Dear Editors,
1.
We read with great interest the article by Fin et al entitled “Experience with gluteal V‐Y fasciocutaneous advancement flaps in vulvar reconstruction after oncological resection and a modification to the marking: Playing with tension lines.”1
The authors demonstrated their experience with 59 V‐Y advancement flaps from the gluteal fold to repair post‐vulvectomy residual defects in 30 patients. They proposed a simple modification to the markings of the flap that enabled us to minimise the complications related to surgical wound healing. Likewise, radical surgical procedures are frequently performed for treating vulvar extramammary Paget's disease (EMPD), a rare neoplastic condition that affects the anogenital area of elderly individuals. Following extensive excision of EMPD, aesthetic and functional reconstruction is also important. In terms of reconstruction, preserving the important deep structure around the perineal body and medial thigh is crucial for a patient's quality of life.
In this study, we introduce the “Pikachu‐shaped” flap for reconstructing EMPD defects (Figure 1). Upper flaps were elevated, thereby preserving the midpoint between the upper and lower flaps. Lower flaps were elevated, thus preserving the central zone of the internal pudendal artery perforators. Upper flaps (Pikachu's ear) were rotated downwards to the inguinal crease‐flap meeting point. However, if the defect extends to this point, other reconstructive methods, such as traditional keystone flap, should be considered.2
Figure 1.
Schematic figure for Pikachu flap reconstruction in extramammary Paget's disease (EMPD)
In our case, we encountered a 15 × 17‐cm‐sized defect following total vulvectomy (Figure 2). The flap, which looks like the Pokemon Pikachu on the right side, was harvested, while the traditional keystone flaps were harvested on the left side as we described very recently.3 The “Pikachu‐shaped” flap is a novel and reliable alternative option that is modified from a traditional keystone flap.4 The flap can be harvested superficially, freeing it from serious donor site lymphoedema complications by preserving the deep structures of the perineal area and proximal thigh.
Figure 2.
(A) A 58‐year‐old woman with extramammary Paget's disease (EMPD) on her vulva. (B) A 15 × 17 cm perineal defect following wide excision of EMPD. (C) Early postoperative view. (D) Postoperative view at 1 month
CONFLICT OF INTEREST
The authors declare no potential conflict of interests.
FINANCIAL DISCLOSURES
None reported.
Ethical approval
This study was approved by the Institutional Review Board of the CHA University and conducted in accordance with the Declaration of Helsinki.
ACKNOWLEDGEMENTS
This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korea government (MSIP; Ministry of Science, ICT & Future Planning) (No. 2017R1C1B5017180 and 2017R1B5A2085456, TH Park).
REFERENCES
- 1. Fin A, Rampino Cordaro E, Guarneri GF, Revesz S, Vanin M, Parodi PC. Experience with gluteal V‐Y fasciocutaneous advancement flaps in vulvar reconstruction after oncological resection and a modification to the marking: playing with tension lines. Int Wound J. 2018. (in press). [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2. Lee JW, Kim CW, Park TH. Customized reconstruction with modified keystone flaps. J Dermatol. 2018;45(7):844‐849. [DOI] [PubMed] [Google Scholar]
- 3. Park TH. Aesthetic reconstruction of extensive pubic keloids using bilateral modified keystone flaps. J Dermatol. 2018. (in press). [DOI] [PubMed] [Google Scholar]
- 4. Kim CW, Kim JH, Lee JW, Park TH. Varicella zoster reactivation immediately following keystone flap reconstruction of a radiated back wound. Int Wound J. 2018. (in press). [DOI] [PMC free article] [PubMed] [Google Scholar]