Grabb’s Encyclopedia of Flaps Upper Extremities, Torso, Pelvis, and Lower Extremities

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The endovaginal packing was removed on the seventh postoperative day without analgesics, and visual
exploration of the endoneovagina showed a healthy and viable artificial vagina with adequate
measurements. Labial edema was a minor complication. All the patients considered their reconstructions to
have had satisfactory cosmetic results. Patients who have a partner (the first two in the series) reported
adequate sexual relationships with no difficulties; intercourse with the use of lubricants was possible 3 to 4
weeks postoperatively. No urinary infection or urethral-anal incompetence were noted. Problems secondary
to the reconstruction, such as the need for meticulous hygiene for 6 months postoperatively, were minor.
FIGURE 430.4 Diagram of operative technique (refer to text). (From Giraldo et al., ref. 10, with permission.)
Endovaginal examination performed by adult speculum showed adequate dimensions and no complications,
such as epidermic cysts, local infections, introital strictures, neovaginal stenosis, or mechanical lesions.
Persistent hair within the vagina was finer and more dispersed in the younger patients (16 to 17 years of
age); in a patient with the longest follow-up (4 years), cutaneous methaplasia and incipient hairy atrophy,

most dispersed on the left hemivagina, were verified. Depth and width were measured carefully and without
pressure, by means of the number of fingers that could be introduced. In all cases, bidigital vaginal
examinations were possible until the indicis PIP joint was passed.
SUMMARY
Paired vulvoperineal fasciocutaneous flaps have been used for complete vaginal reconstruction in six
patients with Mayer- Rokitansky syndrome. Results have been encouraging.
References
1. Morton KE, Davies E, Dewhurst J. The use of fasciocutaneous flaps in vaginal reconstruction. Br J Obstet
Gynaecol 1986;93:970.
2. Hagerty RC, Vaughn TR, Lutz MH. The perineal artery axial flap in reconstruction of the vagina. Plast
Reconstr Surg 1988;82:344.
3. Dumanian GA, Donahoe PK. Bilateral rotated buttock flaps for vaginal atresia in severely masculinized
females with adrenogenital syndrome. Plast Reconstr Surg 1992;90:487.
4. Wee JT, Joseph VT. A new technique of vaginal reconstruction using neurovascular pudendal-thigh flaps:
a preliminary report. Plast Reconstr Surg 1989;83:701.
5. Woods JE, Alter G, Meland B, Podratz K. Experience with vaginal reconstruction utilizing the modified
Singapore flap. Plast Reconstr Surg 1992;90:270.
6. McIndoe AH, Banister JB. An operation for the cure of congenital absence of the vagina. J Obstet
Gynaecol Br Empire 1938;45:490.
7. Giraldo F, Gaspar D, Gonzalez C, et al. Treatment of vaginal agenesis with vulvoperineal fasciocutaneous
flaps. Plast Reconstr Surg 1994;93:131.
8. Giraldo F, Mora MJ, Solano A, et al. Anatomic study of the superficial perineal neurovascular pedicle:
implications in vulvoperineal flap design. Plast Reconstr Surg 1997;99:100.
9. Cormack GC, Lamberty BGH. A classification of fasciocutaneous flaps according to their patterns of
vascularization. Br J Plast Surg 1984;37:80.
10. Giraldo F, Solano A, Mora MJ, et al. The Malaga flap for vaginoplasty in the Mayer-Rokitansky-Kuster-
Hauser syndrome: experience and early-term results. Plast Reconstr Surg 1996;98:305.

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Chapter 431
New Technique of Vaginal Reconstruction Using Neurovascular
Pudendal-Thigh Flaps
V. T. JOSEPH
J. T. K. WEE
EDITORIAL COMMENT
This is an excellent and reliable technique. The location of the vessels is tricky but easily learned. Most of
the other local techniques of vaginal reconstruction are based on Dr. Wee's original description of the
vessels.
The neurovascular pudendal-thigh flap is a useful one that can reliably reconstruct the vagina in congenital and
acquired conditions. The technique is simple, safe, and reliable, with no stents or dilators required. The
reconstructed vagina has a natural angle and is sensate, and donor-site scarring in the groin is inconspicuous.
INDICATIONS
Previous attempts to reconstruct the vagina (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11) suffered from a variety of
disadvantages, including the necessity of stenting, an unphysiologic angle of the reconstructed vagina, the
precarious vascularity of some flaps, and donor-site morbidity. Cadaveric studies (12) of the blood and
nerve supply of the perineum, medial groin, and upper thigh led to the design
of the neurovascular pudendal-thigh flap, which enables reconstruction of an innervated vagina with skin
flaps that have a robust and reliable blood supply. The technique is superior to previously available
methods. It is simple, safe, and reliable. No stents or dilators are needed, and the reconstructed vagina has
a physiologic angle for intercourse and is sensate. Donorarea scars in the groin are well hidden.
However, in squamous cancers of the vulva and lower third of the vagina, there is a high possibility of
lymphatic spread to the groin; in such cases, it may be prudent to avoid the pudendal- thigh flap, as its use
would then be tantamount to using potentially malignant tissue for reconstruction.
The procedure is not limited to vaginal reconstruction: it may be used for the closure of difficult perineal
wounds and fistulas, especially after irradiation. In males, it may be used to reconstruct the scrotum or
penis.
ANATOMY
The internal pudendal artery supplies the perineum by means of its first branch, the inferior rectal artery, which
courses through the anal region, and then by means of the perineal artery, which enters the superficial perineal
pouch at the base of the perineal membrane. The perineal artery, after giving off the transverse perineal artery,
continues on as the posterior labial arteries. The posterior labial arteries anastomose with branches of the deep
external pudendal artery, as well as the medial femoral circumflex artery and the anterior branch of the obturator
artery over the proximal part of the adductor muscles (Figs. 431.1, 431.2, 431.3).
The main anastomoses are with the deep external pudendal artery. Hence, by a process of “capture” of adjacent

territory of the deep external pudendal artery, the posterior labial arteries extend to the femoral triangle. This is
the vascular basis of the pudendal-thigh flap, which is nourished by this direct cutaneous system of arteries. The
deep fascia and the epimysium over the proximal part of the adductor muscles underlying the flap should be
included in the flap, to prevent injury to the direct cutaneous arteries when the flap is elevated (Fig. 431.4). The
veins closely follow the arterial supply.
The posterior region of the labia majora is supplied medially by the posterior labial branches of the perineal
nerve from the pudendal nerve. Laterally, the perineum is supplied by the perineal rami of the posterior
cutaneous nerve of the thigh. The anterior region of the labia majora is an indeterminate area of mixed
innervation, supplied by the pudendal, ilioinguinal, and genitofemoral nerves.
FIGURE 431.1 Corrosion cast demonstrating arterial anastomosis around the thigh and pudendal region. (From
Wee and Joseph, ref. 12, with permission.)
FIGURE 431.2 Dissection showing anastomosis between the main arterial trunks in the groin. (From Wee and
Joseph, ref. 12, with permission.)
The posterior part of the pudendal-thigh flap retains its innervation from the posterior labial branches from the
pudendal nerve, as well as from the perineal rami of the posterior cutaneous nerve of the thigh when it is

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elevated. The anterior
part of the flap near the medial corner of the femoral triangle, supplied by nerve twigs of the genitofemoral and
ilioinguinal nerves, may be denervated in the process of elevation. Hence, sensation would be retained only in
the lower part of the reconstructed vagina.
FIGURE 431.3 Diagrammatic illustration of arterial supply of the pudendal-thigh flap. (From Ehrlich RM, Alter GJ,
eds. Reconstructive and plastic surgery of the external genitalia. Philadelphia: WB Saunders Co., 1996, with
permission.)
FIGURE 431.4 The subfascial plane in which the flap is elevated. (From Wee, Joseph, ref. 12, with permission.)
FLAP DESIGN AND DIMENSIONS
A skin flap measuring 15 × 6 cm, with its posterior skin margin at the level of the posterior end of the introitus,
can be raised as a skin island borne on a subcutaneous pedicle supplied by the posterior labial arteries (Fig.
431.3). It can be transposed through 70 degrees to meet its counterpart from the opposite side, forming a cul-de-
sac in the midline. By raising the flap with the deep fascia of the thigh and the epimysium of the adductor
muscles, an additional barrier is created, which prevents inadvertent damage to the neurovascular structures of
the flap. It is probable that the addition of the layer of fascia may confer improved vascularity on the flap, as in a
type A fasciocutaneous flap (13).
The flap is essentially horn-shaped, with the flare of the horn at its base. It is planned lateral to the hair-bearing
area of the labia major and centered on the crease of the groin. The base of the flap is marked transversely at
the level of the posterior end of the introitus. In the adult, the base can be 6 cm wide. This will allow direct
closure of the donor site without much undermining. The flap can measure up to 15 cm in length and still remain
safe. This places the tip of the flap in the femoral triangle. The dimensions of the flap can be made proportionally

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smaller in prepuberal females. A flap 15 × 6 cm is safe in adults, since it is arterialized throughout its length by
the posterior labial and deep external pudendal arteries (Fig. 431.5).
In congenital cases, the plane between the base of the bladder and the rectus has to be created. A Foley
catheter in the bladder and a finger or Hegar dilator in the rectum would facilitate the development of this plane
and avoid visceral injuries. In ablative cancer resection, the lower marginal incision to remove the vagina usually
ends as a circumferential incision at the mucocutaneous junction with the labia minora. The posterior skin margin
of the flap is sutured to the opposite margin and also to this circumferential incision at the mucocutaneous
junction.
FIGURE 431.5 Diagrammatic illustration of progressive steps in the surgical procedure for pudendal-thigh flap
vaginal reconstruction. (From Ehrlich RM, Alter GJ, eds. Reconstructive and plastic surgery of the external
genitalia. Philadelphia: WB Saunders Co., 1996, with permission.)
OPERATIVE TECHNIQUE
The patient is placed in a lithotomy position with the legs in stirrups. The bladder is catheterized. The abdomen
is prepared to allow simultaneous laparotomy or pelvic exenteration. A narrow transverse drape at the level of
the pubis separates the abdomen from the perineum.
The incision, beginning at the tip of the flap, is deepened through skin and subcutaneous tissue down to deep
fascia on two sides, except for the posterior margin of the flap. The subfascial plane is developed, raising the
epimysium of the adductor muscles with the deep fascia. The deep fascia is tacked to the skin flap to prevent
shearing. The flap is elevated until the posterior skin margin is reached. The margin is incised through dermis to
subcutaneous tissue to a depth of 1.0 to 1.5 cm, and then undermined in a plane parallel to the skin for a
distance of about 4 cm posteriorly (Fig. 431.6). This enables the flap to be transferred through 70 to 90 degrees,
to meet its counterpart in the midline, and to allow the posterior skin
margin of the flap to be sutured to the labia minora. This is effected by elevating the labia off the pubic rami and
the perineal membrane.

FIGURE 431.6 Vaginal atresia: outline of flaps for reconstruction. (From Ehrlich RM, Alter GJ, eds.
Reconstructive and plastic surgery of the external genitalia. Philadelphia: WB Saunders Co., 1996, with
permission.)
FIGURE 431.7 Flap margins demarcated. Labial attachment divided, showing tunnel for cross-passage of flap.
(From Ehrlich RM, Alter GJ, eds. Reconstructive and plastic surgery of the external genitalia. Philadelphia: WB
Saunders Co., 1996, with permission.)
At this plane of elevation of the labia off the periosteum of the pubic rami and the peroneal membrane (in order to
tunnel the flaps), there is no danger of denervating the labia, as the posterior labial nerves have already entered
the labial fat pad far behind posteriorly. The clitoral nerves are also in no danger, because they do not pass
through the superficial perineal pouch, but instead course through the deep perineal pouch to reach the clitoris.
The flaps are tunneled under the labi (Fig. 431.7). The posterior suture line where both flaps meet is completed
first, with the flaps everted through the introitus. After the tip is reached, the anterior suture line is then begun.
The tip of the cul-de-sac is then invaginated and anchored to the curve of the sacrum in the totally exenterated
pelvis, by taking a large bite of periosteum with nonabsorbable sutures (Fig. 431.8). Correspondingly, the tip of
the new vagina may be anchored to the rectum or bladder in anterior or posterior partial exenterations. In
congenital cases, the tip of the new vagina may be moored to whatever pelvic structures are suitable, e.g., to
uterine rudiments. The opening of the vagina is sutured to the mucocutaneous edge of the labia minora. Drains
are inserted into the cavity containing the vagina, as well as flap donor sites. The patient is kept in bed with
thighs adducted, until healing occurs. Urinary catheter drainage is continued throughout.

FIGURE 431.8 Both flaps tunneled through and apex being sutured. (From Ehrlich RM, Alter GJ, eds.
Reconstructive and plastic surgery of the external genitalia. Philadelphia: WB Saunders Co., 1996, with
permission.)
FIGURE 431.9 Flaps sutured together to create neovagina. Donor areas closed by primary suture. (From Ehrlich
RM, Alter GJ, eds. Reconstructive and plastic surgery of the external genitalia. Philadelphia: WB Saunders Co.,
1996, with permission.)
Only the lower part of the flap can be seen through the introitus for its circulation to be monitored postoperatively
(Fig. 431.9). Photoplethysmography may be used to monitor the deeper part of the flap, if desired. Attempts at
monitoring the flap by cutting the dermis with a #15 blade to elicit bleeding, would cause pain because the flaps
retain their innervation.
CLINICAL RESULTS
In a preliminary small series of three patients, there were no complications, even as experience with the
technique was being accumulated. This illustrates the robustness and intrinsic viability of the flaps.
Reconstruction of a stable, skin-lined vagina was achieved, with no vaginal contraction. No stenting or

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dilatation was required to maintain the dimensions of the reconstructed vagina, unlike the situation with
some other techniques. In contrast to other procedures utilizing the
gracilis myocutaneous flap, even at its most reliable use, there was no incidence of flap necrosis.
The pudendal-thigh flap is very robust, with a reliable blood supply. There have been no problems with flap
survival in our limited series. Among advantages of this procedure are the following. (1) This is a simple
technique that can be completed in 2 or 2.5 hours with little blood loss. (2) The blood supply of the flaps is
reliable and leads to early wound healing. (3) No stents need be maintained, since the reconstructed vagina
is stable. (4) The introduction of well-vascularized flap tissue into the pelvic cavity after exenteration aids in
obliterating dead space, leading to primary healing of the exenterated cavity. (5) The angle of inclination of
the vagina is physiologic and natural. (6) The linear scars of the donor sites are well-hidden in the groin
crease and perineum; no thigh wounds need to be made to raise the flaps or harvest skin grafts. (7) The
reconstructed vagina is sensate and retains the same innervation of erogenous zones of the perineum and
upper thigh.
SUMMARY
The neurovascular pudendal-thigh flap procedure can be used reliably to reconstruct the vagina in
congenital and acquired conditions.
References
1. Goldwyn RM. History of attempts to form a vagina. Plast Reconstr Surg 1977;59:319.
2. Frank RT. The formation of an artificial vagina without operation. Am. J Obstet Gynecol 1938;35:1053.
3. McIndoe A. The treatment of congenital absence and obliterative conditions of the vagina. Br J Plast Surg
1949;2:254.
4. Williams EA. Congenital absence of the vagina: a simple operation for its relief. J Obstet Gynaecol Br
Commonwealth 1964;71:511.
5. McCraw JB, Massey FM, Shanklin KD, Horton CE. Vaginal reconstruction with gracilis myocutaneous
flaps. Plast Reconstr Surg 1976;58:176.
6. Heath PM, Woods JE, Podratz KC, et al. Gracilis myocutaneous vaginal reconstruction. Mayo Clin Proc
1984;59:21.
7. Lagasse LD, Berman ML, Watring WG, Ballon SC. The gynecologic oncology patient: restoration of
function and prevention of disability. In: L McGowan ed. Gynecologic Oncology. New York: Appleton-
Century- Crofts, 1978;398.
8. Lacey PM, Morrow CP. Myocutaneous vaginal reconstruction. In: Morrow CP, Smart GE, eds.
Gynecologic oncology. Berlin: Springer-Verlag, 1986. P. 255.

9. Wheeless CR. Vulvar-vaginal reconstruction. In: Coppleson M, ed. Gynecologic oncology: fundamental
principles and clinical practice Vol. 2. Edinburgh: Churchill Livingstone, 1981, 933.
10. Song R, Wang X, Zhou G. Reconstruction of the vagina with sensory function. Clin Plast Surg
1982;9:105.
11. Wang TN, Whetzel T, Mathes SJ, Vasconez LO. A fasciocutaneous flap for vaginal and perineal
reconstruction. Plast Reconstr Surg 1987;80:95.
12. Wee JTK, Joseph VT. A new technique of vaginal reconstruction using neurovascular pudendal-thigh
flaps: a preliminary report. Plast Reconstr Surg 1989;83:701.
13. Dibbell DG. A fasciocutaneous flap for vaginal and perineal reconstruction (Discussion). Plast Reconstr
Surg 1987;80:103.

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Chapter 432
“Short” Gracilis Myocutaneous Flaps for Vulvovaginal
Reconstruction
J. T. SOPER
EDITORIAL COMMENT
The use of the short skin paddle over the proximal portion of the gracilis myocutaneous flap unquestionably
increases flap viability, since the skin paddle is notoriously unreliable on the distal third of the muscle.
Described in another chapter (Chapter 442), the transverse orientation of the skin island over the gracilis
muscle will provide for a longer island of skin.
In the short gracilis flap modification of the classic long gracilis flap, the dominant vascular pedicle supplying the
gracilis muscle is deliberately sacrificed, and a smaller myocutaneous unit is developed from the medial thigh.
INDICATIONS
The long gracilis flap has been used for a variety of complex pelvic reconstructions (1, 2, 3, 4, 5, 6, 7). In a
modified short gracilis flap
(7, 8), a smaller skin island is developed and the primary vascular pedicle is deliberately sacrificed. Direct
comparisons of reconstructions using both long and short gracilis flaps have revealed no increase in flap
loss or other flap-specific complications with the use of the short flap (7, 8, 9). The short flap can be
considered merely a modification or variation of the long flap, and both forms are often used by the
reconstructive surgeon.
Currently, the short flap is our preference, when a gracilis myocutaneous flap is used for neovaginal
reconstruction after pelvic exenteration. We are reluctant to use this flap, if there has been hypogastric or
obturator artery ligation or chemoradiation delivered to the groin, situations that would theoretically impair
the vascularity of the short flap.

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FIGURE 432.1 Diagram showing comparison of the size and location for short (A) and long (B) gracilis flap
skin islands. Skin for the island should be harvested posterior to a line from the pubic tubercle to the medial
tibial plateau.
ANATOMY
The thin, strap-like gracilis muscle is the most medial adductor of the thigh. It originates from the pubic tubercle
and runs posterior to the adductor longus, to insert into the medial tibial plateau.
The gracilis muscle derives its major blood supply from a vascular perforator from branches of the medial femoral
circumflex artery. This supports a large territory of skin extending along the medial thigh and into the distal third
of the thigh posterior to the adductor longus. The dominant vascular pedicle is constant in location, entering the
deep gracilis muscle, with paired venae comitantes and nerve approximately 6 to 8 cm distal to the pubic
tubercle, after passing between the adductor longus and brevis muscles (Fig. 432.1). An accessory
blood supply, derived from anastomotic terminal branches of the obturator and pudendal arteries, enters within
the proximal 1 to 3 cm of the gracilis muscle (Fig. 432.1). These accessory vessels are not as well-defined as the
dominant vascular pedicle, but they can support the short gracilis myocutaneous flap for pelvic reconstructions.
FLAP DESIGN AND DIMENSIONS
The gracilis flap can be rotated either anteriorly or posteriorly within a wide arc of rotation, allowing the flap to be

deployed for anterior vulvar or groin reconstruction, neovaginal formation, or repair of posterior vulvar and
perineal defects. The arc of rotation of the classic flap is around the mobilized dominant vascular pedicle, while
the short flap is rotated around the origin of the muscle from the pubic tubercle. If a classic long gracilis flap is
developed, the proximal muscle can be divided to facilitate rotation but, usually, there is sufficient mobility so that
division of the muscle is not necessary. Furthermore, division of the proximal muscle deprives the flap of its
secondary blood supply.
OPERATIVE TECHNIQUE
The patient is positioned in the modified Whitmore position, using Allen stirrups with the hips abducted
approximately 45 degrees and flexed slightly. The medial thighs are prepped to the knees, to allow access to the
full skin island, if needed. A guideline is drawn on the medial thigh from the pubic tubercle to the medial tibial
plateau, along the margin of the adductor longus muscle. The skin island supplied by the gracilis will be located
posterior to this line. A 10- to 14-cm long × 5- to 8-cm wide ellipsoid skin island centered over the proximal
gracilis muscle will be used for the short flap, with the proximal margin located at the crural fold (Fig. 432.2).
FIGURE 432.2 The skin island for the short gracilis flap is harvested by incising the anterior margin first, to
facilitate identification of the gracilis muscle. Relationships of primary and secondary blood supplies to the
gracilis muscle are schematically illustrated.
A full-thickness incision is made along the anterior and distal margins of the skin island through the fascia (Fig.
432.1). It is important that the incision be either straight to the fascia or slightly flared at its base, so that the skin
will not be undermined and lose vascularity. The skin is loosely anchored to the fascia with temporary interrupted
sutures, to prevent shearing of the fat away from the underlying fascia during manipulation of the flap. The belly
of the gracilis muscle is identified at the distal margin of the flap, posterior to the adductor longus. It is isolated
and divided. The remainder of the full-thickness incision is completed around the margin of the skin island
through the fascia.
The gracilis is mobilized from its bed with sharp and blunt dissection. It is important to work from the distal tip of
the flap toward the origin, so that the dominant vascular pedicle can be identified and preserved, if desired (Fig.
432.3). The dominant vascular pedicle enters the deep anterior belly of the gracilis approximately 6 to 8 cm from
the pubic tubercle, emerging from underneath the belly of the adductor longus muscle. With its paired venae

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comitantes, it is easily distinguished from the loose areolar tissue between the muscles. The nerve usually enters
with, or just proximal to, the dominant vascular pedicle. If a classic long flap is to be used, the pedicle is
mobilized; if a short flap is to be used, the pedicle is cross-clamped, divided, and ligated (Fig. 432.3). The nerve
can usually be spared, to provide muscular innervation and sensibility to the skin island in the short flap, but may
be sacrificed. The remainder of the gracilis flap is mobilized to its origin. In a short flap, the 2 to 3 cm of the
proximal gracilis muscle should not be aggressively skeletonized, so that small accessory vessels are not
stripped away from the muscle.
FIGURE 432.3 After developing the skin island dividing the distal gracilis muscle, the flap is elevated from the
medial thigh. The primary vascular pedicle is identified (A), entering the muscle 7 to 8 cm from its origin.
Although this vascular pedicle is preserved in the long flap, it is deliberately sacrificed (B) in the short gracilis
flap.
For neovaginal construction, a subfascial tunnel is constructed to the vaginal introitus with sharp and blunt
dissection. The tunnel should allow passage of the gracilis flap freely without pressure. Bilateral flaps are rotated
posteriorly through the tunnels and allowed to hang freely between the patient's legs. The neovaginal tube is
constructed by approximating the skin edges with interrupted absorbable sutures.
When unilateral or bilateral flaps are used for vulvar reconstructions, the flaps are rotated either anteriorly or
posteriorly, depending on the defect, without use of the subfascial tunnels. The muscle is anchored to the deep
tissues of the defect with loose interrupted sutures, and the skin approximated with interrupted absorbable
sutures.
The thigh incisions are irrigated and closed in layers over closed suction drains. Patients are allowed to
ambulate within 24 to 48 hours after surgery.
CLINICAL RESULTS
Patients receiving the gracilis flap for pelvic reconstruction have undergone radical surgery, often with prior
irradiation or combined chemoradiation; any analysis of complications should recognize the morbid nature of
these procedures. If gracilis flaps are used during an exenteration, the neovaginal reconstruction can be
performed by a second team, without interrupting the abdominal procedure.
Flap-specific complications can be arbitrarily divided into those related to the donor site and those involving

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the flap specifically. In our experience, patients with short gracilis flaps tend to have fewer donor-site
infections or hematomas than those who receive long gracilis flaps (9). Additionally, patients with short flaps
have smaller medial-thigh scars than those with long flaps. However, these donor-site complications are
usually only minor inconveniences, rather than major sources of morbidity.
Complications involving the flap include introital stenosis, neovaginal prolapse, flap loss, and indirect
complications of rectovaginal fistula formation caused by tissue pressure upon a rectosigmoid anastomosis.
Stenosis of the vaginal introitus is observed in approximately 9 percent of patients, occasionally requiring
operative revision in women who desire intercourse, but it is also a relatively minor complication. Avoidance
of a circular introital scar and proper planning at the time of neovaginal formation can usually prevent this
complication. Overall, approximately 47 percent of our patients are sexually active after gracilis flap
reconstruction (9).
Neovaginal prolapse has been observed more frequently in patients receiving the classic long gracilis flap
than in those with short gracilis flap neovaginas after exenteration (10); in our experience, prolapse after
exenteration occurs in only 3 percent of patients (9). This relatively low incidence is probably related to a
compulsive effort to fit the neovagina snugly within the pelvic crater, and to anchor it to the sacral hollow,
symphysis, and/or levator plate.
Flap loss of varying degrees is observed in approximately 10 to 20 percent of patients with gracilis flaps,
ranging from minor loss of skin and subcutaneous tissue from the tips or margins of the flaps, to complete
loss of one or both myocutaneous units (1, 2, 3, 4, 5, 6, 7, 8, 9, 10). Flap loss of less than 50 percent of the
flap is usually considered only a minor inconvenience. Patients in this category are treated with dilute
peroxide irrigation until there is a good base of granulation tissue. The muscle usually survives, and a
functional neovagina or vulvar reconstruction results after muscle reepithelialization.
Loss of more than 50 percent of the flap usually requires operative debridement. Total loss of the
myocutaneous unit frequently occurs in these patients, often resulting in chronic vaginal stenosis or other
pelvic complications. We analyzed factors associated with the loss of gracilis myocutaneous flaps in 22
women with classic long flaps and in 24 with short flaps for pelvic reconstruction (9). The incidence of major
flap loss was 14 and 17 percent, respectively, a nonsignificant difference.
Considering various clinical and operative factors, only performance of a gracilis flap neovagina, in
conjunction with pelvic exenteration combined with rectosigmoid anastomosis, was significantly associated
with major flap loss, compared to other exenterative procedures or other types of radical pelvic procedures.
It is possible that pressure on the myocutaneous unit from surrounding tissue compromises venous return or
blood flow into the flap. Similarly, a myocutaneous flap might jeopardize healing of a rectosigmoid
anastomosis. It has been reported (5) that two of three patients in a series receiving gracilis flaps under
these conditions developed major flap loss and rectovaginal fistula. Use of a single gracilis flap, a smaller
flap such as the bulbocavernosus myocutaneous flap, or a rectus myocutaneous or myoperitoneal flap
might avoid these complications, when neovaginal reconstruction is performed in conjunction with
rectosigmoid anastomosis.
SUMMARY
The short gracilis flap modification can be successfully utilized for complex pelvic reconstructions. Analysis
of flap-specific complications indicates that the risk of loss for a gracilis neovagina is increased, when the
procedure is performed following pelvic exenteration with rectosigmoid anastomosis, compared to total
pelvic exenteration or other radical pelvic reconstructions.

References
1. McCraw JB, Masey, FB, Shanklin, KD, et al. Vaginal reconstruction with gracilis myocutaneous flaps. Plast
Reconstr Surg 1976;58:176.
2. Becker DW, Massey FM, McCraw JB. Myocutaneous flaps in reconstructive pelvic surgery. Obstet
Gynecol 1979;54:178.
3. Morrow CP, Lacey CG, Lucas WE. Reconstructive surgery in gynecologic cancer employing the gracilis
myocutaneous pedicle graft. Gynecol Oncol 1979;7:176.
4. Berek JS, Hacker NF, Lagasse LD. Vaginal reconstruction performed simultaneously with pelvic
exenteration. Obstet Gynecol 1984;63:318.
5. Lacey CG, Stern JL, Feigenbaum S, et al. Vaginal reconstruction after exenteration with use of gracilis
myocutaneous flaps: the University of California at San Francisco experience. Am J Obstet Gynecol
1988;158:1278.
6. Cain JM, Diamond A, Tourimi HK, et al. The morbidity and benefits of concurrent gracilis myocutaneous
graft with pelvic exenteration. Obstet Gynecol 1989;74:185.
7. Copeland CJ, Hancock KC, Gershenson DM, et al. Gracilis myocutaneous vaginal reconstruction
concurrent with total pelvic exenteration. Am J Obstet Gynecol 1989;160:1095.
8. Soper JT, Larson D, Hunter VJ, et al. Short gracilis flaps for vulvovaginal reconstruction after radical pelvic
surgery. Obstet Gynecol 1989;74:823.
9. Soper JT, Rodriguez G, Berchuck A, et al. Long and short gracilis flaps for vulvovaginal reconstruction
after radical pelvic surgery: comparison of flap-specific complications. Gynecol Oncol 1995;56:271.
10. Soper JT, Berchuck A, Creasman WT, et al. Pelvic exenteration: factors associated with major surgical
morbidity. Gynecol Oncol 1989;35:93.

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Chapter 433
Reconstruction of The Vagina Using The Modified “Singapore”
Flap
J. E. WOODS
P. YUGUEROS
W. J. KANE
EDITORIAL COMMENT
This flap also demonstrates the reliability of the circulation to the perineal area and its usefulness for
vaginal reconstruction.
A modification of the originally described (1) Singapore flap for vaginal reconstruction is a single-stage
procedure, with excellent flap reliability, simplicity, and a relatively brief time required to carry out the procedure.
INDICATIONS
There are various techniques for reconstructing the vagina. We have concluded that the simplest and most
acceptable
approach in our hands is a modification of the flap originally described by Wee and Joseph (1), which we
have modified (2). This modification involves a single-stage procedure with excellent flap reliability and the
potential for normal or near-normal function, with minimal donor-site morbidity and technical simplicity.
ANATOMY
Pudendal thigh flaps are based on the posterior labial arteries, which are a continuation of the perineal artery.
These arteries anastomose with branches of the deep external pudendal artery, as well as the medial femoral
circumflex artery, and the anterior branch of the obturator artery over the proximal portion of the adductor muscle.
When elevated, the posterior portion of the flap retains innervation from the posterior labial branches from the
pudendal nerve, as well as from the perineal rami of the posterior cutaneous nerve of the thigh. Thus, the flaps
may be expected, at least in their proximal portions, to be partially sensate (1).
FLAP DESIGN AND DIMENSIONS
The flaps, which are designed to measure 15 × 6 cm, are raised bilaterally in the groin crease just lateral to the
labia majora, and include the deep fascia and the epimysium of the adductor muscles, to avoid inadvertent
damage to the neurovascular structures. The base of the flap is located at the level of what would be the normal
posterior margin of the vaginal introitus, before its disruption by surgery.
OPERATIVE TECHNIQUE
While the flaps were originally designed and used as island flaps (1), because so many patients have had
previous heavy radiation and multiple procedures, as well as concomitant intraoperative irradiation, we simply
divide the labia posteriorly, allowing them to retract forward, avoiding any possible flap compromise, and allowing

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for optimal insetting. This permits easy suturing and insetting of the pedicle flaps, with some minimal aesthetic
loss that has not appeared to be a concern of patients. Figure 433.1A-F illustrates the technique diagram-
matically and photographically.
After the flaps have been elevated, they are sutured together with moderately long-lasting absorbable sutures,
and they provide a pouch that is ample for normal intercourse. Once the pouch is completed, it is invaginated
into the cavity, which may require partial closure after a total exenteration. The remnants of the portions of the
flap remaining outside the cavity are sutured to the wound margins, to provide completion of the repair.
Since this procedure is often done at the time of total or partial exenteration, and the gynecologic surgeon is
continuing intraabdominal surgery concomitantly with our repair, we have provided a nonabsorbable suture
attached to the apex of the pouch, which is then fixed by the intraabdominal surgeon to the sacrum or adjacent
structures. A Vaseline-coated pack is placed in the vagina with an external tag to allow easy removal, and a T-
binder is used to maintain the pack within the cavity. The pack may be changed on a daily basis after the second
postoperative day, and helps to maintain the position of the vagina, with the T-binder in place, during the initial
several weeks of healing. This minimizes the probability of prolapse, when the apex of the pouch cannot be fixed
in the pelvis.
We prefer to use absorbable sutures in areas where suture removal at a later date will occasion a great deal of
discomfort, utilizing 2-0 or 3-0 Vicryl in the suturing of the pouch.
CLINICAL RESULTS
In 31 patients in whom this procedure was carried out, many of them under adverse circumstances after
extensive ablative procedures and both previous and intraoperative irradiation, only one flap failure
occurred, and this was in an extremely heavily-irradiated patient. We have experienced dehiscence and
other wound complications occasionally, but these have been related almost totally to extensive ablative
procedures and irradiation, rather than to the flap itself. Of course, function varies with the patient's age and
degree of debilitation from extensive radiation and chemotherapy. We have performed the procedure in
irradiated patients who have received radiotherapy to the inguinal and perineal regions, but do so with
some caution, as this has been the only situation in which we have seen flap failure. Even with a history of
radiation, if there are not extensive stigmata signifying radiation damage, we have carried out the procedure
without significant morbidity.
There have been some problems with stenosis at the neointroitus, but these can be minimized by the use of
dilators once healing has occurred or, occasionally, by a small Z-plasty type of procedure.
SUMMARY
This single-stage procedure, a modification of the Singapore flap, has been very useful in cases of vaginal
reconstruction. The flaps are reliable and technically simple, with the potential for normal or near-normal
function, and minimal donor-site morbidity.

FIGURE 433.1 Diagrammatic representation of vaginal reconstruction using the modified Singapore flap. A:
Exenteration defect prior to reconstruction. B: Partial suturing of defect with 6- × 15-cm flaps straddling the
inguinal crease. C: Flaps elevated at the subfascial level, with division of the labia posteriorly, to allow easy
insetting of the neovagina without incision of the skin at the base of the flaps. D: Initial suturing of the flaps
is carried out to evert the flap edges into the neovagina, avoiding burial of the dermis. E: The completed
pouch prior to insetting. Note preliminary closure of the donor defects. F: Nearly completed suturing of
neovagina after insetting. (From Woods et al., ref. 2, with permission.)
References
1. Wee JT, Joseph VT. A new technique of vaginal reconstruction using neurovascular pudendal-thigh flaps:
a preliminary report. Plast Reconstr Surg 1989;83:701.
2. Woods JE, Alter G, Meland B, Podratz K. Experience with vaginal reconstruction utilizing the modified
Singapore flap. Plast Reconstr Surg 1992;90:270.

Chapter 434
Rectus Abdominis Flaps in Vaginal and Pelvic Reconstruction
G. R. TOBIN
EDITORIAL COMMENT
This chapter reflects another method of vaginal reconstruction. Release of the pedicle of the muscle is
important for closure of this very reliable flap.
Rectus abdominis flaps and their variations are readily adaptable to all types of exenterative pelvic surgery, to
reconstruction of all patterns of vaginal resection, and to defects of the groin, external pelvis, vulva, and
perineum (1, 2, 3, 4).
INDICATIONS
Radical pelvic resection of the vagina and endopelvic organs creates exceptionally difficult reconstructive
challenges that are well-served by the distally-based rectus abdominis muscle- skin flap carrying an
inversely-tubed epigastric skin paddle to form a neovagina. None of the other described techniques of
vaginal reconstruction (5, 6, 7, 8) provides as much volume of well-vascularized tissue to defects that are
usually irradiated. In addition to restoring sexual function, rectus abdominis flaps block entry of the bowel
into the pelvis, revascularize the irradiated pelvic-cavity wall, and lessen the incidence of pelvic infection,
fistulae, and chronically-open perineal wounds. Even when intercourse will likely not be resumed
postoperatively, the patient receives the benefit of pelvic filling with well-vascularized tissue to lessen
infections and healing complications.
The flap was developed specifically for vaginal reconstruction in the radical pelvic resection defect (1),
although it can be varied and used in other conditions of vaginal absence. It has become the choice of
many experienced surgeons for oncologic reconstruction, because it provides a highly reliable vaginal
replacement, while also filling the endopelvic defect with well-vascularized tissue. The excellent perfusion of
the flap revascularizes the defect and reduces the incidence of postoperative pelvic infections, while the
bulk of the flap and muscle pedicle serves to block bowel herniation.
When male patients having abdominal-perineal resection or exenteration would benefit from the bulk and
revascularization provided by this flap, the flap is deepithelialized to the deep dermal level and placed in the
pelvic space without being tubed. If a skin paddle is required for perineal closure, an appropriately-sized
island is left on the distal paddle beyond the deepithelialized portion and inset into the perineal defect.
Additional advantages of the flap result from its exceptional versatility in paddle design and placement.
Following a supralevator extenteration, flaps from the thigh or groin (7, 8) must be passed around the
retained vaginal cuff through a difficult dissection. With the rectus abdominis flap, the distal end is simply
joined to the vaginal cuff at the cut end. With some rectal and posterior vaginal-wall resections for rectal
lesions, the bladder and anterior vaginal wall can be retained. In these cases, the paddle is designed with
dimensions appropriate to the resection and inset along the margins of the retained anterior vagina, without
complete tubing. If partial vulvectomy is required with the vaginectomy, the distal end of the flap is enlarged
and opened onto the perineum in a trumpet-like fashion (see Fig. 434.4C).
Circumstances in which the flap is not indicated include transection of the muscle and vascular pedicle by

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previous incision. Deep inferior epigastric vessel ligation probably also precludes use of the flap. The most
distal of the segmental collateral vessels entering the posterolateral surface of the muscle are usually
preserved in transfer, and these could theoretically supply the flap in the absence of the deep inferior
epigastric vessels, but I am not aware that this has yet been established. Another reservation is in
reconstruction of vaginal agenesis when the abdomen is unscarred (Rokitansky-Kuester-Hauser syndrome
and related conditions). Since a less conspicuous donor-site scar is preferable to a long vertical scar,
design of the flap with a transverse skin paddle placed just below the umbilicus, as in the paddle used for
TRAM-flap breast reconstruction (9), provides a more acceptable donor-site scar for this group of patients,
if vaginal reconstruction with flap tissue is preferred over skin grafts and stents (Abbe-McIndoe technique)
(10, 11).
ANATOMY
The anatomic features relevant to the rectus abdominis muscle-skin flap are shown in Figure 434.1A. The rectus
abdominis muscle-skin flap is based on either of the paired rectus abdominis muscles spanning the abdominal
wall from
the ventral thoracic cage to the pubis on either side of the linea alba. The dense rectus sheath fascia encases
the upper three-quarters of the muscle, but the posterior rectus sheet is absent distal to the linea arcuata.
FIGURE 434.1 Cutaneous paddle designs of rectus abdominis flaps for reconstruction showing the relationship
of the paddle to the muscle, vascular pedicle, laparotomy incision, and surface landmarks. A: Diagram of the
most frequently used design, with a vertical paddle axis aligned with the muscle. B: Diagram of the transverse
paddle, which can be used to lessen tissue bulk in the deep pelvis. (From Tobin et al., ref. 2, with permission.)
The blood supply to the upper muscle is the superior epigastric vessels, which are divided in transfer of this flap.
These are a continuation of the internal mammary vessels and run on the deep surface of the muscle. The
overlying epigastric skin is supplied by cutaneous perforators from the muscle, which pass through the anterior
rectus sheath.
The blood supply of the distal muscle is the deep inferior epigastric vessels, which originate from the external

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iliac vessels near the inguinal ligament, and run on the deep surface of the distal muscle. Cutaneous perforators
from this portion of the muscle supply the hypogastric abdominal skin, which is also supplied by the superficial
inferior epigastric vessels that run in a parallel pattern in the subcutaneous tissue.
The deep inferior and superior epigastric vascular systems are joined by anastomic vessels across a vascular
watershed in the mid-portion of the muscle near the umbilicus. This allows the entire muscle-skin unit to receive
a vascular supply from either end. For example, this flap carries an epigastric skin paddle supplied by cutaneous
perforators from the upper muscle, across the vascular watershed from the deep inferior epigastric vascular
pedicle. This mirrors the vascular supply of the TRAM flap used for breast reconstruction, in which hypogastric
skin is carried by cutaneous perforators from the lower muscle supplied across the watershed from the superior
epigastric pedicle (9).
The muscle also receives a collateral vascular supply from segmental vessels that accompany the motor nerves
entering the posterolateral border of the muscle. In transposition of this flap, most of these are divided to permit
transfer, but the most caudal one or two can usually be preserved in vaginal reconstruction. More distal transfers
require dividing all of them.
FLAP DESIGN AND DIMENSIONS
The full cutaneous territory of the flap extends vertically from the costal margin to the pubis, and horizontally from
lines defined by the ipsilateral anterior superior iliac spine and contralateral mid-inguinal line. Therefore, the
cutaneous paddle can be designed in a wide variety of patterns within this area and can be placed anywhere
along the course of the muscle. The most common cutaneous paddle design for vaginal reconstruction is a wide
vertical ellipse centered over the upper half of the muscle, extending from just below the umbilicus to just below
the costal margin, and approximately 20 to 25 cm long (Fig. 434.1A). The paddle width is related to the intended
luminal diameter by the formula within, an 11-cm-wide paddle provides a luminal diameter of about 3.5 cm. If
needed, substantially greater paddle widths of up to three times this size can be reliably carried, when placed
within the vascular territory described above.
An alternative cutaneous paddle design that is occasionally useful is a transversely-oriented ellipse placed just
above or just below the umbilicus (Fig. 434.1B). The half of the ellipse forming the proximal neovagina is
centered over the muscle, and the half of the ellipse forming the distal neovagina extends either medially across
the mid-line (as in Fig. 434.1B), or laterally toward the flank. This allows the distal neovagina to be made much
less bulky when the endopelvic passage is narrow and bulk is unwanted, such as in vaginectomies with bladder
preservation and colonic pull-through for low rectal anastomosis. Placement of the transverse paddle above the
umbilicus better protects the usual stoma sites, while placement of the
paddle first below the umbilicus leaves a lower scar profile and can be used if stomas are not needed.

FIGURE 434.2 Demonstrating steps of the operative procedure. A: Schema of a vertical flap transposition from
the abdominal field to the groin region for formation of the vaginal pouch, which allows simultaneous construction
of the urinary conduit and colostomy. (From Tobin et al., ref. 2, with permission.) B: Flap transposition in a
patient showing the flap and donor site. C: Formation of the neovagina by inverse tubing of the paddle and
closure of the anterior rectus sheath in process.
Deepithelialized, untubed paddles are used in males when the benefits of well-vascularized tissue bulk are
desired without a vaginal reconstruction. If needed, a distal skin island can be preserved and inset into the
perineal defect.
OPERATIVE TECHNIQUE
The steps of the operative technique are demonstrated in Figures 434.2, 434.3, 434.4. Following incision of the
skin paddle, a corresponding island of the underlying anterior rectus sheath is incised. This fascial island can be
made narrower than the overlying skin paddle, to permit direct closure of the remaining anterior rectus sheath. A
0.5- to 1.0-cm-wide strip of anterior rectus sheath adjacent to the linea alba, and another lateral strip of anterior
rectus sheath 3 to 4 cm wide, are left in situ (Fig. 434.2A-C) for subsequent direct closure of the anterior fascial
layer.
FIGURE 434.3 Inverse tubing method of the skin paddle used to create a vaginal pouch. (From Tobin et al., ref.
2, with permission.)
The muscle is transected at the level of the skin-paddle cephalic end, and the superior epigastric vessels are
divided. The skin paddle and muscle pedicle are then elevated from the underlying posterior rectus fascia by
sequential division of the segmental neurovascular pedicles that enter the lateral muscle border. This is
continued only until the flap is sufficiently mobilized to reach the recipient site. Distal to the skin paddle, the

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anterior rectus sheath is left in situ and attached to the overlying hypogastric skin and subcutaneous tissue, to
provide abdominal-wall structure following flap transfer.
Subsequent to flap elevation, the vaginal pouch is formed by inverse tubing of the skin paddle. This is done with
the flap transposed distally onto the groin region surface, which allows a second surgical team to construct a
urinary conduit and colostomy while the vagina is simultaneously being formed. The lateral margins and
periumbilical apex of the paddle are sutured to each other, to form a pouch closed on one end with the skin on
the inside (Fig. 434.3). The flap is then passed through the distal mid-line peritoneal incision into the pelvis, and
the open end of the vaginal pouch is inset
into the vaginal cuff or perineal defect, to form a neo-introitus (Fig. 434.4A-D).
FIGURE 434.4 Closure of the donor defect after inset of neovagina and stomas. A: Diagram illustrating direct
closure of the anterior rectus fascia donor site above the umbilicus (arrows) and abdominal-wall closure below
the umbilicus by suture of the anterior rectus fascia to the linea alba. B: Direct closure of the cutaneous donor
site in continuity with the laparotomy. C: Neovagina and vulva reconstructed in a patient who had a simultaneous
exenteration and vulvectomy. D: Neovagina reconstructed in a patient who had a supralevator exenteration. The
introitus and a short vaginal cuff were preserved. (Fig. 434.4A and B from Tobin et al., ref. 2, with permission.)
Following placement of colostomy and urinary conduit stomas, the abdominal donor site and the lower abdomen
are closed directly. At the skin-fascial paddle donor site, the lateral and medial strips of the anterior rectus sheath
may be sutured together, to provide a second layer of fascial closure over the intact posterior rectus sheath.
Occasionally, these fascial margins cannot be completely approximated due to excess tension; they are then
simply inset into the underlying posterior rectus sheath. This method of fascial inset without anterior sheath

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closure was used routinely in the initial group of patients reconstructed with this flap (1); no hernias or fascial
bulges occurred at the fascial donor site. However, the theoretic potential for donor-site weakness led us to
leave fascial margins and to close the anterior rectus sheath whenever possible (2, 3).
Distal to the umbilicus, the mid-line anterior rectus-sheath incision is closed by suturing it to the linea alba over
the transposed muscle pedicle (Fig. 434.1A). The skin-paddle donor site is closed directly in continuity with the
laparotomy incision by direct approximation of the elliptical margins. Closed suction drains are used at both
donor and recipient sites. Stents or dilation of the neovagina are not needed postoperatively.
CLINICAL RESULTS
We have used the rectus abdominis flap in reconstruction of radical pelvic resections in over 100 cases
since 1983 (1, 2, 3). Our experience with the flap in vaginal reconstructions has been substantially more
favorable than with gracilis flaps (7, 12, 13) or any other method that we used previously.
Advantages of rectus abdominis reconstructions are many. First, the obliteration of the residual endopelvic
space and the exclusion of bowel allowed by the bulk of the flap and location of the pedicle are far superior
to any other flap. Second, rectus abdominis flaps are far more reliable than gracilis flaps (7, 12). The
gracilis flap has one of the highest incidences of flap loss, and the rectus abdominis has one of the lowest
(14). Third, a single flap restores the vaginal pouch, compared with bilateral flaps that are required by the
gracilis and several other
flap reconstructions. Fourth, the rectus abdominis donor site closes in continuity with the laporotomy
incision and avoids additional donor sites on the thighs, which are occasionally sensitive (13). Fifth, surface
quality is excellent, and stents or dilators are not required to maintain neovaginal luminal dimensions.
Finally, revascularization of irradiated pelvic wounds is provided by the excellent vascularity of the flap, and
the incidence of infection after radical pelvic surgery when this flap is used has fallen dramatically from that
occurring before its introduction.
In our cases to date, we have had only one complete flap loss, which occurred in a heavy smoker whose
iliac artery was severely narrowed and occluded postoperatively. There was one other significant partial
paddle loss, a 30 percent loss, successfully treated by skin grafting the muscle bed. There was one partial
prolapse. We have had no donor-site hernias or bulges, and we have not used any prosthetic patches to
reinforce the donor site.
SUMMARY
The distally-based rectus abdominis muscle-skin flap is a highly reliable, versatile technique for vaginal
reconstruction, endopelvic revascularization, and reconstruction of large defects of the pelvic exterior, lower
abdomen, groin, or perineum. The procedure is recommended over other methods of vaginal reconstruction
for radical pelvic resections.
References
1. Tobin GR, Day TG. Vaginal and pelvic reconstruction with distally based rectus abdominis myocutaneous
flaps. Plast Reconstr Surg 1988;81:62.

2. Tobin GR, Pursell SH, Day TG. Refinements in vaginal reconstruction using rectus abdominis flaps. Clin
Plast Surg 1990;17:705.
3. Tobin GR. Pelvic, vaginal and perineal reconstruction in radical pelvic surgery. Surg Oncol Clin North Am
1994;3:397.
4. Shepherd JH, Van Dam PA, Jobling TW, Breach N. The use of rectus abdominis myocutaneous flaps
following excision of vulvar cancer. Br J Obstet Gynaecol 1990;97:1020.
5. Goldwyn RM. History of attempts to form a vagina. Plast Reconstr Surg 1977;59:319.
6. Doering DL, Bosscher JR, Tobin GR. Pelvic reconstructive surgery. In: Shingleton HM, et al., eds.
Gynecologic oncology: current diagnosis and treatment. Philadelphia: WB Saunders, 1996;486-502.
7. McCraw JB, Massey FM, Shanklin KD, et al. Vaginal reconstruction with gracilis myocutaneous flaps.
Plast Reconstr Surg 1976;58:176.
8. Hurwitz DJ, Dweibel PC. Gluteal thigh flap repair of chronic perineal wounds. Am J Surg 1985;150:386.
9. Hartrampf CR, Scheflan M, Black PW. Breast reconstruction with a transverse abdominal island flap. Plast
Reconstr Surg 1982;69:216.
10. Abbé R. New method of creating a vagina in a case of congenital absence. Med Rec 1898;54:836.
11. McIndoe A. Treatment of congenital absence and obliterative conditions of the vagina. Br J Plast Surg
1950;2:254.
12. Heath PM, Woods JE, Podratz MD, et al. Gracilis myocutaneous vaginal reconstruction. Mayo Clin Proc
1986;59:21.
13. Massey FM. Vulvovaginal reconstruction following radical resection. Clin Obstet Gynecol 1986;29:617.
14. Mathes S, Nahai F. Muscle and myocutaneous flaps. In: Goldwyn RM, ed. The unfavorable result in
plastic surgery: avoidance and treatment, 2nd ed. Boston: Little, Brown, 1984;111.

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Chapter 435
Transpelvic Rectus Abdominis Flap Reconstruction of Defects
Following Abdominal-Perineal Resection
S. S. KROLL
EDITORIAL COMMENT
It is important to divide the rectus muscle completely, rather than to use the muscle as a point of pedicle
attachment. The vasculature is extramuscular in the inferior portion and will leave a much smaller opening in
the perineal reflection than is required by passing the muscle through.
Defects left after abdomino-perineal resection (APR) of rectal cancers are often very slow to heal secondarily,
particularly if radiotherapy has been administered. An effective method of achieving a healed wound is to transfer
an inferiorly-based rectus abdominis myocutaneous flap to the perineum through the pelvis immediately following
the APR (1).
INDICATIONS
The most common indication for this procedure is an APR for treatment of rectal cancer (Fig. 435.1). The
flap is most useful for previously irradiated patients, but can also be used in non-irradiated patients in order
to achieve primary healing
and to keep the bowel away from the perineum, if the patient needs subsequent radiotherapy. Variations of
the procedure can also be used for vaginal reconstruction (2), and for the reconstruction of defects
following radical removal of the sacrum for treatment of advanced sarcomas.
FIGURE 435.1 A large defect after abdomino-peroneal resection for treatment of rectal carcinoma. (From
Kroll et al., ref. 1, with permission.)
ANATOMY, FLAP DESIGN AND DIMENSIONS
The flap is a standard vertical rectus abdominis myocutaneous flap based on the deep inferior epigastric vessels
(Fig. 435.2) (3, 4). The flap tip should be extended past the costal margin to increase the potential arc of rotation,
should that be necessary. The random portion over the rib cage should extend laterally, parallel to the ribs and

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following the direction of the underlying blood vessels. Flap width will depend on abdominal skin laxity, but is
always at least 8 cm, usually more.
OPERATIVE TECHNIQUE
An inferiorly-based rectus abdominis myocutaneous flap is elevated in the usual manner (3) on the side opposite
the planned colostomy. The inferior part of the flap (closer to the pedicle) is deepithelialized, so that the exposed
skin paddle will come from the upper abdomen. The rectus muscle insertion on the pubis is usually not detached,
to protect the pedicle against excessive traction. The flap is transferred through the pelvis into the perineal
defect, and the area of exposed skin is marked. The flap is brought back up to the abdomen, to deepithelialize
the remaining skin that will be buried, then passed back to the perineum, where it will remain permanently. The
posterior rectus sheath is released with a horizontal incision to avoid restriction of the pedicle, which might
otherwise impede vascular flow and lead to partial flap loss.
In the perineum, the flap skin paddle can be used to reconstruct missing vaginal wall or external skin (Fig. 435.3).
If no skin is required, the entire flap can be deepithelialized and buried in the pelvis, to provide needed bulk and
to be a source of non-irradiated tissue to improve healing.
Once the flap has been delivered to the perineum, the general surgeon returns to perform the colostomy, if one
is required. After that has been completed, the abdomen is
closed. The superior part of the posterior rectus sheath is closed to the midline fascia with heavy running suture.
(I use No. 1 Novafil, but Prolene or nylon will work fine.) The posterior sheath inferior to the horizontal release is
left open, so that the pedicle will not have any interference. The anterior sheath is closed from top to bottom in
two layers, using the same heavy running suture (5). The subcutaneous wound is closed over a drain using 2-0
Vicryl for Scarpa's fascia and 3-0 buried Vicryl for the dermis. Sutures or staples are used for the skin, depending
on the surgeon's preference. Because of the skin sacrifice, the umbilicus will be displaced to one side, while the
colostomy placed through the opposite (usually the left) rectus abdominis muscle will be drawn to the mid-line.
FIGURE 435.2 Diagram showing required horizontal incision made in the posterior rectus sheath near the
pedicle origin, so that the sheath does not kink the pedicle where it turns into the pelvis.

FIGURE 435.3 After passing the flap through the pelvis, the flap tip is brought out in the perineum to repair the
skin defect. (From Kroll et al., ref. 1, with permission.)
CLINICAL RESULTS
The blood supply to the flap is generally good and, barring a technical error, flap necrosis is uncommon
unless the surgeon has forgotten to release the posterior rectus sheath near the origin of the deep inferior
epigastric vessels, as described above. Similar to post-TRAM-flap surgery, ventral hernias or bulges can
occur, if the fascial repair has not been meticulous (5). Wound dehiscence in the perineum occurs
occasionally, but is generally a self-limiting problem. Seromas can also develop, particularly if the wound
has not been adequately drained.
SUMMARY
The transpelvic rectus abdominis flap is a relatively simple, reliable, and effective way to bring non-
irradiated tissue into the lower pelvis or perineum. It is particularly useful for immediate repair of defects
created by APR, but difficult to perform later. It should be considered whenever an APR must be performed
in an irradiated wound, especially if a large defect is anticipated.
References
1. Kroll SS, Pollock R, Jessup JM, Ota D. Transpelvic rectus abdominis flap reconstruction of defects
following abdominal-perineal resection. Am Surg 1989;55:632.
2. Tobin GR, Day TG. Vaginal and pelvic reconstruction with distally based rectus abdominis myocutaneous
flaps. Plast Reconstr Surg 1988;73:734.
3. Mathes SJ, Nahai F. Clinical atlas of muscle and musculocutaneous flaps. St. Louis: Mosby, 1979.

4. Mathes SJ, Nahai F. Clinical applications for muscle and musculocutaneous flaps. St. Louis: Mosby,
1982.
5. Kroll SS, Marchi M. Comparison of strategies for preventing abdominal- wall weakness after TRAM flap
breast reconstruction. Plast Reconstr Surg 1992;89:1045.

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Chapter 436
Penile Skin Flap for Vaginal Reconstruction in Male Transsexuals
R. MEYER
Transsexualism has been recognized as a serious gender disorder (1). Once there were very few surgeons who
would undertake the transformation of male genitals into those of the opposite sex. Today, more surgeons are
challenged by these operations, and such surgeons work concurrently with psychiatrists and endocrinologists.
The method I present is used to create a neovagina in the male transsexual using the penile skin as an island
flap for vaginal lining (2, 3, 4). The labia are shaped with scrotal skin using two Z-plasties; a small bud of corpus
cavernosum covered by innervated glans skin substitutes for a clitoris. This method has the double advantage of
needing only one intervention and of providing a very satisfying aesthetic and functional result (Fig. 436.1).
INDICATIONS
There have previously been four different techniques used to form a vulva and a vagina in the male
transsexual: (1) invagination of the penile skin as an anteriorly based flap, (2) use of a full-thickness penile
skin graft for the vaginal lining, (3) use of a split-thickness skin graft for vaginal lining, scrotal and penile
skin forming only the labia, and (4) use of penile skin as a
posteriorly based flap. With the previous invagination of penile skin as an anteriorly or posteriorly based
flap, a second intervention was needed to resect the redundant scrotal skin and to shape the labia.
Surgeons using this two-stage procedure wished to avoid cutting through the skin at the base of the flap in
order not to jeopardize the blood supply of the penile skin.
FIGURE 436.1 A-C: Three representative cases showing late results.
I am proposing a fifth technique: Using a penile skin flap to construct a neovulva and neovagina, I perform a
one-stage aesthetic and functional procedure. Since I cut through the skin and not through the
subcutaneous tissue, I still maintain sufficient vascularization.
FLAP DESIGN AND DIMENSIONS
In my one-stage procedure, the penile skin is invaginated as an island flap. I perform ablation of the corpora
cavernosa, castration, and plastic construction of a neovagina in the same procedure.

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FIGURE 436.2 A: The anatomic relationships of the neovagina. B: Anatomy at the beginning of the intervention.
My technique consists of forming a cavity between the bladder and the rectum to receive invaginated penile skin.
In order to obtain an anterior convergence of the labia in front of a newly built clitoris at the base of the
amputated corpora cavernosa, I perform a very superficial Z-plasty in the lower inguinal zone bilaterally. By
removing a large amount of scrotal skin on both sides of the new vaginal introitus and at the perineal
commissure, in addition to the bilateral anterior Z-plasty, I cut the skin practically all around the penile flap. The
flap, deprived of any cutaneous continuity, remains connected to surrounding tissue only by a dense
subcutaneous vascular layer that ensures its blood supply. Thus the penile flap becomes a subcutaneous island
flap (Fig. 436.2). In the last few years I have added a construction of a sensitive clitoris to my procedure. For that
purpose, I combine my method of
invaginating the penile skin with the technique of Eldh (5), which is included in his two-flaps procedure using
penile and scrotal skin sutured together. In this technical addition, the neurovascular bundle of the penis is
dissected free together with a part of the glans and brought to the site of a neoclitoris through a slit in the skin.
FIGURE 436.3 A: Intraoperative view at the beginning of the procedure. B: Dissection of the corpora cavernosa
from the penile skin. C: The corpora cavernosa fully separated from the penile skin.
OPERATIVE TECHNIQUE
After placing a urinary catheter in position, the first step consists of dissecting the penile skin, together with the
skin of the glans, from the corpora cavernosa and the corpus spongiosum through an 8-cm midline incision in the
posterior part of the scrotum (Fig. 436.3). I leave as much as possible of the subcutaneous penile blood supply,

P.1167
P.1168
P.1169
preserving the perineal arteries and veins (see Fig. 436.2). At this point a dorsal part of the glans, which is
attached to the dissected neurovascular bundle, is trimmed to achieve a suitable size and is shaped to simulate
the clitoris. It is brought out by means of a slit in the penile skin some centimeters anterior to the urethral meatus.
The neurovascular pedicle is placed in a gentle curve under the penile flap in order to avoid kinking. The
preserved part of the preputial skin is used to create a hood by suturing these edges to the edges of the slit. The
proximal segment of the corpus spongiosum is dissected free from the corpora cavernosa before proceeding to
their ligature and transection at their base. The two remaining stumps of the corpora are sutured together in the
midline to construct a small, erectile neoclitoris.
Bilateral orchiectomy is the next step. The spermatic cords and accompanying vessels are sectioned at the level
of the inguinal ring, and suture ligatures are applied to their stumps. The penile flap is then pulled downward,
and a horizontal incision is made at its anterior base at the proper location of the new orificium urethrae.
Together with the previously inserted catheter, the urethra is passed through this hole, trimmed to a new
adequate length, and its free edges are sutured to the skin.
Formation of the new vaginal cavity is begun by a horizontal incision in the perineum. I transect the fascia
diaphragmatis urogenitalis inferior (Denonvillier's), cut the rectourethral muscle and levator ani muscle in the
midline, and enlarge the vaginal introitus created this way by blunt dissection between the bladder and rectum,
following the urethra up to the prostate (Fig. 436.4). The inverted penile skin is then pushed into the new vaginal
cavity and held in position by packing with an ointment-treated gauze roll only or by a rubber foam mold in a
condom. The posterior base of the penile flap is trimmed and sutured to perineal skin, while the redundant
scrotal skin is removed.
To give a natural appearance to the labia majora, a bilateral Z-plasty is performed in the lower inguinal zone.
The anterior branches converge in front of the site of the neoclitoris, which is emphasized by folding the skin of
the glans with pinching mattress sutures. Beneath, a budlike prominence has been shaped from the remaining
tissue of the corpora cavernosa (Fig. 436.5). A Penrose drain is inserted into the perineal cavity on each side.
The urethral catheter and the vaginal packing are removed between the fifth and seventh postoperative days. An
inflatable silicone obturator is then inserted and used without interruption for 2 to 3 months (Fig. 436.6).
CLINICAL RESULTS
My experience with 85 operated patients shows that the subcutaneous vascular supply of the penile island
flap is quite adequate. When a split-thickness skin graft is used for vaginal lining and the scrotal and penile
skin is used only for labial reconstruction, one encounters the disadvantages of all split-thickness skin
procedures. With the use of a full-thickness penile skin graft for the vaginal lining, the hazard of a poor
“take” is even greater. In my hands, full-thickness skin grafts have been useful
for enlarging, and especially for deepening, the neovagina secondarily in cases of insufficient caliber and
length.

FIGURE 436.4 A,B: Anatomy after resection of the corpora cavernosa. (Continued)
FIGURE 436.4 (Continued) C: Intraoperative view of the new vaginal space ready to receive the
invaginated penile skin.

FIGURE 436.5 A,B: The bilateral Z-plasties performed in the lower inguinal zone to give a natural
appearance to the labia majora. The anterior branches converge in front of the site of the neoclitoris
obtained from the remaining tissue of the corpora cavernosa and innervated parts of the glans. C: The end
of the procedure.
FIGURE 436.6 One month postoperatively. Control with a Plexiglas obturator.
Since the vulva is tailored by extensive resection of scrotal skin and bilateral Z-plasties, only three patients
needed a secondary aesthetic correction. I have observed two strictures of the new urethral meatus. In one
patient, however, a retracted meatus was corrected surgically after 3 months. In four patients, a
rectovaginal fistula that needed secondary closure appeared later in the postoperative course. This
probably occurred as a result of pressure from the obturator.
Of my 85 operated male transsexuals, 6 are married as females. A great number of these patients also
desire additional operations, such as augmentation mammaplasty, rhinoplasty, blepharoplasty,
laryngoplasty, and voice change.
In the last 18 years, among patients who consulted me for surgical treatment of gender identity problems,
only about 20 percent underwent surgery. This reflects not only the difficulty of diagnosis, but also the fact
that although surgery seems currently to be the only efficient therapeutic procedure for the true transsexual,
expected social integration fails in many instances. It is therefore very important to continue postoperative
psychiatric treatment to ensure ultimate success. A functionally and aesthetically satisfactory operative
procedure represents only the beginning of a new life.

SUMMARY
A subcutaneous island skin flap created from the penis can be effectively used in a one-stage procedure to
create a neovagina. It obviates the problems associated with both skin grafts and procedures that involve
more than one stage.
References
1. Edgerton MT. Transsexualism: a surgical problem. Plast Reconstr Surg 1973;52:74.
2. Meyer R, Boscovic D. Problem of transsexualism. Atti del Simposio de Chirurgia Riparatrice dell'Uretra,
Ban, 1970.
3. Meyer R, Kesselring UK. Dio Neubildung eines aeusseren weiblichen Geschlectsapparates beim
Transsexuellen. In 13. Jahrestagung der Deutschen Gesellschaft fuer Plastische and
Wiederherstellungschirurgie, September 1975, Stuttgart, Stuttgart: Thieme-Verlag, 1977.
4. Meyer R, Kesselring UK. Der maennliche Transsexualismus. Gynaekol Rundsch 1978;18:96.
5. Eldh J. Construction of a neovagina with preservation of the glans penis as a clitoris in male transsexuals.
Plast Reconstr Surg 1993;91:985.

Chapter 437
Rectosigmoid Flap for Vaginal Reconstruction
S. K. KIM
K. J. PARK
EDITORIAL COMMENT
The reviewing editor has limited, if any, experience in reconstructing the vagina with a rectosigmoid pedicle
flap. Its main application appears to be in reconstruction of the vagina in male-to- female transsexuals. I do
not think it would be appropriate for congenital vaginal atresia, for which progressive dilators are likely to
give a better result. Abnormal or excessive mucus secretion, with or without a malodorous effect and the
possibility of bleeding, should be considerations in using the rectosigmoid flap.
Many methods are used for vaginoplasty, including the split-thickness skin graft, full-thickness skin graft, and
inverted penile skin flap. However, these procedures are not entirely satisfactory in cases of reconstructed
vaginal stenosis, inadequate vaginal length, or poor lubrication. The small intestine, ascending colon, and
sigmoid colon can be used in an intestinal flap procedure. The authors have modified a previously described
method in which a loop of rectosigmoid is isolated, closed at one end, and brought down on its vascular pedicle
as a neovagina, and then anastomosed to the perineum. The reconstructed vagina has good tactility, adequate
size, rare cavity constriction, and natural internal lubrication.
INDICATIONS
The female external genitalia are composed of the clitoris, labia majora and labia minora, and vagina. In
reconstruction, the most important aim is to reconstruct a vagina with normal sexual function. Rectosigmoid
flap vaginoplasty (1) is considered the best choice in the case of congenital vaginal atresia (Mayer-
Rokitansky-Küster-Hauser syndrome), male-to-female transsexual patients who have received penectomy
and orchiectomy, female pseudohermaphroditism, vaginal defect after ablation of cervical cancer, and
vaginal trauma (2).
ANATOMY
The blood supply of the rectosigmoid intestinal flap is based on the superior hemorrhoidal artery from the inferior
mesenteric artery (Fig. 437.1). Innervation of the flap is from the autonomic system, with sympathetic (inferior
mesenteric and hypogastric nerve) and parasympathetic components (hypogastric plexus).
FLAP DESIGN AND DIMENSIONS
A transverse Pfannenstiel incision is made along the lines of skin cleavage just above the symphysis. The upper
skin flap is dissected from the underlying rectus muscles, and the usual midline incision of the muscles and
peritoneum is made. After exploration of the abdomen with a self-retaining retractor, and beginning in the left
lateral gutter along Toldt's line, mobilization of the sigmoid colon is begun. After dissection of the medial
peritoneum of the sigmoid colon, the avascular plane between the visceral fascia and parietal fascia of the
rectum is dissected with electrocautery. The critical point of these procedures is the protection of the superior

rectal vessels from any injury or trauma.
After dissection of the peritoneum in the Douglas pouch, the anterior dissection of the rectum is performed to
below 2 to 3 cm of peritoneal reflection. After full mobilization of the rectosigmoid, transections of the rectum and
mesorectum are made. Although mesorectal transection can be safely performed with electrocautery, the
superior rectal artery and vein are best ligated for prevention of accidental bleeding during the procedures of the
perineal team. The rectum is transected with a linear stapler after mesorectal dissection. The bleeding of the
distal rectal stump can be secured with simple interrupted absorbable sutures or packing of gauze. The bleeding
of the proximal rectal stump (distal end of the rectosigmoid flap) can be safely controlled with electrocautery. The
next important step is the preservation of the vascular arcades after several ligations of mesenteric vasculature.
In these procedures, surgeons should pay careful attention to preserve not only the superior rectal vessels for
the rectosigmoid flap, but also vascular arcades or marginal vessels for the sigmoid colon.
FIGURE 437.1 The intestinal anatomy and arterial supply from the inferior mesenteric and superior hemorrhoidal
arteries. A 12- to 14-cm length of rectosigmoid is resected, and the superior hemorrhoidal artery is retained.
A 12- to 14-cm segment of the rectosigmoid is isolated with the vascular pedicle. The proximal side of
rectosigmoid flap is closed with staples or continuous absorbable suture. The final step of the abdominal
operation is completed by performing the colorectal anastomosis, using the intraluminal stapler (end-to-end or
side-to-end), without tension between the sigmoid colon and distal rectal stump (Fig. 437.1). The rectosigmoid
flap is brought down through the peritoneal opening to the perineal introitus by using Allis forceps.
OPERATIVE TECHNIQUE
The current operation is performed with a two-team approach by plastic and general surgeons. The general
surgery team isolates the rectosigmoid intestinal flap, and the plastic surgery team makes the vaginal cavity
through a dissection between the penis and rectum in transsexual patients. In other patients, we create sufficient
length and width of the vaginal cavity through the opening of the obstructed vagina. The blood supply of the
rectosigmoid intestinal flap is based on the superior hemorrhoidal artery from the inferior mesenteric artery.
Innervation of the flap is from the autonomic system, with sympathetic (inferior mesenteric and hypogastric nerve)
and parasympathetic components (hypogastric plexus). When isolating the rectosigmoid intestinal flap, we resect
a 12- to 14-cm length of rectosigmoid, keeping the superior hemorrhoidal artery, and then perform end-to-end or
side-to-end anastomosis between the remaining sigmoid colon and rectum, by using an intraluminal stapler
(Proximate ILS; Ürünler, Ankara, Turkey). The proximal portion of the rectosigmoid flap is closed with 3-0 Vicryl

suture.
FIGURE 437.2 A vaginal cavity made by incising the transversus perinei superficialis muscle between the bulbus
spongiosus of the penis and rectum. The remaining distal penile crus are sutured to each other and then placed
on the anterior portion of the urethral orifice.
In patients with an intact penis and scrotum, we execute penectomy and orchiectomy, and then construct a
urethral opening at the proper site. Clitoroplasty using the penile glans is performed in patients who desire a
clitoris. However, most do not want this, because a constructed clitoris is unsatisfactory in shape, so we suture
the remaining distal penile crura to each other and attach them to the anterior portion of the urethral orifice for
substitution of a clitoris (Fig. 437.2). This procedure offers patients excellent sexual sensitivity. The
bulbospongiosus muscle is stripped of the bulky urethral portion and used to augment the new labia majora.
In the orchiectomy, we remove the testes and epididymis but preserve the spermatic cord and surrounding
tissues to form sufficient volume in the labia majora. For penectomy patients, we create a vaginal cavity by
incising the transversus perinei superficialis muscle and fibrous connections. Bundles of puborectalis and
rectovesicalis muscles must be cut to create a cavity of sufficient size. After complete blunt dissection of the
Denonvilliers fascia (septum rectovesicale), we transfer the prepared rectosigmoid flap to the new vaginal cavity
through the peritoneal opening of the peritoneal reflex region. We then suture the end of the rectosigmoid flap to
the skin of the new vaginal orifice (Fig. 437.3). One or two Silastic drains are placed inside the new vaginal wall
through the vaginal orifice, and a suction drain (Hemovac, Zimmer, Milan, Italy) is inserted in the abdominal
cavity. A sponge packing (Merocele; Urban and Fischer Verlag, Munich, Germany) is inserted in the new vaginal
cavity for snug approximation of the rectosigmoid flap and the surrounding tissue.
CLINICAL RESULTS
The cosmetic and functional results of rectosigmoid vaginoplasty were excellent. The reconstructed vagina
revealed a mean vaginal cavity depth and width of 13 cm and 3.8 cm, respectively (2). Postoperatively, all
patients could enjoy sexual intercourse with orgasm (2, 3). Complications were relatively rare, but excessive
mucus discharge (3, 4), constriction of the vaginal orifice (3), abdominal pain, vaginal bleeding during
intercourse, and constipation were complications in the early postoperative period in some patients (2). The
rectosigmoid vaginoplasty was safe, and the rate of satisfaction was also very high.

FIGURE 437.3 The position of the new vagina and the suture line. The segment usually does not run all the
way down to the perineum. Skin flaps are generally necessary to form the lower vaginal segment.
After examining patients who underwent rectosigmoid vaginoplasty, we analyzed the results by follow-up
study. The reconstructed vaginas were of adequate size for sexual intercourse, and the cosmetic
configuration was good, with rare malodor. All patients were able to have intercourse, and none
experienced vaginal stenosis.
SUMMARY
Rectosigmoid vaginoplasty is considered very safe because the resultant cosmetic configuration and
function are well maintained over the long run. Especially for transsexual patients, who have received
penectomy and orchiectomy, congenital vaginal atresia patients, and those with vaginal injury after removal
of malignant tumor of the uterus, rectosigmoid vaginoplasty is considered the best choice.
References
1. Baldwin JF. The formation of an artificial vagina by intestinal transplantation. Ann Surg 1904;40:398.
2. Kim SK, Park JH, Lee KC, et al. Long-term results in patients after rectosigmoid vaginoplasty. Plast
Reconstr Surg 2003;112:143.
3. Darai E, Toullalan O, Besse O, et al. Anatomic and functional result of laparoscopic-perineal neovagina
construction by sigmoid colpoplasty in women with Rokitansky's syndrome. Human Reprod 2003;18:2454.
4. Moudouni S, Koutani A, Attya AI, et al. The use of isolated sigmoid colon segment for vaginal replacement
in young adults. Urol Nephrol 2004; 30:567.

Chapter 438
Bilateral Superomedial Thigh Flaps for Primary Reconstruction of
The Vulva
B. HIRSHOWITZ
The bilateral superomedial thigh flap can be raised and transferred to reconstruct either the vulva or the scrotum
without recourse to delay procedures.
INDICATIONS
The main application of the flap so far has been in patients following radical excision of the vulva for
malignancy (1, 2). See Chapter 457 for flap use in scrotal defects.
ANATOMY
The superomedial thigh skin flap is a probable arterial flap with ample blood supply derived from three main
sources (3) (Fig. 438.1):
1. The deep external pudendal artery—a direct cutaneous artery—is a branch of the femoral artery lying deep to
the fascia lata, which it pierces on the medial side of the thigh.
2. The anterior branch of the obturator artery, which is itself a branch of the anterior trunk of the internal iliac
artery, curves downward along the anterior margin of the obturator foramen and supplies the gracilis and
adductor muscles and the overlying skin.
3. The medial femoral circumflex artery, which supplies muscular branches to the gracilis and adductor muscles
and is a musculocutaneous artery, arises from either the femoral or profunda femoral artery.
The use of superomedial thigh flaps ensures virtual normal sensation, since both the genital branch of the
genitofemoral nerve and the ilioinguinal nerve are likely to be retained with these flaps. This fact may have
importance for the erotic propensity of the vulva and scrotum.
FLAP DESIGN AND DIMENSIONS
With the patient in a lithotomy position, the flap is outlined adjacent to a scrotal or labial defect. The base of the
flap overlies the adductor longus muscle, while distally the flap reaches lateral to the perineum. The width of the
flap roughly corresponds to the width of the defect. Its shape is rectangular, but in the case of a smaller defect, it
can be curved inward laterally.
OPERATIVE TECHNIQUE
The flap is raised off the underlying fat distally and, more proximally, off the fascia lata covering the origin of the
gracilis and adductor longus muscles. Blunt dissection is used to free the flap as its base is approached, and
care is taken to avoid damaging any large perforating vessels.
Vulvar reconstruction commences with approximation of the proximal part of the medial flap margins to reform the
subpubic area. This is followed by suturing the flaps together in the region of the perineal body, and last, the flap
margins are sutured to the mucosa around the urinary meatus and vaginal orifice. However, during final suturing,
some readjustment of the suture line may be necessary.

P.1171
Primary closure of the donor site is undertaken when the defect is small and, in elderly subjects, when the skin is
lax. With the larger defect, closure of part of the donor site in its inferolateral aspect may be delayed (Fig.
438.2C) or a skin graft may be applied. Primary closure of the donor site under undue tension may cause
embarrassment to the flap circulation.
CLINICAL RESULTS
The viability of the flap before its medial transposition can be confirmed by intravenous fluorescein, but in
14 flaps raised so far (for both scrotal and vulvar defects), no compromise to the circulation was
encountered.
SUMMARY
The superomedial thigh skin flap has proven a reliable method of resurfacing large vulvar defects.
FIGURE 438.1 Schematic diagram of the superomedial thigh flap with its probable arterial and nerve
supply.

P.1172
FIGURE 438.2 A: Recurrence of Paget's disease of vulva. The outlines for the wide reexcision and the
adjacent thigh flaps are shown. B: A large defect resulted from the excision. Both flaps have been raised.
C: Suturing of the flaps has been almost completed. Part of the right donor site has been left for delayed
suturing because of tension. D: Reconstructed vulva 3 months postoperatively.
References
1. Rutledge FN, Sinclair M. Treatment of intraepithelial carcinoma of the vulva by excision and graft. Am J
Obstet Gynecol 1968;102:806.
2. Delgado G. Plastic procedures in cancer of the lower genital tract. Am J Obstet Gynecol 1978;131:775.
3. Har-Shai Y, Hirshowitz B, Marcovich A, et al. Blood supply and innervation of the supermedial thigh flap
employed in one-stage reconstruction of the scrotum and vulva—an anatomical study. Ann Plast Surg 1984;
13:504.

Chapter 439
V-Y Advancement Myocutaneous Gracilis Flap for Reconstruction
of The Vulva
I. J. PELED
Y. ULLMANN
EDITORIAL COMMENT
This is a most satisfactory technique to reconstruct the vulva following surgical excision. The method is
simple and will simulate the vulva quite nicely.
Vulvar reconstruction is sometimes necessary following mutilating surgical procedures. The V-Y advancement
myocutaneous gracilis flap combines the advantages of the V-Y principle and the muscle flap.
INDICATIONS
Reported methods for vulvar reconstruction have included direct suture, skin grafts, and flap plasty (1, 2).
The gracilis myocutaneous flap (3) has been used mainly as a rotation island flap (4), and V-Y
advancement flaps are commonly used as cutaneous flaps. Myocutaneous flaps have been reported for use
in ischial and sacral pressure sores (5) and anal reconstruction (6). The V-Y advancement myocutaneous
gracilis flap combines the advantages of the V-Y principle and the muscle flap. It can be used for
reconstruction of the vulva following vulvectomy, with and without lymphadenectomy, and after direct
trauma.
ANATOMY
The created skin triangles are random flaps supplied by perforators coming from the underlying gracilis muscle.
The gracilis is a type II muscle, with the medial femoral circumflex branch of the profunda femoris artery being the
main pedicle. There are usually two to three vascular pedicles, with the superior one dominant. Division of the
muscle in the distal third of the thigh enables the upward mobility of this myocutaneous flap.
FLAP DESIGN AND DIMENSIONS
With the patient in the lithotomy position, unilateral or bilateral (Fig. 439.1A) triangles are drawn on the inner
aspect of the thigh overlying the gracilis muscle; the triangles are based at the created defect, with the width of
the flap the same as the width of the defect. The apex of the triangle, which is 30 to 45 degrees, reaches the
junction of the lower and middle thirds of the medial thigh.
OPERATIVE TECHNIQUE
The skin is incised following the markings until the gracilis muscle is reached. The muscle is divided distal to the
apex of the skin triangle, thus allowing complete mobility of the musculocutaneous flap(s) (Fig. 439.1A and B).
The proximal insertion of the gracilis in the pubis does not interfere with the proximal advancement of the flap
although, in some patients, it may be divided for better release. The flap is sutured to the remaining vaginal
mucosa, and the donor area is closed in a V-Y advancement fashion (Fig. 439.1C and D).

P.1173
One flap can easily close the entire defect and, by splitting the base of the triangle, the contralateral side can be
reached.
When bilateral flaps are raised, some redundancy in the skin is allowed; this can be used to simulate the labia
majora.
FIGURE 439.1 A 58-year-old female patient after radical vulvectomy and bilateral lymphadenectomy. A:
Triangular flaps drawn on both sides of the defect, above the gracilis muscle. B: Schematic representation of the
division of the gracilis muscle. C: Result at the end of the procedure. The flaps are sutured to the remaining
vaginal mucosa. D: At 1 year postoperatively. (From Peled, ref. 8, with permission.)
CLINICAL RESULTS
We have used this procedure for reconstruction after radical vulvectomy and bilateral lymphadenectomy.
Most of the patients had bilateral flaps fabricated, but some of them had very satisfactory results with the
unilateral flap. The technique combines the reliability of myocutaneous flaps with the simplicity and
usefulness of V-Y advancement island flaps (7, 8). By using this procedure for reconstruction of the vulva,
we have obtained satisfactory results, with only very minor complications of delayed wound healing.
SUMMARY
Reconstruction of the vulva with V-Y advancement triangular island myocutaneous gracilis flaps is safe and
simple to perform. It combines the reliability of myocutaneous flaps with the simplicity of the V-Y
advancement principle, yielding very good results with relatively scarce minor complications.
References

1. Korlof B, Nylen B, Tillinger KG, Tjernberg B. Different methods of reconstruction after vulvectomies for
cancer of the vulva. Acta Obstet Gynecol Scand 1977;58:411.
2. Nahai F. Muscle and musculocutaneous flaps in gynecologic surgery. Clin Obstet Gynecol 1981;24:1277.
3. McCraw TB, Massey FM, Shanklin KH, Horton CE. Vaginal reconstruction with gracilis myocutaneous
flaps. Plast Reconstr Surg 1976;58:176.
4. Soper JT, Rodriguez G, Berchuck A, Clarke-Pearson DL. Long and short gracilis myocutaneous flaps for
vulvovaginal reconstruction after radical pelvic surgery: comparison of flap-specific complications. Gynecol
Oncol 1995;56:271.
5. Wingate GB, Friedland TA. Repair of ischial pressure ulcers with gracilis myocutaneous island flaps. Plast
Reconstr Surg 1978;62:245.
6. Peled IJ, Manny J, Wexler MR, Luttwak EM. The triangular island skin flap for the treatment of anal
ectropion. Dis Colon Rectum 1984;27:33.
7. Peled IJ, Wexler MR. The usefulness and versatility of V-Y advancement flaps. J Dermatol Surg Oncol
1983;9:1003.
8. Peled IJ. Reconstruction of the vulva with V-Y advanced myocutaneous gracilis flaps. Plast Reconstr Surg
1990;86:1014.

Chapter 440
Gluteal Thigh Flap for Reconstruction of Perineal Defects
R. L. WALTON
D. J. HURWITZ
J. BUNKIS
EDITORIAL COMMENT
This is an excellent flap and its reliability is dependable as one elevates the skin and underlying fascia over
the posterior thigh. If designed as an innervated flap, it may give rise to most uncomfortable dysesthesias.
The cutaneous territory of the descending branch of the inferior gluteal artery provides an excellent source of
sensate coverage for defects of the perineum (1, 2, 3, 4, 5).
INDICATIONS
The gluteal thigh flap is an extremely reliable flap for providing closure of groin, perineal, sacral,
trochanteric, and ischial defects. It represents a significant alternative to muscle or musculocutaneous flaps,
particularly in the ambulatory patient. There is no functional defect imposed by its use.
Its inherent nerve supply can be used to provide sensibility over critical pressure areas, with minimal donor-
site morbidity. By incorporating the posterior fascia lata (femoral fascia), the gluteal thigh flap has been
used in the support and closure of perineal hernias.
ANATOMY
Theoretically, the skin of the entire posterior thigh can be elevated as an axial cutaneous flap. The inferior
gluteal artery is a terminal branch of the dorsal parietal division of the internal iliac artery. It exits the pelvis
between the piriformis and coccygeus muscles through the lower portion of the sciatic foramen and descends in
the interval between the femur and tuberosity of the ischium. In its course beneath the gluteus maximus muscle,
the inferior gluteal artery gives off multiple perforating branches to this muscle which then supply the skin of the
inferior buttock (3, 6).
Just proximal to its emergence from the inferior margin of the gluteus maximus muscle, the artery anastomoses
with the obturator and medial femoral circumflex arteries and sends several deep branches to the hamstring
muscles. It then extends along the midline of the posterior thigh deep to the posterior femoral fascia (posterior
fascia lata) from the ischium to the popliteal region.
There is considerable anatomic variation in the size of the inferior gluteal artery. The cutaneous territory of the
posterior thigh probably has a dual blood supply (Fig. 440.1)—that arising from a subfascial plexus created by
the descending branch of the inferior gluteal artery and a fascial plexus lying above the deep fascia that is fed by
musculocutaneous perforators of the femoral and obturator arteries or the inferior gluteal artery. To a variable
degree, both vascular systems feed a plexus of vessels just superficial to the deep fascia. A poorly developed
inferior gluteal artery may be inadequate as the sole nutrient support for an island pedicle flap, and in such
instances, proximal perforating vessels of the femoral system must be preserved.

P.1175
In part, the venous drainage from the gluteal thigh flap parallels its arterial supply. Usually, several venae
comitantes accompany the descending branch of the inferior gluteal artery in the thigh. In the proximal thigh, one
vein may course medially through the subcutaneous tissue to drain into the saphenous vein. More often, the
veins continue beneath the gluteus maximus muscle to join the internal iliac system. In addition, there is a parallel
superficial venous system above the posterior femoral fascia in the subcutaneous tissue. This system forms
multiple anastomoses with surrounding muscle perforators superior, medial, and lateral to the cutaneous
territory. Peninsular flaps in this region rarely demonstrate venous congestion due to insufficient collateral
drainage. Island flaps, however, may be prone to develop this complication unless the descending inferior gluteal
vascular pedicle is fully developed and included in the flap.
The gluteal thigh flap is innervated by the posterior femoral cutaneous nerve (Fig. 440.2). This nerve is
composed of several fascicles that emerge from the sciatic foramen with the inferior gluteal vessels. The
fascicles then converge to form the
main trunk of the nerve. This juncture is located near a point midway between the ischium and the greater
trochanter. The nerve then extends axially down the posterior thigh below the femoral fascia to the popliteal
fossa. It is intimately associated with and lies medial to the descending branch of the inferior gluteal artery.
FIGURE 440.1 Dual blood supply of the gluteal thigh flap. The subfascial plexus is supplied by the inferior
gluteal vessels, and the fascial plexus is supplied by musculocutaneous and fascial perforating vessels.
The cutaneous territory of the posterior femoral cutaneous nerve is represented by the S1-S3 dermatomes and
extends superiorly from a line joining the ischium and the greater trochanter, laterally to the posterior border of
the tensor fasciae latae, medially from a line joining the ischium to the medial femoral condyle, and inferiorly to
the popliteal fossa.
FLAP DESIGN AND DIMENSIONS
Island pedicle modifications of this flap can reach further and provide a more tailored closure. The dissection,
however, is technically more difficult and carries the risk of injury to the vascular pedicle.
The thickness of the gluteal thigh flap may vary from 2 to 12 cm. Thicker flaps are more common in females and
obese males. While thick flaps are more cumbersome and difficult to transpose, they may be advantageous in
providing padding over pressure points in denervated extremities; a thin flap may be unsatisfactory for these
purposes.
In the ambulatory patient, sacrifice of the posterior femoral cutaneous nerve poses no major sensory deficit. It is
important, however, to inform the patient of possible numbness along the posterior thigh and popliteal region.

P.1176
FIGURE 440.2 Flap anatomy. The inferior gluteal artery exits the sciatic foramen beneath the piriformis and
courses beneath the gluteus maximus muscle (shaded). At the inferior border of the gluteus maximus, the artery
gives off several deep branches to the hamstrings. In approximately two-thirds of patients, it continues down the
posterior midline of the thigh beneath the femoral fascia as the descending branch. The posterior femoral
cutaneous nerve emerges from the sciatic foramen as several fascicles that converge at the inferior border of the
gluteus maximus to form the main trunk of the nerve. The nerve then descends down the posterior midline of the
thigh medial to the descending branch of the inferior gluteal artery. The right side of the diagram depicts the
anatomic relationships of important structures after flap elevation.
Centered over its axial vessels, the flap may measure up to 34 cm in length and 15 cm in width. The flap can be
transposed with the gluteus maximus muscle as a compound musculocutaneous flap or transferred alone as a
direct cutaneous arterialized flap (3, 4).
The gluteal thigh flap is designed over the central axis of its neurovascular pedicle (Fig. 440.3). This is located
midway between the greater trochanter and the ischial tuberosity and is perpendicular to the gluteal crease.
Doppler assessment is quite helpful in precise identification of the proximal position of the inferior gluteal artery in
the buttock. Beyond the gluteal crease, however, the course of the descending branch of this vessel is difficult to
determine by this method.
The point of rotation of the flap (Fig. 440.4) varies according to the demands for coverage. In peninsular flaps,
the cone of rotation absorbs up to one-third of the flap's length—this fact must be considered in planning.
Generally, one chooses a point of rotation that is located midway between the greater trochanter and the ischial
tuberosity. If an axial extension incorporating the gluteus maximus muscle is contemplated, the point of rotation
can be extended to the sciatic foramen, which is approximately 5 cm above the ischial tuberosity. This maneuver
increases the potential reach of the flap. In island pedicle modifications, the sciatic foramen can serve as the
pivot point of the flap, extending its reach to the sacrum, groin, and deep perineal regions.