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Repair after vulvectomy: A survey of thirty-nine cases
REPAIR AFTER VULVECTOMY: A SURVEY OF THIRTY-NINE CASES By FRANKROBINSON, F.R.C.S. Plastic Surgeon, Manchester Regional Hospital Board
THIS is a report of personal experience in a specialised field dealing with repair after vulvectomy for both malignant and non-malignant conditions. MALIGNANT CASES
It is proposed to discuss the malignant cases first (Table I). The age of the patients varied from 28 to 79 years, twenty-six of the thirty-three patients being over 50, and of these eleven were over 60 and nine over 7° . TABLE I Malignant Cases, 33 /
.
Radical vulvectomy with node dissection-Secondary grafting
27
Radical vulvectomy without node dissection-Primary grafting . Primary flap repair Direct closure
2 I I
Vulval stenosis after radical vulvectomy-Bilateral rotation flap repair
2
Secondary Grafting after Radical Vulvectomy with Node D i s s e c t i o n . This procedure has been carried out in twenty-six cases of squamous-cell carcinoma and in one of malignant melanoma. It is generally agreed by gyn~ecologists that the treatment of choice in carcinoma of the vulva is operative--radical vulvectomy with bilateral inguinal• node dissection as described by Way (I948). The skin of both inguinal triangles,• the inguinal glands, and Cloquet's gland are removed en bloc. Frequently a femoral hernia presents after exploration of the femoral canal and this is repaired. The vulva, including the labia and the clitoris, is then resected in continuity, both• ischiorectal foss~e being entered. Part of the urethra may be taken (Fig. I). Originally many surgeons left the large wound (Fig. 2) to granulate and close in naturally--a process which takes three months. Way, however, in his article, stated that he employed Thiersch grafting when the wounds were clean to reduce: the time of stay in hospital. In Manchester, Professor W. I. C. Morris felt that skin grafting would greatly accelerate healing, and the first two cases were grafted• in I95I some fourteen and thirty-one days after operation respectively. Sheets of split skin were applied and bandaged into position. Both operations were only partially successful and supplementary grafts were required, but the first patient: went home seven weeks after the radical operation. For the next few cases strips of skin were applied to the pubic and inguinal 293
294
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
parts of the wound and shorter strips or squares around the vaginal orifice. T h e technique developed was so successful that it was used for six years without significant change. Then, on occasions, large sheets of skin were tried again but once more were not found to be as satisfactory. During the last ten years, therefore, the procedure has been as follows. Preparation and Operation,--Patients are first seen some ten days after vulvectomy when the large wound is beginning to clean up. Baths are being taken daily and wet dressings of Eusol and saline applied afterwards. The wound is
FIG. I
FIG. 2
Fig. I.--Block of tissue resected in radical vulvectomy with bilateral node dissection. Fig. 2.--Large granulating wound resulting from radical vulvectomy with bilateral node dissection.
usually free from slough except at diathermy sites or around ligatures, although there may be persistent sloughs at the wound edges and over the pubis. Swabs :are taken weekly. In approximately half the cases grafting can be carried out during the next week, but it may be delayed for a week or two in the remainder. Delay may be .due to general causes such as chest complications or, not uncommonly, deep venous thrombosis, or to local causes such as slow sequestration of slough and rarely infection with hmmolytic streptococci. On the average, cases were grafted on the twenty-second day. Just prior to operation, preparation with local streptomycin or chloramphenicol compresses may render the wound sterile. Operation is carried out with the legs widely separated on a board. The raw :area is dried and exudate removed (Fig. 3). I f grafting has been delayed for four ,or more weeks, exuberant granulations may be scraped off. The grafts are applied as strips to the abdominal and inguinal parts of the wound, some being cut short for use around the vaginal and urethral orifices. A self-retaining catheter is :inserted (Figs. 4 and 5). For most of the cases the dressing consisted of Jelonet covered by teased-out gauze soaked in chloramphenicol solution packed around the catheter and over the whole surface. Dry gauze was fixed over this by strapping. In the last four cases, with the appreciation of the excellent results of graft exposure in the treatment of burns, the dressing has been omitted and the take has been almost complete in every one. Post-operative Treatment.mAn antibiotic is given for five days. When dressings
REPAIR AFTER VULVECTOMY:
A SURVEY OF THIRTY-NINE CASES 295
are used these are removed on the third day and fresh compresses applied after the grafts have been cleaned. On the fifth day daily dressings are begun. The catheter is removed after a week and baths recommenced. In the event of a good take the area is almost healed two weeks after operation. Results.--These have been gratifying. The take has been very good in almost all cases and loss, sufficient to necessitate further grafting, has been met with in ;
FIG. 3
FIG. 4
FIG. 5 Figs. 3 to 5.--Diagrams to show operative field, method of grafting, and insertion of indwelling catheter.
only five out of the twenty-seven cases. Two of these were re-grafted with success. In one, where the take had been only 3° per cent. because of overlooked streptococcal infection, further operation was refused and another patient aged 77 was allowed to heal slowly in view of poor general condition. Refrigerated grafts were used in one case with success. Figs. 6 and 7 demonstrate the appearance of the operative field after complete healing. In I955 the writer was anxious to determine if the late results justified the simple procedure and reviewed eleven cases. The results were very satisfactory. The grafted areas had contracted remarkably from above downwards and somewhat from side to side, but all were soundly healed. Functional disability was less than expected, and all the patients were able to live a normal life. One, aged 58, played golf regularly. Movement of the hips was not limited, but oedema of one or both legs was present in eight cases with ulceration in one. I t is now the practice to fit elastic stockings prior to operation, and these are
296
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
worn through convalescence after the patients go home. Many patients find that they can discard the stockings twelve months after operation without further increase in the oedema (Morris, 1959). Other complications met with include prolapse of the anterior or posterior vaginal walls, and where the urethra has been partly resected there is prolonged incontinence. This often clears u p completely, and then one finds a marked prolapse of the urethral mucosa which forms a rosette of congested tissue encircling the meatus.
Fla. 6
FIG. 7 Result after secondary grafting.
Two patients, grafted late, developed vulval stenosis, and treatment of these cases by flaps is dealt with later. Discussion.--The writer was interested during this work in carrying out some form of primary repair and several times assisted with vulvectomy, perhaps carrying out a block dissection on one side. In no case did his gynmcological colleagues or the anmsthetist consider that primary repair was justifiable. He has thus no experience of primary repair by grafts as described by SchmlTer et al. (I955), or by advancing flaps from the medial sides of the thighs now advocated by Way (1957). Morris feels that he is reluctant to adopt this flap procedure which involves suturing skin in tension to an undercut vaginal wall, as the vagina may be converted into a rigid tube with prolapse almost inevitable. Way developed the use of flaps because he rarely found secondary grafting to be successful. This opinion was also that of Isaacs and Topek (I957), who stated that " Grafting in such denuded areas is rarely successful and better results are usually attained by allowing marginal epithelialisation. Complete healing may take three or fbur months." These discouraging reports have not, fortunately, been confirmed in this series of cases. An alternative approach to the problem is described in a very detailed paper by Twombly (1953). He sacrifices less vulvar and inguinal skin than Way and
REPAIR AFTER VULVECTOMY:
A SURVEY OF T H I R T Y - N I N E
CASES
297
is able to carry out complete wound closure. The vulva wound usually heals by first intention and the groin heals in 5o per cent. of cases. He does not cover the suture lines. Where skin necrosis becomes evident, he advises against prolonged waiting to graft the raw areas, preferring to cover them by pinch grafts as soon as they are clean. The grafts are left exposed to the air as in the later cases of the present series. Green et al. (1958) also achieve skin closure frequently without, they say, the danger of local recurrence. They emphasise the nutritional problems that
FIG. 8 FIG. 9 Fig. 8.--Defect produced by radical vulvectomy without gland dissection. Fig. 9.--Irnmediate repair by free split-skin grafting.
arise when large areas are left to granulate. They used " small skin grafts, immediate or delayed in a few cases, to cover defects over the symphysis, which occasionally could not be satisfactorily closed."
Primary Repair after Vulveetomy without Node Disseetion.--Three patients, two suffering from recurrence after local vulvectomy and one from recurrence after radiation treatment, were treated by vulvectomy only. In one, aged 79, radical vulvectomy was carried out with very careful hmmostasis (Fig. 8). It had been intended to carry out a flap repair, but the patient's condition was not very good so a sheet of graft was sutured into position and carefully- overtied (Fig. 9). The take was poor (only 30 per cent.), the first dressing being carried out after a week. Patch refrigerated grafts were applied ten days later with only partial success and healing occurred after eight weeks with considerable contracture. In a second patient, aged 75, strips of grafts were quickly sutured into the large defect, and again the dressing was overtied. The graft took only partly (about 3° per cent.), and further operation was not possible as coronary thrombosis occurred. The patient died fourteen weeks after operation. Primary grafting of this extensive deep wound, therefore, appears to be unlikely to be successful and is not recommended. It is felt that if the patient is not fit for
298
BRITISH JOURNAL OF PLASTIC SURGERY
a primary repair by flaps, secondary grafting should be carried out later. McKelvey (1947) and Way (1948) both confirmed this view, but, as mentioned already, Schaeffer reported one successful case. Only one primary flap repair has been done in a patient of 76 (Figs. IO and I I). One large flap (Fig. 12) based posteriorly was raised and the vulva closed with
FIG. I I
FIG. I2 FIG. I3 Flap delineated and transposed to close vulval a n d perineal defect.
advancement of the opposite edge of the wound. Although its colour was good at the end of the operation (Fig. I3), it was not appreciated at the time that the base of the flap would be obstructed if the patient was nursed on her back. The flap was largely lost (Fig. 14) and the raw area was grafted ten days after the primary operation with limited success. It was almost three months before complete healing occurred. It is intended to undertake further primary repair when the opportunity presents itself.
REPAIR
AFTER
VULVECTOMY:
A SURVEY OF
THIRTY-NINE
CASES
299
Primary Direct Closure after Vulveetomy and Abdomino-perineal Resection of the R e c t u m . - - D i r e c t closure may occasionally be possible. An obese lady aged 4 6 had a carcinoma involving the perineum and anal margin, and the operation was combined with abdomino-perineal resection of the rectum. The .closure of the skin around the urethra :and the vagina was performed without .drainage, and although there was slight breakdown posteriorly due to hmmatoma the eventual result was satisfactory.
Bilateral Rotation Flap Repair for Stenosis after Radical Vulveetomy.-T w o cases grafted two months after primary operation developed gross scarring and contracture, the urethra and vagina being covered in by scar tissue except for an orifice I cm. in diameter, through which micturition took place F~G. 14 with difficulty. In each, frequent dilataResult--necrosis of distal flap. fion led to temporary relief only. The scar was dissected, the urethra and vagina defined, and two large flaps, based posteriorly and anteriorly respectively, rotated inwards to form a new vulva and perinenm. The secondary defects were grafted. The flaps healed anteriorly b y first intention, but there was some loss behind the vagina and to the left of the ~anus. Micturition, however, became free and painless, and the final functional :result was excellent in each case. NON-MALIGNANT CASES
(Table II)
Primary Grafting after Simple Vulvectomy for Leukoplakia.--Dr Fletcher Shaw has found that simple vulvectomy with direct suture has resulted on several occasions in partial breakdown, secondary infection, slow healing, and scar formation. The operation consists of removing vulval skin, the labia, and the clitoris, but does not extend deeply into the ischiorectal fossa: and leaves a more superficial defect than radical vulvectomy. In an attempt to improve the results in five cases, sheets of split skin were sutured into the defect and dressings overtied very much as in one of the malignant cases mentioned above. The dressing was taken down after seven days. Table II Non-malignaut Cases, 6 Local vulvectomy for leukoplakia-Primary grafting
5
Vulval stenosis after local vulvectomy-Bilateral rotation flap repair
I
Results.--In two patients the take was almost complete and the wound healed :in four weeks. In one, an extensive excision with removal of peri-anal and much buttock skin, I5 per cent. of the graft was lost over the buttock. This area
300
BRITISH JOURNAL OF PLASTIC SURGERY
contracted down and the patient went home virtually healed after seven weeks. In the remaining two cases the take was patchy with slow healing after baths and dressings and eventually there was some contraeture. Even so, follow-up showed that when the graft had softened there was negligible functional disability. Further cases have been treated by colleagues.
FIG. 16
FIG. 17
FIG. I8 Delineation of flaps and closure.
Bilateral Rotation Flap Repair for Stenosis.--This case provided, after cadaveric experience, the first opportunity of using bilateral rotation flaps as already described. Extensive local vulvectomy for leukoplakia with primary suture and subsequent breakdown led to vaginal and anal stenosis, making coitus impossible and necessitating a colostomy after failure of repeated anal dilatation (Fig. 15). The scar was excised to free the vaginal alld anal orifices, the anal skin being largely absent (Fig. 16). Two flaps were raised and rotated inwards, their inner edges being sutured to the vaginal and allal mucosa (Figs. 17 and 18). The secondary defects were grafted. As with the two subsequent cases, mentioned above, there'
REPAIR AFTER VULVECTOMY : A SURVEY OF THIRTY-NINE CASES 301 was some loss behind and to the left o f the anus. T h e vaginal stenosis was relieved, but there was considerable permanent scarring in the perineum and it has not been possible to close the colostomy. SUMMARY AND CONCLUSIONS Personal experience of repair after vulvectomy is b a s e d on thirty-nine cases treated during the last ten years. I. Thirty-three Malignant C a s e s . - - T w e n t y - s e v e n patients had undergone radical vulvectomy with bilateral node dissection. T h e extensive wound was closed b y secondary free grafting, on the average twenty-two days after resection. T h e results were satisfactory. It is pointed out that these favourable findings have not always been reported previously. Primary repair was attempted, twice by free grafts and once by a single flap, in three cases o f vulvectomy without gland dissection. T h e results were not good and, although it is hoped to gain further experience of flap repair, primary free grafting is not recommended. On one occasion, obesity and a coincident abdomino-perineal resection allowed closure by direct suture. Late stenosis with urinary obstruction was relieved in two cases b y a rotation flap repair. 2. S i x Non-malignant Cases.--In five patients local vulvectomy for leukoplakia was successfully followed by immediate grafting. T h e defect here is more superficial than in the operation for malignancy. Severe vulval and anal stenosis was met with in one case after wide excision without grafting. A rotation flap repair completely relieved the vaginal but not the anal stenosis. I wish to thank Professor W. I. C. Morris, Dr D. Fletcher Shaw, and Dr A. H. C. Walker for inviting me to co-operate with them in this work and for giving me every facility. When it began, I was Senior Registrar to Mr Randell Champion, whose advice and encouragement were invaluable. The photographs are from the Department of Medical Illustration, Manchester United Hospitals.
REFERENCES COLLINS,~. M., BURMAN,R. G., and MATTHEWS,N. M. (1956). Amer.J. Surg., 92, 37. GREEN,T. H., jun., ULFELDER,H., and MEltS, J. V. (1958). Amer. J. Obstet. Gynec., 75, 848. ISAACS,J. H., and TOPEK,N. H. (1957). Amer. ft. Obstet. Gynec., 73, 1277. MCKELVEY,J. L. (1947). Amer. ft. Obstet., 54, 626. MORRIS, W. I. C. (1959). Personal communication. SCHAEFFER,C. F., MARCKS,K., TREVASKIS,A.~ TUARK,M., and GEARHART,L. (1955). Amer. ft. Surg., 9 o, 593. SHAW,D. F. (1955). Personal communication. TWOMBLY,G. H. (1953). Cancer, 6, 516. WAY, S. (1948). Ann. R. Coll. Surg. Engl., 3, 187. - - (1957). In "Progress in Gynecology," vol. 3, P. 489. Ed. by J. V. Meigs and S. H. Sturgis. New York: Grune & Stratton.
THIS is a report of personal experience in a specialised field dealing with repair after vulvectomy for both malignant and non-malignant conditions. MALIGNANT CASES
It is proposed to discuss the malignant cases first (Table I). The age of the patients varied from 28 to 79 years, twenty-six of the thirty-three patients being over 50, and of these eleven were over 60 and nine over 7° . TABLE I Malignant Cases, 33 /
.
Radical vulvectomy with node dissection-Secondary grafting
27
Radical vulvectomy without node dissection-Primary grafting . Primary flap repair Direct closure
2 I I
Vulval stenosis after radical vulvectomy-Bilateral rotation flap repair
2
Secondary Grafting after Radical Vulvectomy with Node D i s s e c t i o n . This procedure has been carried out in twenty-six cases of squamous-cell carcinoma and in one of malignant melanoma. It is generally agreed by gyn~ecologists that the treatment of choice in carcinoma of the vulva is operative--radical vulvectomy with bilateral inguinal• node dissection as described by Way (I948). The skin of both inguinal triangles,• the inguinal glands, and Cloquet's gland are removed en bloc. Frequently a femoral hernia presents after exploration of the femoral canal and this is repaired. The vulva, including the labia and the clitoris, is then resected in continuity, both• ischiorectal foss~e being entered. Part of the urethra may be taken (Fig. I). Originally many surgeons left the large wound (Fig. 2) to granulate and close in naturally--a process which takes three months. Way, however, in his article, stated that he employed Thiersch grafting when the wounds were clean to reduce: the time of stay in hospital. In Manchester, Professor W. I. C. Morris felt that skin grafting would greatly accelerate healing, and the first two cases were grafted• in I95I some fourteen and thirty-one days after operation respectively. Sheets of split skin were applied and bandaged into position. Both operations were only partially successful and supplementary grafts were required, but the first patient: went home seven weeks after the radical operation. For the next few cases strips of skin were applied to the pubic and inguinal 293
294
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
parts of the wound and shorter strips or squares around the vaginal orifice. T h e technique developed was so successful that it was used for six years without significant change. Then, on occasions, large sheets of skin were tried again but once more were not found to be as satisfactory. During the last ten years, therefore, the procedure has been as follows. Preparation and Operation,--Patients are first seen some ten days after vulvectomy when the large wound is beginning to clean up. Baths are being taken daily and wet dressings of Eusol and saline applied afterwards. The wound is
FIG. I
FIG. 2
Fig. I.--Block of tissue resected in radical vulvectomy with bilateral node dissection. Fig. 2.--Large granulating wound resulting from radical vulvectomy with bilateral node dissection.
usually free from slough except at diathermy sites or around ligatures, although there may be persistent sloughs at the wound edges and over the pubis. Swabs :are taken weekly. In approximately half the cases grafting can be carried out during the next week, but it may be delayed for a week or two in the remainder. Delay may be .due to general causes such as chest complications or, not uncommonly, deep venous thrombosis, or to local causes such as slow sequestration of slough and rarely infection with hmmolytic streptococci. On the average, cases were grafted on the twenty-second day. Just prior to operation, preparation with local streptomycin or chloramphenicol compresses may render the wound sterile. Operation is carried out with the legs widely separated on a board. The raw :area is dried and exudate removed (Fig. 3). I f grafting has been delayed for four ,or more weeks, exuberant granulations may be scraped off. The grafts are applied as strips to the abdominal and inguinal parts of the wound, some being cut short for use around the vaginal and urethral orifices. A self-retaining catheter is :inserted (Figs. 4 and 5). For most of the cases the dressing consisted of Jelonet covered by teased-out gauze soaked in chloramphenicol solution packed around the catheter and over the whole surface. Dry gauze was fixed over this by strapping. In the last four cases, with the appreciation of the excellent results of graft exposure in the treatment of burns, the dressing has been omitted and the take has been almost complete in every one. Post-operative Treatment.mAn antibiotic is given for five days. When dressings
REPAIR AFTER VULVECTOMY:
A SURVEY OF THIRTY-NINE CASES 295
are used these are removed on the third day and fresh compresses applied after the grafts have been cleaned. On the fifth day daily dressings are begun. The catheter is removed after a week and baths recommenced. In the event of a good take the area is almost healed two weeks after operation. Results.--These have been gratifying. The take has been very good in almost all cases and loss, sufficient to necessitate further grafting, has been met with in ;
FIG. 3
FIG. 4
FIG. 5 Figs. 3 to 5.--Diagrams to show operative field, method of grafting, and insertion of indwelling catheter.
only five out of the twenty-seven cases. Two of these were re-grafted with success. In one, where the take had been only 3° per cent. because of overlooked streptococcal infection, further operation was refused and another patient aged 77 was allowed to heal slowly in view of poor general condition. Refrigerated grafts were used in one case with success. Figs. 6 and 7 demonstrate the appearance of the operative field after complete healing. In I955 the writer was anxious to determine if the late results justified the simple procedure and reviewed eleven cases. The results were very satisfactory. The grafted areas had contracted remarkably from above downwards and somewhat from side to side, but all were soundly healed. Functional disability was less than expected, and all the patients were able to live a normal life. One, aged 58, played golf regularly. Movement of the hips was not limited, but oedema of one or both legs was present in eight cases with ulceration in one. I t is now the practice to fit elastic stockings prior to operation, and these are
296
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
worn through convalescence after the patients go home. Many patients find that they can discard the stockings twelve months after operation without further increase in the oedema (Morris, 1959). Other complications met with include prolapse of the anterior or posterior vaginal walls, and where the urethra has been partly resected there is prolonged incontinence. This often clears u p completely, and then one finds a marked prolapse of the urethral mucosa which forms a rosette of congested tissue encircling the meatus.
Fla. 6
FIG. 7 Result after secondary grafting.
Two patients, grafted late, developed vulval stenosis, and treatment of these cases by flaps is dealt with later. Discussion.--The writer was interested during this work in carrying out some form of primary repair and several times assisted with vulvectomy, perhaps carrying out a block dissection on one side. In no case did his gynmcological colleagues or the anmsthetist consider that primary repair was justifiable. He has thus no experience of primary repair by grafts as described by SchmlTer et al. (I955), or by advancing flaps from the medial sides of the thighs now advocated by Way (1957). Morris feels that he is reluctant to adopt this flap procedure which involves suturing skin in tension to an undercut vaginal wall, as the vagina may be converted into a rigid tube with prolapse almost inevitable. Way developed the use of flaps because he rarely found secondary grafting to be successful. This opinion was also that of Isaacs and Topek (I957), who stated that " Grafting in such denuded areas is rarely successful and better results are usually attained by allowing marginal epithelialisation. Complete healing may take three or fbur months." These discouraging reports have not, fortunately, been confirmed in this series of cases. An alternative approach to the problem is described in a very detailed paper by Twombly (1953). He sacrifices less vulvar and inguinal skin than Way and
REPAIR AFTER VULVECTOMY:
A SURVEY OF T H I R T Y - N I N E
CASES
297
is able to carry out complete wound closure. The vulva wound usually heals by first intention and the groin heals in 5o per cent. of cases. He does not cover the suture lines. Where skin necrosis becomes evident, he advises against prolonged waiting to graft the raw areas, preferring to cover them by pinch grafts as soon as they are clean. The grafts are left exposed to the air as in the later cases of the present series. Green et al. (1958) also achieve skin closure frequently without, they say, the danger of local recurrence. They emphasise the nutritional problems that
FIG. 8 FIG. 9 Fig. 8.--Defect produced by radical vulvectomy without gland dissection. Fig. 9.--Irnmediate repair by free split-skin grafting.
arise when large areas are left to granulate. They used " small skin grafts, immediate or delayed in a few cases, to cover defects over the symphysis, which occasionally could not be satisfactorily closed."
Primary Repair after Vulveetomy without Node Disseetion.--Three patients, two suffering from recurrence after local vulvectomy and one from recurrence after radiation treatment, were treated by vulvectomy only. In one, aged 79, radical vulvectomy was carried out with very careful hmmostasis (Fig. 8). It had been intended to carry out a flap repair, but the patient's condition was not very good so a sheet of graft was sutured into position and carefully- overtied (Fig. 9). The take was poor (only 30 per cent.), the first dressing being carried out after a week. Patch refrigerated grafts were applied ten days later with only partial success and healing occurred after eight weeks with considerable contracture. In a second patient, aged 75, strips of grafts were quickly sutured into the large defect, and again the dressing was overtied. The graft took only partly (about 3° per cent.), and further operation was not possible as coronary thrombosis occurred. The patient died fourteen weeks after operation. Primary grafting of this extensive deep wound, therefore, appears to be unlikely to be successful and is not recommended. It is felt that if the patient is not fit for
298
BRITISH JOURNAL OF PLASTIC SURGERY
a primary repair by flaps, secondary grafting should be carried out later. McKelvey (1947) and Way (1948) both confirmed this view, but, as mentioned already, Schaeffer reported one successful case. Only one primary flap repair has been done in a patient of 76 (Figs. IO and I I). One large flap (Fig. 12) based posteriorly was raised and the vulva closed with
FIG. I I
FIG. I2 FIG. I3 Flap delineated and transposed to close vulval a n d perineal defect.
advancement of the opposite edge of the wound. Although its colour was good at the end of the operation (Fig. I3), it was not appreciated at the time that the base of the flap would be obstructed if the patient was nursed on her back. The flap was largely lost (Fig. 14) and the raw area was grafted ten days after the primary operation with limited success. It was almost three months before complete healing occurred. It is intended to undertake further primary repair when the opportunity presents itself.
REPAIR
AFTER
VULVECTOMY:
A SURVEY OF
THIRTY-NINE
CASES
299
Primary Direct Closure after Vulveetomy and Abdomino-perineal Resection of the R e c t u m . - - D i r e c t closure may occasionally be possible. An obese lady aged 4 6 had a carcinoma involving the perineum and anal margin, and the operation was combined with abdomino-perineal resection of the rectum. The .closure of the skin around the urethra :and the vagina was performed without .drainage, and although there was slight breakdown posteriorly due to hmmatoma the eventual result was satisfactory.
Bilateral Rotation Flap Repair for Stenosis after Radical Vulveetomy.-T w o cases grafted two months after primary operation developed gross scarring and contracture, the urethra and vagina being covered in by scar tissue except for an orifice I cm. in diameter, through which micturition took place F~G. 14 with difficulty. In each, frequent dilataResult--necrosis of distal flap. fion led to temporary relief only. The scar was dissected, the urethra and vagina defined, and two large flaps, based posteriorly and anteriorly respectively, rotated inwards to form a new vulva and perinenm. The secondary defects were grafted. The flaps healed anteriorly b y first intention, but there was some loss behind the vagina and to the left of the ~anus. Micturition, however, became free and painless, and the final functional :result was excellent in each case. NON-MALIGNANT CASES
(Table II)
Primary Grafting after Simple Vulvectomy for Leukoplakia.--Dr Fletcher Shaw has found that simple vulvectomy with direct suture has resulted on several occasions in partial breakdown, secondary infection, slow healing, and scar formation. The operation consists of removing vulval skin, the labia, and the clitoris, but does not extend deeply into the ischiorectal fossa: and leaves a more superficial defect than radical vulvectomy. In an attempt to improve the results in five cases, sheets of split skin were sutured into the defect and dressings overtied very much as in one of the malignant cases mentioned above. The dressing was taken down after seven days. Table II Non-malignaut Cases, 6 Local vulvectomy for leukoplakia-Primary grafting
5
Vulval stenosis after local vulvectomy-Bilateral rotation flap repair
I
Results.--In two patients the take was almost complete and the wound healed :in four weeks. In one, an extensive excision with removal of peri-anal and much buttock skin, I5 per cent. of the graft was lost over the buttock. This area
300
BRITISH JOURNAL OF PLASTIC SURGERY
contracted down and the patient went home virtually healed after seven weeks. In the remaining two cases the take was patchy with slow healing after baths and dressings and eventually there was some contraeture. Even so, follow-up showed that when the graft had softened there was negligible functional disability. Further cases have been treated by colleagues.
FIG. 16
FIG. 17
FIG. I8 Delineation of flaps and closure.
Bilateral Rotation Flap Repair for Stenosis.--This case provided, after cadaveric experience, the first opportunity of using bilateral rotation flaps as already described. Extensive local vulvectomy for leukoplakia with primary suture and subsequent breakdown led to vaginal and anal stenosis, making coitus impossible and necessitating a colostomy after failure of repeated anal dilatation (Fig. 15). The scar was excised to free the vaginal alld anal orifices, the anal skin being largely absent (Fig. 16). Two flaps were raised and rotated inwards, their inner edges being sutured to the vaginal and allal mucosa (Figs. 17 and 18). The secondary defects were grafted. As with the two subsequent cases, mentioned above, there'
REPAIR AFTER VULVECTOMY : A SURVEY OF THIRTY-NINE CASES 301 was some loss behind and to the left o f the anus. T h e vaginal stenosis was relieved, but there was considerable permanent scarring in the perineum and it has not been possible to close the colostomy. SUMMARY AND CONCLUSIONS Personal experience of repair after vulvectomy is b a s e d on thirty-nine cases treated during the last ten years. I. Thirty-three Malignant C a s e s . - - T w e n t y - s e v e n patients had undergone radical vulvectomy with bilateral node dissection. T h e extensive wound was closed b y secondary free grafting, on the average twenty-two days after resection. T h e results were satisfactory. It is pointed out that these favourable findings have not always been reported previously. Primary repair was attempted, twice by free grafts and once by a single flap, in three cases o f vulvectomy without gland dissection. T h e results were not good and, although it is hoped to gain further experience of flap repair, primary free grafting is not recommended. On one occasion, obesity and a coincident abdomino-perineal resection allowed closure by direct suture. Late stenosis with urinary obstruction was relieved in two cases b y a rotation flap repair. 2. S i x Non-malignant Cases.--In five patients local vulvectomy for leukoplakia was successfully followed by immediate grafting. T h e defect here is more superficial than in the operation for malignancy. Severe vulval and anal stenosis was met with in one case after wide excision without grafting. A rotation flap repair completely relieved the vaginal but not the anal stenosis. I wish to thank Professor W. I. C. Morris, Dr D. Fletcher Shaw, and Dr A. H. C. Walker for inviting me to co-operate with them in this work and for giving me every facility. When it began, I was Senior Registrar to Mr Randell Champion, whose advice and encouragement were invaluable. The photographs are from the Department of Medical Illustration, Manchester United Hospitals.
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