GYNECOLOGIC ONCOLOGY 19, 79-89 (1984)

Immediate Vaginal Reconstruction following Resection for

Malignancy Using the Gluteal Thigh Flap
BRUCE M. ACHAUER, M. D.,’ PATRICIA BRALY, M.D., MICHAEL L. BERMAN,
M.D., AND PHILIP J. DISAIA, M.D.
Division of Plastic Surgery and the Department of Obstetrics and Gynecology, University of
California, Irvine, California 92717
Received June 29, 1983

Immediate flap closure of perineal defects following extirpative procedures for gynecologic
malignancies is highly desirable. Advantages include more rapid healing, reduced infection
rate, decreased nutritional demands, early rehabilitation, greater safety in radiated fields,
and more functional results. The posterior thigh flap, deriving its blood supply from the
inferior gluteal artery, was used in 7 patients (9 flaps) with excellent results. The flap has
proven reliable and quite feasible at the time of resection. While most partial pelvic or
vaginal defects can be reconstructed with a single flap, bilateral flaps are recommended
for more extensive defects. The major postoperative problem has been discomfort while
sitting and paresthesias along the distribution of the posterior cutaneous nerve. To avoid
these problems, the flap should be rotated distal to the ischium and, in subtotal reconstruction,
the nerve excluded.

INTRODUCTION
Since Dupuytren’s first attempt at vaginal reconstruction in 1817 [l], many
tissues have been employed including skin grafts, intestine, peritoneum, omentum,
bladder, fascia lata, amnion, and skin flaps [2]. A more recent advance in vaginal
reconstruction has been the widespread use of musculocutaneous flaps [3]. Nahai’s
recent report details the anatomy and techniques employed with musculocutaneous
flaps in gynecologic surgery [4]. Despite the excellent reliability of several mus-
culocutaneous flaps, the skin island of the gracilis flap which has been used
widely in reconstruction following pelvic exenteration and similar extirpative
procedures has not been proven reliable. The muscle has a segmented blood
supply which makes skin beyond its mid-portion unsafe and the skin is easily
sheared from the underlying muscle [5].
Hurwitz has described a posterior thigh flap whose blood supply is derived
from the inferior gluteal artery (IGA) [6]. This has proven very reliable in re-
constructing complex defects of the perineum [7]. This inferior gluteal artery
flap has proven to be ideally suited for wound closure and vaginal reconstruction
following extirpative procedures of the female reproductive system.

’ To whom reprint requests should be addressed: Division of Plastic Surgery, University of California,
Irvine Medical Center, 101 City Dr. S., Orange, Calif. 92668.

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0090-8258184$1.50
Copyright 0 1984 by Academic Press, Inc.
All rights of reproduction in any form reserved.
80 ACHAUER ET AL.

Immediate flap reconstruction has several important advantages over a delayed

procedure. A large, open wound adds greatly to postoperative morbidity while
flap closure allows primary wound healing. The risk of postoperative infection
is reduced with a closed wound, nutritional demands are less, while ambulation
and rehabilitiation can be started earlier. Because most of these patients have
received radiotherapy, local tissues heal poorly, while employing well-vascularized
tissue from outside the irradiated area enhances wound healing, thereby allowing
greater freedom in selecting procedures that can be performed. In addition, bowel
complications are reduced with flap closure by providing an uninfected, well-
vascularized pelvic floor to which loops of bowel will adhere. Furthermore, if
the oncologic surgeon knows that immediate reconstruction is readily available,
more radical resections which might have a greater likelihood of cure can be
undertaken. Finally, flaps (particularly innervated flaps) potentially permit more
satisfactory sexual function and local hygiene.
FLAP DESIGN
The landmarks for the inferior gluteal artery flap are illustrated in Fig. 1. The
IGA supplies the gluteus maximus muscle and terminates as a cutaneous vessel
to the mid posterior thigh. It parallels the course of the posterior cutaneous
nerve of the thigh. The nerve lies deep to the fascia and to the IGA; therefore,
inclusion of the nerve assures inclusion of the artery in the flap as well as
providing a sensate flap. In order to achieve this, the distal portion of the gluteus
maximum muscle must also be included in the dissection.
This thick and reliable flap can be extended to the mid thigh and probably
beyond [7]. The width is determined by how much tissue can be removed while
permitting primary closure of the donor defect but should not exceed 12 cm.
The bony landmarks are marked the night before surgery with the patient standing
and bending forward at the waist.
When the extirpative surgery is finished, either unilateral or bilateral flaps can
be used as needed. The procedure is done with the patient in the lithotomy
position. Some adjustment of the stirrups and redraping are usually required,
creating maximal flexion of the hips by raising the stirrups and tilting them
cephalad.
The proximal end of the flap is de-epithelialized and passed via a commodius
subcutaneous tunnel to the vaginal area. An attempt should be made to keep
the point of rotation below the ischial tuberosity. A tunnel is preferred to an
incision connecting the two areas (to avoid sagging of the flap pedicle when the
patient is standing). Performing the reconstruction adds about 2 hr to the operative
time with approximately 500 cc of additional blood loss. All surgical sites are
drained and the patient is placed on an air-fluidized bed (Clinitron) postoperatively
to prevent pressure on the flap. Additional fluids (and possibly calories) are
needed for patients on these beds but wound care is simplified.
CASE REPORTS
Case I
A Ml-year-old Caucasian female presented to the Gynecologic Oncology Division
in April 1979 with a IS-cm exophytic lesion on the left lateral vaginal wall at
 VAGINAL RECONSTRUCTION 81

Sciatjc nerve

Gluteus maximus

Inferic 3r gluteal vessels

Pastel .ior cutaneous nerve

FIG. IA. Anatomical landmarks and design of the flap. The flap is centered over the posterior
cutaneous nerve and inferior gluteal vessels.

the level of the hymenal ring. There were no palpable inguinal lymph nodes.
Biopsy of the lesion showed invasive, poorly differentiated squamous cell cancer.
After the options of surgery vs radiation therapy were discussed in detail with
the patient, she decided to have radiation. Between April and June 1979 the
patient had 5040-r-adswhole pelvis external radiation followed by two interstitial
implants.
Approximately 1 year later the patient developed a rectovaginal fistula, at
which time she had an exploratory laparotomy with an end-sigmoid colostomy.
No evidence of recurrent tumor was found. She was noted to have radiation
necrosis in December 1980 which progressed in severity to the point of severe
incapacitation because of intractable pain despite several attempts at debridement
82 ACHAUER ET AL.

Gluteus maxin

Sciatic nerve

Biceps fern01

FIG. 1B. Flap elevated. Part of the gluteus maximus muscle has been included as well as the
posterior cutaneous nerve of the thigh.

and intensive local therapy. In February 1981 the patient underwent a revision
of her colostomy and extensive perineal debridement with bilateral posterior
thigh flap reconstruction. This difficult wound healed primarily and a functional
vagina was created.
Case I1
A 51-year-old Caucasian female presented to an outside hospital in June 1979
with complaints of rectal bleeding. The work-up at that time revealed an anterior
rectal mass which, on biopsy, was found to be a poorly differentiated adeno-
carcinoma of the rectum. After a negative metastatic work-up, the patient underwent
an abdominoperineal resection in July 1979. At that time she was noted to have
 VAGINAL RECONSTRUCTION 83

surgical stage Duke C-II poorly differentiated adenocarcinoma with metastases

in 7 of 12 lymph nodes.
After refusing the recommended chemotherapy, she did well until July 1980
when she was noted to have a vaginal recurrence that was excised. After 1 year
of 5-FU chemotherapy an exploratory laparotomy with lysis of adhesions was
performed for a small bowel obstruction, at which time no recurrent cancer could
be found.
In July 1981 she was referred to the Gynecologic Oncology Division after she
was found to have another vaginal recurrence, approximately 3 x 4 cm in size.
The patient underwent vaginectomy with excision of the right ischiorectal fossa
and inferior gluteal thigh flap reconstruction of the perineum and vagina. She
had a benign postoperative recovery and within 3 months of surgery was engaging
in a full range of daily activities, including sexual intercourse. In July 1982,
however, she presented with vaginal bleeding and pain radiating to the right
thigh. The patient was found to have a biopsy-proven recurrence on the right
lateral vaginal wall and on the perineum in addition to metastasis in a right
preauricular lymph node.
Case ZZZ(Fig. 2)
This 55year-old gravida 4, para 3, SAB 1 Caucasian presented in June 1978
with a 3 x 4-cm exophytic lesion at the urethral meatus. The patient underwent
a bilateral inguinal lymphadenectomy and exploratory laparotomy with selective
pelvic lymphadenectomy for a well-differentiated carcinoma of the vagina and
vulva. Postoperatively she was treated with 5000 rads whole pelvis radiation
with a perineal port followed by 3000-rads intracavitary radiation.
In August 1979 she was diagnosed as having a recurrence in the anterior vagina
which was treated with an anterior exenteration with ileal conduit construction
and formation of a split thickness skin graft neovagina. Recurrence of this tumor
at the vaginal introitus was excised locally in December 1979.
In August 1981 she developed recurrence in the right labium and posterior
vagina for which a posterior exenteration with bilateral posterior thigh flap re-
construction of the perineum and vagina was done. Another superficial recurrence
was diagnosed 3 months later and, since then, these have been fairly well controlled
with wide local excision. There were no postoperative complications except for
some difficulty in sitting.
Case IV
This 55-year-old Caucasian female had a posterior vaginal mass diagnosed as
a leiomyosarcoma in January 1979. Recurrences were excised locally on four
occasions between January 1980 and June 1981 during which time the patient
refused more radical resection.
In September 1981 she was found to have another recurrence and, after a
negative metastatic work-up, the patient agreed to a more definitive surgical
procedure only if she would have a functional vagina after the surgery. She
underwent a posterior exenteration with formation of an end-sigmoid colostomy
and a posterior thigh flap reconstruction of her perineum and posterior vagina.
She had an uneventful postoperative recovery.
84 ACHAUER ET AL.
 VAGINAL RECONSTRUCTION 85

One year postoperatively she is disease-free with excellent sexual function.

Because of paresthesias in the region of the donor site, exacerbated by sitting
on the flap pedicle which had been routed over the ischium, the pedicle and
PCN of the thigh were divided, improving her symptoms.
Case V
This patient is a 46-year-old Caucasian, status posthysterectomy and whole
pelvis radiation therapy for cervical cancer (stage and histology unknown) 25
years ago. She presented to the Gynecologic Oncology Division in October 1981
with the diagnosis of a rectovaginal fistula. The patient underwent an examination
under anesthesia with biopsies of the fistula and a diverting colostomy. Biopsies
revealed an adenocarcinoma of the rectum.
The patient subsequently underwent a posterior pelvic exenteration with a left
posterior thigh flap reconstruction of the perineum and vagina. Her postoperative
recovery was complicated by febrile episodes thought to be secondary to repeated
urinary tract infections and a wound infection at the donor site on her left thigh.
She was discharged home on the 26th postoperative day. Approximately 6 months
postoperatively the patient underwent a uretero-ureterostomy for a uretero-vaginal
fistula. She is currently doing well without evidence of recurrent disease. Further
flap revision is planned to obtain a more sexually functional result.
Case VI (Fig. 3)
This 19-year-old Black female had a 7-month history of vulvar swelling. A
biopsy of a left labial mass in May 1982 showed an alveolar rhabdomyosarcoma.
The patient underwent a left radical hemivulvectomy, bilateral groin node dissection,
and a posterior thigh flap reconstruction of the vulva in June 1982. She was
found to have positive left inguinal and left pelvic lymph nodes and was started
on Vincristine, Dactinomycin, and Cytoxan chemotherapy.
Currently she is 8 months postoperative with complete healing of the surgical
area and no clinical evidence of disease. The reconstructed vagina functions well
and she has had no wound healing problem. The area has withstood postoperative
radiation well although she does note paresthesia of the thigh.
Case VZZ(Fig. 4)
This 51-year-old Caucasian G3P3 had a vaginal hysterectomy in 1978 for a
benign condition. In 1980 she was diagnosed as having a Stage II squamous cell
cancer of the vagina and was treated with 5000-rads whole pelvis radiation
followed by two interstitial implants. A recurrence in the vagina was found in
March 1982 for which she underwent a total pelvic exenteration with formation
of an ileal conduit and end sigmoid colostomy. She had a protracted postoperative

FIG. 2. (A) Defect following extirpation of recurrent squamous cell carcinoma. This case was
done early in the series and it was felt necessary to turn the patient to do the reconstruction. (B)
Two flaps have been brought to the midline and are sutured together to create a vagina. The donor
defects are closed primarily. (C) The flaps are in position. Two small flaps afford the most realistic
vaginal reconstruction. The labia can be simulated by the base of the triangle.
 FIG. 3. (A) Left side of the perineum and vagina have been excised for rhabdomyosarcoma. (B)
A long flap has been elevated. (C) The flap has been rotated into position. This flap, was not tunneled
because the space appeared to be too restricted. This does pose a problem later. If at all possible,
it is much better to tunnel the flap to prevent sagging and an abnormal contour.
86
 FIG. 4. (A) Patient in lithotomy position following extirpation of vulva and vagina. PL single flap
has be en tmtlined on the right thigh and the area to be de-epithelialized is cross-hatch1 ed . Two Raps
would ha1 ,e been preferable for a more definitive reconstruction. However, the patif ml :‘s relig jous
beliefs WC nrld not allow blood transfusions; therefore, in the interests of time and bll 00 ‘d loss, one
large i lap was used for the entire reconstruction. (B) Flap elevated showing the don or defect and
the de -epi thelialized base of the flap. A tunnel will be created to pass this tissue in1 .O the vii]
area. CC) Completely healed reconstruction. Not only is the perineum healed, but a potenl ially
functic ma1 vagina has been created which also has sensation.

87
88 ACHAUER ET AL.

hospital stay because of both a refusal to accept blood transfusions on religious

grounds and a second laparotomy for a small bowel obstruction. At that time
biopsies of the introitus revealed persistent disease. In September 1982the patient
underwent a radical vulvectomy, vaginectomy, and proctectomy with closure of
the perineal defect using a right posterior gluteal myocutaneous thigh flap. The
patient again had a prolonged postoperative hospital stay but was discharged
home 2 months postoperatively. She experienced no added morbidity from the
flap reconstruction except purulent drainage from the flap donor site for 3 weeks
postoperatively. Currently the patient is doing well without evidence of recurrent
disease.

DISCUSSION
The cases presented are all unique, dimcult wound closure problems. In addition,
vaginal function was to be sacrificed without reconstruction. Because the flap
is so well vascularized, there were no instances of flap necrosis and all wounds
healed primarily. All patients complained of pain in the donor area and most
had difficulty sitting for several months. One patient has undergone division of
the pedicle and the posterior cutaneous nerve of the thigh 1 year postoperatively
with marked reduction of her symptoms. It is now recommended that the pedicle
be tunneled to the perineum distal to the ischium. It might also be preferable to
exclude the nerve from the flap, especially if any innervated vagina remains.
Subtotal defects are adequately reconstructed with a single flap; bilateral flaps
are indicated in large pelvic defects such as those encountered following a total
exenteration if the patient’s condition will tolerate the additional surgery. If the
patient’s condition was compromised, a second flap could be used later with
additional contouring of the flap at the second procedure. The bulkiness of the
flap has been an advantage because of the magnitude of the defects to be filled.
Flaps are particularly important when the levator system is removed concomitantly
with pelvic exenteration and in cases of pre- or postoperative radiotherapy.
To be of use, a flap reconstruction should be able to be performed in a single
stage, be very reliable, and not have significant donor site problems. The inferior
gluteal ‘artery flap fulfills these requirements. The major drawback has been
discomfort in the ischial and thigh area. Specific suggestions for avoiding these
problems are a more distal location of the tunnel and leaving the posterior
cutaneous nerve of the thigh intact.

SUMMARY
Seven patients have undergone vaginal reconstruction following extirpation
surgery with the inferior gluteal artery flap. All of the flaps survived and healed
primarily. Morbidity was reduced and the postoperative quality of life improved
dramatically. Refinements in the procedure are being made continually. It can
be performed in the lithotomy position at the time of exenteration. Later procedures
may be required for the best possible vaginal reconstruction; however, wound
healing is obtained in a timely, reliable manner with this flap. In extensive pelvic
defects, two flaps are recommended but one is sufIicient for more limited resections.
 VAGINAL RECONSTRUCTION 89

REFERENCES
1. Dupuytren, G. Cited in Judin, S.: Surg., Gynecol. Obstet. 44, 530 (1927).
2. Magrina, J. F., and Masterson, B. J.: Vaginal reconstruction in gynecological oncology: A review
of techniques, Obstet. Gynecol. Survey 36, l-10 (1981).
3. McGraw, J. B., Massey, F. M., Shanklin, K. D., and Horton, C. E. Vaginal reconstruction with
gracilis myocutaneous flaps, Plast. Reconstr. Surg. 58, 176-183 (1976).
4. Nahai, F. Muscle and musculocutaneous flaps in gynecologic surgery, Clin. Obstet. Gynecol. 24,
1277-1317 (1981).
5. Vasconez, L. O., McGraw, J. B., and Hall, E. J. Complications of musculocutaneous flaps, Clin.
Plust. Surg. 7, 123-132 (1980).
6. Hurwitz, D. J., Swartz, W. M., and Mathes, S. J. The gluteal thigh flap: A reliable, sensate flap
for the closure of the buttock and perineal wounds, Plast. Reconstr. Surg. 68, 521-532 (1981).
7. Achauer, B. M., Turpin, I. M., and Fumas, D. W. Gluteal thigh flap in reconstruction of complex
pelvic wounds, Arch. Surg. 118, 18 (1983).