Perineal reconstruction with double gracilis muscle flap in vulvar cancer. Case report and literature review

Abstract

Different gynecological neoplasms, regardless of the clinical stage, may present recurrence despite the established treatment and require ultraradical surgical rescue by pelvic exenteration, with a high percentage of complications and impairment of quality of life, and sometimes generate perineal defects that require immediate reconstruction. Because of this, different methods have been used for the closure of the perineal wound as primary closure and rotation of pedicled flaps. The goals in the reconstruction are: To improve the quality of life, symmetry and sensitivity and, if possible, sexual function, so as to diminish the in-hospital stay and time in rehabilitation for extensive wounds. The gracilis myocutaneous flap is possible because of its vascular pedicle based on the circumflex femoral medial artery with sensory innervation through the cutaneous femoral nerves or branches of the obturator nerve. The defect in vulvar or anal neoplasms requires a negative surgical margin with an extensive perineal dissection, and the coverage with a single flap is not enough, so in 1984 the first bilateral was described. These flaps can even preserve sensitivity and allow additional reconstruction with a neovagina, so the approach of these patients requires to be multidisciplinary. We present the case of a 57-year-old female patient, with stage II vulvar cancer, initially treated with chemotherapy and radiotherapy concomitant with local disease progression, for which total pelvic exenteration with vulvectomy and perineal reconstruction with flap was proposed. Bilateral gracilis muscle.