title: Surgical therapy of vulvar cancer: how to choose the correct reconstruction?
abstract: OBJECTIVE
  To create a comprehensive algorithmic approach to reconstruction after vulvar cancer ablative surgery, which includes both traditional and perforator flaps, evaluating anatomical subunits and shape of the defect.
  
  
  METHODS
  We retrospectively reviewed 80 cases of reconstruction after vulvar cancer ablative surgery, performed between June 2006 and January 2016, transferring 101 flaps. We registered the possibility to achieve the complete wound closure, even in presence of very complex defects, and the postoperative complications. On the basis of these experience, analyzing the choices made and considering the complications, we developed an algorithm to help with the selection of the flap in vulvoperineal reconstruction after oncologic ablative surgery for vulvar cancer.
  
  
  RESULTS
  We employed eight types of different flaps, including 54 traditional fasciocutaneous V-Y flaps, 23 rectus abdominis myocutaneous flaps, 11 anterolateral thigh flaps, three V-Y gracilis myocutaneous flaps, three free style perforators V-Y flaps from the inner thigh, two Limberg flaps, two lotus flaps, two deep inferior epigastric artery perforator flap, and one superficial circumflex iliac artery perforator flap. The structures most frequently involved in resection were vulva, perineum, mons pubis, groins, vagina, urethra and, more rarely, rectum, bladder, and lower abdominal wall.
  
  
  CONCLUSIONS
  The algorithm we implemented can be a useful tool to help flap selection. The key points in the decision-making process are: anatomical subunits to be covered, overall shape and symmetry of the defect and some patient features such as skin laxity or previous radiotherapy. Perforator flaps, when feasible, must be considered standard in vulvoperineal reconstruction, although in some cases traditional flaps remain the best choice.
authors.affiliation: Department of Plastic and Reconstructive Surgery, Fondazione Policlinico Gemelli, Rome, Italy. stefanogentileschi@gmail.com.
authors.forename: Stefano
authors.identifier: http://orcid.org/0000-0001-9682-4706
authors.initials: S
authors.lastname: Gentileschi
authors.affiliation: Department of Plastic and Reconstructive Surgery, Fondazione Policlinico Gemelli, Rome, Italy.
authors.forename: Maria
authors.identifier: http://orcid.org/0000-0002-0228-9114
authors.initials: M
authors.lastname: Servillo
authors.affiliation: Department of Gynecology, Fondazione Policlinico Gemelli, Rome, Italy.
authors.forename: Giorgia
authors.identifier: http://orcid.org/0000-0002-4147-3491
authors.initials: G
authors.lastname: Garganese
authors.affiliation: Department of Gynecology, Fondazione Policlinico Gemelli, Rome, Italy.
authors.forename: Simona
authors.identifier: http://orcid.org/0000-0002-9062-8197
authors.initials: S
authors.lastname: Fragomeni
authors.affiliation: Department of Plastic and Reconstructive Surgery, Fondazione Policlinico Gemelli, Rome, Italy.
authors.forename: Francesca
authors.identifier: http://orcid.org/0000-0002-7109-7482
authors.initials: F
authors.lastname: De Bonis
authors.affiliation: Department of Gynecology, Fondazione Policlinico Gemelli, Rome, Italy.
authors.forename: Giovanni
authors.identifier: http://orcid.org/0000-0001-5911-8255
authors.initials: G
authors.lastname: Scambia
authors.affiliation: Department of Plastic and Reconstructive Surgery, Fondazione Policlinico Gemelli, Rome, Italy.
authors.forename: Marzia
authors.identifier: http://orcid.org/0000-0003-2893-8562
authors.initials: M
authors.lastname: Salgarello
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D005260:Female; D013509:Gynecologic Surgical Procedures / Q000009:adverse effects / Q000379:methods; D006801:Humans; D008875:Middle Aged; D011183:Postoperative Complications / Q000453:epidemiology; D019651:Plastic Surgery Procedures / Q000379:methods*; D012189:Retrospective Studies; D013524:Surgical Flaps / Q000009:adverse effects; D014844:Vulva / Q000601:surgery*; D014846:Vulvar Neoplasms / Q000601:surgery*
keywords: Algorithm; Perforator Flap; Perineal Reconstruction; Vulvar Neoplasms; Vulvar Reconstruction; Vulvoperineal Reconstruction