VULVAR AND PERINEAL RECONSTRUCTION
Split-Thickness Skin Grafting
The establishment and easy applicability of split-thickness skin grafts have enhanced the gynecologists’ role in reconstruction of the vulva. When wide local excision of vulvar lesions creates large defects, a segmental skin graft can be applied so that skin approximation without tension will ensure a better cosmetic result. Primary closure and segmental grafting can be used at the same surgical sitting.
The presence of multifocal vulvar, perineal, and perianal lesions occasionally necessitates the removal of multiple areas of skin. Reapproximation is difficult. The technique of removing just the vulvar skin (i.e., skinning vulvectomy) and preserving the subcutaneous tissue and vulva blood supply is preferred. A rich bed of tissue is available for skin-graft applications. Although operative time and hospital stay are lengthened when skinning vulvectomy and grafting are performed, better cosmetic results with few residual sequelae are obtained. Among these sequelae are graft-take failure in the range of 5% to 15% and an impairment of sensation in both the grafted area and the graft site. The mons pubis is a potential graft selection site.
Use of Incisions and Skin Grafts
Introital stenosis after surgery is not always responsive to dilation. Simple surgical procedures, such as vertical incisions at the fourchette, constitute a first approach. These incisions are closed in horizontal fashion to widen the introitus. In cases of introital stenosis or the absence of a perineal body, a Z-plasty type of operation can be performed. If larger areas of the vulva need to be covered after radical surgery, local flap grafts can be used.
Use of the Labia Minora (Full-Thickness Graft)
Patients with prior vulvar surgery may experience complications such as dyspareunia, introital stenosis, hoods over the urethral orifice, vulvar scarring, and vulvar breakdown with infection. In these patients, vulvar reconstruction can be performed by using full-thickness grafts. Full-thickness grafts use both the epidermis and the dermis. In general, these grafts can be used to cover small areas so that the donor site can be closed primarily. For the gynecologists, possible donor sites include the labia minora, upper medial thigh, and groin.6 The size of the graft should be larger than the area to be covered secondary to the high primary contracture rate. The use of skin grafting at the time of initial vulvar surgery can circumvent many of the aforementioned complications.
Labial Pedicle Flap (Martius)
After radiation therapy, hypoxia, necrosis, and ulceration can compromise genital tract tissues. Conditions such as vesicovaginal, rectovaginal, and urethrovaginal fistulas can be the sequelae of pelvic irradiation. Repair of injured tissue in these areas necessitates the introduction of healthy unirradiated tissue. The closure of these defects can be approached with the use of the labial fat pad, a technique originally devised by Martius.7 The Martius procedure provides tissue support and a new blood supply to the surgical site. The labial fat pad is supplied anteriorly by the superior external pudendal artery and inferiorly by the perineal branch of the internal pudendal artery. As a labial pedicle, the bulbocavernosus muscle and surrounding fat is isolated. This pedicle is tunneled paravaginally and then introduced into the vaginal canal, where it can be used to repair bladder and urethral fistulas or rectovaginal fistulas. Both labial fat pads can be used.
Creation of a rhomboid flap is a useful approach for repairing defects occurring after partial vulvectomy has been performed for carcinoma in situ of the vulva or re-excision of the vulva for in situ disease. The flaps are created such that a graft is not necessary and adequate closure without tension is obtained.
Vaginal reconstruction is critical for maintenance of sexual functioning, psychosocial health, restoration of body image, and for pelvic support to prevent bladder, rectal, and pelvic prolapse. Among the conditions leading to impairment of vaginal function are the following:
- Surgical removal of the upper vagina or the entire vagina at the time of conservative, radical, or ultraradical surgery
- Contraction, constriction, erosion, or ulceration of the vagina after irradiation for cervical, vaginal, or endometrial cancer
- Fistula formation
The technique of vaginal reconstruction depends on the length of the remaining vagina, the viability of the tissue, and the accompanying deficit as a result of the treatment method. Procedures that have been described include split-thickness and full-thickness skin grafts, peritoneal grafts, omental grafts, vulvovaginal grafts, large- and small-bowel grafts, bladder segment grafts, and myocutaneous flaps.
Split-Thickness Skin Grafting
In the absence of irradiation, vaginal reconstruction can be achieved by the placement of a split-thickness skin graft in the vaginal canal. Skin can be taken from the lower abdomen, the lateral hairless inguinal area, the posterior medial thigh, or the posterior medial buttocks. The graft usually varies from approximately 0.015 to 0.017 inches in thickness. Initially, split-thickness grafts contract approximately 20% compared with full-thickness grafts, which may contract up to 50%. However, the secondary contracture, which occurs as the wound heals, is much less for the thicker grafts. Therefore, thicker grafts are more pliable and contract less. The donor site usually heals without difficulty in 14 to 21 days; however, a residual scar will remain at the donor site. Graft-take ranges from 75% to 90%. This method of creating a neovagina can be used in patients who have had a partial or complete vaginectomy for intraepithelial or invasive carcinoma of the vagina or in patients who have had either an anterior or a total pelvic exenteration. When the latter is performed, creation of a vascular bed may be required; this can be created surgically with the use of an omental pedicle flap or muscle pedicle flap.
When using a split-thickness graft, a vaginal stent is necessary to keep the vagina patent. The stents are tailored to the size of the vagina. They should be easy to remove and should not remain in place for prolonged amounts of time. Excessive pressure should not be exerted on the graft as it can lead to vascular compromise and draft necrosis. After stent removal, topical estrogen can be used and the vaginal canal is kept open, either naturally or by the use of a mold. The mold is used for approximately 3 to 4 months if the patient is not sexually active; less time is required if the patient is sexually active.
Complications of vaginal reconstruction include loss of viability of the graft, stenosis of the vagina, and rectovaginal and vesicovaginal fistula. Long-term complications of vaginal grafts include vaginal dryness, vaginal prolapse, and the rare development of squamous cell carcinoma of the graft. Thus, split-thickness skin grafts have emerged as one of the two more commonly used techniques for reconstruction of the female genital tract after treatment for gynecologic malignancies.
Use of Pelvic Peritoneum or Omentum
When the length of the vagina would be compromised at the time of radical or ultraradical surgery, intraoperative procedures can be used to lengthen the vagina. A simple procedure involves the use of pelvic peritoneum.
Peritoneum from the vesicouterine pouch or from the cul-de-sac (extension of the peritoneum from the bladder and rectum) is preserved at the time of radical surgery and attached to anterior and posterior vaginal edges. The most superior or cephalad peritoneal edges are sutured in the midline. Thus, a peritoneal pouch that is an extension of the existing vaginal canal is created. Using this method, the vaginal depth can be extended by at least 2 to 3 cm. In addition, omental pedicle or pelvic peritoneum can be used to cover the pelvic floor and the dome of the denuded vaginal canal. Approximately 3 to 6 weeks after surgery, after vaginal patency is maintained, a split-thickness skin graft can be applied to the vaginal tube.
The current-day procedures use either the basic technique or minor modifications of the original Abbe-McIndoe-Williams procedure. This procedure begins with an incision of the labia majora. The inner lateral edges of the incised skin are then approximated to create a tubular vagina. This tube is interior to the reapproximated outside edges of the incision.
This technique allows the creation of a functional vagina in approximately 6 to 8 weeks. Advantages of this procedure are that dissection of the perineum is not necessary, the vagina retains its sensory function, routine dilation is not required, hospitalization is decreased, and the patient is able to ambulate early.
This procedure is exceedingly useful after vaginectomy or when shortening of the vaginal canal has occurred, such as after radical hysterectomy or vaginal irradiation, when the length of the vagina is compromised.
Among the complications of this operation are stenosis of the canal, prolapse of the vagina, and the rare occurrence of either rectovaginal or ileovaginal fistulas. A change in the direction of the vaginal canal occurs after surgery. In addition, the vaginal skin usually is dry, and lubrication is required before coitus. Occasionally, there is hair growth in the neovagina.
Another technique reported by Simmons and Millard19 and West and coworkers for creation of a vagina involves the dissection and creation of a new vagina between the compromised posterior vagina and the anterior rectum. This rare surgical procedure is used when there is severe vaginal stenosis secondary to irradiation. A vaginal pouch as large as 10 cm in length and 5 cm in width can be created and lined with a split-thickness skin graft. A vaginal mold and continued vaginal dilation are required to prevent scarring.
SEGMENT OF BOWEL.
In the past, the intestines have been used to fashion a vaginal tube. At the time of exploratory celiotomy, a vaginal tube can be created by using either a loop of ileum or a segment of the sigmoid colon. Preservation of the blood supply to the bowel segment is critical to the success of this operation. The segment is used either to fashion a neovagina entirely or to attach it to a vaginal remnant to augment vaginal length.
This method was popular with European surgeons but is rarely used today. It served as an impetus for the development of current-day techniques, because routine canal dilation and the use of stents were circumvented. Mucous secretion from either the ileum or the sigmoid, primarily the sigmoid, was bothersome to many patients.
USE OF THE BLADDER DOME.
A less-popular method for creation of a neovagina involves the use of the bladder dome. A segment of bladder is resected, the epithelium is removed, and this portion of the bladder is used to fashion an upper vagina. Usually, this procedure is followed by application of a split-thickness skin graft to fashion the lower vagina. This procedure is rarely used today.
USE OF A MYOCUTANEOUS FLAP.
The presence of gaping defects in the pelvic-vaginal cavity after ultraradical surgery such as a total pelvic exenteration has necessitated the use of larger flaps. Myocutaneous flaps have enjoyed increasing popularity in these instances. One favorite technique involves using the gracilis muscle to close the pelvic defect and create an adequate vagina. To reduce the bulk associated with this flap, a shortening of the flap with equally efficacious results has been recommended.
Rectus abdominal muscle flaps have also been used for vaginal reconstruction. One advantage is that only a single flap is necessary, compared with two gracilis flaps, and, second, the donor site incision can be closed with the laparotomy incision in cases of exenterative procedures. Disadvantages of the rectus muscle flap include difficulty of stoma placement and that a two-team approach may no longer be possible.
With the trend toward better cosmesis oncologists have attempted to enhance patient comfort and acceptance after radical surgery. One such advancement has been the creation of a continent urinary conduit. The large and small intestines are used to create a urinary reservoir intra-abdominally, and although an abdominal wall stoma still is present, there are several advantages for the patient. The stoma is smaller and the patient does not have to constantly wear a urinary receptacle. In addition, a low rectal anastomosis or anastomosis of the colon, rather than an end sigmoid colostomy, allows the patient to be free of a conduit for the stool. These two refinements significantly enhance the body image of the patient undergoing radical pelvic surgery.
Walton, L, Gehrig, P, Glob. libr. women’s med.
Morley GW, Delancey JOL: Full-thickness skin graft vaginoplasty for treatment of the stenotic or foreshortened vagina. Obstet Gynecol 77: 485, 1991
Hoskins WJ, Park RC, Long R et al: Repair of urinary tract fistulas with bulbocavernous myocutaneous flaps. Obstet Gynecol 63: 588, 1984
Burke TW, Morris M, Levenback C et al: Closure of complex vulvar defects using local rhomboid flaps. Obstet Gynecol 84: 1043, 1994
Soper JT, Larson D, Hunter VJ: Short gracilis myocutaneous flaps for vulvovaginal reconstruction after radical pelvic surgery. Obstet Gynecol 74: 823, 1989
Benson C, Soisson AP, Carlson J et al: Neovaginal reconstruction with a rectus abdominis myocutaneous flap. Obstet Gynecol 81: 871, 1993
Burke TW, Morris M, Roh MS et al: Perineal reconstruction using single gracilis myocutaneous flaps. Gynecol Oncol 57: 221, 1995
Chambers JT, Schwartz PE: Mobilization of anterior vaginal wall and creation of a neourethral meatus after vulvectomies requiring resection of the distal part of the urethra. Surg Gynecol Oncol 164: 274, 1987
Elstein M: Cloacal reconstruction and use of bilateral ischiocavernosus muscle flap for construction of the perineal body. Case Report. Br J Obstet Gynaecol 93: 402, 1988