A Simplified Algorithmic Approach to Vulvar Reconstruction According to Various Types of Vulvar Defects

Various surgeons adopt various vulvar reconstruction methods for different types of vulvar defects to restore anatomical structures. Vulvar reconstruction has relatively few references as it is performed in many different ways. Our report aimed to create a simplified reconstruction algorithm that can be used to select the reconstruction flap and to compare clinical outcomes.

The patients who underwent vulvar reconstruction between April 2017 and May 2020 were retrospectively reviewed. The reconstruction flap was selected according to a suggested algorithm, which accounted for the defect location depending on the vulvo-thigh junctional crease-the visual landmark of the inferior pubic ramus-and proper perforator location. Postoperative surgical complications, functional outcomes, and oncologic outcomes were analyzed according to the histologic and flap types.

Forty-seven patients underwent reconstruction with 31 internal pudendal artery perforator flaps (66%) and 16 profunda artery perforator flaps or transverse upper gracilis flaps (34%). The histologic type included 21 extramammary Paget disease (44.7%), 20 squamous cell carcinoma (42.6%), and 6 other types (12.8%). Postoperative complications, including wound and functional complications, occurred in 10 patients (21.3%). There were more cases of wound complications with profunda artery perforator flaps and transverse upper gracilis flaps (37.5%) than those with internal pudendal artery perforator flaps (12.9%) (P = 0.04). There were 7 cases (14.9%) of 2-year oncologic recurrence with no significant differences in terms of histologic or flap types.

According to our suggested simplified algorithm, various types of flaps resulted in reliable surgical outcomes with minimal complication rates and acceptable functional and oncologic outcomes, and the primary goals of vulvar reconstruction were achieved effectively. Using our algorithm, selection of the reconstruction method could be simplified and specified despite the complexity of vulvar defects.