FLAP RECONSTRUCTION FOLLOWING
GYNAECOLOGIC TUMOR RESECTION
Introduction
While minimally-invasive approaches and the use of
neoadjuvant therapies have been introduced into the field
of gynaecologic oncology, there are still those patients
whose best option for survival is ultra-radical surgery.
Such surgeries can be curative, but they are associated
with significant complications both in the long-term
and short-term and can leave the patient substantially
disfigured. The development of reconstructive techniques
in vulvo-vaginal surgery has been a key innovation to
improve the patient outcomes as well as quality-of-life.
As such, it is important for gynaecologic oncologists to
be well-versed in such procedures.
Indications
Reconstruction of the vagina, vulva, and/or pelvic floor
may be necessary in the treatment of numerous types of
cancers and various different procedures. Patients may
undergo pelvic exenterations as a salvage effort usually
in the recurrent setting for cervical, vaginal, vulvar,
endometrial, anal/rectal, or urothelial cancers. The
extirpative phase involves the en-bloc resection of all the
pelvic viscera and, in some cases, portions of the vulva.
The procedure is performed most commonly for cervical
cancer patients with isolated central recurrence. While
the rate of cervical cancer has decreased in the developed
world due to the advent of the widespread pap screening
with further reduction anticipated from the introduction
of the HPV vaccine, cervical cancer remains the third
most common cancer across the world and the most
common cause of cancer-related death for women in the
developing world (GLOBOCAN, Pisani et al. 1999).
Since the pelvic exenteration was introduced by
Brunschwig in 1948, advancements in technique and
perioperative practices have led to great improvement
in morbidity and mortality and its establishment as
standard of care in carefully-selected patients with
locally-advanced cervical cancer (Brunschwig et al.
1948). Starting in the 1970s, the reconstructive phase
was introduced to include vaginal and, if necessary,
vulvoperineal reconstruction, an integral development
924
Sara Isani, MD
116
Gary L. Goldberg, MD
not only when measured by psychosexual effects but also
for decreasing the rate of post-operative complications.
Vulvar cancer accounts for 5% of all gynaecologic
cancers, but the incidence is slowly increasing. This
increase is most likely a reflection of the aging population
(the disease has a median age of diagnosis of 68) but the
number of affected younger women is also rising (SEER
2009, Joura et al. 2000). Surgical resection remains the
mainstay in the treatment of vulvar cancers. However,
there has been a trend towards less radical surgery
with equivalent outcomes in terms of recurrence
and survival. While en-bloc radical vulvectomy and
bilateral inguinofemoral lymphadenectomy used to
be standard, now radical local excision with unilateral
lymphadenectomy is often sufficient for disease in lateral
locations. Regardless of technique, it remains clear that
adequate tumor-free margins are still a key determinant
of survival (Chan et al. 2007). Most vulvar lesions can
undergo primary closure, but larger defects may require
skin grafts or flaps to complete the repair.
Reconstruction of the vulvovaginal tissue may
be performed not at time of tumor debulking but as a
secondary procedure for patients who develop adverse
effects of surgical resection or radiation treatment
including vaginal fistulas, vaginal stenosis, vaginal
shortening, or chronic vulvar radiation dermatitis.
Goals of Reconstruction
The overall disease burden is such that 15 per 100,000
women every year have dysfunction of the vagina or
vulva secondary to gynaecologic malignancy, and some
may benefit from a reconstructive procedure. (Hockel &
Dornhafer et al. 2008). Vaginal reconstructive techniques
have been developed to treat congenital vaginal agenesis
or for gender reassignment. However, the reconstructive
demands of cancer-related procedures are very different
for these patients who are older, have medical co-
morbidities, and frequently have had previous radiation
therapy, all of which significantly impact wound-healing.
Furthermore, they are left with large defects caused by
extirpation requiring bulkier tissue implants. The goal
 Flap Reconstruction Following Gynaecologic Tumor Resection
is to create a functional neovagina of adequate tubular
diameter and length to permit sexual intercourse. At
this time, it is not possible to regain the neurosensory or
lubricating functions of a real vagina.
Vulvoperineal reconstruction is targeted to achieve
closure for large defects, afford cosmesis to establish
symmetry and form, and restore some level of normal
anatomical relationships of the perineum that may have
been lost from the surgical resection. Limitations at this
time prevent re-creation of vulvar structures such as
the clitoris, labia minora, and glands, all of which have
important roles in sexual function as well.
Pelvic floor reconstruction during total pelvic
exenteration is integral for wound healing to the denuded
and most likely irradiated pelvic floor by introducing
new vasculature and tissue bulk. While one of the most
common and dreaded post-operative complications
of pelvic exenterations had been the development of
small bowel fistulas and adhesion-related obstructions,
the acceptance of flaps for reconstruction has led to a
decreased incidence of intestinal complications and
pelvic abscesses by keeping the small bowel out of the
pelvis and bringing in a vascular pedicle that is outside
the radiated field. (Miller et al. 1995, Jurado et al. 2009,
Butler et al. 2008, Berek et al. 2005) Therefore, the
goal of the reconstructive phase is not only to improve
psychosexual function for the patient but also to decrease
postoperative morbidity.
Techniques for Vulvovaginal
Reconstruction
Skin Grafts
Either split- or full-thickness skin grafts can be appropriate
for superficial wounds such as those incurred by skinning
Table 1. Common Flaps for Neovagina Creation
Benefits
Pudendal thigh • Concealed scar
fasciocutaneous • Local sensory distribution
Gracilis myocutaneous • Satisfactory sexual function in majority of
patients
Rectus abdominis • Reliable vascular supply with low rate of
myocutaneous flap necrosis
• Satisfactory sexual function in majority of
patients
• No additional scar if done with
laparotomy
Colon • Minimal rate of flap necrosis
• Satisfactory sexual function in majority of
patients
925
vulvectomy for vulvar neoplasia. Split-thickness skin
grafts are often harvested from the thigh, buttocks, or
scalp, whereas common sites for full-thickness grafts are
the groin or tissue adjacent to the laparotomy incision
(Fowler et al. 2009). Skin grafts do not offer the post-
extirpation pelvis valuable vascularization or bulk,
and while they have been used to cover a tubularized
omental flap to create a neovagina, there are still distinct
disadvantages to their use (Kusiak et al. 1996). Split-
thickness grafts can leave an undesirable donor site scar
during re-epithelialization, whereas the donor site of full-
thickness grafts are closed primarily. Furthermore, skin
grafts can shear and to prevent this occurrence patients
are frequently put on bed rest, which in an older cancer
patient population increases the risk of thromboembolic
events and contributes to general deconditioning. Finally,
there is a high risk of vaginal stenosis without prolonged
use of a vaginal stent for several months (Fowler et al.
2009).
Tissue Flaps
Tissue flaps have the advantage of conferring the rich
new blood supply from their vascular pedicle to the
surgical defect, and the varying tissue volume can be
achieved in the design and choice of the flap. Factors
that must go into the design of a flap include size, depth,
vascular supply, arc of rotation, assurance of tumor-free
tissue, and avoidance of irradiated tissue. Skin flaps can
be categorized as “random” if they are not based on a
dedicated blood supply or “axial” if they have a dedicated
vascular supply. By definition all fasciocutaneous and
musculocutaenous flaps have a single artery or region of
blood supply.
Local skin flaps are most commonly used for vulvar
reconstruction and can be successfully implanted given
Drawbacks
• Reduced sexual function compared to other
flaps
• Vaginal discharge
• Hair-bearing
• Visible additional scar
• Unreliable vascular supply with high rate of flap
necrosis
• Sensation during intercourse referred to thigh
• Complicates choice of location for ostomies
• Insensate
• Mucus production/vaginal discharge
• Vaginal stenosis
 926 Flap Reconstruction Following Gynaecologic Tumor Resection
Vulvar defect
Partial Total Extended
Pubolabial V-Y flap Tensor fasciae latae
Medial thigh V-Y flaps, flap(s)
bilateral Gracilis flap(s)
Gluteal thigh V-Y flaps, Gluteal thigh flap(s)
bilateral Rectus abdominis muscle
Pudendal thigh V-Y flap
flaps, bilateral
Anterior Posterior Lateral
Limberg flap(s) Limberg flap(s) Medial thigh V-Y flap
Anterior labial Posterior labial Gluteal thigh V-Y flap
flap flap Pudendal thigh flap
Figure 1. Classification algorithm of vulvar defects from local
treatment for neoplastic disease and proposed appropriate
reconstructive procedures.
the rich blood supply of the vulvoperineum from the iliac
and femoral vessels (Moschella & Cordova et al. 2000).
The rhomboid (Limberg) flap is a random flap shaped like
a parallelogram with the base width and length roughly
equal and, as such, is limited to fill defects that can be met
by these size and rotational requirements (Chasmar et al.
2007, Hockel & Dornhofer et al. 2008). V-Y advancement
flaps are flaps that are shaped like a “V,” and then slid into
the defect so that after closure, the incision assumes a “Y”
shape. Types of V-Y advancement flaps that are helpful
in vulvo-perineal reconstruction are the (1) pubolabial
amplified flap, which can be mobilized inferiorly from
the mons pubis and offers bilateral coverage of the medial
vulva with a single flap; (Moschella & Cordova et al.
2000). (2) medial thigh flap, which has the ability to cover
a large defect and (3) gluteal fold flap, which can also fill
substantial areas that are more posteriorly-oriented and
has the advantage of the hiding the scar in the skin folds
(Lee et al. 2006, Lazarro et al. 2010). The bulbocavernosus
(Martius) flap is an example of a skin flap possessing a
dual blood supply from the superficial external pudendal
artery cranially and internal pudendal artery caudally
and, therefore, can be raised in either orientation; it is
commonly used to repair fistulas (Green et al. 2010).The
groin flap (based on the medial circumflex artery) and
the mons pubis flap (based on the superficial external
pudendal artery) have reliable vascular sources, but these
can get disrupted when en bloc lymph node dissection is
performed (Niranjan et al. 2006). On the other hand, the
groin flap proves advantageous when modified separate
skin incisions are employed since it can be raised through
this same incision (Bertani et al. 1990).
Fasciocutaneous flaps are axial pattern flaps that
include a dedicated blood supply contributing rich
vascularization and can be transferred to wide defects
without the bulkiness of musculocutaneous flaps.
Pudendal thigh flaps are based on the perforating vessels
Vaginal defect
Partial Total Extended
Sigmoid-colon flap Rectus abdominus
Pudenndal thigh muscle flap
flaps, bilateral Gracilis flaps
Gluteal thigh flap(s)
Pudendal thigh fleps
Sigmoid-colon flap
Planar Circumferential
Anterior Posterior Distal Proximal
Anterior labial flap Posterior labial flap Pudendal thigh Sigmoid-colon flap
Pudendal thigh flap Pudendal thigh flap flap, bilateral
Figure 2. Classification algorithm of vaginal defects from local
treatment for neoplastic disease and proposed appropriate
reconstructive procedures.
of the extensive anastomotic network of the superficial
external pudendal, deep external pudendal, internal
pudendal, obturator, and medial circumflex arteries.
As a collection of flaps, they take the appearance of a
lotus flower with each flap resembling a lotus petal (Yii
et al. 1996). The most commonly used is the modified
pudendal thigh fasciocutaneous flap (Singapore) fed by
the internal pudendal neurovascular supply. It can be
used for partial vulvar reconstruction if still available
after resection and also for the repair of vaginal defects,
most often partial ones for which not as much tissue
volume is desired. (Woods et al. 1992, Cordeiro et al.
2002). This flap also has the benefit of a hidden donor
site scar within the inner groin fold, but it is hair-bearing,
so patients undergoing vaginal reconstruction should be
forewarned (Gleeson et al .1994). The anterolateral thigh
flap is a distant flap but can be used in vulvoperineal
reconstruction because its long pedicle from the lateral
circumflex femoral artery grants it excellent mobility
(Luo et al. 2000, Lannon et al. 2011).
Musculocutaneous flaps offer bulk for deep
defects such as those encountered at the time of total
exenteration or extended radical vulvectomy. The
gracilis flap introduced by McCraw et al. in 1976 was
the first musculocutaneous flap to be used for vaginal
reconstruction at the time of pelvic exenteration
(McCraw et al. 1976). Its mobility is limited by the
medial circumflex artery pedicle, although the short
gracilis flap modification, in which the medial circumflex
artery is not preserved and the flap is fed by branches of
the obturator artery, alleviates this problem (Soper et al.
1995). Since the gracilis flap has a high flap loss rate of
13-38% and unsightly scars, most surgeons have moved
towards the RAM (rectus abdominis musculocutaneous)
flap, either transversely- (TRAM), vertically- (VRAM),
or obliquely-oriented, based on the reliable blood supply
via the inferior epigastric artery (Fowler et al. 2009).
 Flap Reconstruction Following Gynaecologic Tumor Resection
Since the pelvic exenteration requires a laparotomy,
there is also no additional donor site scar (Smith et al.
1998, Soper et al. 2007). There have been no differences
shown between the VRAM and the TRAM with regards
to donor-site or recipient-site complications (Soper et al.
2005a). A variation of the flap based on the same blood
supply, the RAMP (rectus abdominis musculoperitoneal)
flap, utilizes the posterior rectus fascia and includes the
peritoneal lining and medial transversalis abdominis,
excluding the cutaneous tissues and anterior rectus fascia.
The RAMP flaps may be advantageous in cases where
less tissue volume is desired, such as for obese patients,
but they are associated with a much increased donor-
site complication rate, including hernia formation, and
higher risk of developing vaginal stenosis when fixing
circumferential vaginal defects, as would be the case in a
total pelvic exenteration (Soper et al. 2005b).
Intestinal flaps for vaginal reconstruction from both
small and large bowel have been used, but the sigmoid
colon is the most commonly employed segment at this
time (Bridoux et al., Hockel & Dornhofer et al. 2008,
Hawighorst-Knapstein et al. 1997). This approach is
best suited if a laparotomy is being performed and for
circumferential or total defects. Patients do complain
of vaginal discharge given the mucus production of
the bowel. Additionally, there can be substantial flap
contraction, so at least a 15-centimeter segment of
sigmoid should be harvested (Fotopoulou et al. 2008).
Outcomes
The published literature on vulvovaginal reconstructive
procedures is mostly comprised of small retrospective
studies. Even some of the larger series are from single
institutions but still include heterogeneous populations
of patients with regards to cancer status (type of
cancer, invasive versus non-invasive, primary versus
recurrent), reconstructive procedures, and time periods
covered during which there may have been changes in
perioperative practices. Given the increasingly infrequent
need for pelvic exenteration and radical procedures from
improved screening and primary therapy, there are very
few prospective studies and no randomized, controlled
trials. The majority of the data comes from pelvic
exenterations or abdominoperineal resections.
Overall complication rates for procedures of the
vulva/vagina including both resection and primary
reconstruction range from 39 to 69% (Ratliff et al.).
For pelvic exenterations, these complication rates are
in the context of 5-year survivals of approximately 50%
and median progression-free survival of 42 months
(Goldberg et al. 2005, Berek et al. 2005).There are few
studies that compare those undergoing reconstructive
techniques with those who undergo primary closure,
and the existing ones are retrospective in design with an
inherent selection bias. However, those that are available
927
have found equivalent or improved complication rates
for patients who underwent flap reconstruction (Landoni
et al. 1995, Butler et al. 2008, Jurado et al. 2009).
Donor Site
Flap-specific adverse events can be separated into those
occurring at the donor-site, which usually happen in the
immediate post-operative period, and those associated
with the recipient-site, which can have short-term and
long-term sequelae. Donor-site complications include
wound separation/dehiscence and hernia formation. The
overall complication rate is 0-13% of cases, and incisional
hernias develop in less than 10% of those with RAM flaps.
(Smith et al. 1998, Soper et al. 2005, Jurado et al. 2009).
Recipient Site: Short-term
The most important immediate concern for the recipient
site is flap viability, whereas the long-term effects are
usually psychosexual in nature. Studies do not always
differentiate complete and partial necrosis, but in
general, the rate of flap viability during vulvovaginal
reconstruction is greater than 85% (Hockel & Dornhofer
et al. 2008). For reconstruction at the time of pelvic
exenteration, gracilis musculocutaneous flaps have
been found to be inferior to RAM flaps due to a flap
necrosis rate of 13-38% and an overall increased rate of
complications (Fowler et al. 2009, Soper et al. 2007). The
RAM complete flap loss rate for vaginal reconstruction
is estimated to be approximately 5% (Smith et al. 1998,
Cordeiro et al. 2002, Soper et al. 2005a). It is important
to identify not only which types of flaps perform better
but also clinical factors that may impact the development
of flap necrosis so that we can individualize patient or
procedure selection. Peripheral vascular disease and
obesity are associated with higher rates of RAM flap
necrosis secondary to the compromised vascular supply
(Selber et al. 2006, Soper et al. 2005a) Previous radiation
treatment has also been shown to be an independent risk
factor for flap-related complications in a dose-dependent
manner for vaginal reconstruction (Crosby et al. 2010).
However, in a pooled analysis of the existing literature on
vaginal reconstruction specifically using RAM flaps, the
flap necrosis rate of patients with a history of radiation
treatment was found to be at most 3.8%, similar to the
overall loss rate of 5% and, therefore, seems to be a good
option in this patient population (Smith et al. 1998).
Prior abdominal surgery and prior stoma have also been
implicated with the occurrence of RAM flap necrosis,
and angiography does not appear to be an accurate tool
for preoperative evaluation of the vascular supply (Smith
et al. 1998).
Recipient Site: Long-Term
The quality-of-life and psychosexual benefits of vulvo-
vaginal reconstruction are potentially immense but
need to outweigh the immediate post-operative risks.
 928 Flap Reconstruction Following Gynaecologic Tumor Resection
Prospectively-collected data from patients with sexual
partners who were offered vaginal reconstruction via
colonic flap at time of pelvic exenteration showed
that those who opted to have neovagina creation had
significantly better quality-of-life, sexual satisfaction, and
body image scores than those who did not (Hawighorst-
Knapstein et al. 1997). There is less data on sexual
function after vulvar resection, but one study of radical
vulvectomy patients found that flap reconstruction led to
significantly lower incidence of stenosis of the introitus
and sexual dysfunction compared to patients who had
primary closure (Landoni et al. 1995).
The function of a neovagina can be compromised by
several developments: (1) stenosis, most commonly at
the distal site of anastamosis; (2) shortening, as a vaginal
length of at least 4 to 5 cm is thought to be appropriate
for coital function (Cordeiro et al. 2002); (3) prolapse; (4)
fistula; and (5) dryness, which can be improved with the
use of a lubricant. Some of these problems may need to
be addressed with a second surgery. The data on these
complications is scarce, but single studies have shown
that gracilis musculocutaneous flaps are associated with
an 18% prolapse rate; RAM flaps with an 11% stenosis
rate and potentially much higher stenosis rates exceeding
50% for RAMP or colonic flaps, and inadequate vaginal
lengths achieved with pudendal thigh fasciocutaneous
flaps (Ratliff et al. 1996, Goldberg et al. 2005a, Soper et al.
2005b, Fotopoulou et al. 2008, Jurado et al. 2009, Jurado
et al. 2009).
Even absent these anatomical complications, the
vaginal reconstruction may not afford the patient sexual
function and/or satisfaction. While most studies are
retrospective and do not include preoperative assessments
or account for partner availability, the majority (43-
78%) of the patients are able to have sex following the
procedure; even higher rates of sexual activity occur
amongst those who were sexually active preoperatively or
who have available partners. Overall satisfaction or desire
to undergo the procedure again if offered the choice
range from 68-100% (Ratliff et al. 1996, Mirhasemi et
al. 2002, Goldberg et al. 2005, Fotopoulou et al. 2008).
Most studies do not have the power to determine the
factors that significantly influence initiation of sexual
activity following vaginal reconstruction, such as type of
flap although pudendal thigh fasciocutaneous flaps may
confer a lower chance of sexual activity (Gleeson et al.
1994, Jurado et al. 2009). Several prospective or survey
studies have uncovered reasons for sexual dysfunction
that go beyond what the optimal vaginal reconstruction
can offer. Two studies have revealed that the best
determinant of sexual activity is disease-free status
(Smith et al. 1998, Soper et al. 2005a). Control of tumor
is paramount to good quality of life. Additionally, the
presence of ostomies, especially more than one ostomy,
has been correlated to decreased chance of sexual activity
following surgery (Ratliff et al. 1996, Hawighorst-
Knapstein et al. 1997). Finally, a prospective study
demonstrated that after pelvic exenteration with vaginal
reconstruction almost half the patients may have sexual
dysfunction secondary to cancer-associated depression
and anxiety (Fotopoulou et al 2008). Therefore, while we
should strive to improve surgical technique to enhance
the functional abilities of the neovagina, we should also
continue to pursue innovations towards elimination of
ostomies and to use aggressive curative means without
adding extra risk to the patient, measures that will
improve the overall psychosexual function of the patient.
Choosing A Reconstructive Approach
Flaps can be raised locally or can be transplanted from
a distant donor site. While sensory function after flap
repair is difficult to predict, a benefit of local flaps is that
they reflect a sensate distribution more similar to the
recipient site, whereas mobilization of distant flaps can
lead to the patient feeling sensation at the donor site,
such as the thigh, when the recipient site is touched, a
potentially disturbing phenomenon However, a benefit
of distant flaps, particularly in cancer patients for whom
the ultimate concern is always about disease recurrence,
is that they are located farther from tumor-involved
tissue. For example, vulvar cancers often develop in
the background on intraepithelial neoplasia, and new
primary tumors away from the primary tumor site are not
uncommon, so harvesting a flap from residual vulva may
not be optimal. For patients with a history of radiation
treatment, the distant donor site is outside the irradiated
field and would be associated with better wound-healing.
Additionally, there may be a need to raise multiple flaps
to close defects when there are large defects affecting
both sides of the perineum.
Several algorithms for repair of vulvovaginal defects
have been proposed. Cordeiro et al. 2002 proposed a
classification for vaginal defects based on whether they
were planar or circumferential and further categorization
within these two classes based on the location or extent of
vagina involved, and they offered recommendations for
flaps based on the type of defect (Cordeiro et al. 2002).
However, the classification was restricted to patients with
vaginal defects only and no extended defects. Hockel and
Dornhofer et al. 2008 put forward their own algorithm
which included recommendations for vulvar defects,
vaginal defects, as well as extended perineal defects.
While preoperative preparation for the reconstructive
approach is important, often times the extent of resection
of vital organs and soft tissue is not known until the
procedure has commenced. Defects can be quite variable,
but so can other factors that influence the plan such
as age, functional status, body habitus, medical co-
morbidities, history of or plan for radiation, history
of prior surgeries, concomitant stoma formation, and
 Flap Reconstruction Following Gynaecologic Tumor Resection
the patients’ goals for aesthetic and functional results.
Therefore, an individualized intraoperative assessment
by a gynaecologic oncologist familiar with a range of
reconstructive options is vital for the optimization of care
during these demanding radical surgeries.
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