Split Island Pedicled ALT Flap for Bilateral Radical Vulvectomy Defects Reconstruction

Abstract

Radical vulvectomy for vulvar cancer can lead to bilateral vulvar defects. The pedicled anterolateral thigh (ALT) flap is a well described option for its reconstruction. We present our method of using a pedicled ALT flap from one thigh, split into two islands based on separate perforators stacked on either side of midline for reconstruction of these defects, so that the introitus is well maintained.

Between 2019 to 2024 we reconstructed 11 cases of radical vulvectomy defects. Ten of these patients were reconstructed with a single pedicled ALT flap from left thigh. The flap was spilt into two islands based on two perforators, and the distal island was inset for the contralateral vulvar defect and proximal island for the ipsilateral vulvar defect. In one case, two perforators could not be found, so a single flap was used and fenestrated in the middle for inset around the introitus.

There were no cases of complete flap loss. The two flap islands settled well without obstructing introitus. Three of eleven patients had ipsilateral groin native skin flap necrosis. Two were revised and closed primarily on pod 5. One required a pedicled vertical rectus abdominis myocutaneous flap for closure. Two of eleven had dehiscence at posterior aspect toward anus because of fecal soiling which was managed with perineal hygiene and dressings. The average healing time was 3 to 4 weeks.

The split-island pedicled ALT flap is ideal for bilateral radical vulvectomy defects. It sits well within the defect without obstructing the introitus and avoids the need for bilateral flaps. The donor site can usually be closed primarily, allowing early ambulation. Hence, whenever suitable perforators are available, it can be the treated as a first-line option for reconstruction.