Objective
Resection of advanced gynecologic cancers often results to extensive perineal soft tissue defects. The wounds often frequently complicated by radiation, chemotherapy, and contamination. Initial attempt of wound management includes primary and secondary closure, but perineal wounds seemed predisposed to breakdown. Flap reconstruction provides freedom of design and adequate volume when considering rebuilding urethra, vagina, and rectum function. However, due to limited cases and experiences, the role of reconstructive microsurgeon hasn’t been emphasized. We aimed to conduct a study including our experience focused on different treatment modalities that were provided by plastic surgeon for immediate, protective adjuvant, or complication managements in the field of gynecological treatment.

Material and Methods
In this retrospective review, we included patients with gynecological reconstruction received reconstruction by a single surgeon. Demographic data including age, underlying disease, BMI, previous history of perineal cancer and neoadjuvant treatment were recorded. For tumor related factors, we collected information of reconstruction purpose, defect location, size, involved surrounding structures. The details of reconstruction methods like flap type, flap size, blood supply, adjacent structure reconstruction, colostomy or ileostomy as well as postop care including bedrest duration and total hospitalization duration were reviewed. The study focuses on perioperative planning and care, complications and aesthetic outcomes between each reconstruction methods.

Results
A total of 50 patients were enrolled in our study. There are three major roles of the reconstruction: reconstruction and coverage, secondary reconstruction, and organ protection before radiotherapy. While age, underlying disease or previous valvular cancer and excision history were not associated with postop complication, patients had greater risk of developing poor wound healing after radiotherapy. PAP was the most commonly used flap in our serious followed by medial circumflex femoral artery perforator flap. For intra-abdominal organ protection, the omentum flap was our first choice. The risk of complications and total hospital stay remained the same in all groups. Temporary colostomy or ileostomy greatly decreased the risk of wound infection and dehiscence. Most patients doing well while a few patients had constipation but all could be resolved by medication. More patients with PAP flap reconstruction required the revision surgery for aesthetic reasons though the objective aesthetic outcome were similar between groups.

Conclusion
Perineal reconstruction remains a difficult and complex surgery which needs specialized consideration for proper coverage, functional restoration and aesthetic outcome. Both PAP and medial circumflex femoral artery perforator flap were proper options for vulvar defects.

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