Reconstructive and Aesthetic Genital Surgery E-Book

Philip H. Zeplin

• Herausgeber: Thieme
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 343

Veröffentlichungsjahr: 2019

Beschreibung

Your expert introduction to genital surgery techniques

This unique work describes the possibilities and limitations of modern reconstructive and aesthetic surgery of the female and male genitalia.

Reconstruction of congenital and acquired abnormalities or defects – both functional and aesthetic – is a major challenge, as is individualized treatment in the case of diagnostically verified transsexualism. Surgical procedures in this highly sensitive body region require unusually detailed knowledge of the anatomy and a well-founded operative training, which goes beyond specialist training.

Written by a panel of experts in genital surgery, the work successfully links the fields of plastic surgery, gynecology, urology, and dermatology.

Key Features:

• The specialized surgical techniques can be quickly reviewed and understood by means of concise texts and nearly 400 illustrations
• Complications and complication management are directly integrated into the chapters and facilitate a realistic assessment of the risks while suggesting appropriate therapy of the complications themselves
• Numerous case studies illustrate the many facets of a topic using many highquality color photographs and graphics
• Special chapter on genital surgery in the pediatric population

Reconstructive and Aesthetic Genital Surgery will be an essential guide for the surgeon who wants to become acquainted with the complexities and controversies of genital surgery.

This book includes complimentary access to a digital copy on https://medone.thieme.com.

Leseprobe

Reconstructive and Aesthetic Genital Surgery

Philip H. Zeplin, MD

Medical DirectorPlastic and Reconstructive Surgeon, Hand SurgeonSchlosspark Klinik LudwigsburgLudwigsburg Institute of Plastic Surgery LIPSLudwigsburg, Germany

382 illustrations

ThiemeStuttgart • New York • Delhi • Rio de Janeiro

Library of Congress Cataloging-in-Publication Data is available from the publisher.

This book is an authorized translation of the 1st German edition published and copyrighted 2017 by Georg Thieme Verlag, Stuttgart. Title of the German edition: Rekonstruktive und Ästhetische Intimchirurgie

Translator: John Grossman, Gumtow, Germany

Illustrator: Holger Vanselow, Stuttgart, Germany

© 2020. Thieme. All rights reserved.

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ISBN 978-3-13-241289-7

Also available as an e-book:eISBN 978-3-13-241306-1

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Contents

Foreword

Preface

Contributors

Part 1 Plastic Reconstructive Surgery

1 Fundamentals and Principles

1.1 Etiology of Vulvovaginal Defects

D. Ulrich

1.2 Principles of Vulvar Reconstruction

D. Ulrich

1.3 Etiology of Penoscrotal Defects

G. Djedovic, U. M. Rieger

1.4 Principles of Penis and Scrotum Reconstruction

G. Djedovic, U. M. Rieger

2 Techniques

2.1 Fundamentals

P. H. Zeplin

2.1.1 Skin Grafting

P. H. Zeplin

2.1.2 Flaps: Fundamentals

P. H. Zeplin

2.1.3 Fillers and Lipofilling in Genital Surgery

R. Ferrara, S. Schill

2.1.4 Laser Therapy

R. W. Gansel

2.2 Flaps from the Lower Abdominal and Inguinal Region

2.2.1 Myocutaneous Rectus Abdominis Flaps (VRAM, TRAM)

P. H. Zeplin, D. Ulrich

2.2.2 Deep Inferior Epigastric Artery Perforator Flap

D. Ulrich

2.2.3 Mons Pubis and Suprapubic Flap

P. H. Zeplin

2.2.4 Groin Flaps

I. Kuhfuss, S. Hoormann, P. H. Zeplin

2.3 Flaps from the Vulvoperineal Region

2.3.1 Internal Pudendal Artery Flaps

D. Ulrich, P. H. Zeplin

2.3.2 Deep External Pudendal Artery Flap

P. H. Zeplin

2.3.3 Flap from the Anterior Branch of the Obturator Artery

P. H. Zeplin

2.4 Flaps from the Gluteal Region

2.4.1 Inferior Gluteal Artery Perforator Flap

P. H. Zeplin, D. Ulrich

2.4.2 Perforator Propeller Flap for Soft-Tissue Reconstruction in the Genital Region

R. G. Jakubietz

2.5 Flaps from the Thigh

2.5.1 Medial, Anterior, Anteromedial, and Posterior Thigh Flaps

P. H. Zeplin, D. Ulrich

2.5.2 Gracilis Flaps

P. H. Zeplin, D. Ulrich

2.5.3 Rectus Femoris Flap

P. H. Zeplin

2.5.4 Anterolateral Thigh Perforator Flap

P. H. Zeplin, D. Ulrich

2.5.5 Tensor Fasciae Latae Flap

P. H. Zeplin

2.6 Combination of Flaps

D. Ulrich

2.7 Management of Complications

D. Ulrich

2.8 Labia Minora Reconstruction

P. H. Zeplin, M. Nuwayhid

2.8.1 Etiology of Defects of the Labia Minora

2.8.2 Principle of Anterior and Posterior Labia Minora Y-V Flap

2.8.3 Principle of Anterior and Posterior Cross-Labial Flap

2.9 Penis and Scrotum Reconstruction

G. Djedovic, U. M. Rieger

2.9.1 Penis Reconstruction

2.9.2 Scrotum Reconstruction

2.10 Treatment of Specific Clinical Pictures

2.10.1 Reconstructive Surgery After Female Genital Mutilation

R. B. Karim, J. J. Dekker

2.10.2 Peyronie’s Disease

A. El-Seweifi

2.10.3 Necrotizing Fasciitis

G. Djedovic, U. M. Rieger

2.10.4 Lichen Sclerosus

P. Stosius

2.10.5 Scars and Neuromas

D. Ulrich

3 Genital Surgery in Children

3.1 Correction of Congenital Urogenital or Anorectal Malformations in Children

Th. Meyer

3.1.1 Anorectal Malformations

3.1.2 Congenital Urogenital Malformations in Boys

3.1.3 Congenital Urogenital Malformations in Girls

3.2 Traumatic Urogenital or Anorectal Injuries in Children

3.3 Disorders of Sexual Differentiation

Part 2 Functional Aesthetic Surgery

4 Functional and Aesthetic Genital Surgery in the Female

P. H. Zeplin, A. Borkenhagen

4.1 Fundamentals

4.1.1 Anatomy

4.1.2 Physiologic Norms

4.1.3 History and Preoperative Preparations

4.2 Labiaplasty

4.2.1 Labia Majora

U. E. Ziegler, D. von Lukowicz, P. H. Zeplin

4.2.2 Labia Minora

P. H. Zeplin, D. von Lukowicz, S. Schinner, S. Emmes, M. Nuwayhid

4.2.3 Clitoral Hood Reduction

M. Nuwayhid, D. von Lukowicz, S. Schinner, P. H. Zeplin

4.3 Hymen Repair

P. H. Zeplin, D. von Lukowicz

4.3.1 Indication

4.3.2 Surgical Technique

4.4 Perineoplasty

M. Nuwayhid, P. H. Zeplin

4.4.1 Indication

4.4.2 Surgical Technique

4.5 Monsplasty

U. E. Ziegler, P. H. Zeplin

4.5.1 Principle

4.5.2 Surgical Techniques

4.5.3 Complications and Complication Management

4.6 Colporrhaphy

R. W. Gansel, M. Nuwayhid, P. H. Zeplin, F. Schneider-Affeld

4.6.1 Fundamentals

4.6.2 Posterior Colporrhaphy

4.6.3 Bilateral Colporrhaphy

4.6.4 Laser Colporrhaphy.

5 Functional and Aesthetic Genital Surgery in the Male

5.1 Fundamentals

A. El-Seweifi, P. H. Zeplin

5.1.1 Anatomy

5.1.2 History and Preoperative Preparations

5.2 Phalloplasty

A. El-Seweifi, S. Schill

5.2.1 Lengthening Phalloplasty

5.2.2 Penis Augmentation

5.2.3 Glans Augmentation

5.3 Scrotum Lift

A. El-Seweifi, M. Nuwayhid, P. H. Zeplin

5.3.1 Surgical Procedure

5.3.2 Aftercare

5.3.3 Complications

5.4 Buried Penis (Concealed Penis)

D. K. Boliglowa, H. Menke

5.4.1 Introduction

5.4.2 Surgical Technique (Optional and Obligatory Surgical Steps)

5.4.3 Aftercare

5.4.4 Complications and Complication Care

6 Transsexualism

6.1 Fundamentals

U. M. Rieger, G. Djedovic, M. Sohn, S. Morath, J. Schaff

6.2 Male-to-Female Transsexualism

S. Morath, J. Schaff

6.2.1 History

6.2.2 Goal of Treatment

6.2.3 Sequence of the Surgical Procedures

6.2.4 Preparation for Surgery

6.2.5 Positioning

6.2.6 Surgical Technique

6.2.7 Postoperative Bandage

6.2.8 Postoperative Phase

6.2.9 Aftercare

6.2.10 Corrective Surgery

6.2.11 Complications

6.3 Female-to-Male Transsexualism

6.3.1 Background

U. M. Rieger, G. Djedovic, M. Sohn, S. Morath, J. Schaff

6.3.2 Radial Forearm Flap Phalloplasty

U. M. Rieger, S. Morath, J. Schaff, G. Djedovic, M. Sohn

6.3.3 Pedicled Anterolateral Thigh Flap Phalloplasty

J. Schaff, S. Morath

Index

Foreword

As a young sub-specialty, cosmetic genital surgery has shown enormous growth that could hardly be imagined 10 years ago.

Various specialties have contributed important insights and experiences to this new field, including plastic surgery and gynecology, but also urology, dermatology, and psychology.

In such a dynamic field, it is all the more important to create good textbooks that integrate the expertise and experience of the experts and make it available to interested colleagues.

The present work of Dr. Zeplin is an excellent and much needed step in this direction.

For anyone who wants to engage in the field of cosmetic genital surgery, this textbook is certainly a very good start and forms a solid knowledge base upon which subsequent practical training can be based.

There is no doubt that the scope and wealth of knowledge and experience will increase considerably in the coming years. I look forward to seeing the results of the authors’ future efforts in incorporating the numerous new developments in genital surgery into the next edition.

I wish the readers many enlightening moments with this new seminal work.

Düsseldorf, Summer 2019Stephan Günther, MD

Preface

The portrayal of genital surgery in the media has shaped the popular perception of it and increased interest in the subject. The focus of this interest has indisputably been on aesthetic genital surgery, and here especially on the surgical correction of the labia minora. Yet, genital surgery is by no means an offshoot of the beauty industry that merely reflects the spirit of the age. On the contrary, aesthetic genital surgery has arisen from surgeons’ longstanding endeavor to eliminate congenital or acquired anomalies of the external male and female genitals. Surgical interventions in this highly sensitive region of the body require detailed knowledge of the anatomy and solid surgical training extending beyond that required in specialty training for plastic surgeons, gynecologists, urologists, or dermatologists.

Genital surgery is an interdisciplinary field. Physical complaints or aesthetic sensitivities are often associated with emotional comorbidities. In the setting of a holistic therapy concept, these conditions require intensive treatment and must not be ignored. With this book, we seek to contribute to freeing the image of genital surgery from its popular perception as mere lifestyle medicine. Genital surgery is a complex field that requires highly specialized training. Reconstructive genital surgery can help many patients with congenital deformities or defects from trauma or tumor surgery. Even aesthetic genital surgery must serve the patient’s greater good. This book represents the first interdisciplinary work of renowned specialists in the field of genital surgery from the specialties of plastic surgery, pediatric surgery, urology, and dermatology.

The complexity of the field requires a certain demarcation. Classic clinical syndromes from urology such as the treatment of circumcision, from gynecology such as vaginal descensus and prolapse, or from dermatology such as the treatment of skin tumors find no mention in this book. Here we refer the reader to the respective specialized literature. Instead, this book is intended as a reference work applicable to all the specialties that specific lines of inquiry in genital surgery may pertain to.

As we are hardly infallible and the field of genital surgery is steadily advancing, we depend on regular updates. To this end, we call on all our colleagues active in the field of genital surgery to participate in shaping this book in the future.

Philip H. Zeplin, MD

Editor

Philip H. Zeplin, MD

Medical Director

Plastic and Reconstructive Surgeon, Hand Surgeon

Schlosspark Klinik Ludwigsburg

Ludwigsburg Institute of Plastic Surgery LIPS

Ludwigsburg, Germany

Contributors

Dominik Boliglowa, MD

Board Certified Plastic Surgeon

Private Practice “Dominik Boliglowa Chirurg Plastyk”

Krakow, Poland

Ada Borkenhagen, PhD

Associate Professor

University Clinic for Psychosomatic Medicine and Psychotherapy

University Hospital Magdeburg

Magdeburg, Germany

Judith J. Dekker, MD

VU University Medical Center Amsterdam

Amsterdam, Netherlands

Gabriel Djedovic, MD

University Hospital for Plastic, Reconstructive and Aesthetic Surgery

Medical University of Innsbruck

Innsbruck, Austria

Aref El-Seweifi, MD

Masculine Specialty Practice for Urology

Berlin, Germany

Stefan Emmes, MD

Plastikkirurgisk Institutt AS

Rådal, Norway

Robinson Ferrara, MD

Westpfalzklinikum

Clinic for Obstetrics and Gynecology

Kirchheimbolanden, Germany

Reinhard W. Gansel

Laser Medizin Zentrum Rhein-Ruhr

Essen, Germany

Sabrina Hoormann, MD

Sophienklinik

Specialist Clinic for Plastic and Aesthetic Surgery

Stuttgart, Germany

Raphael G. Jakubietz, MD

Professor

Department of Trauma, Hand, Plastic and Reconstructive Surgery (Department of Surgery II)

University Hospital Würzburg

Würzburg, Germany

Refaat B. Karim, MD

Amstelveen Clinic

Amstelveen, The Netherlands

Ingo Kuhfuß, MD

Department of Plastic and Aesthetic Surgery, Hand Surgery

Kath. Krankenhaus Hagen

St.-Josefs-Hospital

Hagen, Germany

Henrik Menke, MD

Professor

Department of Plastic and Hand Surgery, Specialized Burn Center

Sana Klinikum Offenbach

Offenbach, Germany

Thomas Meyer, MD

Professor

Department of General, Visceral, Vascular and Pediatric Surgery (Surgery I)

University Hospital Würzburg

Würzburg, Germany

Susanne Morath, MD

Private Practice for Plastic and Aesthetic Surgery

Munich, Germany

Marwan Nuwayhid, MD

Medical Director

LANUWA Aesthetic Surgery Clinic

Leipzig, Germany

Ulrich M. Rieger, MD

Associate Professor

Clinic for Plastic and Aesthetic Surgery, Reconstructive and Hand Surgery

Agaplesion Markus Hospital

Frankfurt, Germany

Juergen Schaff, MD

Private Practice for Plastic and Aesthetic Surgery

Munich, Germany

Stefan Schill, MD

Nofretete Clinic for Plastic and Aesthetic Surgery

Bonn, Germany

Susanne Schinner, MD

Private Practice for Plastic and Aesthetic Surgery

Munich, Germany

Frank Schneider-Affeld, MD

Clinic for Plastic Surgery and Gynecology

Neumünster, Germany

Michael Sohn, MD

Professor

Head of Department of Urology

Agaplesion Markus Hospital

Frankfurt, Germany

Peter Stosius, MD

Private Practice for Gynecology Dr. Stosius

Starnberg, Germany

Dietmar J. O. Ulrich, MD

Professor

Head of Plastic Surgery

University Hospital for Hand and Reconstructive Surgery

Radboud University Medical Center

Nijmegen, The Netherlands

Dominik von Lukowicz, MD

Private Practice for Plastic and Aesthetic Surgery

Munich, Germany

Philip H. Zeplin, MD

Medical Director

Plastic and Reconstructive Surgeon, Hand Surgeon

Ludwigsburg Institute of Plastic Surgery LIPS

Schlosspark Klinik

Ludwigsburg, Germany

Ulrich Eugen Ziegler, MD

Private Practice for Plastic and Aesthetic Surgery

Stuttgart, Germany

Part 1

Plastic Reconstructive Surgery

1 Fundamentals and Principles

2 Techniques

3 Genital Surgery in Children

1 Fundamentals and Principles

1.1 Etiology of Vulvovaginal Defects

D. Ulrich

There are many different causes of vulvar defects. Tumors of the vulva are the main cause. They represent about 5% of all malignant disorders of the female genital system and about 1% of all malignancies in women. Vulvar carcinomas are observed increasingly often after the fifth or sixth decade of life (▶Fig. 1.1). The modified radical vulvectomy as described by Taussig (1940)12 and Way (1948)13 involves mobilization of a large composite flap of skin and fatty tissue and en bloc resection of the regional lymph tissue together with the primary tumor and adjacent vulvar tissue. Yet, the radical vulvectomy with separate bilateral inguinal lymphadenectomy is also an established surgical procedure.

Advances in surgical treatment and perioperative patient care now allow patients with extensive carcinoma of the vulva that has spread to adjacent organs, such as the urethra, urinary bladder, and/or rectum, to undergo extensive tumor surgery, provided that these patients are in good general health and remote metastases have been excluded. This surgery generally involves anterior, posterior, or total exenteration combined with a radical vulvectomy and an inguinofemoral lymphadenectomy, which leaves large defects (▶Fig. 1.2).

In recent decades, the prevalence of vulvar intraepithelial neoplasia has increased significantly, especially in young women. In diffuse disease, what is known as a skinning vulvectomy may be considered for treatment. Rutledge and Sinclair first described the surgical procedure in 1968,9 which creates a defect only at the level of the dermis (▶Fig. 1.3). The operation can be regarded as a more conservative method in multifocal diffuse vulvar carcinomas in situ. Compared with a total vulvectomy, the procedure yields a far better cosmetic result, and sexual sensation is less impaired. The intervention nonetheless often places a significant emotional burden on the patients, who are often very young.

Malignant melanomas account for about 3% of malignant carcinomas of the vulva and require extensive resection, depending on their stage (▶Fig. 1.4).

Vascular malformations or hemangiomas can require surgical correction in the region of the vagina and vulva in children or later in adults (▶Fig. 1.5). Other congenital deviations such as vaginal atresia can also require early genital reconstruction.

Fig. 1.1 Extensive squamous cell carcinoma of the vulva.

Fig. 1.2 Posterior exenteration with vulvectomy.

Fig. 1.3 Skinning vulvectomy.

Fig. 1.4 Malignant melanoma of the vulva.

Fig. 1.5 Venous malformation of the vulva.

Aside from malignant disease, extensive vulvar defects can also result from necrotizing fasciitis (▶Fig. 1.6). The increase in shaving and piercing in the genital region has coincided with an increased prevalence of this disorder.

Perineal lacerations also warrant mention as a cause of vulvoperineal defects. These soft-tissue injuries occurring during vaginal delivery are divided into four degrees of severity (▶Table 1.1).

The prevalence of first- or second-degree perineal lacerations is said to be about 10 to 15%. More severe perineal lacerations (third degree or higher), occurring in about 1% of all vaginal deliveries, are the most common cause of anal incontinence symptoms and severely impair the patient’s quality of life. Therefore, they should be treated promptly in the immediate postpartum phase. Nonetheless, the sequelae of a perineal laceration, especially scarring and residual soft-tissue defects, often cause physical symptoms that require surgical intervention. The same applies to defects or scarring occurring secondary to surgery such as episiotomy, trauma, or burns (▶Fig. 1.7).

Fig. 1.6 Defect secondary to necrotizing fasciitis.

Table 1.1 Classification of soft-tissue injuries

Degree

Findings

I

Laceration of the skin and subcutaneous tissue in the region of the posterior commissure of the labia majora

II

Like first degree but with additional laceration of the superficial musculature of the rectovaginal septum, that is, the superficial and deep transverse perineal and bulbocavernosus muscles

III

Like second degree but with additional laceration of the external anal sphincter (degree IIIa: < 50%; degree IIIb: > 50%) and internal anal sphincter (degree IIIc)

IV

Like third degree but with additional laceration of internal anal sphincter and opening of the rectum

Fig. 1.7 Painful scar following episiotomy (left) and soft-tissue defect following second-degree perineal laceration (right).

1.2 Principles of Vulvar Reconstruction

D. Ulrich

External identification of female sex is made on the basis of the primary and secondary sex characteristics. Aside from functional deficits, the surgical treatment of vulvar malignancies or trauma that creates an extensive defect in this region often has a severe impact on the affected patient’s body image and self-confidence. Reconstructive measures to restore the morphology of the vulva are repeatedly recommended, yet often they are not routinely performed. Although numerous highly developed surgical techniques for the reconstruction of the female breast have become a part of routine clinical practice, the technique of reconstructing physiologic vulvar and vaginal anatomy to address congenital deviations, tumor resections, or extensive soft-tissue defects is far less advanced.

Reconstructive genital surgery must focus particularly on the restoration of the physiologic features required for reproduction and excretion. Regardless of whether the procedure involves primary reconstruction in the vulvar region or secondary correction of functional impairments following surgery or radiation therapy, the goal of the operation should consist in achieving a balance between the restoration of physiologic anatomy and natural function, on the one hand, and healing the disorder with a high degree of patient satisfaction, on the other. This is especially true in young patients who can suffer severe psychosexual impairments as a result of previous radical gynecologic surgery.

Additionally, one must bear in mind that malignancies in the region of the vulva can frequently recur. Therefore, when a local flap is indicated, care should be taken to select a method that will later allow other local or regional reconstruction options. For example, most patients do not require primary reconstruction of the vulva with V-Y flaps, but the desired result can often be achieved with a pudendal thigh flap. This means that reconstruction with a V-Y flap remains an option in the event of a recurrent malignancy. Using a V-Y flap for primary reconstruction on the other hand usually precludes later reconstruction with a pudendal thigh flap.

In recent years, the fasciocutaneous flap has increasingly gained favor over the myocutaneous flap in the treatment of small- to medium-sized defects of the vulva and vagina. Myocutaneous flaps add bulk due to their volume and as a rule they are not sensitive. Additionally, patients are often bothered by the visible scars at their donor site on the thigh or abdomen. Yet, where there are extensive tissue defects with large wound cavities, recurrences, and prior radiation therapy, a myocutaneous flap remains the first choice. These flaps are used wherever the depth of the defect requires a thicker flap or the excision is so extensive that a local fasciocutaneous flap will no longer suffice. With their large arc of rotation, they provide a good means of reconstruction. The myocutaneous flap also ensures sufficient blood supply in tissue that is often less well perfused as a result of radiation therapy or radical tumor surgery.

Often, combinations of different flap techniques are required to close complex defects; these may also include fasciocutaneous and myocutaneous flaps. In essence, the ultimate success depends on proper patient selection, proper choice of surgical technique, and proper application of that technique.

Note

Important factors in successful closure of a defect:

• Patient selection.

• Proper choice of surgical technique.

• Proper application of the technique.

According to Salgarello et al,10 the ideal flap for reconstruction of the vulva and vagina should:

• Fill the defect with a well-vascularized piece of tissue of similar thickness.

• Include a variable amount of tissue for closing smaller and larger defects.

• Guarantee restoration of function.

• Not cause any symptoms when the patient sits or walks.

• Have a natural, aesthetic appearance.

• Include sensory innervation.

• Allow reconstruction in a single procedure.

1.3 Etiology of Penoscrotal Defects

G. Djedovic, U. M. Rieger

Cutaneous soft-tissue defects in the penoscrotal region often occur as a result of trauma, infection, neoplasia, or surgery. Trauma is the most common cause in younger patients. With respect to prevalence, penetrating and blunt trauma each account for about 45%, although burns (10%) also warrant mention. Infections constitute the second largest group of causes of penoscrotal defects. Aside from complicated wound infections and acne inversa lesions, Fournier gangrene, a mixed bacterial infection that can prove fatal, warrants particular mention. Persons with a compromised immune system, diabetes mellitus, immunosuppression, or poor bodily hygiene are particularly at risk. Tumors primarily include squamous cell carcinomas, which when resected often lead to partial or complete loss of the scrotum or penis.

Note

Causes of penoscrotal defects:

• Trauma.

• Infections.

• Neoplasms.

• Iatrogenic causes.

1.4 Principles of Penis and Scrotum Reconstruction

G. Djedovic, U. M. Rieger

Mutilations in the genital region and also partial or complete loss of the scrotum or penis impair not only the physical and emotional well-being of the patient but often his relationship to his partner as well. The goal of penis and scrotum reconstruction is therefore the restoration of the outward appearance coupled with a functional reconstruction that, under favorable circumstances, will again permit sexual interaction.

Further Reading

[1] Barrena N, Wild R, Mayerson D, López JL. Intraepithelial neoplasms of the vulva: treatment by skinning vulvectomy. Rev Chil Obstet Ginecol. 1987; 52(5):281–285

[2] Basoglu M, Ozbey I, Atamanalp SS, et al. Management of Fournier’s gangrene: review of 45 cases. Surg Today. 2007; 37(7):558–563

[3] Beemer W, Hopkins MP, Morley GW. Vaginal reconstruction in gynecologic oncology. Obstet Gynecol. 1988; 72(6):911–914

[4] Fanfani F, Garganese G, Fagotti A, et al. Advanced vulvar carcinoma: is it worth operating? A perioperative management protocol for radical and reconstructive surgery. Gynecol Oncol. 2006; 103(2):467–472

[5] Höckel M, Dornhöfer N. Anatomical reconstruction after vulvectomy. Obstet Gynecol. 2004; 103:1125–1128

[6] Lee PK, Choi MS, Ahn ST, Oh DY, Rhie JW, Han KT. Gluteal fold V-Y advancement flap for vulvar and vaginal reconstruction: a new flap. Plast Reconstr Surg. 2006; 118(2):401–406

[7] McCraw JB, Massey FM, Shanklin KD, Horton CE. Vaginal reconstruction with gracilis myocutaneous flaps. Plast Reconstr Surg. 1976; 58 (2):176–183

[8] Rettenmaier MA, Braly PS, Roberts WS, Berman ML, Disaia PJ. Treatment of cutaneous vulvar lesions with skinning vulvectomy. J Reprod Med. 1985; 30(6):478–480

[9] Rutledge F, Sinclair M. Treatment of intraepithelial carcinoma of the vulva by skin excision and graft. Am J Obstet Gynecol. 1968; 102(6): 807–818

[10] Salgarello M, Farallo E, Barone-Adesi L, et al. Flap algorithm in vulvar reconstruction after radical, extensive vulvectomy. Ann Plast Surg. 2005; 54(2):184–190

[11] Ulrich DJO, Ulrich F. Rekonstruktionen im Bereich der Vulva. In: Krupp S, Rennekampff HO, Pallua N, eds. Plastische Chirurgie. 32. Erg. Lfg. 12/08. VII-3, 1–20

[12] Taussig FJ:Cancer of the vulva: an analysis of 155 cases. Am J Obstet Gynecol 1940, 40:764–770

[13] Way, S. 1948. The anatomy of the lymphatic drainage of the vulva and its influence on the radical operation for carcinoma. Ann. R. Coll. Surg. Engl. 3:187

2 Techniques

2.1 Fundamentals

P. H. Zeplin

The choice of technique for covering a genital defect essentially depends on the location and size of the defect. The range of plastic and reconstructive techniques, in increasing order of surgical complexity, includes:

• Primary closure.

• Skin grafting (mesh graft, split-thickness graft, full-thickness graft).

• Local flaps (random pattern flaps).

• Pedicle flaps (axial pattern flaps).

• Free flaps with microvascular anastomosis.

2.1.1 Skin Grafting

P. H. Zeplin

Skin grafts are indicated for defects which, by their nature, are either no longer conducive to closure with a primary suture or which do not require a flap.

Skin grafts are cut off from their original blood supply when harvested. From the time they are placed until sufficient revascularization has occurred 3 to 5 days later, they are supplied by diffusion from the wound bed. A graft that heals in place undergoes constant changes in appearance over the next few weeks, yet it will never look identical to the surrounding healthy skin.

Note

Generally favorable conditions for skin grafting include extensive even wounds with a well-vascularized wound bed or granulation tissue with little secretion.

Appropriate wounds should be debrided prior to grafting and should be free of infection. Exposed fatty tissue, bone without periosteum, or tendons without peritendineum will pose a risk to the graft’s vascular supply and integration. In these cases, other options for closing the defect should be considered.

Split-thickness skin grafts, usually in the form of mesh grafts measuring 4 cm2 or larger, are used to close wounds in the genital region. They are used where approximating the edges of the wound for a primary suture would not be feasible or where secondary healing would produce extensive, debilitating scarring and infection. Suitable donor sites for split-thickness skin grafts include the lateral or anterior thigh, or other regions of the body as required, depending on the location of the defect. After harvesting the split-thickness graft with a dermatome (e.g., 0.2 mm), the tissue is fed into a machine that processes it into a mesh graft that can be used to cover one and one-half to three times the original size of the defect. This makes it possible to satisfactorily cover even large and secreting wounds with a limited supply of skin. The graft is fixed with a suture or tissue adhesives, in applicable cases used in combination with a vacuum-assisted closure device to prevent shear forces for occurring on the graft. Because of the location in the genital region, some surgeons recommend their patients additional oral or intravenous antibiotic prophylaxis with a cephalosporin. After the first bandage has been changed (usually after 5–7 days), the patient can be switched to daily ointment gauze treatment or local antibiotic therapy where the progress of healing and the local situation permit it.

Full-thickness skin grafts are autologous skin grafts that include the dermis and epidermis. The range of applications for full-thickness skin grafts in the external genital region may be regarded as rather limited. They are more often used for the reconstruction of defects in the vaginal wall or in cases of vaginal aplasia. Donor sites include the lower abdominal and inguinal region, both medial thighs, and the scrotum. Whenever possible, the dimensions of the full-thickness skin graft should be such that they allow primary closure of the donor site. When the graft is harvested, all subcutaneous fatty tissue must be carefully removed. Hemostasis must be obtained in the wound prior to placing the graft to ensure that it will be properly integrated. Once the graft has been fixed, it is recommended to apply an elastic compression bandage for 3 to 5 days.

2.1.2 Flaps: Fundamentals

P. H. Zeplin

Flaps are differentiated according to their vascular supply as either local flaps, meaning flaps with a random dermal and subdermal vascular network (random pattern flaps), or pedicled flaps, meaning flaps with a defined vascular axis (axial pattern flaps). In random pattern flaps, this supply pattern greatly influences the design options of the respective flap. A ratio of length to width that does not significantly exceed 2:1 will ensure that the flap is sufficiently perfused. In contrast, the length-to-width ratio need not be restrictively maintained in axial pattern flaps; here the length depends on the area supplied by a defined vascular axis. Axial flaps, in which a cutaneous island is created by dividing the bridge of connecting skin, de-epithelializing the flap close to the base, or mobilizing the vascular pedicle to allow subcutaneous tunneling, are referred to as island flaps.

Table 2.1 Mathes–Nahai classification of muscle flaps3

Type

Designation

Example

I

Dominant vascular pedicle

Tensor fascia latae

II

Dominant pedicle with nondominant vessels

Gracilis

III

Two dominant vascular pedicles

Rectus abdominis

IV

Segmental arteries

Sartorius

V

Dominant pedicle with segmental arteries

Latissimus dorsi

Vascular branches that ascend from the deep layer and supply the subcutis and cutis via an epifascial vascular plexus ensure the perfusion of what are known as fasciocutaneous flaps. Such a flap is supplied according to the classification of Mathes and Nahai3 either by a single cutaneous perforating artery (type A), a septocutaneous perforating artery (type B), or one or more musculocutaneous perforating arteries (type C).

Perforator flaps consist of skin and subcutaneous fatty tissue supplied by isolated perforating arteries which pass through deeper layers after arising from their parent vessel. When such a perforator courses through a muscle before penetrating the fascia, it is known as a musculocutaneous perforator and when it courses through a septum, it is referred to as a septocutaneous perforator.

Muscular flaps are classified according to Mathes and Nahai3 (▶Table 2.1) and are based on their respective vascular anatomy.

Local Flaps

If the surgeon decides to use a local flap to cover a defect, then careful preoperative planning is essential. To avoid creating a too large flap, the section to be debrided or excised is outlined first, then the appropriate flap. Everything else is done only after this.

Z-Plasty

The basic principle of the Z-plasty is a gain in length at the expense of width by shifting and transposing two pedicled triangles of skin. For this reason, it is commonly used in lengthening for prevention and treatment of scar contractures and strictures. Careful geometric planning must precede defect coverage; the respective limbs should always be equal. Although any angle between 30 and 90 degrees is possible, the triangular dissection of two or more flaps with an angle of 60 degrees each is regarded as optimal for transposition of the flaps at the expense of the transverse axis. In the presence of extensive findings, multiple Z-plasties are preferable to a single long-limb Z-plasty; the gain in length remains the same, yet multiple Z-plasties reduce the tension.

Pedicled Cutaneous Flaps

Simple skin grafts usually do not suffice in cases where not only skin but deeper lying tissue must also be replaced. Local cutaneous flaps include the full thickness of the skin and the subcutaneous fatty tissue, and they can be raised in the immediate vicinity of the defect while maintaining the vascular supply to the base of the flap.

There are three basic types:

• Advancement flaps.

• Rotation flaps.

• Transposition flaps.

Advancement Flaps

Fig. 2.1 Principle of an advancement flap. Source: Sterry et al.7

Simple pedicled advancement flaps involve the dissection of cutaneous flaps that can be advanced into the defect parallel to their axis. The dimpling of the skin that occurs at the base of the flap, as it is advanced, can be compensated for by excising what are known as the Burow triangles at the base of the flap (▶Fig. 2.1). With the bipedicled advancement flap, also known as a bridge flap, the advancement is 90 degrees to the axis of the flap. Here, additional measures, such as skin grafting, may be required to cover the donor site defect.

V-Y Advancement Flap

Fig. 2.2 Principle of a V-Y flap. Source: Sterry et al.7

The principle of the V-Y advancement flap (▶Fig. 2.2) is a gain in length at the expense of width. A V-shaped cutaneous flap with equal limbs is raised, mobilized, and approximated to the shape of a Y. The axis of the V-shaped flap must correspond to the axis of the advancement. A Y-V flap is the opposite. Here width is gained at the expense of length. After a Y-shaped incision is made, the central triangular tissue flap is approximated to the end of the vertical incision, forming a V.

Rotation Flap

Fig. 2.3 Principle of a rotation flap. Source: Sterry et al.7

Rotation flaps are based on a defined axis of rotation around which the arc-like flap is swung into the adjoining defect. This requires integrating the respective existing defect into a triangular arc along the semicircular incision made to raise the rotation flap. This incision must be at least 5 times as long as the necessary advancement. The choice of the arc and the course of the incision should be determined by the available tissue and its vascular supply (▶Fig. 2.3).

Transposition Flap

Fig. 2.4 Principle of a transposition flap. Source: Sterry et al.7

With axial pattern transposition flaps, the ratio of the flap’s length to its width is of decisive importance. To ensure sufficient perfusion, it should be between 2:1 and 2.5:1 in the genital region. Proper choice of the point of rotation and the length of the flap are also particularly important for successful treatment, as these factors significantly influence postoperative tension in the wound. The length of the flap should invariably be at least one-third longer than the length of the equivalent limb of the triangle to be covered.

With the transposition flap (▶Fig. 2.4), the axial cutaneous flap can be raised without regard to the defect to be covered and then rotated into the defect. Double transposition flaps involve a combination of two transposition flaps. The portion close to the defect is used to cover the defect, whereas the somewhat smaller portion farther away is used to cover the gap created by the closer portion as it is advanced into the defect. Such flaps are used particularly in cases in which the donor site of the first flap cannot be closed without tension simply by approximating the edges of the wound.

Rhomboid Flap

Fig. 2.5 Rhombic flap. (a) Principle of a Limberg flap. (b) Principle of a Dufourmentel flap. Source: Sterry et al.7

Rhomboid flaps are combinations of advancement and transposition flaps. The Limberg rhomboid flap (▶Fig. 2.5) is an axial pattern cutaneous flap that can be used to cover rhombus-shaped defects. In the shape of a parallelogram with four equal sides, it is raised as the extension of the short axis of the defect rhombus on the longitudinal side of the defect. The angle close to the defect is 120 degrees at maximum. The outer incision is made at an angle of 60 degrees parallel to the edge of the wound, and the length of the side corresponds to the dimensions of the defect. The flap is mobilized and rotated into the defect.

With the Dufourmentel flap, the flap angle close to the defect is 155 degrees. At a distance of about the length of one defect side, the outer incision is made parallel to the longitudinal axis of the rhombus-shaped defect at an angle of 60 degrees. Its length depends on the size of the defect and the tension at the site.

2.1.3 Fillers and Lipofilling in Genital Surgery

R. Ferrara, S. Schill

Treatment with injectable filler substances now accounts for a large share of all nonsurgical interventions. The materials in use today are high-molecular-weight compounds that exhibit significant differences in their physical and chemical behavior and are integrated into a complex matrix.

Therefore, a fundamental requirement for using fillers is to acquire a comprehensive understanding of the materials, their structure, their effect in tissue, and their longevity. In addition, the surgeon must of course have sufficient knowledge to correctly apply these materials and to manage any over- or undercorrection (▶Fig. 2.6).

Autologous fat transfer is a surgical procedure that involves not only harvesting the material but also processing and transplanting it. For this reason, it is necessary for the user to be proficient not only in the application but also in the technique of liposuction and the subsequent processing of the fatty tissue. This is important because these factors (i.e., the selection of the donor sites, quality of the fat cells, type of processing of the fatty tissue, transfer technique) all significantly influence the later result (▶Fig. 2.7).

Possible indications for the use of synthetic fillers or autologous fat transfer (lipofilling) include:

• Tissue atrophy or dystrophy.

• Congenital malformations or asymmetries.

• Post-traumatic defects such as those secondary to genital mutilation, birth injuries, cancer surgery, or radiation therapy.

• Desire (possibly for aesthetic reasons) to have the labia majora and minora augmented or the vagina narrowed.

Acute disease, especially infections in the region to be treated, coagulation disorders, or anticoagulant therapy are regarded as contraindications.

Planning Surgery and Treatment

After appropriate examination, photographic documentation, and planning of the procedure, the patient must be thoroughly informed about the effect, the time of the onset of action, and the anticipated long-term effect. The patient’s expectations must be carefully documented, and the extent to which they can be fulfilled should also be discussed. In addition, the surgeon should of course discuss the possibility of complications in some detail and should inform the patient of the possible necessity for corrective or revision procedures (▶Fig. 2.8).

Fig. 2.6 Use of hyaluronic acid. (a) Injection of hyaluronic acid for atrophy. (b) Labia reconstruction with hyaluronic acid.

Given the broad range of fillers in the market, the final decision for one product or another must be made by the respective user. The surgeon should work with products that he or she is familiar with and should adapt the injection technique to the specific region to be treated. In most cases, superficial or local anesthesia will be sufficient for treatment in the vaginal or vulvar region. The injection should be done via a stab incision with atraumatic needles using a tunnel, fan, and tower technique.

Fig. 2.7 Liposuction. (a) Liposuction to obtain fat. (b) Centrifuging the harvested fat. (c) Fat transfer in small syringes. (d) Fat ready for injection.

Fig. 2.8 Site after radical labia resection.

Note

The medial aspects of the knees, medial and lateral thighs, the lower abdominal region, and to a certain extent the upper abdominal region and flanks as well, are regarded as suitable zones for harvesting autologous fat for transplantation.

Fig. 2.9 Lipofilling. (a) Preoperative findings. (b) Injection with blunt cannula. (c) Final positioning of fatty tissue by massage. (d) Labium after fat injection. (e) Lipofilling for penis augmentation with approach at the junction of the inner and outer layer of the foreskin. (f) Lipofilling in the penis with anterograde approach in the setting of lengthening phalloplasty. (g) Lipofilling in the penis: Postoperative findings.

In the hospital, fatty tissue is usually removed under tumescent anesthesia. Different tumescent solutions are used here, but their basic ingredients include a 0.9% saline solution, a vasoconstrictor (such as epinephrine), a local anesthetic, and, in applicable cases, sodium bicarbonate. The solution can be adapted to different needs by varying the component substances. After introducing the tumescent solution into the donor site and waiting for an appropriate interval for the medication to take effect, the surgeon begins with the actual liposuction. This should be done with particular care, using constant low-intensity suction (− 0.5 bar) and a suction cannula with a diameter < 3 mm. Various systems are available for processing the harvested fatty tissue for further transplantation. All of them seek to optimize the quality of the aspirate in order to ensure a high rate of integration into the target tissue. After processing, the fatty tissue is injected through atraumatic needles into the target tissue, wherever possible in several layers, and distributed in a fan-shaped pattern (▶Fig. 2.9). The transplanted material can then be gently massaged into the tissue. Compression therapy of the donor site for 4 to 6 weeks postoperatively is recommended.

Caution

Compression therapy for the penis or in the vaginal or vulvar region has not proven to be effective for the integration of the transplanted tissue.

Complications