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Delayed exposed grafting following radical vulvectomy
DELAYED EXPOSED GRAFTING F O L L O W I N G RADICAL VULVECTOMY By IAN A. McGREGOR, F.R.C.S., F.R.F.P.S.G.
Glasgow and West of Scotland Regional Plastic Surgery Service, Royal Infirmary, Glasgow THE standard treatment of squamous carcinoma of the vulva is by radicaI vulvectomy, and the method described by Way (1948) is now routine. The skirt excision which this procedure entails leaves a raw area which cannot be closed by direct suture. Though such an area will eventually heal spontaneously, the time taken is considerable and the resulting discomfort to the patient not trivial.
FIG. I Late result obtained with successful primary grafting.
The purPose of this paper is to describe a possible method of providing skirt cover. In tackling the problem of free skin grafting in the region of the groin and vulva, the difficulties are those of ha~mostasis, immobilisation, and infection. Before consideration of how these problems may be solved, it is instructive to consider how Hughes (1953, 1957) tackled a similar type of problem, namely that of using free skin grafts around the anus. Infection he found was no problem, provided h~emostasis was satisfactory. When he was able to achieve good h~emostasis at the end of his excisional procedure, he applied his graft primarily in the usual way with a tie-over pressure dressing. I f h~emostasis was less good he used a delayed primary graft, applying his graft within three days of excision with a dry field but before granulations had developed and using a tie-over pressure dressing. He found immobilisation with Elastoplast over wool and padding adequate. 302
DELAYED EXPOSED
GRAFTING FOLLOWING
RADICAL VULVECTOMY
FIG. 2
Results of delayed exposed grafting. Case I shows (A) early state of granulations, (B) graft five days after application, (C) graft healed, (D) late result, showing incidentally a complication of the extensive glandular dissection, namely, a femoral hernia. Case 2 shows (E) granulations immediately prior to grafting, and (F) complete take of the graft. Case 3 (G) and Case 4 (H) show grafts nine days after application.
303
304
BRITISH
JOURNAL
OF PLASTIC
SURGERY
While the problems of free skin grafting after radical vulvectomy are similar in principle, the difficulties of immobilisation and the presence of the urethra in the operation field make the practical problems very much greater. When primary grafting is carried out, the graft must be sutured in place and the tie-over pressure dressing applied to the vulvar area with the patient in the lithotomy position and to the groin and pubis with the legs flat. The movement of the patient from one position to the other makes k difficult if not impossible to get both parts satisfactorily dressed with the correct pressure even with a catheter in place and with the use of plaster immobilisation. As a result, graft "take " tends to be very uncertain. It is possible on occasion to get a 95 per cent. + take of a graft applied in this way, and when this occurs (Fig. I) the result is certainly dramatic, but it is general experience that a take of more than 5° per cent. cannot be expected routinely. Secondary grafting of the residual raw areas is then required, and the healing time is the same as that which would result from delayed grafting if one could be reasonably sure that the delayed graft would take almost completely. Furthermore, if the patient is being nursed in gynmcological wards where t h e care of skill grafts is not routine, k is desirable that a regime which is as simple as possible should be used. After experience of the generally disappointing results o f primary grafting, a simple regime of delayed grafting has been developed and used successfully in thirteen patients without any major difficulties arising (Fig. 2).
METHOD
The technique of exposed grafting has been in use for many years and was described in detail by Calnan and Innes (I957). It is a particularly useful technique where the local conditions make it difficult or impossible to prevent the shearing strains and movements of the graft which are so detrimental to graft take and to vascularisation when the standard pressure dressing techniques are used. The vulvar area and groin are particularly prone to such strains unless most elaborate methods of immobilisation are used. On the other hand, these strains can be easily and completely eliminated if the exposed method of grafting is used. In order to prevent the dislodgment of the graft during the moving of the patient from operating table to bed, the graft--a thin split-skin graft--is cut, stored overnight in the refrigerator, and applied to the raw surface on the following day with the patient in bed. T i m e o f Applieation.--How soon after the vulvectomy the graft can be applied depends to a great extent on the surface left by the gynmcological surgeon and on how rapidly good granulations develop. Tempest (1961) finds that the use of a pressure dressing on the whole area helps the rapid production of good granulations, while we u s e " Hibitane" soaks until the granulations are satisfactory. Probably the presence or absence of residual necrotic material in the operative field is more important than the actual method of preparing the granulations. In any case, the application of the graft should await the development of a clean granulating surface whether this takes ten or twenty-one days. Minor modifications of excisional operative technique which help such a surface to develop rapidly are discussed below.
DELAYED
EXPOSED
GRAFTING
FOLLOWING
RADICAL
VULVECTOMY
305
Application of Graft.--Prior to the cutting and application o f the graft, the usual measures of low residue diet, etc., are taken to prevent the patient's bowels from moving for the first five days after the graft is applied. On the day after the graft is cut, immediately prior to its application, an indwelling Foley catheter is inserted. The patient is positioned with the legs as far apart as is comfortable, remembering that the position must be maintained
FIG. 3 Protection of graft by use of kidney dish strapped across the groin.
uninterrupted for at least five d a y s . A very simple method of keeping the legs in this position by laying sandbags along the inner aspects of thighs and legs has been quite satisfactory. The graft, which can be spread on tulle gras to make handling easier, is laid on the granulations as sheets. It may be made to overlap the margin of the defect, and there should be no gap between individual sheets. Care must be taken to ensure that the graft is in close contact with the granulations at all points and that no bubbles of air are present underneath it. Protection of Graft.--A large kidney dish strapped across the groin with Elastoplast has proved a simple but most~effective protection for the graft (Fig. 3). This type of dish is of a suitable shape and protects the graft without preventing the access of air. A cage is used to keep the bed-clothes off the whole area. Dressing the Graft.--After five days, attachment of the graft is sound enough to allow removal of the tulle gras backing and trimming of any excess or overlap of graft. The catheter can be remo,ced and a careful enema given. Baths can be allowed as soon as the state of the graft permits. A problem arises when the patient is allowed up and the fold of frequently adipose lower abdomen tends to fall over the groin graft and cause intertrigo. Until the graft is well stabilised, measures to avoid the effects of intertrigo are essential to prevent damage to a previously well-taken graft. 3F
306
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
SUGGESTED MODIFICATIONS OF EXCISIONAL TECHNIQUE
Suturing o f Groin.--There is a natural tendency for the gynmcological surgeon to suture the lateral margins of each groin wound to reduce this part of the defect to a minimum. It should be appreciated, however, that an extra one inch or so of raw surface at this particular point does not materially affect the grafting of the defect, and suturing should be stopped at the slightest suggestion of wound tension because secondary breakdown is certainly a factor which will delay the grafting.
~ .
IF~\~
~ SKIN ~
FATTY
/'~ I[,I#Z~. ~ ~f~,.. "~ SUPERFICIAL SPLIT-SKIN J E~I~:._z.~, G R A F T - - ~ ~ ~
FASCIA DEEP FASCIA
I l. c.'4-q L~,4,,...
~.~-~, ~2i
....." ~;"
"~"
I~
[F~
¢;;(-
FIG. 4 Correct (A) and incorrect (B, C, and D) methods of making abdominal incision prior t o grafting. A, Correct method, using vertical incision. B~ C, Oblique cut, either increasing the area of poorly granulating exposed fat or leaving an overhang with " dead space " and grafting difficulty. D, Undercutting leaves overhang with " dead space " and grafting difficulty.
Use of Ligatures.--Not merely the use of the finest catgut ligatures commensurate with safe hremostasis, but the inclusion of only the bleeding vessel in the ligature are both points which help to eliminate the small areas of slough which show where ligatures were applied. This is particularly true of the saphenous vein ligature which is invariably the last part to granulate. Possibly cover by sartorius transplant (Way, I957) may help to prevent this minor annoyance.
Cutting the Flaps.--Many of these women are fat, and in the groin and pubis there is frequently a step of at least one inch from the skin to the external oblique aponeurosis or pubic periosteum. This surface of adipose tissue is always poor to granulate. It eases grafting if the incision in this area is made vertical, and the abdominal flap is not undercut, leaving no eventual overhang to be grafted (Fig. 4). CONCLUSION
There are many possible methods of treating the defect left by radical vulvectomy, and this very fact is a measure of the difficulty of the problem. The method described has the merit of extreme simplicity and has been used in thirteen
DELAYED EXPOSED GRAFTING FOLLOWING RADICAL VULVECTOMY 307 patients with 95 to Ioo per cent. take of the graft in all cases and without any nursing or other problems during the period of immobilisation. SUMMARY A method of delayed grafting of the defect left after radical vulvectomy using the exposed method of split-skin grafting is described. I wish to thank Professor I. Donald and Dr R. A. Tennent, who carried out the radical vulvectomies and in whose wards the subsequent grafts were carried out, for permission to publish these results, and Mr J. S. Tough for his encouragement and advice throughout. The line drawing is the work of M r Robin Callander.
REFERENCES CALNAI% J., and INNES, F. L. F. (1957). Brit. J. plast. Surg., Io, II. I-IIIGHES, E. S. R. (1953). Brit. J. Surg., 41, 639. -(1957). Aust. N . Z . J . Surg., 26, 281. TEMPEST, M. (1961). Personal communication. WAY, S. (1948). Ann. R. Coll. Surg. Engl., 3, 187. -(1957). I n " P r o g r e s s in Gynecology," vol. 3, P- 489. Ed. by J. V. Meigs and S. H. Sturgis. N e w York : Grune & Stratton.
3F*
Glasgow and West of Scotland Regional Plastic Surgery Service, Royal Infirmary, Glasgow THE standard treatment of squamous carcinoma of the vulva is by radicaI vulvectomy, and the method described by Way (1948) is now routine. The skirt excision which this procedure entails leaves a raw area which cannot be closed by direct suture. Though such an area will eventually heal spontaneously, the time taken is considerable and the resulting discomfort to the patient not trivial.
FIG. I Late result obtained with successful primary grafting.
The purPose of this paper is to describe a possible method of providing skirt cover. In tackling the problem of free skin grafting in the region of the groin and vulva, the difficulties are those of ha~mostasis, immobilisation, and infection. Before consideration of how these problems may be solved, it is instructive to consider how Hughes (1953, 1957) tackled a similar type of problem, namely that of using free skin grafts around the anus. Infection he found was no problem, provided h~emostasis was satisfactory. When he was able to achieve good h~emostasis at the end of his excisional procedure, he applied his graft primarily in the usual way with a tie-over pressure dressing. I f h~emostasis was less good he used a delayed primary graft, applying his graft within three days of excision with a dry field but before granulations had developed and using a tie-over pressure dressing. He found immobilisation with Elastoplast over wool and padding adequate. 302
DELAYED EXPOSED
GRAFTING FOLLOWING
RADICAL VULVECTOMY
FIG. 2
Results of delayed exposed grafting. Case I shows (A) early state of granulations, (B) graft five days after application, (C) graft healed, (D) late result, showing incidentally a complication of the extensive glandular dissection, namely, a femoral hernia. Case 2 shows (E) granulations immediately prior to grafting, and (F) complete take of the graft. Case 3 (G) and Case 4 (H) show grafts nine days after application.
303
304
BRITISH
JOURNAL
OF PLASTIC
SURGERY
While the problems of free skin grafting after radical vulvectomy are similar in principle, the difficulties of immobilisation and the presence of the urethra in the operation field make the practical problems very much greater. When primary grafting is carried out, the graft must be sutured in place and the tie-over pressure dressing applied to the vulvar area with the patient in the lithotomy position and to the groin and pubis with the legs flat. The movement of the patient from one position to the other makes k difficult if not impossible to get both parts satisfactorily dressed with the correct pressure even with a catheter in place and with the use of plaster immobilisation. As a result, graft "take " tends to be very uncertain. It is possible on occasion to get a 95 per cent. + take of a graft applied in this way, and when this occurs (Fig. I) the result is certainly dramatic, but it is general experience that a take of more than 5° per cent. cannot be expected routinely. Secondary grafting of the residual raw areas is then required, and the healing time is the same as that which would result from delayed grafting if one could be reasonably sure that the delayed graft would take almost completely. Furthermore, if the patient is being nursed in gynmcological wards where t h e care of skill grafts is not routine, k is desirable that a regime which is as simple as possible should be used. After experience of the generally disappointing results o f primary grafting, a simple regime of delayed grafting has been developed and used successfully in thirteen patients without any major difficulties arising (Fig. 2).
METHOD
The technique of exposed grafting has been in use for many years and was described in detail by Calnan and Innes (I957). It is a particularly useful technique where the local conditions make it difficult or impossible to prevent the shearing strains and movements of the graft which are so detrimental to graft take and to vascularisation when the standard pressure dressing techniques are used. The vulvar area and groin are particularly prone to such strains unless most elaborate methods of immobilisation are used. On the other hand, these strains can be easily and completely eliminated if the exposed method of grafting is used. In order to prevent the dislodgment of the graft during the moving of the patient from operating table to bed, the graft--a thin split-skin graft--is cut, stored overnight in the refrigerator, and applied to the raw surface on the following day with the patient in bed. T i m e o f Applieation.--How soon after the vulvectomy the graft can be applied depends to a great extent on the surface left by the gynmcological surgeon and on how rapidly good granulations develop. Tempest (1961) finds that the use of a pressure dressing on the whole area helps the rapid production of good granulations, while we u s e " Hibitane" soaks until the granulations are satisfactory. Probably the presence or absence of residual necrotic material in the operative field is more important than the actual method of preparing the granulations. In any case, the application of the graft should await the development of a clean granulating surface whether this takes ten or twenty-one days. Minor modifications of excisional operative technique which help such a surface to develop rapidly are discussed below.
DELAYED
EXPOSED
GRAFTING
FOLLOWING
RADICAL
VULVECTOMY
305
Application of Graft.--Prior to the cutting and application o f the graft, the usual measures of low residue diet, etc., are taken to prevent the patient's bowels from moving for the first five days after the graft is applied. On the day after the graft is cut, immediately prior to its application, an indwelling Foley catheter is inserted. The patient is positioned with the legs as far apart as is comfortable, remembering that the position must be maintained
FIG. 3 Protection of graft by use of kidney dish strapped across the groin.
uninterrupted for at least five d a y s . A very simple method of keeping the legs in this position by laying sandbags along the inner aspects of thighs and legs has been quite satisfactory. The graft, which can be spread on tulle gras to make handling easier, is laid on the granulations as sheets. It may be made to overlap the margin of the defect, and there should be no gap between individual sheets. Care must be taken to ensure that the graft is in close contact with the granulations at all points and that no bubbles of air are present underneath it. Protection of Graft.--A large kidney dish strapped across the groin with Elastoplast has proved a simple but most~effective protection for the graft (Fig. 3). This type of dish is of a suitable shape and protects the graft without preventing the access of air. A cage is used to keep the bed-clothes off the whole area. Dressing the Graft.--After five days, attachment of the graft is sound enough to allow removal of the tulle gras backing and trimming of any excess or overlap of graft. The catheter can be remo,ced and a careful enema given. Baths can be allowed as soon as the state of the graft permits. A problem arises when the patient is allowed up and the fold of frequently adipose lower abdomen tends to fall over the groin graft and cause intertrigo. Until the graft is well stabilised, measures to avoid the effects of intertrigo are essential to prevent damage to a previously well-taken graft. 3F
306
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
SUGGESTED MODIFICATIONS OF EXCISIONAL TECHNIQUE
Suturing o f Groin.--There is a natural tendency for the gynmcological surgeon to suture the lateral margins of each groin wound to reduce this part of the defect to a minimum. It should be appreciated, however, that an extra one inch or so of raw surface at this particular point does not materially affect the grafting of the defect, and suturing should be stopped at the slightest suggestion of wound tension because secondary breakdown is certainly a factor which will delay the grafting.
~ .
IF~\~
~ SKIN ~
FATTY
/'~ I[,I#Z~. ~ ~f~,.. "~ SUPERFICIAL SPLIT-SKIN J E~I~:._z.~, G R A F T - - ~ ~ ~
FASCIA DEEP FASCIA
I l. c.'4-q L~,4,,...
~.~-~, ~2i
....." ~;"
"~"
I~
[F~
¢;;(-
FIG. 4 Correct (A) and incorrect (B, C, and D) methods of making abdominal incision prior t o grafting. A, Correct method, using vertical incision. B~ C, Oblique cut, either increasing the area of poorly granulating exposed fat or leaving an overhang with " dead space " and grafting difficulty. D, Undercutting leaves overhang with " dead space " and grafting difficulty.
Use of Ligatures.--Not merely the use of the finest catgut ligatures commensurate with safe hremostasis, but the inclusion of only the bleeding vessel in the ligature are both points which help to eliminate the small areas of slough which show where ligatures were applied. This is particularly true of the saphenous vein ligature which is invariably the last part to granulate. Possibly cover by sartorius transplant (Way, I957) may help to prevent this minor annoyance.
Cutting the Flaps.--Many of these women are fat, and in the groin and pubis there is frequently a step of at least one inch from the skin to the external oblique aponeurosis or pubic periosteum. This surface of adipose tissue is always poor to granulate. It eases grafting if the incision in this area is made vertical, and the abdominal flap is not undercut, leaving no eventual overhang to be grafted (Fig. 4). CONCLUSION
There are many possible methods of treating the defect left by radical vulvectomy, and this very fact is a measure of the difficulty of the problem. The method described has the merit of extreme simplicity and has been used in thirteen
DELAYED EXPOSED GRAFTING FOLLOWING RADICAL VULVECTOMY 307 patients with 95 to Ioo per cent. take of the graft in all cases and without any nursing or other problems during the period of immobilisation. SUMMARY A method of delayed grafting of the defect left after radical vulvectomy using the exposed method of split-skin grafting is described. I wish to thank Professor I. Donald and Dr R. A. Tennent, who carried out the radical vulvectomies and in whose wards the subsequent grafts were carried out, for permission to publish these results, and Mr J. S. Tough for his encouragement and advice throughout. The line drawing is the work of M r Robin Callander.
REFERENCES CALNAI% J., and INNES, F. L. F. (1957). Brit. J. plast. Surg., Io, II. I-IIIGHES, E. S. R. (1953). Brit. J. Surg., 41, 639. -(1957). Aust. N . Z . J . Surg., 26, 281. TEMPEST, M. (1961). Personal communication. WAY, S. (1948). Ann. R. Coll. Surg. Engl., 3, 187. -(1957). I n " P r o g r e s s in Gynecology," vol. 3, P- 489. Ed. by J. V. Meigs and S. H. Sturgis. N e w York : Grune & Stratton.
3F*