Reconstruction, thanks. Thanks for having me. It's going to be a short talk. I am a plastic and reconstructive surgeon and I do a fair bit of cancer reconstruction here at UNC. I have a joint appointment in the Department of Urology because I do reconstructive fibroblasts as well. I'm just going to give an overview of vulva reconstruction and sort of the things that one would expect a regular GYN or somebody who's doing vulvectomies or doing vulva cancer work to know. All right, perfect. I like to quote, this is my mantra in general for reconstruction, the words of Gaspari Tagliacosi, which is that the point of reconstructive and plastic surgery is to rebuild, restore, and make whole. Parts rich in nature are given, but fortune take it away. Not to delight the eye, but to buy the spirit and help the mind of the afflicted. Vulva cancer, the population typically tends to be older patients. This may be recurrent cancer. And so the patient had prior operation or radiation, and that in itself presents challenges. So it's important to know all this information. Patients may have comorbidities, which will affect what you can do. You know, older patient who may not be able to take a lung operation may not be a candidate for, you know, one of the more complex operations. Smokers, a lot of our patients will show up as smokers. And since they have cancer, you don't have enough time to tell them to stop smoking. So it's key to know that and adjust your plan, you know, to sort of prevent the complications that will come from that. Probably most important is to understand the goals of the patient. We're just talking the ability to have normal looking or near normal looking genitalia, or are they interested in sexual function? And then do they currently have urinary function? Is this somebody who already has incompetence and that's something you have to account for? We all are familiar with this anatomy, but sort of in plastics, we will sometimes divide the vulva in our mind into three thirds, the upper third, middle third, and the lower third, with the lower third being including sort of like the perineal body and the middle third being sort of around the vestibule and the upper third being the muscle and clitoris and clitoral hood. Also, just figuring out where the blood supply is going to come from for what you're going to do. And, you know, understanding the internal and external, then they'll also supply, both supply the region and then understanding where the nerves come from is important. One of the first things we like to do as plastic surgeons is do a defect analysis. So identify what parts are missing. And these are three different patients that have different parts missing. So if you go from left to the right, the patient on the left not only has some of our vulva missing, she's also missing her posterior vaginal wall. And a fair number of vulval defects also involve the vaginal cavity. So it's important to identify that before you pick a plan for your reconstruction. On the other hand, the patient in the middle, you know, has had radiation and now has this big non-healing wound with loss of one half of our vulva. So she's a little different from the other lady. She actually doesn't have much of a vaginal defect. And the patient on the right has what is essentially a partial defect, mostly involving just the right side. And so, you know, identify in your mind, is this a unilateral or bilateral defect you're dealing with? Which of the thirds are involved? Is the vagina involved? Is the perineum or anus involved? And in some cases, is the groin violated? Because that could be a source for some of the tissue you'd like to use. In particular, Singapore flaps, you can't do if the patient has already had a dissection or the groin has been otherwise violated. And so I think that just went back. So the reconstructed ladder is typically what all plastic surgeons talk about, going from a simple procedure, simple procedures to complex procedures. So simple being just allowed to heal by dressing. This is always really difficult in the vulva because it's wet and, you know, patients find it hard to dress. So as much as possible, if you can reconstruct and close, it's better than giving them a defect to heal secondarily. And then you go on to healing, closing by primary intention, which I'll show you in a few seconds. Skin grafts don't usually do as well in the groin, again, because it's typically wet. It's hard to get good bolsters. It's hard to make a wound vac fit for places where we have wound vacs. And then you can have regional or local flaps and free tissue transplants, transfers in some cases. This is an example of a patient who had a primary closure. So this is a unilateral vulvectomy. And the patient actually didn't need to even have the libia minora taken out. So we're able to close this patient primarily. The important things to know about primary closure is to pay attention to the layers. There's this carpal laser down there. There's a deep dermal layer. At least have three layers of closure so it doesn't fall over. Important to pick sutures that will absorb most of the time is what we use because then they have a lower risk of infection. The groin has a lot of bacteria sort of hanging around, but from the urine and the stool and all of that. So it's important to use a suture that's removable, a suture that's absorbable typically and will have. Usually I use PDS for my skin. And on the deeper side, sometimes I will use a monocle. The Foley, the use of a Foley is typically important to divert the urinary stream away. You don't want to use it for too long. Usually I try to keep it to two to three days or at most seven days. And then I try to encourage the patients to pee in such a way that they don't drain. Sitting restriction is important because if patients sit, they get a lot more pelvic swelling. And so typically whenever I do vulvar reconstruction, I encourage the patients not to sit. They can lay down, they can be in a lazy boy position, and they can walk. But sitting straight up, I usually tell them to hold off for a good two to three weeks. And they will notice the difference in terms of pain, swelling, healing problems, and of course patient education. And so this is an idea of what this patient's vulva did look like when she was fully healed. So a reasonable result. I just entered your arrangement sort of the next step up where we use various sort of techniques to rotate tissue into the area to get a slightly better result. So this is somebody who had multiple prior operations. I believe she had had prior flaps and so on. And so she then had a vulvectomy, sort of mostly involving the mom's area. And we're able to get her closed by rotating some of the tissue from lateral and from the left side. And there you see there a little upside down Y closure. The tricks for this, some of which are important, is to realize before you start working where the loose tissue is, assess the mobility of surrounding tissue. Again, you want to do your dissection, not just the skin. Otherwise, most of it is not going to heal and it's going to die. So you want to dissect deep to the scar fascia. And you also want to think about the final appearance. You at least want to figure out how a unary stream is going to work and try to close in such a way that she'll get the closest result to normal that is possible for what she has. When adjacent tissue rearrangement cannot work, then we have to do regional flaps. And this schema here shows a picture of the different flaps that we can typically use to reconstruct the vulva, going all the way from the belly to the lateral thigh, to the medial thigh, to the posterior thigh, and to the groin. And I'll show a few of those. This is an example of a patient that I showed you prior who had a partial valvectomy on the right side and eventually got a Singapore flap for closure. And we rotated this flap from a groin straight line closure. And that's what it looks like healed. And this was a composite vulva and vaginal defect. And she was able to heal both parts of her vulva, both the vagina and the vulva. This is a patient who had an anterolateral thigh flap. This is the one who presented chronically with a chronic wound after radiation. So it required us bringing tissue from a lateral thigh and rotating that in to replace that half of a vulva and groin that was missing. So typically a small flap or a gycentesia ringman will not work in the setting of radiation. As you can see, most of that tissue is card and damaged already. So you need to get regional tissue from a little far away. This is an example of a patient who had not just a vulva defect, and we had shown this defect before, she had also, you know, a vaginal defect, posterior vaginal defect. So we were able to get her abdominal rectus down there in the pelvis to replace the posterior vulva. And this patient actually eventually had a bulkier tissue in the posterior vagina, which we then debulked and made smaller with time. And she was actually able to return to sexual function. And this is a rare example of a patient who had loss of essentially of all three components of her vulva and had reconstruction with a free flap from the anterolateral thigh. And this is actually reported by, this was in my case, all the other ones in my case, this is actually a British group that performed this operation where they actually created a vulva for the patient who otherwise there's a bilateral defect, full thickness, both vulva. And so you have to think outside the box for a patient who has this sort of injury. Postoperative care, like we discussed, bedrest, position, sitting restrictions, fully used, dressings, important to use non-adherent dressings and make sure the patient knows how to change it or has family who can. Some of these patients will require physical therapy and rehab to get them moving again. And some will even require dilation therapy with sexual therapists as well if they intend to return to sexual activity. Complications can be delayed wound healing. That's the most common thing. And in most cases that will improve over time with just dressings. And you could have fascial flappers requiring return to the operating room to reoperate, to complete the closure. Unfortunately, recurrence happens in a fair number of patients. And then if it does happen, well, you will work with your surgical oncologist, your gynecological oncologist to then again plan another reconstruction after that. Of course, it gets more challenging the second or third time around. Takeaways is to know the patient goals. If the patient has no intention to have sexual activity and is older, they may not care too much and you may be able to get away with less aesthetic results. A younger person wants more. Know the components of your defects so you can pick the right reconstruction. And involve the plastic surgeon early if you're not just going to do a primary closure or just an tertiary arrangement. Thank you very much, and I appreciate the opportunity to talk to you tonight.

vulva reconstruction

plastic surgeon

reconstructive surgeon

vulva cancer

patient goals