Vaginal Reconstruction With Paired Modified Transverse Upper Gracilis (TUG) Myocutaneous Flaps

Purpose:

Psychological and functional restoration, decreased post-operative complications, and improved wound healing have justified immediate vaginal reconstruction after pelvic exenteration.  Multiple methods have been described.  Flap selection is multifactorial, weighing anticipated needs with specific characteristics and limitations of the selected flap in each individual.  The transverse upper gracilis (TUG) myocutaneous flap, described by Yousif et al. (1992), has improved reliability and donor site cosmesis over traditional longitudinally oriented gracilis flaps.  While TUG has been used primarily in breast reconstruction, herein vaginal reconstruction is described.

Materials and Methods:

A 53 year old female with recurrent squamous cell carcinoma of the anus underwent pelvic exenteration (Image 1).  She had previous as well as intraoperative radiation therapy.  Paired "T" shaped modified TUG flaps were employed for vaginal reconstruction.  The transverse portion was designed to encompass the proximal vascular domain containing the horizontal perforators, along with a narrower longitudinal segment following the gracilis muscle length into the middle vascular domain.  This eliminated the poorly perfused areas of the skin islands often described in traditional gracilis flaps, and resulted in a shorter longitudinal medial thigh 
scar.  The paired flaps were rotated and tunneled beneath skin bridges into the defect, tubularized by suturing in apposition, and then inset within the pelvis to create the neovagina (Image 2).

Results:

The neovagina maintained adequate contours and vaginal depth.  Overall patient satisfaction was very good at final result.  A wound infection at the posterior suture line required irrigation and drainage.  All wounds were healed at 5 months.  The flap was re-contoured at 9 months to decrease flap bulk that distressed the patient when seated.  No functional morbidity was noted at the donor sites.

Conclusions:

The goals of optimizing healing and restoring physical and psychological function, while minimizing infection and postoperative complications can be accomplished with immediate myocutaneous flap reconstruction of the pelvis following pelvic exenteration.  Paired modified TUG flaps provide adequate tissue mass, length, and depth, while minimizing functional morbidity and improving donor site scars.  This configuration yields an additional flap selection, improving on the traditional gracilis design.  Potential advantages over rectus abdominus based reconstruction include decreased functional morbidity and hernias at the donor site, as well as reduction in parastomal hernia risk, with an often-required ileal conduit or end colostomy, by preserving the rectus abdominus.

Image 1

Image 2