V263: ROTATIONAL LABIAL AND INFERIOR PUDENDIAL ARTERY BASED INNER THIGH FLAPS IN VAGINAL RECONSTRUCTION

Video

Introduction and Objectives
The rotational inner thigh flap is well vascularized, maintains sensation, and provides reliable cosmetic and functional results for complex vaginal reconstruction. The purpose of this video is to describe the technique with the rotational flap.

Methods
All women, from 2002-2012, requiring vaginal reconstruction were retrospectively reviewed. Patients who had a rotational inner thigh flaps performed were included in this analysis. Demographics, pre-operative and operative findings, postoperative sexual function and validated body image perception questionnaire, recurrence of vaginal fistula, or vaginal stenosis were analyzed.

Results
A total of 486 women underwent vaginal reconstructive procedures of which 30 patients required rotational inner thigh flaps. Indications were vaginal defects that were difficult to access and or required large amount of coverage. The flap was utilized for (7) recurrent vesicovaginal fistula (VVF) repair or (6) rectovaginal fistula (RVF), (14) vaginal stenosis, (6) complex posterior vaginal wall defects, and (13) prior radiation. The median number of prior surgeries was 3. The operative times (mean 173 minutes + 59), EBL (193 + 92 mL), median LOS (3 days), and perioperative complication (6%- superficial soft tissue infection (1), blood transfusion (1) were observed. Graft survival was 100% and all had good cosmesis with no dehiscence. Successful repair of VVF or RVF occurred in 13 (100%) with 8 (62%) requiring 1 surgery, and 5 (38%) two operations. Those that failed primary repair with recurrent VVF (1) and RVF (4) had a history of radiation in 3 (60%) and bowel diversion was not performed in 3 out of the 4 RVF (75%). Complex posterior defects were successfully repaired in all patients (6) with one patient developing vaginal stenosis. Vaginal depth and width were adequate in 82% overall, with 93% (13) patients with vaginal stenosis successfully repaired. Sexual function was maintained in all except 2 patients. Post-operatively patients completed the body image disturbance questionnaires (BIDQ) which examines negative body image. Patient post-operative body image was maintained with a low (BIDQ) score of 1.96 +.92 which is comparable to the non-surgical general population with a 30% response rate.

Conclusions
The rotational inner thigh flap is a versatile option for complex vaginal reconstruction. Reliable functional and cosmetic results are achieved while maintaining body image with minimal morbidity. Not performing fecal diversion and a history of radiation were associated with risk of recurrence of fistula.

Funding: none