Paraumbilical perforator flap for one-stage reconstruction of a large oncologic vulvar defect: a single case report

Background: Large vulvar defects often results in complex reconstructive problems. Deep inferior epigastric perforator (DIEP) flap was considered as a less invasive and reliable method for vulvar reconstruction. However, tedious dissection of the pedicle vessel requires a longer flap harvesting time. To overcome the disadvantage, paraumbilical perforator (PUP) flap was developed with the perforator only penetrating the retus abdominis muscle. However, no case has previously been reported of using PUP flap for vulvar reconstruction. In our report, we are first writing to share our own clinical experience of using PUP flap as an aid to cover a large vulvar defect. Case: We present a case of a 60-year-old female with a BMI of 30 and recurrent vulvar squamous cell carcinoma, without comorbidities involving hypertension and diabetes mellitus. By the aid of a Doppler probe, PUP was identified and labeled on the skin. A radical vulvectomy without additional treatment (chemotherapy and/or radiotherapy) was subsequently underwent, with a final defect consisting of a campaniform, full-thickness skin defect measuring 15 ×$\times$ 8 cm2${}^2$ without involvement of the urethra and vagina. By the aid of a PUP flap, the large defect was successfully reconstructed in one stage. The duration of surgery is nearly 3 hours. Postoperative management consists of remained urinary catheterization and complete bed rest. Follow-up was respectively performed at 3, 6 months. No local recurrence or distant metastasis was found. Conclusions: Our results suggest that PUP flap has shown to be an alternative and new method for one-stage reconstruction of vulvar defects. Further investigations for this novel flap to treat such cases are needed.

Paraumbilical perforator flap; Vulvar cancer; One-stage reconstruction

[1] Weiss A, Kapetansky DI, Pierce AK. A new method of perineal reconstruction following vulvectomy. Plastic and Reconstructive Surgery. 1980; 65: 824–827.

[2] Eom JS, Kim DY, Kim EK, Lee TJ. The Low DIEP Flap: An Enhancement to the Abdominal Donor Site. Plastic and Reconstruc- tive Surgery. 2016; 137: 7e–13e.

[3] Garvey PB, Buchel EW, Pockaj BA, Casey WJ, Gray RJ, Hernández JL, et al. DIEP and pedicled TRAM flaps: a comparison of outcomes. Plastic and Reconstructive Surgery. 2006; 117: 1711–1721.

[4] Muneuchi G, Ohno M, Shiota A, Hata T, Igawa HH. Deep inferior epigastric perforator (DIEP) flap for vulvar reconstruction after radical vulvectomy: a less invasive and simple procedure utilizing an abdominal incision wound. Annals of Plastic Surgery. 2005; 55: 427–429.

[5] Koshima I, Inagawa K, Yamamoto M, Moriguchi T. New micro- surgical breast reconstruction using free paraumbilical perforator adiposal flaps. Plastic and Reconstructive Surgery. 2000; 106: 61– 65.

[6] Granzow JW, Levine JL, Chiu ES, Allen RJ. Breast reconstruction with the deep inferior epigastric perforator flap: history and an update on current technique. Journal of Plastic, Reconstructive & Aesthetic Surgery. 2006; 59: 571–579.

[7] Koshima I, Moriguchi T, Fukuda H, Yoshikawa Y, Soeda S. Free, thinned, paraumbilical perforator-based flaps. Journal of Recon- structive Microsurgery. 1991; 7: 313–316.

[8] Koshima I, Inagawa K, Urushibara K, Moriguchi T. Paraumbilical perforator flap without deep inferior epigastric vessels. Plastic and Reconstructive Surgery. 1998; 102: 1052–1057.

[9] Cheng A, Saint-Cyr M. Split and thinned pedicle deep inferior epi- gastric perforator (DIEP) flap for vulvar reconstruction. Journal of Reconstructive Microsurgery. 2013; 29: 277–282.

[10] Bracaglia R, D’Ettorre M, Gentileschi S, Tambasco D. Was the surgeon a satisfactory informant? how to minimize room for claims. Aesthetic Surgery Journal. 2014; 34: 632–635.

[11] Gentileschi S, Servillo M, Garganese G, Simona F, Scambia G, Sal- garello M. Versatility of pedicled anterolateral thigh flap in gyne- cologic reconstruction after vulvar cancer extirpative surgery. Microsurgery. 2017; 37: 516–524.

[12] Zhang W, Zeng A, Yang J, Cao D, He X, Wang X, et al. Outcome of vulvar reconstruction in patients with advanced and recurrent vulvar malignancies. BMC Cancer. 2015; 15: 851.

[13] Huang J, Chang N, Chou H, Wu C, Abdelrahman M, Chen H, et al. Pedicle perforator flaps for vulvar reconstruction—New generation of less invasive vulvar reconstruction with favorable results. Gynecologic Oncology. 2015; 137: 66–72.