British Joi~niu/11/ OhsietricF and Gymecology November 1990, Vol. 97: pp. 1020-1025

The use of rectus abdominis myocutaneous flaps following excision of vulvar cancer JOHN H. SHEPHERD, PETER A. VAN DAM, THOMAS W. JOBLING, NICHOLAS BREACH Summary. Rectus abdominis inyocutaneous flaps have bcen uscd in 16 women following radical excision of extensive vulvar cancer. In two women the procedure was part of the primary surgery, in 1 1 €or rccurrence of vulvar cancer and in three for symptomatic palliation. Fiftecn (94%) of t h e grafts took with primary healing. Thirteen of the 16 patients are alive 6-60 months (median 29 months) after surgery and the three who died benefited from symptomatic palliation. Simultancous vulvar reconstruction allows good cosmetic rehabilitation and is an important part of the ariiiametarium for the management of patients with advanced primary or recurrent vulvar carcinoma. This technique offers cxcellent surgical clearance of massive offensive and painful vulvar tumours.

Although there is a trend towards more conservative treatment of in situ carcinoma and microinvasive carcinoma of the vulva, many patients still present with advanced disease which requires radical surgery (Fig. 1) (DiSaia & Crcasman, 1989). Recent preliminary reports indicate that combined radiotherapy and chemotherapy may contribute to enhanced locoregional control in advanced or recurrent diseasc. and may allow lesser surgery with prcscrvation of normal anatomy in selected cases (Thomas eral. 1989). Although we have promising results using this approach with or without surgery (unpublished data) to treat this last Department of Gynaecologiral Oncology, St. Bartholomew's and The Royal Marsden Hospitals, London, United Kingdom

J. H. SHEPHERD Co:onsul/crn/Gynuecologicul Sicrgcon P. A. VAN DAM C'litiicnl Reseurch FeIIopv T. W. JOBLING Senior Regiswar N . BREACH C'onsultunr Reconstructive Surgeon Correspondence: J . H. Shepherd MRCOG. Department of Gyiiaccological Oncology, St. Bartholomcw's Ilospital, West Smithfield, London EAlC: 7BE

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group oi patients, sometimes radical palliative surgery is the only option to relieve the unbearable symptoms which also may present great nursing difficulty. Cavanagh & Shepherd (1982) showed that in selected primary and recurrent stage IV tumours of the vulva. ultraradical excnterative surgery may be warranted. This can be explained by the fact that vulvar cancer is commonly indolent. extends slowly and metastasizes fairly late (DiSaia & Crcasnian 1989). Over half of the recurrences are local. near the site of the primary lesion and can often be treated succcsshlly by local excision and/or interstitial radiation (Simonson 1984;Prempree gi Amornmarn 1984). Most radical vulvectomy operations or wide local excisions of recurrences can be closed primarily or with the assistance of Z-plasty pcdicle flaps (Julian & Woodruff 1974). Ilowever, there arc occasional perineal resections which are so extensive that neither technique is adequate for primary closure. In these cases the myocutaneous flap can be used to cover the resulting largc denuded areas. Various musculocutaneous grafts have been described lor this purpose including the gracilis, rectua abdominis. tensor

Rectiis gruft for vulvar cancPr excision

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addition had a pelvic lymphadenectomy. The second group of 14 patients had surgery and gralting for recurrent vulvar cancer: in 11 patients the operation was intended to be curative and in threc palliativc. Seven of these patients underwent pelvic exenteration (four anterior, two posterior and one total), four had radical vulvectomy and three had a wide local excision. Most of these patients had been treated earlier for recurrent vulvar cancer: ten had previously undergone one or more wide local excisions, 11 radiotherapy and four cheniotherapy for their recurrence. The three patients who underwent a palliative procedure had very painful large fungating tumours producing loul smelling discharge and bleeding. Niey had an cxtremcly poor quality of life and with full informed consent they accepted that surgery was the only option available to relieve their symptoms as they had all received previous radiotherapy elsewhere.

Surgical techriique Fig. 1. A 72-year-old woman presenting with an extensive recurrent rnriderately differentiated squamous carcinoma of the vulva and fungating metaslatic groin nodes. As the lesion was extremely painful, foul smclling and hlccding, shc undcrwetit a palliative resection of the turnour with grafting of thc vulva and groin.

fascia lata, gluteus maximus and lattisimus dorsi flap (Bostwick et al. 1979: Morrow et al. 1979; Nahai et nl. 1079; Berek el a l . 1Y83; Logan et 111. 1984; Taylor et al. 1984; Kennedy et al. 1987). We n o w present the first follow-up study of the usc ofrectus abdominismyocutaneous grafts following radical rescction of vulva1 cancer. Patients and methods The charts of all 16 paticnts who had a perineal rcconstruction with a rectus abdoininis myocutaneous graft at the Royal Marsden and St. Bartholomew’s Hospitals during the last 6 years were revicwcd. Their ages ranged from 25 to 77 ycars (mean 55 years). They have been followed up for 4 to 72 months (median 29 months) after surgery. ‘Iivo patients had surgery for large fungating stage 111tumours. One of them also had a malignant sinus in to the right buttock. Both underwent radical vulvectomy with bilateral groin lymphadcncctoiny and the second patient in

The patient is positioned in thc Lloyd-Davis position. A dual approach is adopted with thc reconstruction inirnediately following the surgical rescction of the tumour. Multiplc sections of the rescction margins are sent for frozen scction in order to confirm complete surgical clearance of the tumoar. As the success ol‘ the grafting procedure is completely dependent on the identification and preservation of the deep inferior epigastric vascular pedicle, it is essential that the surgeon is familiar with the anatomical relations pertinent to this procedure. The flap is marked overlying the rectus abdominis muscle. Taking care not to undercut the cutaneous portion o f the Hap, thc anterior rcctus sheath is incised cranially (Fig. 2), sweeping caudally until the neurovascular bundle is identified. Once the deep inferior epigastric pcdiclc is located thc rectus muscle and overlying skin can be elevated as a unit. ‘l’he posterior rectus sheath is elevated with the flap. Then the flap is introduced through a gcnerous subcutaneous tunnel between the abdominal incision and the perineal defect. carefully avoiding rotation ol the pedicle (Fig. 3 ) . The tunnel must be of adequate sizc to prevent any constriction. If an cxentcration is performed thc pelvic floor is covered with an omental sling. The abdomen is closed by a mass closure technique with Number 1 looped Nylon or PDS. The vulvar skin is closed with intcr-

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ma1 as is outlined in Table I . The average stay in hospital after surgery was 31 days (range 21-71). There were no perioperative deaths. The three patients who underwent palliative surgcry died 4, 8 and 9 months postoperatively with widespread distant metastatic disease. However, they bcnefitcd from satisfactory palliation of their local symptoms. The other 13 patients (81%) are alive (572 months (median 29 months) after surgery. Two of them (12%) proved to have metastatic disease (one metastasih in the piriformis muscle 12 months postoperatively, and one brain metastasis 10 months postopcrativcly treated with radiotherapy). lwo further patients (12%) had a local recirrrencc in the margin of the myocutancous graft (3 and 15 months postoperatively) and required further wide Local excision. ‘ l h e five younger women have functional vaginas and are sexually active. One is trying to conceive and if succcssful hopes for a vaginal delivery. None of the patients showed any evidence of an incisional hernia of the abdominal wound.

Pig. 2. Taking care not to undercut thc cutaneous portion of the flap. thc antcrior rcctiis sheath is incised cranially, sweeping caudally until the ncurovascular hundlc is identified.

rupted stitches and staples are used for the abdominal wound (Fig. 4). Aftcr exenteration the pelvis is drained with a Robinson drain. ‘Ihe abdominal and pelvic wounds are drained with Portovac suction drains. Perioperative prophylactic antibiotics (cefuroxinie and nietronidazole) were given and women were mobilized early after surgery. The grafts were inspected evcry day for skin edge necrosis. If necessary the skin was trimmed and refashioned. Results

Fifteen of the 16 grafts took with primary healing. In one, the rectus abdominis myocutaneous flap necrosed within the first postoperative week, probably due to an insufficient vascular pediclc in a 78-year-old woman with known

which did not require any secondary grafting. Morbidity due to the radical surgery was mini-

thc tumour, one can see the ileal conduit which has been cathetcrizcd.

Rectuc. grnfi ,for vulvur cancer excision

Fig. 3. Grafted vulva immediately postoperatively showing the hcall!iy rcctua abdominis inyocutancous graft, a patent vagina and ttic Portovac suction drainage of the pcririeal wound.

Discussion Great progress has been made in vulvar recnnstruction aftcr radical surgery and many techniques are now available to restore normal anatomy in thcsc paticnts. A split thickness skin graft (STSG), which is a free skin graft completely dctachcd from the donor site, is used primarily to cover skin defects where there was little o r no loss ol subcutaneous tissue, such as after skinning vulvectomy. However, a STSG can have only a limited success il the recipient arca is immcdiatcly overlying bone or has been previously irradiated. In gynaecology, rotational flaps o r transposition flaps are most commonly used to cover extensive full-thickness defects o n the vulva, groin or perianal region after radical surgery (Julian ef id. 1074; Barnhill ef ~ 1 1983; . Gusberg et d.1988). They contain skin, underlying subcutaneous tissue, and occasionally the deep fascia and can be derived lrom adjacent vulvar, perineal, buttock o r thigh skin. However, thc l :1.5 restriction of width to lcngth with cutaneous flaps limits their usc around the pclvis. 'l'he cutaneous rotational flap particularly is

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not very reliable (Stern and Lacey 1987). 7'he principle that the skin can be moved together with the undcrlying muscle was Iirst used in the reconstruction of the cheek using a sternomastoid myocutaneous ilap (Owens 195.5). Since their introduction to gynaecology b y McCraw et al. (lY76), myocutaneous flaps have bccn widcly used for vulvar, vaginal and pelvic reconstruction (Hostwick et al. 1979; Morrow et al. 1979: Nahai et at. 1979; Whccless et nl. 1979: Rerek et ~ d 1983; . Logan et al. 1984; Taylor et ~1.1984; Lacey ef nZ.19XS; Cain et al. 1989; Iilford et id. 1989). Myocutaneous grafts are required when very large defects need to be covered or when the vulva has been irradiated previously. They are vcry suitable for this hecause of a wide arc of rotation and transfer of an island of skin rather than a broad-based peclicle. In addition. myocutaneous flaps also bring a new blood supply to the recipient wound, which has often been devascularized by previous radiotherapy or surgery (McCraw et a/. 1977). Circumstanccs inHuencing choice 01gralt include size, contour, depth of the delormity, proximity of the deformity to the potential donor site, presence of necrosis and infection and the requirement of a new blood supply (Stern & Lacey 1987). In some situations. it is necessary to use several reconstructive procedures simultaneously, or serially; to achieve optimal reconstruct ion. Radical and extcnsivc excision with rectus abdominis grafting of primary advanced and recurrent vulvar cancers in selected cases offers excellent surgical removal of these massive off'lahle 1. Complications related to the grafting procedure and to radical surgcry in the 16 women undergoing radical excision of vulvar cancer with a simultaneous rcctus abdominis myocutaneous flap operation

Myocutaneous Rap operation 1. Loss of the entire flap secondary to insufficient dominant vascular pedicle requiring a tensor fascia lata gi-aft (one patient). 2. Loss of a small segment of the Hap (about 2 x 2 em) not requiring grafting (two patients). Radical surgery

1. Pulmonary embolus successfully medically treated (one patient). 2. Ucep venous thoinbosis (one patient). 3. Urinary tract infection (three patients). 3 . Groin abcess requiring draining (one patient).

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cnsivc and painful tumours. Allowing that most of the patients in this series had received cxtcnsive treatmcnt previously; the overall and disease-free survival is excellent. ‘I’he technique should he reserved for those in whom extensive perineal resection is required to provide adequate clearence of the primary carcinoma or recurrence. At the same time release of severe pcrincal contractures and adequate excision of previously heavily irradiated perineal tissue may be achieved. Distant metastasis is in our opinion a relative contraindication for this type ol radical surgery. However, on occasions the palliative excision of large and painful lesions may be indicated, not only t o obtain symptomatic relief but also to allow- easier nursing and personal hygiene. The use of the rcctus abdominis myocutaneOLIS gralt lor vulvar reconstriiction allows early mohilisation and has a low morbidity. T h e rcctus abdominis myocutaneous flap is an exceptionally versatile Ilap and allows movement of a large segment of skin with the rectus muscle to the groin orperineal area (Logan Br Mathcs 1984). It has the advantage over other flaps that the scars can b e hidden under normal clothing o r a bathing suit. This is particularly importarit lor the cosmetic rehabilitation of younger women where the psychosexual effects from radical gynaccological surgery can be severely disabling.

Acknowledgments I’his work has been supported by a European Community Cancer Research Grant, a NATO Research Grant and a Helgisch Werk Tcgcn Kanker Research Grant.

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thc rhomboid flap after partial vulvcctomy. 06.sfer Gynecol62, 444-447. Rccker D. W., h4assey F. M . 61 McCraw J . B. (1979) Musculocutanous flaps in reconstructive pelvic s w gcry. ahstet Cvnrcol54, 178-lS3. Bcrck J . . Hackcr N . & Lagasse I>. (l98i) Vaginal reconstruction performed simultancouqlywith pelvic cxcntcration. Ohstrt Gynecol63, 31 8-323. HostwickJ.,HillN. C. &Nahai F. (1979) Repair i n the lower abdominal groin or perineum with myocuta-

neous or omental flaps. Plast Kecorrsfr Surg 63, 186-194. Cairi J. M.. Diamond A . , Tamimi H. K . , Greer B. E. 61Figgc D. C. (198Y) The morbidity and benefits of concurrcnt gracilis myocutancous graft with pelvic exenteration. Obstet Gynerol74, 185-189. Cavanagh D. X: Shcpherd J . H. (1982) The place of pelvic exentcration in the primary management of advanced carcinoma of the wilva. (;ynecol Oncol 13, 318-322. Di Saia P. J . 61 Creasnian W. T. (1989) Invasive cancer of the vulva. In Clinicul Gynecologic Oncology. (Bircher S., ed), The CV Mosby Company. St Louis, pp. 242-241. Gusbcrg S. B., Shinglcton H. M. & Ueppe G . (eds) (1988) Reconstructive surgery of the vulva and vagina. In Frmulr Genital Ctrncrr. Churchill Livingstonc, Ncw York, pp. (335-637. Julian C. C;. 61 Woodruff J . 1). (1971) Surgcry of the vulva: vulvcctomy. In C+nrcologic Surgery Errol.;, S n f ~ g u u r d Salvage, ~, (Ridley J. H. ed), Williams and Wilkins. Baltimore; p. 256. Kennedy C. L., Breach N . M., Shephcrd J. H. Rr Hcndry W. F. (1987) The usc o f myocutaneous flaps following radical excision of the external gcnitalia. Br J Uroi 59, 272-276. Lacey C., Stern J . 61 Feigcnbaum S. (19XX) LTaginal reconstruction aftcr exenteration with use of gracilis niyocutancous flaps: the Univcrsity of California, San Francisco expericncc. A m J Obstet Gynecol 158, 1278-1284. Lilford R. J.. Johnson N , RL Ratchclor A. (1989) A new opcration for vaginal agcnesis: construction of a nco-vagina from a rectus abdominus musculocutancous flap. B r / Ohster Gynaeccil91,1089-1094. . 1. (1084) The use of the recLogan S. E. 61Math tus ahdominis myocutaneous flap to reconstruct a groin defect. Br J Plusf Surg 27, 351-353. McCraw J. B., Massey F. M . , Shanklin K . D. 61 Horton C. (1976) Vaginal reconstruction with gracilis myocutaneous flaps. F’lusf Kecon.\friicf Srrrg 58, 176-183.

McCraw J. B., Dibbcll D. G. & Carraway J. H. (1977) Clinical definition of independent myocutancous vascular territories. Plust Hecomfvuct Surg 60? 341.352. Morrow C . P.. Laccy C . G. Rr Lucas W. E. (1979) Rcconstructive surgcry in gynaecologic oncology employingthe gracilis myocutaneous pedicle graft. Gynrcol Oricoll, 176-187. Nahai F. lIilll1. L. Cuc Hester T. R. (1979) Experience with the tensor fascia lata flap. Plusf Keconsf Suvg 63, 788-799. Owens N . (1955) A compound neck pcdiclc designcd for the rcpair of massive fdcial defects. PlusfRrco m t r Surg 15. 369-389. Prcmpree T. 61Amornmarn K.(1984) Radiation treatment of rccurrcnt carcinoma of the vulva. Cancer 54, 1943-1048. Sinionson E. (1984) Treatment of recurrcnt rquainous

Rectus gruft for vulvar cancer excision cell carcinoma o f the vulva. Ann Rudiol Oizcol23, 345-350. Stern J. F. & Lacey C. G. (1987) Vulvovaginal reconstruction lollowing radical surgery. Builliere's CEin Obstet Gynnecol 1, 287-292. Taylor G. I.. Corlett R. J . & Boyd J . B. (1984) The vcrsatile dccp inferior epigastric (inferior rectus abdominis) flap. l?r .I Plusf Surg 37, 330-350. Thomas G., Dctnbo A , , Dc Pctrillo A , , cf al. (1Y8Y)

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Concurrent radiation and chemotherapy in vulvar carcinoma. Gynecol Oncol34, 263-267. Wheelcss C. R., McGibbon B., Dorsey J. H. & Maxwell P. (1079) Gracilis niyocutancous flap in reconstruction of thc vulva and female perincum. 0 6 s ~ Gymcol54, 07-102.

Received 23 November 1989 Accepted 14 March 1990