus flap harvest.
As with any surgery, vaginal reconstruction is not without complications. These complications may be minor such as wound dehiscence, skin necrosis, or partial flap loss to major such as flap failure, fistulas, or hernias. These complications are more likely in patients with preoperative radiation. Immediate flap reconstruction decreases the likelihood of major complications, but there is still a risk. The patients should be counseled preoperatively about these possible complications.
Total or partial flap loss is a relatively low-risk complication given the hardy nature of the pedicled flaps generally utilized in vulvovaginal reconstruction. These complications can largely be avoided with appropriate preoperatively planning and stringent attention to avoiding flap tension and twisting/kinking of the pedicle. The major complications often seen in pelvic exenteration include evisceration or deep pelvic abscesses. Bringing healthy vascularized tissue for dead-space filling and tissue replacement (as opposed to tense primary closure) helps avoid these complications.
Enhancing Healthcare Team Outcomes
In a busy reconstructive practice, the plastic surgeon is involved with a vast number of different specialties and subspecialties to heal wounds and provide solutions to complicated problems. These patients frequently are topics of discussion during interdisciplinary rounds. This interprofessional approach to managing complex injuries or wounds provides the patient with the optimal outcome.