Vulvar reconstruction using the “lotus petal” fascio-cutaneous flap

Introduction

Vulvar reconstruction using the “lotus petal” fascio-cutaneous flap offers a relatively novel means to restore symmetry and functionality after extirpative gynecologic or oncologic procedures. We sought to assess the success rates and morbidity in a large series of consecutively treated patients.

Methods

We performed a retrospective review of 59 consecutive cases of lotus petal flaps performed at a single institution to more accurately assess success and complication rates.

Results

We identified 80 flaps performed among the 59 patients between September 1, 2008 and March 30, 2013. The median (range) age was 59 years (24–89) and the median (range) BMI was 27 kg/m² (19–34). The indications for vulvar/perineal excision were as follows: 39 (66.1%) vulvar carcinoma or melanoma, 12 (20.3%) vulvar dysplasia, 5 (8.5%) colorectal disease and 3 (5.1%) cases of hidradenitis suppurativa. The mean defect area, determined by post-fixation pathology specimen was 29 cm². Medical or surgical complications occurred in 36% of patients of which superficial wound separation was the most common (15%). There were no cases of complete flap loss, but partial loss occurred in 7 (8.8%) cases. 3 (5.1%) patients required re-operation prior to discharge with one case requiring skin grafting. Delayed surgical revision was required in 4 patients for partial flap loss (2) or stricture/stenosis (2).

Conclusion

The lotus petal flap is safe for use in gynecologic reconstruction, with acceptable short- and long-term complication rates. Previous reports of smaller series likely underestimate the risk of complications through case selection.     

Outcome of the management of massive postpartum hemorrhage using the algorithm “HEMOSTASIS”

Objective

To evaluate whether the algorithm “HEMOSTASIS” (help; establish etiology; massage the uterus; oxytocin infusion and prostaglandins; shift to operating theater; tamponade test; apply compression sutures; systematic pelvic devascularization; interventional radiology; subtotal/total abdominal hysterectomy) was of value in the systematic management of postpartum hemorrhage (PPH).

Methods

A retrospective analysis was performed of all women who experienced massive primary PPH (blood loss > 1500 mL) in 2008 at St George's Hospital, London, UK. The success of the HEMOSTASIS mnemonic in PPH management was determined by assessing clinical outcome following adherence to the protocol.

Results

Patient notes were available for 95 (83.3%) of the 114 cases of primary PPH. Hemostasis was achieved in 63 (66.3%) women via use of additional oxytocics (“O”); 19 (20.0%) via suture of tears and 10 (10.5%) via tamponade (“T”); 1 (1.1%) via application of compression suture (“A”); 1 (1.1%) via systematic devascularization (“S”); and 1 (1.1%) via subtotal/total hysterectomy (“S”). There were no maternal deaths.

Conclusion

The decremental pattern of more complex interventions used demonstrates that the algorithm can provide a logical management pathway to reduce blood transfusions, hysterectomies, admissions to intensive care units, and maternal deaths.