Vulvovaginal reconstruction following radical surgery.
An important aspect of the care of women with a gynaecological malignancy is not only improved survival, but complete rehabilitation. There are a number of reconstructive techniques available which can be used at the time of radical surgery, or at some later date, to correct the untoward effects of therapy. Whenever possible, the least morbid, yet most reliable reconstructive procedure should be performed at the initial surgery to decrease postoperative morbidity and wound infection and improve rehabilitation and body image. For many situations there is no single ideal procedure, therefore one should be familiar with several techniques in order to select or adapt the procedure best suited to the circumstances. The split thickness skin graft (STSG) is used primarily to cover skin defects where there has been little or no loss of subcutaneous tissue, such as after skinning vulvectomy for carcinoma in situ. It is also the procedure of choice for vaginal reconstruction after simple vaginectomy for extensive in situ carcinoma and for congenital absence of the vagina. It may also be useful in the management of vaginal distortion, secondary to previous surgery or radiation therapy. In gynaecology, full thickness skin flaps are used when there has been major loss of skin and subcutaneous tissue of the vulva, groin or vagina. Defined arterial and fasciocutaneous flaps are more reliable than random cutaneous flaps, but they are not mutually exclusive in their application. Thus, one or the other may be used for the same defect in differing patients, depending on the situation. Circumstances that dictate which flap is preferable include size, contour, depth of the deformity, proximity of the deformity to the potential donor site, presence of necrosis and infection, and the requirement for new blood supply, as in an irradiated wound. In appropriately selected patients the myocutaneous flap will provide the most reliable source of a new blood supply. If the requirement for a new blood supply is of paramount importance, and the myocutaneous flap is too thick, the skin and subcutaneous tissue may be sacrificed to reduce the size of the flap. A STSG can then be applied at a later time to achieve the desired result. There are many other situations when several reconstructive procedures used simultaneously, or serially, may be required to achieve a balance between anatomy and function. However, ultimate success will depend largely on patient selection, familiarity with the procedures, and exacting surgical technique.
Stern
J L
JL
Lacey
C G
CG
D005260:Female; D006801:Humans; D016038:Skin Transplantation; D013524:Surgical Flaps; D014621:Vagina / Q000601:surgery*; D014844:Vulva / Q000601:surgery*