RECONSTRUCTIVE

Gluteal Fold V-Y Advancement Flap for Vulvarand Vaginal Reconstruction: A New FlapPaik-Kwon Lee, M.D., Ph.D.

Moon-Seop Choi, M.D.Sang-Tae Ahn, M.D., Ph.D.

Deuk-Young Oh, M.D.Jong-Won Rhie, M.D., Ph.D.

Ki-Taik Han, M.D., Ph.D.Seoul, Korea

Background: Soft-tissue reconstruction following vulvar cancer resection is adifficult challenge because of the functional, locational, and cosmetic impor-tance of this region. Although numerous flaps have been designed for vulvarreconstruction, each has its disadvantages.Methods: The authors introduce the gluteal fold fasciocutaneous V-Y advance-ment flap for vulvovaginoperineal reconstruction after vulva cancer resection.This flap is supplied by underlying fascial plexus derived from perforators of theinternal pudendal artery and musculocutaneous perforators of underlying mus-cle. The sensory supply of this flap comes from the posterior cutaneous nerveof the thigh and the pudendal nerve. An axis of V-shaped triangular flap isaligned to the gluteal fold. A total of 17 flaps were performed in nine patients.Results: All flaps survived completely, with no complications except for smallperineal wound disruption in three patients.Conclusions: This flap is thin, reliable, sensate, easy to perform, and hasmatched local skin quality and concealed donor-site scar on the gluteal fold. Inaddition, it can cover large vulvovaginal defects because it can be advancedfarther as a result of the character of the gluteal fold area. In our experience,the gluteal fold fasciocutaneous V-Y advancement flap has proven very useful forvulvar reconstruction, especially at the point of donor-site scar, flap thickness,and degree of flap advancement. (Plast. Reconstr. Surg. 118: 401, 2006.)

Vulvar cancer accounts for 5 percent of allfemale genital cancers and 1 percent of allmalignancies in women. It can be ob-served more frequently after the fifth or sixthdecade of life. Recently, there has been an in-crease in the incidence of vulvar cancer. Vulvarcancer is a diffusing disease that permeates intoregional lymphatics, requiring radical resectionwith inguinal lymph node dissection fortreatment.1 Characteristically, this area is easilycontaminated by secretions from the vaginalexocrine gland and vulnerable to infection afterflap surgery. Furthermore, soft-tissue reconstruc-tion following vulvar cancer surgery presents adifficult challenge.The ideal flap for vulvar defects should be

sensate and thin with a reliable blood supply,and should present a less conspicuous donor-sitescar. A large vulvovaginoperineal defect is oftencreated by radical excision of cancer because of

the nature of vulvar cancer. Therefore, unlessthe flap is adequate for mobilization, scar con-tracture and tension may result in cosmetic andfunctional impairment, such as vaginal exposureand deviation of the urinary stream.We used the V-Y advancement flap from the

medial thigh and gluteal fold island flap forvulvar reconstruction. However, there are somedisadvantages associated with each one.In this article, to overcome these disadvan-

tages, we present a new gluteal fold fasciocuta-neous V-Y advancement flap that (1) is sensateand thin with a reliable blood supply, (2) can beadvanced easily, (3) presents a concealed scar onthe gluteal fold and groin area, and (4) can beperformed in a single-stage procedure.

PATIENTS AND METHODSThis flap can be used to cover extensive vulvar

defects, which include the anterior commissure,perianus, vaginal inner wall, and the labia majoraand minora. The apex of the triangular flap ismarked on the gluteal fold and the base of this flapis an open wound margin (Fig. 1).

The skin is incised down to the underlyingmuscle fascia with meticulous electrocauteriza-tion. The flap is mobilized by elevating the un-

From the Department of Plastic Surgery, The Catholic Uni-versity of Korea College of Medicine.Received for publication October 28, 2004; accepted May 8,2006.Copyright 2006 by the American Society of Plastic SurgeonsDOI: 10.1097/01.prs.0000227683.47836.28

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derlying muscular fascia proximally and distally.The amount of mobilization can be determinedaccording to defect size. Caution is required to

avoid injury to perforators as much as possible.This flap is advanced in a V-Y fashion and is se-cured to the recipient site, reaching the vaginalinner wall with no tension. After the dog-ear isremoved, the skin is closed layer by layer. Water-tight closure should be performed on the vaginalmucosa. Finally, we apply Dermabond (EthiconInc., Somerville, N.J.) to lower the risk of postop-erative infections from the bacterial contamina-tion and vaginal discharge.

RESULTSFrom April of 2003 to March of 2004, we per-

formed 17 gluteal fold V-Y advancement flaps forvulvoperineal defects in nine patients after vulvec-tomy with or without inguinal lymph node dissec-tion. The age of the patients ranged from 23 to 70years, averaging 56 years (Table 1).

Of the nine patients, six had squamous cellcarcinoma and radical vulvectomy with inguinallymph node dissection, and three had vulvar in-traepithelial neoplasia and simple vulvectomywithout inguinal lymph node dissection. All pa-tients underwent reconstruction using gluteal foldV-Y advancement flaps. Follow-up after operationranged from 6 months to 1 year, with a mean of8.6 months.

All flaps survivedwithoutmajor complications.In three patients, partial dehiscence occurred atthe junction of the two advanced flaps and peri-neal skin, which were healed by conservative treat-ment. All patients had sensation on the flap.

To assess flap sensation, we performed sensorytests such as two-point discrimination, superficialpain, superficial touch, temperature, and vibra-tion on the triangular flap of five patients (cases 2,3, 5, 8, and 9) after surgery. The triangular flapswere divided into three zones: proximal, center,and distal. Follow-up for sensory testing rangedfrom 11 months to 1 year 10 months after surgery.The results showed that all flaps had good sensa-tion (all five modalities) in three zones. The prox-

Fig. 1. Schematic diagram of the flap. (Above) Preoperative de-sign. The apex of the triangular flap ismarked on the gluteal foldand the base of this flap is on the open wound margin. (Below)After insetting of the flap. This flap is advanced in a V-Y fashion.

Table 1. Summary of Patients

Patient Age (yr) Sex Diagnosis and Site Operation Complications

1 70 F SCC, vulva RV/LD/bilateral V-Y Partial dehiscence2 40 F VIN, vulva SV/bilateral V-Y None3 70 F SCC, vulva RV/LD/bilateral V-Y None4 68 F SCC, vulva RV/LD/bilateral V-Y Partial dehiscence5 58 F SCC, vulva RV/LD/bilateral V-Y Partial dehiscence6 65 F SCC, vulva RV/LD/bilateral V-Y None7 23 F VIN, vulva SV/bilateral V-Y None8 37 F VIN, vulva SV/unilateral V-Y None9 53 F SCC, vulva RV/LD/bilateral V-Y Partial dehiscenceSCC, squamous cell carcinoma; VIN, vulvar intraepithelial neoplasia; RV, radical vulvectomy; SV, simple vulvectomy; LD, inguinal lymph nodedissection.

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imal zone in three patients, the distal zone in onepatient, and the center zone in one patient hadslightly decreased sensation compared with theother zones. In a unilateral case (case 8), 12months after surgery, static two-point discrimina-tion using Semmes-Weinstein monofilamentshowed 6 cm in the proximal, 4 cm in the center,and 4 cm in the distal zone, which was comparableto that of the unaffected side; 2.5 cm in the vulvararea, 4 cm in the groin area, and 4 cm in thegluteal fold area. The proximal zone of the flapshowed a markedly decreased sensation (two-point discrimination) compared with the oppositevulvar area. However, a less significant decrease insensation (two-point discrimination) was observedwhen compared with the opposite groin and glu-teal fold area, which corresponded to the flapcomponents. The other four sensory modalitiesshowed similar results with two-point discrimina-tion, which implies that the proximal zone showsslightly decreased sensation compared with theother zones.

As a temporary side effect, all patients sufferedfromdeviated urinary stream, but this was resolvedspontaneously with time. Postoperative scarringwas natural in the groin and gluteal fold area.Furthermore, revision for aesthetic or functionalproblems was not necessary for any of the patients.

CASE REPORTSCase 2

A 40-year-old woman was diagnosed with vulvar in-traepithelial neoplasia by excisional biopsy. Two glutealfold V-Y advancement flaps for the vulvovaginoperinealdefect were performed. Reconstruction was satisfac-tory, with no major complications. The donor-site scarwas concealed on the gluteal fold line and was aesthet-ically acceptable (Fig. 2).Case 8

A 37-year-old woman was diagnosed with vulvar intra-epithelial neoplasia by excisional biopsy. We designed agluteal foldV-Y advancement flap after simple vulvectomywithout inguinal lymph node dissection. The flap waselevatedwith fascia and advanced to the vulva defect area.The donor-site scar was concealed on the gluteal fold andwas aesthetically acceptable (Fig. 3).

DISCUSSIONIn the past, radical vulvectomy defects had

been reconstructed using two bilateral longitudi-nal incisions and repaired by primary closure, skingrafts,2 local flaps,3 or myocutaneous flaps basedon gracilis,4 tensor fasciae latae,5 or rectusabdominis.6 There is no doubt that flaps are su-perior to skin grafting or direct closure in terms of

the aesthetic and functional aspects of reconstruc-tion. Recently, the fasciocutaneous flap has be-come the preferred choice in reconstruction ofvulvar defects, becausemyocutaneous flaps are toobulky and leave an unsightly scar on the legs orabdomen.

In the 1990s, a perineal blood supply from theinternal pudendal artery received more attention.Thus, numerous fasciocutaneous flaps have beenintroduced by plastic surgeons. For example, pu-dendal thigh flaps for vaginal reconstruction,7,8perineal artery axial flaps,9 vulvoperineal fascio-cutaneous flaps,10 V-Y advancement flaps from themedial thigh,1113 and gluteal fold island flaps1416have been used for vulvovaginal reconstruction.Recent advances in the knowledge of the cutane-ous and fascial vascular anatomy have resulted inthe widespread use of those flaps. However, thepudendal thigh and vulvoperineal flaps are ap-plied only to vaginal reconstruction,7,8 and theperineal artery flap is suitable for moderate sizedvulvar defects after vulvectomy.9 Among theseflaps, the V-Y advancement flap from the medialthigh or gluteal fold island flap has been widelyused for vulvovaginal reconstruction by many sur-geons. The latter is supplied by the superficialperineal artery, the terminal branch of the inter-nal pudendal artery,14 and the former is based onthe suprafascial vascular plexus from the superfi-cial and deep femoral arteries.

Until 2002, we hadusedV-Y advancement flapsfrom the medial thigh or gluteal fold island flapsfor vulvar defects as well. Fromour experience, V-Yadvancement flaps from themedial thigh are thin,reliable, and relatively easily elevated and havematched local skin quality. However, the vaginalwall is exposed because of limited advancementand tension of the flaps, and a conspicuous donor-site scar is left on the medial thigh. Gluteal foldisland flaps are similar to the labia majora andshow a concealed donor-site scar on the glutealfold, but are bulky, requiring a secondary debulk-ing procedure.

To overcome these disadvantages, we modifythe axis of the V-Y advancement flap from themedial thigh to the gluteal fold. In particular, thelong axis of the V-shaped triangular flap is locatedat the gluteal fold and its base shares the marginof the vulvar defect. This flap can be advancedfarther because of the redundant soft tissue of thegluteal fold area and profuse blood supply fromperforators of the internal pudendal artery. Inaddition, this flapmaintains sensation bymeans ofthe posterior cutaneous nerve of the thigh and thepudendal nerve. Our surgical procedure does not

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involve dissection of the perforators of the inter-nal pudendal artery, and the rami of the pudendalnerve, the main sensory supply of our flap, whichare paired with perforators of the internal puden-

dal artery, are not injured; thus, the sensation ofthe flap is preserved.

We assessed postoperative flap sensation byconventional methods of sensory testing, such as

Fig. 2. The patient in case 2, a 40-year-old woman with vulvar intraepithelial neoplasia, underwent simple vulvectomy andbilateral gluteal fold V-Y advancement flap surgery. (Above, left) Vulvar defect and flap design. The apex of the triangular flapis marked on the gluteal fold. (Above, right) The flap is elevated as a fasciocutaneous flap. (Center, left) The flap is advanced inV-Y fashion and the skin is closed. (Center, right, and below) Anterior and posterior views 6 months after surgery. The scar isaesthetically acceptable and the vagina inner wall is minimally exposed.

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two-point discrimination, superficial pain, super-ficial touch, temperature, and vibration, not forthe purpose of demonstrating an ideal sensoryflap for the vulvar area but to suggest that our flap

has sensation. Unfortunately, it was not possible toretrospectively obtain preoperative values as a con-trol, and only five of nine patients were availablefor follow-up sensory testing postoperatively. The

Fig. 3. The patient in case 8, a 37-year-old woman with vulvar intraepithelial neoplasia, underwent simple vulvectomy andunilateral gluteal foldV-Yadvancementflapsurgery. (Above, left)Unilateral vulvardefect andflapdesign. (Above, right) Theflapis elevated as a fasciocutaneous flap. (Center, left) The flap is advanced in V-Y fashion and the skin is closed. (Center, right, andbelow) Anterior andposterior views6months after theoperation. The scar is aesthetically acceptable and the vagina innerwallis minimally exposed.

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results of sensory testing showed that all flaps hadgood sensation. Even though the results are notconsistent in all five patients, the decreased sen-sation in the proximal zone of the flap may berelated to the surgical dissection of the proximalportion of the flap to enhance the advancement ofthe flap for covering a large defect. None of thepatients experienced any discomfort or problemsin carrying out normal activities, including sexualactivity at long-term follow-up of over 1 year.

This flap is thin, sensate, reliable, easy to ele-vate, has matched local skin quality, and createsconcealed scars on the groin area and gluteal fold.All operation scars are confined to the vulvoperi-neal area and reconstruction can be performed ina single stage. The only problem is the introduc-tion of hairy skin of the remaining labium majorainto the vaginal wall in most cases. However, thehairy skin portion is narrow and sparse in density,producing no sexual disturbance or cosmeticproblems.

CONCLUSIONBased on the donor-site scar, thickness of flap,

and degree of flap advancement, we suggest thatthe gluteal fold fasciocutaneous V-Y advancementflap is a better method for reconstruction of vul-vovaginoperineal defects after vulvectomy.

Paik-Kwon Lee, M.D., Ph.D.Department of Plastic SurgeryKangnam St. Marys Hospital

The Catholic University of Korea College of Medicine505 Banpo-dong, Seocho-guSeoul 137-040, South Korea

pklee@catholic.ac.kr

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Am. J. Obstet. Gynecol. 185: 294, 2001.

2. Rutledge, F., and Sinclair, M. Treatment of intraepithelialcarcinoma of the vulva by skin excision and graft. Am. J.Obstet. Gynecol. 6: 806, 1968.

3. Julian, C. G., Callison, J., and Woodruff, J. D. Plastic manage-ment of extensive vulvar defects. Obstet. Gynecol. 38: 193, 1971.

4. McCraw, J. B., Massey, F. M., Shanklin, K. D., and Horton, C.E. Vaginal reconstruction with gracilis myocutaneous flaps.Plast. Reconstr. Surg. 58: 176, 1976.

5. Chafe, W., Fowler, W. C., Walton, L. A., and Currie, J. L.Radical vulvectomy with use of tensor fasciae latae myocu-taneous flap. Am. J. Obstet. Gynecol. 145: 207, 1983.

6. Shepherd, J. H., Van Dam, P. A., Jobling, T. W., and Breach,N. The use of rectus abdominismyocutaneous flaps followingexcision of vulvar cancer. Br. J. Obstet. Gynaecol. 97: 1020,1990.

7. Wee, J. T. K., and Joseph, V. T. A new technique of vaginalreconstruction using neurovascular pudendal thigh flaps: Apreliminary report. Plast. Reconstr. Surg. 83: 701, 1989.

8. Woods, J. E., Alter, G., Meland, B., and Podratz, K. Experi-ence with vaginal reconstruction utilizing the modified Sin-gapore flap. Plast. Reconstr. Surg. 90: 270, 1992.

9. Hagerty, R. C., Vaughn, T. R., and Lutz, M. H. The perinealartery axial flap. Ann. Plast. Surg. 31: 28, 1993.

10. Giraldo, F., Gaspar, D., Gonzalez, G., Bengoechea, M., andFerron, M. Treatment of vaginal agenesis with vulvoperinealfasciocutaneous flaps. Plast. Reconstr. Surg. 93: 131, 1994.

11. Tateo, A., Tateo, S., Bernasconi, C., and Zara, C. Use of V-Yflap for vulvar reconstruction. Gynecol. Oncol. 62: 203, 1996.

12. Carramaschi, F., Ramos, M. L., Nisida, A. C., Ferreira, M. C.,and Pinotti, J. A. V-Y flap for perineal reconstruction follow-ing modified approach to vulvectomy in vulvar cancer. Int. J.Gynaecol. Obstet. 65: 157, 1999.

13. Persichetti, P., Simone, P., Berloco, M., et al. Vulvo-perinealreconstruction: Medial thigh septo-fascio-cutaneous islandflap. Ann. Plast. Surg. 50: 85, 2003.

14. Hashimoto, I., Nakanishi, H., Nagae, H., Harada, H., andSedo, H. The gluteal-fold flap for vulvar and buttock recon-struction: Anatomic study and adjustment of flap volume.Plast. Reconstr. Surg. 108: 1998, 2001.

15. Moschella, F., and Cordova, A. Innervated island flaps inmorphofunctional vulvar reconstruction. Plast. Reconstr.Surg. 105: 1649, 2000.

16. Ragoowansi, R., Yii, N., and Niranjan, N. Immediate vulvarand vaginal reconstruction using the gluteal-fold flap: Long-term results. Br. J. Plast. Surg. 57: 406, 2004.

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