Both color Doppler US and CT angiography resulted in accurate DIEP mapping. Color Doppler US was superior for measuring perforator artery calibers, and CT angiography was superior for estimating the intramuscular course of the perforator vessel and identifying superficial venous communications. Considering x-ray exposure and results of this study, employing multidetector CT angiography is suggested only in selected cases.

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ObjectiveTo create a comprehensive algorithmic approach to reconstruction after vulvar cancer ablative surgery, which includes both traditional and perforator flaps, evaluating anatomical subunits and shape of the defect.MethodsWe retrospectively reviewed 80 cases of reconstruction after vulvar cancer ablative surgery, performed between June 2006 and January 2016, transferring 101 flaps. We registered the possibility to achieve the complete wound closure, even in presence of very complex defects, and the postoperative complications. On the basis of these experience, analyzing the choices made and considering the complications, we developed an algorithm to help with the selection of the flap in vulvoperineal reconstruction after oncologic ablative surgery for vulvar cancer.ResultsWe employed eight types of different flaps, including 54 traditional fasciocutaneous V-Y flaps, 23 rectus abdominis myocutaneous flaps, 11 anterolateral thigh flaps, three V-Y gracilis myocutaneous flaps, three free style perforators V-Y flaps from the inner thigh, two Limberg flaps, two lotus flaps, two deep inferior epigastric artery perforator flap, and one superficial circumflex iliac artery perforator flap. The structures most frequently involved in resection were vulva, perineum, mons pubis, groins, vagina, urethra and, more rarely, rectum, bladder, and lower abdominal wall.ConclusionThe algorithm we implemented can be a useful tool to help flap selection. The key points in the decision-making process are: anatomical subunits to be covered, overall shape and symmetry of the defect and some patient features such as skin laxity or previous radiotherapy. Perforator flaps, when feasible, must be considered standard in vulvoperineal reconstruction, although in some cases traditional flaps remain the best choice.

The objective of this study was to assess the reconstructive options after radical, extensive vulvectomy; relate them to tumor characteristics; and select a choice of flaps able to correct every remaining defect. This study is a retrospective review of a 4-year experience with 31 flaps in 20 consecutive vulvar reconstructions. Three of the 31 flaps presented nonsignificant delayed healing at their tips and 3 other flaps developed a major breakdown related to an infection or an error in flap planning. According to the authors, the size of the defect is the main issue that must be taken into consideration during the establishment of reconstructive needs. Closure of vulvar defects is preferably performed using fasciocutaneous flaps, which are very reliable flaps and can be raised with different techniques to meet different needs. A flap is then chosen with the fewest potential complications. An algorithm has been thus established: Small to medium-size defects are closed with island V-Y flaps, island gluteal fold flaps, or pedicled pudendal thigh flaps. Among them, the island V-Y flap is the workhorse flap for vulvar reconstruction because of its versatility, reliability, and technical simplicity compared with its very low complication rate. If the vulvar defect is large and/or reaches the vulva-crural fold, V-Y flaps are also preferred to close these large and posteriorly extended excisions. If the vulvar defect is very large, extending both anteriorly and posteriorly, the use of a distally based, vertically oriented rectus abdominis muscle flap is recommended. Using this algorithm, immediate vulvar reconstruction with pedicled local or regional flaps can be performed easily and reliably.

Our study shows that lymphaticovenular anastomosis improves HRQoL in patients affected by ULL and LLL. Additionally, both a reduction of episodes of lymphangitis and a decrease in the need of conservative therapy were observed in this cohort of patients.