RECONSTRUCTIVE

Gluteal Fold V-Y Advancement Flap for Vulvar

and Vaginal Reconstruction: A New Flap
Paik-Kwon Lee, M.D., Ph.D.
Moon-Seop Choi, M.D.
Sang-Tae Ahn, M.D., Ph.D.
Deuk-Young Oh, M.D.
Jong-Won Rhie, M.D., Ph.D.
Ki-Taik Han, M.D., Ph.D.
Seoul, Korea

Background: Soft-tissue reconstruction following vulvar cancer resection is a

difficult challenge because of the functional, locational, and cosmetic importance of this region. Although numerous flaps have been designed for vulvar
reconstruction, each has its disadvantages.
Methods: The authors introduce the gluteal fold fasciocutaneous V-Y advancement flap for vulvovaginoperineal reconstruction after vulva cancer resection.
This flap is supplied by underlying fascial plexus derived from perforators of the
internal pudendal artery and musculocutaneous perforators of underlying muscle. The sensory supply of this flap comes from the posterior cutaneous nerve
of the thigh and the pudendal nerve. An axis of V-shaped triangular flap is
aligned to the gluteal fold. A total of 17 flaps were performed in nine patients.
Results: All flaps survived completely, with no complications except for small
perineal wound disruption in three patients.
Conclusions: This flap is thin, reliable, sensate, easy to perform, and has
matched local skin quality and concealed donor-site scar on the gluteal fold. In
addition, it can cover large vulvovaginal defects because it can be advanced
farther as a result of the character of the gluteal fold area. In our experience,
the gluteal fold fasciocutaneous V-Y advancement flap has proven very useful for
vulvar reconstruction, especially at the point of donor-site scar, flap thickness,
and degree of flap advancement. (Plast. Reconstr. Surg. 118: 401, 2006.)

ulvar cancer accounts for 5 percent of all

female genital cancers and 1 percent of all
malignancies in women. It can be observed more frequently after the fifth or sixth
decade of life. Recently, there has been an increase in the incidence of vulvar cancer. Vulvar
cancer is a diffusing disease that permeates into
regional lymphatics, requiring radical resection
with inguinal lymph node dissection for
treatment.1 Characteristically, this area is easily
contaminated by secretions from the vaginal
exocrine gland and vulnerable to infection after
flap surgery. Furthermore, soft-tissue reconstruction following vulvar cancer surgery presents a
difficult challenge.
The ideal flap for vulvar defects should be
sensate and thin with a reliable blood supply,
and should present a less conspicuous donor-site
scar. A large vulvovaginoperineal defect is often
created by radical excision of cancer because of
From the Department of Plastic Surgery, The Catholic University of Korea College of Medicine.
Received for publication October 28, 2004; accepted May 8,
2006.
Copyright 2006 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000227683.47836.28

the nature of vulvar cancer. Therefore, unless

the flap is adequate for mobilization, scar contracture and tension may result in cosmetic and
functional impairment, such as vaginal exposure
and deviation of the urinary stream.
We used the V-Y advancement flap from the
medial thigh and gluteal fold island flap for
vulvar reconstruction. However, there are some
disadvantages associated with each one.
In this article, to overcome these disadvantages, we present a new gluteal fold fasciocutaneous V-Y advancement flap that (1) is sensate
and thin with a reliable blood supply, (2) can be
advanced easily, (3) presents a concealed scar on
the gluteal fold and groin area, and (4) can be
performed in a single-stage procedure.

PATIENTS AND METHODS

This flap can be used to cover extensive vulvar
defects, which include the anterior commissure,
perianus, vaginal inner wall, and the labia majora
and minora. The apex of the triangular flap is
marked on the gluteal fold and the base of this flap
is an open wound margin (Fig. 1).
The skin is incised down to the underlying
muscle fascia with meticulous electrocauterization. The flap is mobilized by elevating the un-

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Plastic and Reconstructive Surgery August 2006

avoid injury to perforators as much as possible.
This flap is advanced in a V-Y fashion and is secured to the recipient site, reaching the vaginal
inner wall with no tension. After the dog-ear is
removed, the skin is closed layer by layer. Watertight closure should be performed on the vaginal
mucosa. Finally, we apply Dermabond (Ethicon
Inc., Somerville, N.J.) to lower the risk of postoperative infections from the bacterial contamination and vaginal discharge.

RESULTS

Fig. 1. Schematic diagram of the flap. (Above) Preoperative design. The apex of the triangular flap is marked on the gluteal fold
and the base of this flap is on the open wound margin. (Below)
After insetting of the flap. This flap is advanced in a V-Y fashion.

derlying muscular fascia proximally and distally.

The amount of mobilization can be determined
according to defect size. Caution is required to

From April of 2003 to March of 2004, we performed 17 gluteal fold V-Y advancement flaps for
vulvoperineal defects in nine patients after vulvectomy with or without inguinal lymph node dissection. The age of the patients ranged from 23 to 70
years, averaging 56 years (Table 1).
Of the nine patients, six had squamous cell
carcinoma and radical vulvectomy with inguinal
lymph node dissection, and three had vulvar intraepithelial neoplasia and simple vulvectomy
without inguinal lymph node dissection. All patients underwent reconstruction using gluteal fold
V-Y advancement flaps. Follow-up after operation
ranged from 6 months to 1 year, with a mean of
8.6 months.
All flaps survived without major complications.
In three patients, partial dehiscence occurred at
the junction of the two advanced flaps and perineal skin, which were healed by conservative treatment. All patients had sensation on the flap.
To assess flap sensation, we performed sensory
tests such as two-point discrimination, superficial
pain, superficial touch, temperature, and vibration on the triangular flap of five patients (cases 2,
3, 5, 8, and 9) after surgery. The triangular flaps
were divided into three zones: proximal, center,
and distal. Follow-up for sensory testing ranged
from 11 months to 1 year 10 months after surgery.
The results showed that all flaps had good sensation (all five modalities) in three zones. The prox-

Table 1. Summary of Patients

Patient
1
2
3
4
5
6
7
8
9

Age (yr)

Sex

Diagnosis and Site

Operation

70
40
70
68
58
65
23
37
53

F
F
F
F
F
F
F
F
F

SCC, vulva
VIN, vulva
SCC, vulva
SCC, vulva
SCC, vulva
SCC, vulva
VIN, vulva
VIN, vulva
SCC, vulva

RV/LD/bilateral V-Y
SV/bilateral V-Y
RV/LD/bilateral V-Y
RV/LD/bilateral V-Y
RV/LD/bilateral V-Y
RV/LD/bilateral V-Y
SV/bilateral V-Y
SV/unilateral V-Y
RV/LD/bilateral V-Y

Complications
Partial
None
None
Partial
Partial
None
None
None
Partial

dehiscence
dehiscence
dehiscence

dehiscence

SCC, squamous cell carcinoma; VIN, vulvar intraepithelial neoplasia; RV, radical vulvectomy; SV, simple vulvectomy; LD, inguinal lymph node
dissection.

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Volume 118, Number 2 Gluteal Fold V-Y Advancement Flap

imal zone in three patients, the distal zone in one
patient, and the center zone in one patient had
slightly decreased sensation compared with the
other zones. In a unilateral case (case 8), 12
months after surgery, static two-point discrimination using Semmes-Weinstein monofilament
showed 6 cm in the proximal, 4 cm in the center,
and 4 cm in the distal zone, which was comparable
to that of the unaffected side; 2.5 cm in the vulvar
area, 4 cm in the groin area, and 4 cm in the
gluteal fold area. The proximal zone of the flap
showed a markedly decreased sensation (twopoint discrimination) compared with the opposite
vulvar area. However, a less significant decrease in
sensation (two-point discrimination) was observed
when compared with the opposite groin and gluteal fold area, which corresponded to the flap
components. The other four sensory modalities
showed similar results with two-point discrimination, which implies that the proximal zone shows
slightly decreased sensation compared with the
other zones.
As a temporary side effect, all patients suffered
from deviated urinary stream, but this was resolved
spontaneously with time. Postoperative scarring
was natural in the groin and gluteal fold area.
Furthermore, revision for aesthetic or functional
problems was not necessary for any of the patients.

CASE REPORTS
Case 2
A 40-year-old woman was diagnosed with vulvar intraepithelial neoplasia by excisional biopsy. Two gluteal
fold V-Y advancement flaps for the vulvovaginoperineal
defect were performed. Reconstruction was satisfactory, with no major complications. The donor-site scar
was concealed on the gluteal fold line and was aesthetically acceptable (Fig. 2).

Case 8
A 37-year-old woman was diagnosed with vulvar intraepithelial neoplasia by excisional biopsy. We designed a
gluteal fold V-Y advancement flap after simple vulvectomy
without inguinal lymph node dissection. The flap was
elevated with fascia and advanced to the vulva defect area.
The donor-site scar was concealed on the gluteal fold and
was aesthetically acceptable (Fig. 3).

DISCUSSION
In the past, radical vulvectomy defects had
been reconstructed using two bilateral longitudinal incisions and repaired by primary closure, skin
grafts,2 local flaps,3 or myocutaneous flaps based
on gracilis,4 tensor fasciae latae,5 or rectus
abdominis.6 There is no doubt that flaps are superior to skin grafting or direct closure in terms of

the aesthetic and functional aspects of reconstruction. Recently, the fasciocutaneous flap has become the preferred choice in reconstruction of
vulvar defects, because myocutaneous flaps are too
bulky and leave an unsightly scar on the legs or
abdomen.
In the 1990s, a perineal blood supply from the
internal pudendal artery received more attention.
Thus, numerous fasciocutaneous flaps have been
introduced by plastic surgeons. For example, pudendal thigh flaps for vaginal reconstruction,7,8
perineal artery axial flaps,9 vulvoperineal fasciocutaneous flaps,10 V-Y advancement flaps from the
medial thigh,1113 and gluteal fold island flaps14 16
have been used for vulvovaginal reconstruction.
Recent advances in the knowledge of the cutaneous and fascial vascular anatomy have resulted in
the widespread use of those flaps. However, the
pudendal thigh and vulvoperineal flaps are applied only to vaginal reconstruction,7,8 and the
perineal artery flap is suitable for moderate sized
vulvar defects after vulvectomy.9 Among these
flaps, the V-Y advancement flap from the medial
thigh or gluteal fold island flap has been widely
used for vulvovaginal reconstruction by many surgeons. The latter is supplied by the superficial
perineal artery, the terminal branch of the internal pudendal artery,14 and the former is based on
the suprafascial vascular plexus from the superficial and deep femoral arteries.
Until 2002, we had used V-Y advancement flaps
from the medial thigh or gluteal fold island flaps
for vulvar defects as well. From our experience, V-Y
advancement flaps from the medial thigh are thin,
reliable, and relatively easily elevated and have
matched local skin quality. However, the vaginal
wall is exposed because of limited advancement
and tension of the flaps, and a conspicuous donorsite scar is left on the medial thigh. Gluteal fold
island flaps are similar to the labia majora and
show a concealed donor-site scar on the gluteal
fold, but are bulky, requiring a secondary debulking procedure.
To overcome these disadvantages, we modify
the axis of the V-Y advancement flap from the
medial thigh to the gluteal fold. In particular, the
long axis of the V-shaped triangular flap is located
at the gluteal fold and its base shares the margin
of the vulvar defect. This flap can be advanced
farther because of the redundant soft tissue of the
gluteal fold area and profuse blood supply from
perforators of the internal pudendal artery. In
addition, this flap maintains sensation by means of
the posterior cutaneous nerve of the thigh and the
pudendal nerve. Our surgical procedure does not

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Fig. 2. The patient in case 2, a 40-year-old woman with vulvar intraepithelial neoplasia, underwent simple vulvectomy and
bilateral gluteal fold V-Y advancement flap surgery. (Above, left) Vulvar defect and flap design. The apex of the triangular flap
is marked on the gluteal fold. (Above, right) The flap is elevated as a fasciocutaneous flap. (Center, left) The flap is advanced in
V-Y fashion and the skin is closed. (Center, right, and below) Anterior and posterior views 6 months after surgery. The scar is
aesthetically acceptable and the vagina inner wall is minimally exposed.

involve dissection of the perforators of the internal pudendal artery, and the rami of the pudendal
nerve, the main sensory supply of our flap, which
are paired with perforators of the internal puden-

404

dal artery, are not injured; thus, the sensation of

the flap is preserved.
We assessed postoperative flap sensation by
conventional methods of sensory testing, such as

Volume 118, Number 2 Gluteal Fold V-Y Advancement Flap

Fig. 3. The patient in case 8, a 37-year-old woman with vulvar intraepithelial neoplasia, underwent simple vulvectomy and
unilateral gluteal fold V-Y advancement flap surgery. (Above, left) Unilateral vulvar defect and flap design. (Above, right) The flap
is elevated as a fasciocutaneous flap. (Center, left) The flap is advanced in V-Y fashion and the skin is closed. (Center, right, and
below) Anterior and posterior views 6 months after the operation. The scar is aesthetically acceptable and the vagina inner wall
is minimally exposed.

two-point discrimination, superficial pain, superficial touch, temperature, and vibration, not for
the purpose of demonstrating an ideal sensory
flap for the vulvar area but to suggest that our flap

has sensation. Unfortunately, it was not possible to

retrospectively obtain preoperative values as a control, and only five of nine patients were available
for follow-up sensory testing postoperatively. The

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results of sensory testing showed that all flaps had
good sensation. Even though the results are not
consistent in all five patients, the decreased sensation in the proximal zone of the flap may be
related to the surgical dissection of the proximal
portion of the flap to enhance the advancement of
the flap for covering a large defect. None of the
patients experienced any discomfort or problems
in carrying out normal activities, including sexual
activity at long-term follow-up of over 1 year.
This flap is thin, sensate, reliable, easy to elevate, has matched local skin quality, and creates
concealed scars on the groin area and gluteal fold.
All operation scars are confined to the vulvoperineal area and reconstruction can be performed in
a single stage. The only problem is the introduction of hairy skin of the remaining labium majora
into the vaginal wall in most cases. However, the
hairy skin portion is narrow and sparse in density,
producing no sexual disturbance or cosmetic
problems.

CONCLUSION
Based on the donor-site scar, thickness of flap,
and degree of flap advancement, we suggest that
the gluteal fold fasciocutaneous V-Y advancement
flap is a better method for reconstruction of vulvovaginoperineal defects after vulvectomy.
Paik-Kwon Lee, M.D., Ph.D.
Department of Plastic Surgery
Kangnam St. Marys Hospital
The Catholic University of Korea College of Medicine
505 Banpo-dong, Seocho-gu
Seoul 137-040, South Korea
[email protected]

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406

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