Good evening. Welcome to today's webinar. I'm Dr. Susan Barr, and I'm the moderator for tonight's webinar. Before we begin, I'd like to share that we will take questions at the end of the webinar, but you can submit them at any time by typing them into the question box on the left-hand side of the event window. Today's webinar is entitled Flats and Urogynecologic Surgery and is being presented by Dr. Martha Matthews. Dr. Matthews is a professor of surgery at Cooper Medical School of Rowan University in the Division of Plastic Surgery. She's a graduate of Jefferson Medical College. She completed a general surgery residency at Thomas Jefferson University Hospital and a plastic surgery residency at Eastern Virginia Graduate School of Medicine. She's a former program director of the Cooper Plastic Surgery Residency Program and is the chair of the Cooper Graduate Medical Education Committee. Dr. Matthews is involved in committees of many national plastic surgery organizations and is a senior examiner for the American Board of Plastic Surgery. Her special interests include cleft lip and palate surgery, gynecologic reconstruction, and medical education. Welcome, Dr. Matthews. Thank you. And I'm very honored to be asked to give this webinar for you. And so tonight as said, we're going to be talking about various flaps in urogynecologic surgery. I will say that we're going to be talking about a bunch of flaps in the female genital area, some of which are more applicable to cancer reconstructions than urogynecologic. But I've included most of the more common flaps that are used in this area just to give you a complete overview. To start with the basics in plastic surgery, we have a concept called the reconstructive ladder. And basically in the reconstructive ladder, you go from simple things to more complex things. And that's sort of a just a pillar of how we approach problems of reconstruction. Ideally, we'd like to replace like tissue with like tissue, isn't always possible. And then we'd look at things going from simple like healing by secondary intention all the way up to free tissue transfers where we're moving large blocks of tissue and doing microvascular anastomosis in order to maintain their blood supply. Again, sticking with the basics, flaps and grafts. A graft gets its blood supply from the recipient site. And so important things in choosing a graft rather than a flap would be in wound characteristics, you have to have adequate blood supply in the recipient area in order to vascularize the graft. And you also have to have adequate coverage of vital structures. And the other part of that is the reconstructive requirements that would lend themselves to a graft would be things that are somewhat less complicated in general. Also, that require a thin coverage or in cases in which the aesthetic issues drive a graft to be the better choice than the flap or the donor site drives the graft to be the better choice. Grafts are not really commonly used in gynecologic reconstruction. Now, a flap on the other hand brings its own blood supply with it. It generally is the treatment of choice that would be for a wound or recipient site that has poor blood supply. So, radiated beds would be classic for this. Also, extremely scarred wound beds would be classic for calling out for a flap rather than a graft or healing by secondary intention for that matter or many of these other simpler methods of reconstruction. Also, the reconstructive requirements might lead one to choose a flap over a graft, especially if you need thicker coverage or some sort of three-dimensional coverage. And also, for aesthetic issues in that many times a flap will look more normal than a graft will. And so, in female genital reconstruction, we are more likely to be doing some sort of flap than a graft in most cases. As far as grafts go, skin grafts, of course, are something we all know. They aren't very commonly used or at least I don't get asked to do them very commonly because they're really not great to use in radiated fields. You need a clean wound. You would need a relatively small defect and it doesn't provide any sort of bulk or padding. And so, often it will not look great. It may cover the wound but it isn't ideal in terms of aesthetics and it often isn't ideal functionally because it doesn't produce the normal bulk in the area where you're trying to put it. The other graft that's sometimes used in gynecologic reconstruction are fat grafts. And again, not real common but I'm just mentioning it for completeness sake. People do or have reported using fat grafts around the urethra for treatment of urinary incontinence. I'm sure that my audience is more expert than I in that. And fat grafts are also used for labia majora augmentation on a cosmetic basis and it's something that works reasonably well for that. In deciding what flap to use, there are many things I take into consideration. One is the requirements of the recipient site and the other is the requirements of the donor site. On the recipient site size, the first thing is, of course, the amount of coverage needed, the size of the defect. And that drives much of flap choice. Also, what local tissues are available, the type of tissue that's needed and the aesthetics of the recipient site and how that flap would fit in to give the best aesthetics possible in that. As far as the donor site in choosing flaps, again, what kind of tissue is needed will drive some of the choice of donor site. We have flaps that are mostly skin with very little subcutaneous tissue, flaps that have a lot of subcutaneous tissue in skin, flaps with muscle and skin and subcutaneous tissue, flaps that are just muscle and then some specialized ones there. And so, the consideration of what kind of tissue would work best for that defect is important. A big question is, will it reach to where you need it to go? Of course, we can do free flaps pretty much anywhere and take tissue from far, far away and move it. But that's not a very common thing to have to do in GYN reconstruction because, fortunately, we do have regional options that reach and work for most areas. In choosing a donor site, we also want to minimize the aesthetic defect from the donor site. We'd like to keep it hidden as much as possible or have a scar that is acceptable to the patient and isn't going to, in and of itself, cause a problem later on. So, there has to be a fair trade-off between what you are taking and the downside of what you are taking. And sometimes, I might choose a flap that is perhaps not quite as reliable because the donor defect is more acceptable. And we'll see that coming later on as we go through the flaps specifically. So, again, here we are, Flaps 101. There are various types of flaps. Random pattern flaps derive their blood supply from the dermal-subdermal plexus. So, their blood supply is not named. It's random. And so, a random pattern flap can be designed in any direction you want it to be and has its limitations in terms of its size because that dermal-subdermal plexus is not real robust after a certain size to it. And there's a concept called the length-to-width ratio that's important in random pattern flaps. So, the base of the flap, its width, should be probably not less than a third of the length. In other words, the length should be no more than three times the width of the flap, but probably safer to be two times the width of the flap. And again, that depends on where it is, whether there's been radiation and that sort of thing. But the blood supply to a skin flap that's a random pattern flap comes from its base and then runs along the flap. So, eventually, the blood supply isn't going to be so great and the tip of the flap will be ischemic in that case. You don't want to have that. So, there are a lot of considerations to planning in a random pattern flap to make sure that it works well and doesn't give you a problem. An axial pattern flap does have a specific blood supply and it's via a direct cutaneous vessel. And so, that type of flap has a better blood supply than a random pattern flap, should be more reliable, but less versatile because you do have to plan it such that it contains that axial vessel within it to keep it alive. And then we have muscle, myocutaneous, fasciocutaneous, septocutaneous flaps. They're all variants on the same concept, which is that there is a blood supply to a muscle usually, but it also could be a blood supply that goes directly to fascia via intermuscular septums or via a perforator from the muscle. And then that vessel supplies an overlying area of skin and subcutaneous tissue. And the vessels that come from that muscle into the skin are called perforators. They perforate the fascia and give blood supply to the skin that's overlying it. And so, the muscle is a carrier for the skin in that case. Now, you can also use a pure muscle flap without the skin attached to it and any myocutaneous flap that you do, you could also do as a pure muscle flap by not including the skin with it. So, let's talk about those different kinds of flaps. And first, we're going to, again, we're going to use our reconstructive bladder and go from the more simple ones to the more complex ones. So, random pattern flaps are used usually to reconfigure scars. And so, examples of that would be a Z-plasty or a W-plasty. They can be used to fill a defect with a local tissue. And some examples of that are rotation flaps, advancement flaps, V to Y flaps. The limitations of a random pattern flap are that it relies on the laxity of the surrounding defect. You're robbing Peter to pay Paul, but if Peter doesn't have a whole lot of excess, it's not going to work real well. It's also not useful when the local tissue is poor because if you're rotating bad tissue into a defect, it's not surprising it doesn't do well. Random pattern flaps are not generally used in radiated areas. They're not real useful in heavily scarred areas because you can't really transfer a flap like that with scar going across it because the vascularity just isn't good enough. They usually are relatively small and lack bulk. And all in all, their blood supplies are not the greatest, let me say. Now, local flaps are basically adjacent tissue transfers or local tissue rearrangements. So, in the CPT coding world, all of these various flaps, and we'll have some diagrams of them in the next slide so you can see them, but all of them are considered to be local tissue rearrangements or adjacent tissue transfers, depending upon what terminology you want to use. And so, for coding purposes, when you're doing these, they're described by the anatomic location and by the surface area of the flap itself plus the primary defect. So, the size of the defect plus all of the undermining or whatever you did to do that local tissue rearrangement. And those codes are used for all of these various flaps. And so, among other areas, the genital area uses the 140 series, 40 and 41, for flaps of less than 10 centimeters squared and then 10 to 30. And then the series 14301 and 14302 are not specific to any general area, but are done for these larger flaps. And it's not terribly difficult to get a flap that's 60 centimeters squared in many areas, and certainly in the genital area when you're doing these reconstructions. So, that would be how you would code them if you were going to use them. So, here's some examples of local tissue rearrangements. And so, in that top left one shows some examples of Z-plasties and V to Y-plasties. Those give you length at the expense of width. So, a Z-plasty, as it's drawn in that diagram, when the Zs are lifted and transposed, the scar or the vertical length of that wound gets longer, but the way it gets longer is by making the width narrower. And the same thing really is happening in that V to Y-plasty there. If you go over to the right top, you see a nice little flap there. It's called a 4-flap Z-plasty. And the reason I put it in here for you all is that if you look at the diagram of where that is used, it's being used in that area in the first web space of the hand between the thumb and the index finger, that U-shape. And in this application that they show you the diagram for, it's used to deepen the first web space between the index finger and the thumb. If you look at the shape of that in that nice U, it sort of might remind you of the posterior lip of the vagina, the posterior foreshadowing. This is the type of flap that could be useful in that area if you have a scar band contracture to do. It's a little bit confusing, so it is useful to look at the diagram if you're going to do one of those. But it works really nicely and gives you a lot of length. Rotation flaps, probably everyone is familiar with those. And then in the center is one called a rhomboid flap. The rhomboid flaps are pretty similar to a rotation flap, except that it gives you both transverse and longitudinal advancement. And these are random patterns, remember, so they can be drawn in any direction. And so hence the diagram there that shows you the four of them sort of spinning around the clock. And the dotted line on those diagrams that defines the flap is placed so that if you pinch that V together, you want to place that where there's a lot of laxity. And that's how you rob Peter to pay Paul for that particular flap. And then if you look at the bottom right, the V-Y advancement flaps, that flap's blood supply is based on the subcutaneous tissue. You cut that as an island, but it's attached to the underlying fat and subcutaneous tissue. And you can shift that, in this case, forward or up and then close where it came from, primarily together as a V-to-Y kind of thing. And these are all pretty useful flaps, particularly when you're not talking about radiated reconstructions and when you don't have a real big defect, but you feel like it's too big to just suture closed. So I'll show you an example of one of these that I just did recently. This lady had had a positive margin and a recurrence of a squamous cell carcinoma that was excised in the past. And this is the defect that was left. And it was possible to haul it together, but she had a couple other surgeries before, and it was pretty tight. And so what we chose to do was a rhomboid flap. And I'm going to toggle back. If you look at that one in the center, and then you look at this, you can see the similarity there. And the part that is drawn out on her thigh was cut. The base of the flap is about from 12 o'clock to 2 o'clock, and that's where the blood supply is coming from. It rotates counterclockwise into that defect. And the tip of that V-shape drawing there is going to the most posterior portion of the recipient site. And then the other is closed together. And so that's an example of a local tissue rearrangement. It was a defect that was not radiated. It was a little tight but not awful and didn't seem to warrant the invasiveness of a gracilis flap or something like that. And so those are the utility of that. So now in moving on to things beyond local tissue rearrangement, I sort of separated this into vulvar and vaginal because there are some different considerations with those two sets of flaps. So again, I'm sure that none of this is news to anyone who's listening to this webinar with just anatomy for local flaps. The important thing for most of the things we're going to talk about first is that anatomy of the internal pudendal system because there's a lot of different reconstructive options around the perianal and groin crease area that can be used for reconstructions in this area. So the options for vulvar reconstruction locally, the internal pudendal flaps of various kinds, the posterior labial artery flap, gracilis, the interlateral thigh flap is a nice flap to use if you need a lot of tissue, and the posterior thigh flap. And those five would take care of the vast majority of the reconstructive needs around the vulva. So the first one I'm going to talk about is the posterior labial artery flap, also called the Singapore flap. The reason it's called the Singapore flap is it was described by a group from Singapore. They didn't call it that, but that is pretty commonly how it's known. And that is a flap that's based on the posterior labial artery, which is the terminal vessels from the internal pudendal system. And this is just a patient example that I did recently. And this lady basically has a cloaca here. She has a big discontinuity in her anal area into the vagina. And the concern was she'd had a couple attempts at repair before there was scarring there. And Dr. Lipitskaya, who is the urogynecologist that I work with, was concerned that they needed to build up the perineal body and to really create a good definition between the anus and rectum and the vagina. So here is a picture of her on the left. Before anything was done on the right, you see that the rectal portion of this had been repaired. And again here. And so what we did was lifted a Singapore flap, a posterior labial artery flap. I'm sorry. The flap on your diagram there is on the patient's right. The flap I did is actually on her left. And there you can see it being held across. But you can see from the drawing on the cartoon that the flap is sort of a finger-based thing that runs right along the groin crease. The posterior labial artery sort of sits right in that crease. So if you center that flap over it, you're going to catch the artery. It's a little bit of a tricky flap in that the artery isn't necessarily real. It's certainly not palpable. And sometimes you can't even really get a good Doppler of it. But it runs in the subcutaneous tissues. It sort of dives deep somewhere posterior to the mid-portion of the vagina. And usually it's not necessary to chase it much back further than that in order to get it to lift and turn. The nice thing about this flap is that the donor defect is very well hidden. It's right there in the groin crease. And it is a very useful thing in the area of the perineal body. And the posterior vulva works very nicely there. It can reach all the way to the anterior. But your blood supply is getting a little shaky the further, the longer you make this flap. And there's probably some better choices if you need an entire one-side reconstruction there. Now, the posterior labial artery flap is very similar to one that I'm sure you're much more familiar with than I am. Because this is not a flap that in plastic surgery we really use or need. But the Marcius flap uses the labia majora fat pad. And it probably benefits from the same blood supply that the Singapore flap does. It's a little more medial. So it's probably using more of the branches rather than the direct arterial supply. And of course that flap is just fat. And it doesn't carry skin with it. And it's used mostly for fistulas and that sort of thing. But it's basically a very similar concept and very similar blood supply to do that. Now, the posterior, you have to be a little careful with the Singapore flap. Because as I said, that vessel dives beneath some superficial fascia. And it's not a huge vessel. So you could easily come across it and not realize that you were doing that. So you do have to have a little bit of suspicion of where it is and keep an eye out for it. And also not lift that flap way back posterior to the anus. Because if you do, you're going to come across the vessel because it's not running superficial back there. The other flap that is extremely useful in the vulvar area are the variants on the internal pudendal flaps. And the internal pudendal artery comes out from medial to the ischium. And there are multiple branches in that whole area. And there are many patterns that you can use to move this flap. You can do it as a pedicle flap and leave the base of it attached. You can turn it into an island flap and spin it around. You can do it in a V to Y fashion. And it's all based on these perforators from the internal pudendal artery. The vascular triangle in which those perforators are going to be found is basically from the posterior edge of the vagina down to the anus and over to the ischial tuberosity. So if you are within that triangle, there's probably plenty of blood supply, particularly if you haven't had any radiation. And in general with these flaps, you're not dissecting out a specific blood vessel. You're just leaving that area pretty much undisturbed and depending upon the multiple perforators from it for your blood supply. This flap, this blood supply is also often called a lotus petal flap. The reason for the name is that if you look at the cartoon there, the drawing on the top left shows a bunch of different flap options drawn all sort of with their tips centered in that perineal body area. And to the authors of that paper, that looked like a lotus flower. So they call that a lotus petal flap and that's a very common way of referring to it in plastic surgery. But if you were going to call it by its blood supply, it would really be an internal pudendal artery flap. And you can see in the example there, those particular lotus petals were drawn out along the gluteal creases and then incised and lifted up with their bases being kept intact medially. And then these particular ones were spun about 90 degrees and inset and then the donor defects were closed primarily. And that is a reasonably normal looking area considering the defects that you were, that one started with, with these. The next thing we're going to talk about is the gracilis myocutaneous flap and today talk about it right now, talk about it for vulvar and we'll talk about it again for vaginal reconstruction. The gracilis can be used as a muscle only flap or as a myocutaneous flap. There are perforators from the muscle that go out onto the skin of the medial thigh and you can move the muscle with the medial thigh skin. The gracilis has a dominant proximal blood vessel supply and from the medial femoral circumflex artery and it is about 10 centimeters distal to the pubic tubercle where that is. And then further down on the muscle, you'll have some minor pedicles that are entering into the muscle as well and providing blood supply. But the gracilis will survive on that proximal pedicle. The distal pedicles are of no use whatsoever in gynecologic reconstruction. So from that point of view, it's a very good thing that they're not dependent on it. There are a few problems with the gracilis muscle or myocutaneous flap in terms of reconstruction. The first is that that pedicle position is somewhat variable. Usually, it's around 10 centimeters from the pubic tubercle but it can be considerably more distal than that and if it is, the flap's not going to reach. Unfortunately, there's not a way on physical examination, you would know that. We could get an arteriogram, of course, in everyone that we were thinking about doing that flap on but generally, we don't. We cross our fingers and usually, it's okay. Once in a while, you're very lucky and the vessels take off more proximally than that but that's typically where it is. So you don't get the whole length of that muscle when you use it because it doesn't spin based on its attachment up there to the pelvis. It spins based on the vascular pedicle. The other issue with the gracilis muscle is that the skin paddle is very robust proximally but not at all robust down distally where that, as you can see in the diagram, the muscle is very thin and small. In reality, the skin paddle that you can take with it is really not at all reliable about where you see labeled on their second minor pedicle. You're not going to be able to really get a reliable skin paddle that runs distal to that. The other problem with it is that the skin paddle isn't necessarily all that firmly attached to the muscle and so you have to be pretty careful when you're raising it and also when you're transferring it that you keep the skin paddle attached to the muscle. I actually tack it to the muscle periodically just to make sure it doesn't happen. The first gracilis vaginal reconstruction I did in practice years and years ago, I did the flaps and turned them up and passed them into the pelvis to my assistant who gave a good pull and pulled one of the skin flaps, one of the skin paddles completely off the muscle. I learned my lesson with that one and it is one that you have to be careful with. As you can see in this particular patient diagram, this is someone who had cancer and had an enormous defect. She had very floppy thighs and we were able to get that whole thing closed with two gracilis flaps. As you can see in the final result on the right side, that flap is a little bit dusky and struggling a little bit. I pushed that pretty hard. It did do okay but it sort of illustrates that you don't necessarily have the most robust flap in the world. The other thing about a gracilis and also the other thigh blaze flaps we're going to talk about is that it is an entirely different kettle of fish when you're working on obese patients. Unfortunately, a lot of our patients are obese and we are sort of stuck with the subcutaneous tissue thickness that we have. In some cases, these flaps aren't really even possible particularly when you're talking about using them for vaginal reconstruction because they simply won't fit. In a vulvar situation, that's not so much a problem but it may require a revision down the road to thin it because much of that sort of thinning stuff you can't really do acutely with these flaps. It's something to keep in mind. Another flap that's quite popular is the interolateral thigh flap. That flap is a fasciocutaneous flap. Its blood supply is via the descending branch of the lateral femoral circumflex artery. That artery comes along and it runs along the anterior border of the vastus lateralis. In some cases, it runs sort of within the vastus lateralis which is a little bit of a pain. Then it has several perforators out to the skin from there. It's an extremely robust flap and you can get a very large flap from it especially if you're willing to skin graft the donor site. Of course, it's as thick as whatever the person's subcutaneous thickness is. If you have a heavy patient, it's a big flap. You can see from that diagram there that that individual had an enormous defect. The ALT that we did there, we made actually an opening in it for the vagina to come out and the urethra. It actually worked quite well. If you look at her right leg, that's skin graft donor site. We had to do a skin graft to a thigh. Again, for such a large defect, it worked quite well. It will reach anywhere in the vulvar region for reconstruction. The last one I'm going to talk about is the posterior thigh flap. That is a skin flap based on the descending and the terminal branch of the inferior gluteal artery. It basically runs right down the mid-back of the thigh. It can be useful. You can see the diagram there or the drawing on the patient how with that vessel attached proximally, you can rotate that flap into the vulvar region pretty easily. Again, it suffers from the same problem. If you have a heavy patient, it's going to be a big flap. The other problem with that one is that the vessel is not necessarily really easy to find. That can make it a little bit nerve-wracking when you're doing that procedure. Moving on to vaginal reconstructions, it's important to understand that our choices in vaginal reconstruction are driven by the defect. There is a classification system for vaginal defects. The type 1s are partial defects and the type 2s are circumferential. In the type 1s, of course, you can have a defect in any quadrant of the vagina. In the type 2s, you can have a total defect or one of the superior portion of the vagina. Generally, it would not be usual to have a circumferential lower vaginal defect with the upper vagina intact. Again, your choices there, some of them are the same. The Singapore flaps, your Marcius flap in some cases, rectus abdominis, which is a new one we'll talk about, the bracillus, which is very commonly used. Then the ALTs and then some of the less common ones with that. Let's talk about the rectus abdominis flap first. The rectus abdominis would be my choice for most large vaginal defects, certainly for a total vaginal reconstruction and also for a posterior vaginal wall that's part of the posterior exoneration or an anterior vaginal wall when part of an anterior exoneration. The rectus abdominis muscle has multiple perforators to the skin. Most of them are peri-umbilical. It's got a very hardy blood supply to the skin. You can take an extremely large skin paddle with it. The vessels for it are the inferior epigastrics, which are quite large and usually quite healthy. This flap works very well. The downside to it is you're sacrificing a rectus muscle, which does cause some donor problems. You do have the loss of strength of the anterior abdominal wall and also the potential for hernia. The other thing that makes it problematic is that if the patient is going to be getting a stoma, I have to coordinate with the surgeon doing the colostomy as to whether they're okay with me taking it or not. It's especially problematic in cases of total exoneration because there are two stomas and they aren't really very happy about bringing a stoma through the abdominal wall where there isn't a rectus muscle. They're also very unhappy about bringing them both through the same side. Sometimes there's negotiation that goes along with that. You can see here in this picture the patient. She's a very lean patient, thank God. It was just a joy to do because of that. You can see the donor site there. Then you can see a long-term post-op result with the flap visible there in the posterior vaginal wall and a little bit into the perineum with that. The rectus can also be laid just along the posterior wall. It can be rolled up and made tubular to make a neovagina. A lot of different things you can do with it. The other common flap used for vaginal reconstruction is the gracilis myocutaneous flap. This would usually be my flap of choice when I can't use a rectus abdominis. Generally, for a full vaginal reconstruction, you need to use both. If you're just doing an anterior or posterior wall, you can use one. Those flaps are raised up. Then I create a tunnel between the donor site for the flap and the vagina. Then pass those flaps through the tunnel. Then sew them to each other in a tubular way. Then it gets spun and pushed up into the pelvis. We anchor it to the posterior sacrum. Then do the closure in the introitus to do that. It's a nice flap in that it fills dead space really well. It has great depth. The rectus flap may not have the best depth, depending, but it's bulky. The turning point is variable, as I said, depending on where the vessels are actually taking into the muscle. Cingapore flaps are also used for vaginal reconstruction. These photos show a person in whom I did that as a reconstructive option. You can see the outline of the two flaps right there in the groin crease. They're passed beneath a tunnel into the vagina. Then sewn together and placed up there. The donor site's very inconspicuous. The flaps themselves are thin. There's no functional loss. The disadvantage to this one is that the depth of the vagina isn't super. It's okay. For some people, it's completely fine. In others, it's not quite as good. In someone who is morbidly obese, this would be the flap I would go to because the others are just too large and you can't get them into the pelvis when you've got someone who's very heavy. Then we have a couple I'm just going to mention for completeness sake, some more unusual ones. The colon flap, a piece of sigmoid colon, can be taken left on its inferior mesenteric blood supply. You have to do a bowel anastomosis and then that can be used for vaginal reconstruction. It's a very common way of doing vaginal construction in transgender patients. It can sometimes be used as a salvage procedure in a patient in whom a flap reconstruction didn't work. It has its uses, but it's not really commonly done and we tend to try and avoid requiring to do bowel anastomosis when we don't have to. The other one to know about is the omental flap and its utility would generally be to put between the vagina and the bladder in the case of the fistula or something like that. You could, in theory, tube the omentum and skin graft the inside of it and make a vagina, but that would not be a very common thing to do. It's more of something of putting vascularized tissue in between the vagina and something else. One of its problems is that you don't know how big it is until you're in there. Some people have very robust omentums and some people have very flimsy ones as you know from being in the abdomen. You're not real sure it's going to reach or it's going to be big enough for your purposes until you're actually in there, but it's a good flap especially if you're in the abdomen anyway for things like that. Okay, so that concludes my formal presentation and we can move to questions. Thanks, Dr. Matthews. For those of you participating in the webinar, if you would go ahead and submit your questions and we're going to start going through a couple of these. We have several questions about the Singapore flap. Someone is asking for you to talk specifically about the exact incision in the skin, though I'm not sure if they're talking about the vulvar or the vaginal one, but then there is a follow-up question asking about is there a difference in your exact incision, so I'll let you. Okay, sure. I think that probably the best thing for this is I'm going to put up this slide that showed it using it for a vaginal reconstruction, but the design of the flap is really the same either way. You'd like it to be centered right on that groin crease there. Sometimes you can doppler the vessel and when you can doppler the vessel, that's very useful and it makes you feel good, but I've done successful flaps where I couldn't find it on a doppler, but it worked anyway. The location is really quite consistent and you can make these, as you can see, pretty wide. Those are about probably five or six centimeters in width and it's reliable about where you can see it anteriorly, about at the level of the pubis, pretty reliable, and then its base should be, if you're looking at the vagina, it would be about somewhere between nine o'clock and eight o'clock on the left side, three and four on the right, so its base is usually a little bit posterior to that midpoint, the mid-lateral point of the vagina on each side. Of course, you can go anterior to that if you don't need to be that far posterior, like if you're going to use it across the anterior vulva, for instance, you don't need to have its base quite so far posteriorly. If you're using it in the perineal body area it needs to be you know go a little bit further posterior. But you would incise there and go right down to the fascia and then lift it lift the flap up off the fascia. As you lift it up if you take a doppler on the undersurface of it you can usually find where the artery is and trace it backwards so that you don't cut it by accident. Sometimes you see it sometimes you don't. It can be fairly small but it doesn't seem to matter they're pretty robust. And then those donor sites of course just get closed primarily to each other. Donor sites in the perineal area frequently dehis. I try all sorts of stuff but it doesn't I don't know that any of it really matters greatly. I do them with sometimes I do drain sometimes I don't. I don't think it makes any difference you know like many things it's based on whatever the last complication I had. I'll try and do something different but usually I don't think it really matters. When you're closing these it's helpful to use a fairly heavy I use an absorbable stitch like a PDS but some people do use a non-absorbable braided suture and catch the superficial fascia of the thigh and then stitch it to the periosteum of the ischium or the muscle fascia of the gracilis adductor to hold that distal thigh skin up so that there's not so much tension. Also I have taken to using some non-absorbable sutures in that area just as a sort of belt and suspenders thing because those wounds are under a good deal of tension and it's an area that's moist it's got a lot of germs tends to does it's not rare to have some minor wound dehiscence in there with those. Okay you had another question I think you partially answered this one asking about post-operative care for large flaps do you use dressings, drains, antibiotics? Okay I use I don't usually use drains in the case of like an ALT flap or sometimes with gracilis flaps I'll use drains in the donor area I don't use them in the recipient area. When I'm doing a total vaginal reconstruction with you know with either an anterior or posterior total exenteration generally the people who are up in the abdomen the colorectal surgeons particularly in the urologist they leave a drain in the pelvis anyway I don't in particular care one way or another but it's their drain but I'll use them in those donor sites for a Singapore flap or a lotus petal internal pudendal flap I don't drain those I haven't noticed any difference one way or another. I generally as I said I'm using mostly absorbable sutures but I do use some non-absorbable at the turning points where there's a lot of tension and things like that and I generally when I use those I use proline because it slides out really easily and I usually leave them in two or three weeks. With someone who's been radiated I definitely use prolines and leave them in for a long time because those things tend to fall apart a lot. One thing I do do with many flaps is I use a hip abduction pillow at the end of the case to keep the knees apart. The orthopedic people have them for total hips and they're big foam things that you strap on it goes between the knees and the reason I use those is when people are in bed particularly when they're laying on their sides their legs come together and if the flap is crossing there it can kink it and compromise its blood supply. So I use that for just a couple days until it's a little bit more stable and until the patient's a little bit more able to control where they are and such. For most flaps in the vulvar area I let people walk immediately and they can lay but they can't sit. I don't really let them sit for on the short end of it maybe three or four days for one that's not really in an area that's going to be directly sat upon and that has good blood supply. For one that's a little shaky like that flap I showed you that was a little bit purple or for the bigger ones or the ones that are really in areas where they're going to have pressure I wait about five to seven days before I let them start to sit and then it has to be on a really padded surface and work their way up in time for that. We have another participant asking about hair follicles in your flaps and how do you handle that? Do you pre-treat with laser? Well yeah any place that's got hair is still going to have hair. It would be nice to pre-treat with the laser. Our insurers in my area aren't going to cover it and I really don't have a patient population that would pay for that. It's also you know as you know not a sure thing that you're going to have that that it's going to completely work. The other thing is that in my you know again in practical terms I usually don't have the luxury of time for doing that. It's for the normal leg hair like for vaginal reconstruction that just has never been a problem that any patient has really brought to me. With a Singapore flap depending on the patient yeah there can be quite a bit of hair there. A lot of patients who end up needing this operation don't really have a lot of hair either because they're elderly or if they've been radiated and that sort of thing. And so it hasn't been a big problem but I think that's just by virtue of the typical patient. Of course these flaps when they're used in the vagina they're skin flaps they're not vaginal mucosa and so they are going to retain the characteristics of skin. So they do you know have a little bit of an odor sometimes because the skin if the skin gets macerated you might have a little bit of white discharge. It's sort of like if your skin's under a cast for a long time and it gets moist that and that's just one of the facts of life of flaps like that. Once everything's healed the patient can douche if they want to use a washcloth whatever. It's again doesn't seem to be a big issue that patients come back to me long term. I mean in reality as a plastic surgeon I see them until they're healed and then they never see me again. So if something came out two weeks ago or two months two years later I wouldn't necessarily know it. And we have a quick case here that somebody is struggling with. They said they have a patient who has a scarred introitus from lichen planus. She couldn't tolerate dilation and asking how you would surgically approach the patient to open her introitus. Okay. Well I guess my first question is how deep does that go? Is their normal vagina above it? Because if there is probably those Singapore flaps are your best option because they're right there and shouldn't be you would not normally see the skin disease out that far onto the leg. I suppose you could but that would be my first thought on that is to do that. You probably could get by with one because you know you can make it fairly wide and it doesn't you know once you've had it released and you have the space it doesn't you don't have to remove all of the scar if it's you know just that scar and not cancer. So I think that would probably be the thing that I would think about first with that. Okay. I'm going to try to combine a couple of these questions. Looks like they're focusing on labial surgery either how you approach it or how you would treat over-reception from a labiaplasty. There's some specific questions about do you use clitoral hood flaps or YV advancement flaps? Yeah that's a tough problem. Full disclosure I have not thank God had to deal with any of the ever one of the you know those severe mutilation kind of injuries that female circumcision type of thing. I think that probably if yeah if if there's enough tissue there to do a VY advancement sort of the clitoral hood that's the most probably the most aesthetic thing in the least invasive with that. But so many of those you know each patient is very different so it's hard to to have a one size fits all answer to that. And some of the other kind of local tissue rearrangements in that area can sometimes be useful also. It's a little tough to get that that you know to that three dimensionality of that clitoral hood. And so if you can do it by leapfrogging some labial residual labial tissue or whatever and then worry about the labial defect that can be helpful too. And someone is asking if you ever choose to do a peritoneal flap? For a vaginal reconstruction if I'm I'm not exactly sure what you tell what use would be for use would be for people have described using it for a vaginal reconstruction either with the skin graft or using it letting it epithelialize wouldn't be my first choice now. But and I don't really have any experience with it with that like I said it wouldn't really be my first choice. Okay I'm going to take one last question here and they're asking if you use a doppler to find the blood supply when you're doing the Martius flap? You could it's really got a bunch of it's really not a single vessel that's going to be going there. I mean you might find a single vessel but it's going to be an arborization of stuff. So those flaps are the more anterior you leave your base of that and the broader the base of it the more vascularity is going to go into it. If you look at let me pull up this slide here. Okay so if you look at that diagram for the Singapore flap and you look at the main vessel that's coming up that's running right beneath the posterior labial artery. Okay so if you go to those little branches that are going towards the vagina those two of them there that's really where your blood supply is for that. And I suppose in theory you might be able to find a fairly large blood vessel but in practice as long as you leave the base broad and not take it too far posterior and keep it fairly deep in your dissection you should be having a lot of those vessels contribute to it and give it better blood supply. So you know the doppler might help you to do that but you're probably I mean to do a dissection even for the posterior labial flaps generally you're not really dissecting that vessel out for much of a distance you're just you know where it is you stay below it and you don't come through it and you don't go really heavily dissecting around it in most circumstances. You can but in general you don't. Great well with that I think we will wrap it up and let everyone know that Dr. Matthews slides will be available. So on behalf of the Oggs Education Committee Dr. Matthews we thank you for a fantastic presentation. Obviously lots of interest tonight and terrific questions. Please join us for our next webinar it's titled Why Aren't My Laxatives Working? It's a primer on the role of the pelvic floor in the development of chronic constipation and will be presented by Dr. Darren Brenner on May 13th. Thank you all have a good evening. you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you you

Flaps

Urogynecologic Surgery

Dr. Martha Matthews

Reconstructive Options

Vulvar Defects

Vaginal Defects

Random Pattern Flaps

Myocutaneous Flaps

Fasciocutaneous Flaps

Blood Supplies

Internal Pudendal System

Flap Reconstruction

Post-operative Care

Labial Surgery