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Plastic & Reconstructive Surgery:
doi: 10.1097/PRS.0b013e3181cb6661
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Pedicled Unilateral External Pudendal Artery Perforator Flap: A New Technique for Reconstruction of Congenital Vagina Agenesis

Huang, Jung-Ju M.D.; Han, Chien-Min M.D.; Lee, Chyi-Long M.D., Ph.D.; Cheng, Ming-Huei M.D., M.H.A.

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Division of Reconstructive Microsurgery; Department of Plastic and Reconstructive Surgery (Huang)

Department of Obstetrics and Gynecology (Han, Lee)

Division of Reconstructive Microsurgery; Department of Plastic and Reconstructive Surgery; Chang Gung Memorial Hospital; Chang Gung University; College of Medicine; Taipei, Taiwan (Cheng)

Correspondence to Dr. Cheng, Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University, College of Medicine, Taoyuan, Taiwan, 5, Fu-Hsing Street, Kweishan, Taoyuan 333, Taiwan, minghueicheng@gmail.com

Sir:

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Congenital vagina agenesis is rare.1 Ideal vaginal reconstructions should achieve functional restoration in one-stage reconstruction with minimal donor-site morbidity and postoperative contracture. A pedicled fasciocutaneous flap based on a perforator from the external pudendal artery on the medial thigh was used for vagina reconstruction.

A 12-year-old patient with vagina agenesis presented with lower abdominal pain of 1 month's duration. Genomic study revealed a karyotype 46XX without other anomalies. A neovagina was created and stented with a syringe 3 cm in diameter after hymenotomy and drainage of hematometra by the gynecologist. The patient sustained recurrent hematometra and vaginal stenosis, with poor compliance on regular vaginal dilatation 2 months later. The neovagina was recreated with a cylindrical defect 4 cm in length and 3 cm in diameter. Perforators from the external pudendal artery were mapped on the left medial upper thigh by a handheld Doppler probe. A 4 × 15-cm rectangular fasciocutaneous external pudendal artery perforator flap was designed (Fig. 1). The pedicled flap based on a skeletonized perforator was dissected suprafascially (Fig. 2). The flap was sutured as a tube and transferred to the defect. The donor site was closed primarily. At a follow-up of 6 months, the patient had regular menstruation, with a neovagina 3 cm in diameter.

Fig. 1
Fig. 1
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Fig. 2
Fig. 2
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Traditionally, vaginal agenesis reconstruction has involved nonsurgical regular dilatation and surgical creation following skin graft resurfacing.2 Revision is often inevitable for poor compliance on dilatation. An intestinal flap is a good physiologic substitute.3 However, unpleasing scar and discharge and risk of intestinal adhesion limit its application. Myocutaneous flaps are usually too bulky for vagina agenesis reconstruction.4 A pudendal thigh flap presents a good option with a reliable blood supply, an easily hidden donor scar, and a simple technique.5 The only drawback is hair growth and the requirement for bilateral flaps to form a tube-shaped neovagina and achieve wound primary closure.5 The unilateral external pudendal artery perforator flap is a refinement to include a longer, hairless skin flap from the medial thigh based on its perforators.

The perforator-based flap has a longer pedicle than an island pedicle flap, with an equally reliable blood supply. The perforator flap design is more versatile, without the restriction of pedicle direction and length. A longitudinal flap design along the long axis of the thigh is a better design to achieve a longer flap and allow primary donor wound closure. The tension of wound closure on groin skin is larger in a transverse direction than in the vertical direction. A unilateral donor site is adequate for vaginal reconstruction and the donor wound can be closed primarily if the flap width is less than 7 cm. It saves time on flap dissection and inset. A scar in the medial thigh is acceptable. Minimal hair growth of medial thigh skin in the neovagina will be less troublesome. The pedicled, unilateral, external pudendal artery perforator flap is a reliable one-stage procedure with adequate flap size, thin and hairless skin, and minimal donor-site morbidity for the reconstruction of congenital vagina agenesis.

Jung-Ju Huang, M.D.

Division of Reconstructive Microsurgery

Department of Plastic and Reconstructive Surgery

Chien-Min Han, M.D.

Chyi-Long Lee, M.D., Ph.D.

Department of Obstetrics and Gynecology

Ming-Huei Cheng, M.D., M.H.A.

Division of Reconstructive Microsurgery

Department of Plastic and Reconstructive Surgery

Chang Gung Memorial Hospital

Chang Gung University

College of Medicine

Taipei, Taiwan

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REFERENCES

1. Templeman CL, Lam AM, Hertweck SP. Surgical management of vagina agenesis. Obstet Gynecol Surg. 1999;54:583–591.

2. Michala L, Cutner A, Creighton SM. Surgical approaches to treating vaginal agenesis. BJOG. 2007;114:1455–1459.

3. Chen HC, Chana JS, Feng GM. A new method for vaginal reconstruction using a pedicled jejunal flap. Ann Plast Surg. 2003;51:429–431.

4. Casey WJ III, Tran NV, Petty PM, Stulak JM, Woods JE. A comparison of 99 consecutive vaginal reconstructions: An outcome study. Ann Plast Surg. 2004;52:27–30.

5. Wee JT, Joseph VT. A new technique of vaginal reconstruction using neurovascular pudendal-thigh flaps: A preliminary report. Plast Reconstr Surg. 1989;83:701–709.

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