Wide Local Excision of the Vulva, With Primary Closure Or Z-plasty Flap

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Wide Local Excision of the Vulva,
With Primary Closure Or Z-plasty Flap

A wide local excision is indicated for women with in situ or microinvasive carcinoma of the vulva. The goal of this operation is to remove the carcinoma and a 2-cm margin of normal skin surrounding the gross lesion. It is imperative that prior to making the incision the surgeon measure the margin with a centimeter rule and outline it with a marking pen to ensure that the specimen is adequate.

If the 2-cm margin is not measured and the skin is not marked prior to the incision, all too often the specimen sent to the pathologist will not have an adequate margin.

In most cases, adjacent vulvar skin can be mobilized and used to effect a primary closure of the vulva. This is done in two layers after adequate hemostasis has been achieved.

In cases where extensive lesions are removed and the defect is too large for primary closure, a Z-plasty flap may be used to cover the wound without resorting to a split-thickness skin graft.

Physiologic Changes. The in situ carcinoma is removed without significant alteration of the physiology of the vulva.

Points of Caution. Preoperative measurement and marking of the diseased areas are mandatory. The Z-plasty flap or primary closure should be completed, as large defects should not be left in the vulvar area to simply granulate in and epithelialize. If primary closure is to be performed, adjacent vulvar skin should be adequately mobilized so that the suture line enclosing the vulva is not under tension.

If the excised defect is too large for primary closure, as demonstrated by tension on the suture line, the Z-plasty flap procedure should be performed. In this case, care should be taken to ensure that (1) the distance from point A to point B on the Z-plasty flap is shorter than the distance from point B to the margin of excised defect and (2) there is an adequate blood supply entering the base of the flap. It is essential that all tissues be adequately mobilized to avoid any tension on any suture line within the flap area.

Patients who have undergone a Z-plasty flap procedure recover best with complete bed rest for 7 days. Intermittent pressure cuffs are applied to the legs for thromboembolic prophylaxis. Defecation should be postponed by a low-residue diet and the administration of Lomotil, 1 tablet q.i.d. for 7 days.

Patients having primary closure for relatively small vulvar defects do not require bed rest or bowel restriction.

Technique

Wide Local Excision

The patient is placed in the dorsal lithotomy position. The perineum is prepped and draped. With a centimeter ruler, a 2 cm margin is measured around the lesion and marked with brilliant green solution. Frequently, the labia minora have to be sacrificed.

The margin of the lesion is excised down to the subcutaneous tissue, and the tissue is elevated with forceps. The entire lesion with its 2-cm margin and its subcutaneous tissue is excised.

Meticulous hemostasis is achieved at this point with fine pickups and electrocautery. Larger vessels are delicately tied with 4-0 or 5-0 delayed synthetic absorbable suture. At this point the defect is measured, and the surgeon decides whether to proceed with primary closure of the wound or with a Z-plasty flap.

Primary Closure

Adequate mobilization of adjacent vulvar skin is made by sharp and blunt dissection. It is essential that the wound be closed without tension. Sutures should merely hold the tissue that has been adequately mobilized and approximated.

A continuous layer of 4-0 synthetic absorbable sutures stitched with an intestinal needle is used to close the subcutaneous space.

A subcuticular technique can be used to approximate the skin, using 4-0 synthetic absorbable suture. Small stainless steel skin clips can also be used and can be removed on the seventh or eighth postoperative day. Fine nylon sutures can be used in either a mattress technique or the so-called flap stitch technique. These are removed on the seventh or eighth postoperative day.

Z-Plasty Flap

If the lesion to be removed leaves an excessively large defect, primary closure may be impossible. In these cases, a Z-plasty flap may be the procedure of choice.

The defect is measured with a ruler. The medial margin usually extends from the clitoral area to the posterior fourchette of the vagina and is equal to the distance on the proposed flap by the line marked A-D. It is essential that the base of the flap from B to the lateral edge of the defect be wider than the length of the flap. The blood supply to the flap will enter through this area, and if the length of the flap is longer than the width of the base, the flap will have insufficient blood supply, and its tip may necrose. A scalpel is used to incise the border of the flap through a full thickness of skin and subcutaneous fat. Meticulous hemostasis must be achieved at this point.

The portion of the flap marked a should be stitched with fine synthetic absorbable suture to the ventral margin of the defect. This suture should be in the form of a flap stitch that enters the full thickness of the skin of the margin of the defect and is brought through the flap with a subcuticular technique. The needle reenters the subcuticular layer of the flap skin adjacent to the first suture, then reenters the full thickness of the margins of the defect from the subcutaneous layer and exits the cutaneous layer adjacent to the first suture. This flap stitch aids healing by less constricture of the blood supply in the flap. The second suture should be placed in the posterior fourchette of the vagina and be brought to the angle of the flap marked D with the same stitch described above. At this point, the part of the flap marked C should be sutured with the flap stitch to the angle (ABC) created by the entire Z-plasty. After the margins of the flap have been sutured, the surgeon can make adjustments if necessary. If undue tension is noted at any particular point, it can be released by greater mobilization of adjacent skin.

Several techniques are acceptable for suturing the flap to the adjacent recipient skin and vaginal wall. The new stainless steel skin clips have the advantage of being inert and causing little tissue reaction. They can be left in for long periods of time to allow for complete closure and healing of the wound. Synthetic absorbable suture material can be utilized and, in general, gives improved cosmetic result. Sutures of fine nylon, in the flap stitch technique, can be used throughout the closure. These require removal after the margins of the wound have completely healed. Patients who have undergone large perineal Z-plasty flaps should remain in bed for a minimum of 6-7 days.

Thromboembolic prophylaxis utilizing the contemporary technique of intermittent pressure cuffs is essential. Defecation should be delayed for 6-8 days until the margin of the flap has sealed. This is achieved by a low-residue diet and the administration of Lomotil tablets q.i.d.