Vaginal Reconstruction with Modified Singapore Flap in MRK Syndrome Patients

PURPOSE: Mayer-Rokitansky-Kuster syndrome(MRK) is second common cause of primary amenorrhea. It is a syndrome of vaginal aplasia and Mullerian duct anomaly. Vaginal aplasia varies from agenesis of whole vagina to aplasia of upper 2/3. For reconstructing vagina, various methods are introduced. Gracilis myocutaneous flap was the first attempt in that the flap is used in vaginal reconstruction. Various flap-based vaginal reconstruction methods have been introduced. Modified Singapore flap (pedicled neurovascular pudendal thigh fasciocutaneous flap) is one of those methods that used posterior labial artery as pedicle, and pudendal nerve branch as sensory root. As its donor lies on inguinal crease that is easily hidden and there are benefits on sexual intercourse by early sensory recovery, authors think that modified Singapore flap is effective for young MRK syndrome patients. METHODS: Eight patients underwent surgery between 2008 and 2010. The flap was designed on both groin area with external pudendal artery branch as a pedicle. All flaps were fixated in pelvic cavity with absorbable suture, and additional compression on neovaginal wall was supplied by polyvinyl alcohol sponge(Merocel(R)). RESULTS: All patients were successfully reconstructed without flap related complications such as congestion or partial flap loss. The average size of the flap(each side) was 69.34cm2. Polyvinyl alcohol sponge(Merocel(R)) was inserted into neovagina for 5 days on every patient. One case of rectal laceration was occurred while making pelvic pocket by OBGY team. Other complications such as lumen narrowing, wound contracture or vaginal prolapsed were not reported during 8 months of follow up. CONCLUSION: Modified Singapore flap is a sensate fasciocutaneous flap that is thinner than other myocutaneous flap such as VRAM, and more durable over skin graft. Therefore this is a good choice for vaginal reconstruction in MRK syndrome. And known complications of Modified Singapore flap could be reduced with careful procedure and mild compression techniques.

Clinical significance of muscle sparing verticle rectus abdominis myocutaneous flap for vaginal reconstruction / 中华医学美学美容杂志

Objective To evaluate the method for vaginal treconstruction with muscle sparing verti-cle rectus abdominis myocutaneous flap(MS-VRAM flap). Methods From September 2006 to April 2008, MS-VRAM flaps were used for vaginal reconstruction in 9 patients (20 to 35 years old), ancl all ca-ses were congenital absence of vagina. Before operation, the inferior epigastrie arteries were detected by the Doppler and the flaps based on the perforators ranged from 6 cm×20 cm. MS-VRAM flaps were ele-vated and then transferred to reconstruct the vagina. Results All 9 cases of MS-VRAM flaps survived completely. No complications occurred at donor site of abdominal wall. With 2-12 months' follow-up, the patients were satisfied with the results. Conclusion Despite technical difficulties in elevating the MS-VRAM flap, the flap is a good choice for vaginal reconstruction.

Vaginal Reconstruction with Pudendal Thigh Flaps

Reconstruction of vagina can be accomplished by various methods. But in most cases they require stents or dilators and the angle of vagina is unphysiologic. Donor site scars are also formidable. We used pudendal thigh flaps described by Wee and Joseph to overcome the disadvantages of the traditional techniques. We performed the bilateral use of the flap to reconstruct vagina in 6 patients with congenital viginal atresia and the unilateral use to reconstruct vaginal defect in one patient after oncologic resection. The vaginas were successfully reconstructed with either bilateral or unilateral 6 x 12 cm pudendal thigh fasciocutaneous flap based on the terminal branches of the superficial perineal artery. All 13 pudendal thigh flaps in 7 patients survived completely and the vagina was reconstructed in one stage. The flaps were sensate and the vaginal dimensions were well maintained without stents or dilators. This technique seems superior to other methods as is already known. But the donor site scars became widened in 4 patients although they were in the groin crease. There were also minimal complications such as wound dehiscence in 1 patient, prolapse of flap in 1 patient, and some hair growth in the flaps in 3 patients. We report the use of pudendal thigh flaps for vaginal reconstruction and discuss the functional and aesthetic results in this article

Gluteal Fold Fasciocutaneous Turnover Flap for Reconstruction of Perineum and Vaginal Wall

Soft tissue reconstruction after tumor surgery in the area of the perineum and vagina presents a difficult challenge. The reconstructive surgeons solve this problem primarily using skin graft, local fasciocutaneous or musculocutaneous flaps, although free tissue transfer is also used. Closure of deep defects is preferably performed using a musculocutaneous flap, but in more superficial cases, use of a less bulky fasciocutaneous flap is used. The fasciocutaneous flap has been proven not necessarily to include the muscular layer for sufficient blood supply. Moreover, elevation of pure skin and fascia rather than that of musculocutaneous unit increases the flexibility individualizing the flap design. A 60-years-old female suffered from protrusion of anterior vaginal wall with a significant residual perineal defect and loss of the posterior vaginal wall after Mile's operation and radiation therapy. A new fasciocutaneous turnover flap as a modification of the gluteal fold fasciocutaneous flap was designed to solve the particular reconstructive problems. The flap is based on branches of the internal pudendal artery. In our case the flap survived without complications and donor scar was inconspicuously located in the gluteal fold. This new flap eventually enabled the successful reconstruction of the posterior vaginal wall and perineal soft tissue defect.

Applied anatomy and clinical evaluation of vaginal reconstru ction using the pudendal-thigh island flaps / 中华医学美学美容杂志

Objective To introduce the anatomic basis and evaluat ion of clinical application of the pudendal-thigh island flaps us ing for vaginal reconstruction. Methods The blood supply and innervation to the skin and fascia of the pudendal-thigh region were studied in 5 female cadavers (with 10 sides). 20 patients who underwent vaginal reconstruction with pudendal-thigh island flaps were followed-up, and all the women were married for more than 3 years. Results There were multiple blood supply in the pudendal-thigh area. The cuta neous arterial vessels come from the posterior labial artery, the external pudendal artery and the anterior cutaneous branches of obturator artery. The posterior labial artery was one of the internal pudendal artery branches, a nd the diameter of it was 0.9～1.7 mm (1.3mm in average) in its original site, w hich was 22～35 mm (26mm in average) from the perineal midline. It gave off 4 ～7 branches to the major labia and the pudendal-thigh area while running alon g the lateral site of the major labia accompanying vein and nerve. 20 patients w ho were followed-up satisfied with their perineal appearance and with 10. 2 cm depth of neovagina in average. Twenty neovagina remained supple, and sexually active without difficulty. Conclusions The pedicle of the pudendal-thigh island flaps using for vaginal reconstruction is the post erior labial neurovascular bundle. The flap has reliable blood supply, survive s easily, transfers with partial sensation and few complications. This tech nique introduces a modified approch of vaginal reconstruction using bilateral pudendal- thigh island flaps with satisfactory cosmetic and functional resu lts.