Journal of Plastic, Reconstructive & Aesthetic Surgery

Evaluation of the impact of a protocol for immediate vulvar reconstruction after vulvectomy

Vulvar cancers are usually diagnosed at an advanced stage and require wide surgical resections in the form of vulvectomy. Immediate vulvar reconstruction can potentially reduce the reoperation rate and postoperative complications. With this objective, we introduced a protocol for immediate vulvar reconstruction. This study, five years after its introduction, assesses the impact of this intervention on the postoperative evolution of vulvectomy patients. In January 2017 we introduced a protocol for immediate vulvar reconstruction that considered four criteria of high risk for postoperative dehiscence. Patients who meet the criteria were reconstructed at the time of the vulvectomy. To assess the impact of the protocol, we prospectively registered all included patients over a 5 years period (2017-2022). As a control group, we reviewed the vulvectomised patients at our centre from January 2012 to January 2017 (5 years) who would have met the protocol. No statistically significant differences were found in the epidemiological data (age, diabetes mellitus diagnosis, and obesity diagnosis) or in the tumour characteristics (tumour size). We obtained a statistically significant difference in the incidence of complications and need for reintervention, in favour of the reconstruction group. Our study shows the medical and economic benefits for vulvar cancer patients of immediate vulvar reconstruction.

Feasibility, indications and complications of SCIP flap for reconstruction after extirpative surgery for vulvar cancer

Surgical therapy for vulvar cancer involves wide defects that often require flap-based reconstruction. The goal of the reconstruction is fast wound healing with low donor site morbidity. This is a retrospective observational cohort study in which we reviewed all patients who underwent surgery for vulvar cancer followed by reconstruction using the Superficial Circumflex Iliac Artery Perforator (SCIP) flap between 2015 and 2020. The primary outcome measure of this investigation was the incidence of wound complications. The secondary outcomes were the surgical indications in terms of establishing the anatomical subunits involved in the resection that made us choose this flap for reconstruction. This study adheres to the STROBE guidelines. Thirty-two patients were included; in two cases, the flap was performed bilaterally for a total of 34 SCIP flaps. The mean age of patients was 70.6 ± 8.6 years, and the mean BMI was 26.8 ± 4.7. The SCIP flap was always feasible. The mean flap size was 128.8 ± 74.3cm Our results suggest that the advantages of SCIP flap for the reconstruction of vulvoperineal defects secondary to vulvar cancer surgery include low complication rate, minimal donor site morbidity, quick dissection, proximity of donor and recipient sites, possibility to harvest large skin islands of variable thickness and chimeric flaps.

Clinicopathologic features and surgical management in vulvovaginal melanoma – A retrospective single-center study

Vulvovaginal melanoma is a rare malignancy with a poor prognosis. This study aimed to review cases of vulvovaginal melanoma treated at Helsinki University Hospital. Objective was to evaluate the clinicopathologic features, treatment, and factors affecting outcome. A single-center retrospective review was conducted on patients treated between 2001 and 2021. Data were collected from medical records. Clinicopathologic features, treatment, survival, and prognostic factors were analyzed. A total of 21 patients were included in the analysis. Localization was vulvar in 86% (n = 18) and vaginal in 14% (n = 3). The median age at diagnosis was 80 years. Initial treatment included surgery in 18 patients (86%), with wide local excision in 19%, radical excision in 62%, and pelvic exenteration in 4.8%. Negative margins were achieved in 83% (n = 15). Eleven (52%) patients underwent inguinal treatment: sentinel lymph node biopsy in 33%, direct lymphadenectomy in 14%, and both in 4.8%. Nine patients experienced melanoma recurrence. Recurrences were locoregional (n = 1), distant (n = 4), and both locoregional and distant (n = 4). Median disease-free survival was 18.9M and median overall survival (OS) was 36.5M. The 5-year relative OS was 20%. Melanoma was the cause of death in seven patients (33%). Vaginal localization tended to worsen prognosis. Nodal status was the only melanoma characteristic significantly associated with survival. Surgical radicality did not affect survival. Vulvovaginal melanoma is associated with extremely poor survival rates and high recurrence rates, primarily involving distant metastasis. In local control, wide local excision seems to be a viable alternative to more radical surgery. Nodal status is a key prognostic factor emphasizing the importance of further research into the applicability of sentinel lymph node biopsy for vulvovaginal melanoma.

The combined use of pedicled profunda artery perforator and bilateral gracilis flaps for pelvic reconstruction: A cohort study

The result of an extra-levator abdominoperineal excision of the rectum (ELAPE) is a composite three-dimensional defect. This is performed for locally advanced anorectal cancer, and may involve partial excision of the vagina. The aim of reconstruction is to achieve wound healing, restore the pelvic floor and to allow micturition and sexual function. We aim to evaluate the concurrent use of profunda artery perforator (PAP) and bilateral gracilis flaps for vaginal and pelvic floor reconstruction. We performed a retrospective case note review of patients undergoing pelvo-perineal reconstruction with combined gracilis and PAP flaps between July 2018 and December 2019. Eighteen pedicled flaps were performed on six patients with anal or vulval malignancies. All underwent pre-operative radiotherapy. Four patients had extended abdominoperineal tumour resections, while two patients underwent total pelvic exenteration. The median age was 57 (range 47-74) years, inpatient stay was 22 (11-47) days and the follow-up was 10 (5-21) months. Four patients developed partial perineal wound dehiscence, of which one was re-sutured. One patient had a post-operative bleed requiring radiological embolisation of an internal iliac branch and had subsequent 1cm PAP flap loss. All other flaps survived completely. Median time to heal was 4 (1-6) months. This is the first series reporting combined bilateral gracilis and PAP flaps for pelvic reconstruction. The wound dehiscence rate and healing times were expected in the context of irradiation and radical pelvic tumour resection. This is a reliable technique for perineal and vaginal reconstruction with minimal donor site morbidity.