Local Skin Flaps for Lichen Sclerosus Sequelae — Long-Term Outcomes
Local skin flap advancement / rotation is the surgical option for LS-related vulvar contractures and tissue deficits that exceed what perineoplasty + de-adhesion can correct but stop short of skinning vulvectomy with a perforator flap. The literature is dominated by a single landmark long-term series (Rangatchew 2017, mean 8.4 yr follow-up) and a unique qualitative study of the patient-and-partner experience (Brauer 2016). Together these define what surgeons should counsel patients to expect over a decade-scale horizon — a window the rest of the LS surgical literature does not reach.[1][2]
For the broader LS surgical ladder see Perineoplasty + De-Adhesion (simpler) and Skinning Vulvectomy + aOAP Flap (more extensive); for the disease context see Lichen Sclerosus.
The Landmark Long-Term Series — Rangatchew 2017
| Parameter | Detail |
|---|---|
| Centre / period | Single plastic-surgery centre, Denmark; 1990–2013[1] |
| n | 38 consecutive histologically verified LS patients |
| Preoperative dyspareunia | 87% (33/38); 24 with apareunia |
| Survey response / clinical follow-up | 87% / 78% |
| Mean follow-up | Survey 7.6 yr; clinical 8.4 yr |
Short-term outcome (mean 10 mo)
- Only 5 of 33 patients (15%) still reported dyspareunia — a near-inversion of the preoperative state.[1]
Long-term outcome (mean 7.6 / 8.4 yr) — central finding
| Domain | Result |
|---|---|
| Reported surgical benefit | 75% |
| Satisfied / very satisfied (cosmesis + overall) | 74% |
| Improved sexual life | 58% |
| Dyspareunia at long-term survey | 20 / 24 patients |
The clinically defining pattern is the LS-relapse stratification at ~8 years:
| Relapse category | Proportion | Clinical impact |
|---|---|---|
| No relapse | 12% | Sustained surgical benefit |
| Minor LS relapse | 50% | Coitus preserved; dyspareunia "considerably minor" vs preoperative state |
| Severe LS relapse | 38% | Apareunia recurs |
Net interpretation: 88% relapse some LS at 8 yr, but for half of those the relapse is mild enough to preserve coitus — a clinically meaningful gain measured against a baseline of apareunia.[1]
Local-Flap Options Applicable to LS Sequelae
Rangatchew did not individually enumerate the flaps used; the broader vulvar-reconstruction literature defines the practical menu.[3][4][5]
Sliding (advancement) flaps — best for contractures (the LS-typical deformity)
- Y-V advancement — most commonly used for vulvar contractures. In Reid's mixed series 95.8% of 146 contractures were addressable by simple sliding designs (Y-V or "maple leaf").[3]
- V-Y advancement — described as the "workhorse" for vulvar reconstruction; reliable, technically simple, very low complication rate. Raised from pubolabial, medial-thigh, or gluteal positions.[5][6]
- Pubolabial V-Y amplified flap — downward advancement plus bilateral medial rotation; restores the entire vulva from a single design. Sensate via ilioinguinal-nerve branches.[6]
Pivoting (rotation / transposition) flaps — best for tissue deficits
- Rhomboid (Limberg) flap — small-to-moderate defects; Burke 15 flaps in 13 patients with only 2 minor wound separations.[7]
- Lotus petal (pudendal-thigh) flap — fasciocutaneous, internal pudendal artery perforators, raised from the genitocrural sulcus; 80-flap series with 36% complications but no total flap loss.[8]
- Gluteal-fold fasciocutaneous island flap — pudendal-artery musculocutaneous perforators with pudendal sensate inflow.[6]
Operative principle in LS: contractures are the predominant deformity → sliding / advancement designs are first-choice; pivoting designs are reserved for true tissue deficit.[3]
Complication Profile
| Study | n (flaps / pts) | Indication | Primary healing | Complications | Flap loss | Final success |
|---|---|---|---|---|---|---|
| Reid 1997[3] | 207 / 191 | Mixed vulvar (incl. LS) | 89.9% | 65 in 42 pts | NR | 93.2% function restored |
| Burke 1994[7] | 15 / 13 | Vulvar resection | 87% | 2 minor dehiscences | 0% | 100% |
| Kwong 2025[9] | 136 / 69 | Benign + malignant vulvar | 92.6% none-to-mild at d 7 | 5 necrotic in 2 pts | 3.6% partial | All healed by d 30 |
| Commenge 2025[10] | 46 / 27 | Vulvar cancer | 78.3% at 4 wk | 33.3% (dehiscence 17.4%; infection 21.7%) | 0% total | All healed |
Across vulvar flap literature, viability > 85%, partial flap loss 10–30%, donor-site morbidity 0–4%. LS-specific risk multiplier: chronic TCS use thins the epidermis and impairs healing — counsel patients accordingly.[11]
Patient Experience — Brauer 2016 (the only qualitative LS-surgery study)
19 women interviewed after vulvar surgery for LS-related sexual pain.[2]
| Outcome | Proportion | Detail |
|---|---|---|
| Decreased sexual pain | 68% (13/19) | 4 pain-free; 9 shifted from "pain" → "discomfort"; reported improved sexual function, increased activity / intimacy, reinstated sense of adequacy |
| Stopped intercourse for pain | 26% (5/19) | Included 1 secondary vaginismus and 1 premorbid generalized unprovoked vulvodynia — conditions surgery does not address |
| Decreased LS symptoms in daily life | 95% (18/19) | Even among non-coital-improvement subgroup |
A defining qualitative finding: 4 of the 5 women who stopped intercourse could not communicate with their partner about sexual matters and could not adapt their sexual repertoire — outcome was as dependent on the couple dynamic as on the operation.[2]
Clinical implication: Brauer's conclusion is that preoperative sexological couple-based consultation is needed to (1) exclude comorbid vaginismus / generalized vulvodynia, (2) assess the couple's pre-existing sexual life and communication, and (3) evaluate willingness to incorporate non-coital pain-free activity.[2]
Psychosexual Burden — Why Patients Choose Surgery Despite Relapse Risk
Quantitative and qualitative evidence consistently document the LS psychosexual cost that motivates surgery:
- Higher rates of depression, decreased sexual QoL, diminished work productivity vs healthy controls.[12]
- Dominant qualitative themes of suffering, isolation, interference with daily and sexual activities, and grieving the former healthy self; negative genital self-image; loss of intimate relationship quality.[13]
This context explains the high willingness to accept a procedure with a 38% severe-relapse rate at 8 years.
Comparison Across the LS Surgical Ladder
| Procedure | n | Follow-up | Short-term improvement | Long-term satisfaction | Long-term relapse |
|---|---|---|---|---|---|
| Local skin flaps[1] | 38 | 8.4 yr | 85% (15% residual dyspareunia) | 74% | 50% minor; 38% severe |
| Perineoplasty (Rouzier)[14] | 64 | Variable | 90% improved | 86% improved sexual quality | NR systematically |
| Perineoplasty + de-adhesion (Lauber)[15] | 41 | 2.3 yr (median) | Significant (p = 0.02) | 90% | High; not quantified |
| Skinning vulvectomy + aOAP (O'Dey)[11] | 61 | 1 yr only | Significant (p < 0.001) | NR | Not yet assessable |
Rangatchew uniquely captures the time-dependent erosion of surgical benefit — excellent at 10 mo, substantially eroded but still net-positive at 8 yr.
Counseling Points
- Short-term results are excellent — 85% achieve coitus restoration within months.[1]
- Long-term LS relapse is the rule, not the exception — ~88% experience some relapse by 8 yr, but severity stratifies.[1]
- Even with relapse, most patients report benefit — 75% benefit / 74% satisfied at 8 yr; temporary restoration is itself valued.[1]
- Indefinite topical clobetasol is mandatory — adherence to maintenance therapy reduces adhesions, scarring, and vulvar SCC risk (0% vs 4.7% adherent vs non-adherent in a 507-patient cohort).[16]
- Preoperative sexological couple-based assessment — exclude vaginismus / vulvodynia; assess communication and sexual repertoire (Brauer).[2]
- Reoperation is foreseeable — Reid reported 21 / 191 needed Z-plasty or a second flap; chronic LS biology means re-stenosis is possible.[3]
See Also
- Perineoplasty + De-Adhesion (LS Introital Stenosis)
- aOAP Flap (Skinning Vulvectomy + Perforator Reconstruction)
- Microfat / Nanofat Grafting — VLS section
- Lichen Sclerosus
- V-Y Advancement (foundations)
- Vulvar Reconstruction (atlas / database)
References
1. Rangatchew F, Knudsen J, Thomsen MV, Drzewiecki KT. Surgical treatment of disabling conditions caused by anogenital lichen sclerosus in women: an account of surgical procedures and results, including patient satisfaction, benefits, and improvements in health-related quality of life. J Plast Reconstr Aesthet Surg. 2017;70(4):501–508. doi:10.1016/j.bjps.2016.12.008
2. Brauer M, van Lunsen RH, Laan ET, Burger MP. A qualitative study on experiences after vulvar surgery in women with lichen sclerosus and sexual pain. J Sex Med. 2016;13(7):1080–1090. doi:10.1016/j.jsxm.2016.04.072
3. Reid R. Local and distant skin flaps in the reconstruction of vulvar deformities. Am J Obstet Gynecol. 1997;177(6):1372–1383; discussion 1383–1384. doi:10.1016/s0002-9378(97)70078-4
4. Höckel M, Dornhöfer N. Vulvovaginal reconstruction for neoplastic disease. Lancet Oncol. 2008;9(6):559–568. doi:10.1016/S1470-2045(08)70147-5
5. Salgarello M, Farallo E, Barone-Adesi L, et al. Flap algorithm in vulvar reconstruction after radical, extensive vulvectomy. Ann Plast Surg. 2005;54(2):184–190. doi:10.1097/01.sap.0000141381.77762.07
6. Moschella F, Cordova A. Innervated island flaps in morphofunctional vulvar reconstruction. Plast Reconstr Surg. 2000;105(5):1649–1657. doi:10.1097/00006534-200004050-00008
7. Burke TW, Morris M, Levenback C, Gershenson DM, Wharton JT. Closure of complex vulvar defects using local rhomboid flaps. Obstet Gynecol. 1994;84(6):1043–1047.
8. Argenta PA, Lindsay R, Aldridge RB, et al. Vulvar reconstruction using the "lotus petal" fascio-cutaneous flap. Gynecol Oncol. 2013;131(3):726–729. doi:10.1016/j.ygyno.2013.08.030
9. Kwong FL, Pounds R, Farah Y, Yap JKW. Vulval flap reconstruction in women with benign, preneoplastic and malignant vulval conditions: a prospective study. BJOG. 2025;132(8):1156–1165. doi:10.1111/1471-0528.18156
10. Commenge V, Martinez A, Ricotta G, et al. Use of the genito-crural island perforator flap in vulvar reconstruction: a single-center experience. Int J Gynecol Cancer. 2025;36(2):102847. doi:10.1016/j.ijgc.2025.102847
11. O'Dey DM, Rosendahl M, Mordehay D, Kameh Khosh M. Anterior obturator artery perforator (aOAP) flap: a last-resort treatment option for sexual dysfunction in lichen sclerosus et atrophicus. J Plast Reconstr Aesthet Surg. 2024;95:331–339. doi:10.1016/j.bjps.2024.05.046
12. Jabłonowska O, Woźniacka A, Szkarłat S, Żebrowska A. Female genital lichen sclerosus is connected with a higher depression rate, decreased sexual quality of life and diminished work productivity. PLoS One. 2023;18(4):e0284948. doi:10.1371/journal.pone.0284948
13. Sadownik LA, Koert E, Maher C, Smith KB. A qualitative exploration of women's experiences of living with chronic vulvar dermatoses. J Sex Med. 2020;17(9):1740–1750. doi:10.1016/j.jsxm.2020.06.016
14. Rouzier R, Haddad B, Deyrolle C, et al. Perineoplasty for the treatment of introital stenosis related to vulvar lichen sclerosus. Am J Obstet Gynecol. 2002;186(1):49–52. doi:10.1067/mob.2002.119186
15. Lauber F, Vaz I, Krebs J, Günthert AR. Outcome of perineoplasty and de-adhesion in patients with vulvar lichen sclerosus and sexual disorders. Eur J Obstet Gynecol Reprod Biol. 2021;258:38–42. doi:10.1016/j.ejogrb.2020.12.030
16. Committee on Practice Bulletins–Gynecology. Diagnosis and management of vulvar skin disorders: ACOG Practice Bulletin No. 224. Obstet Gynecol. 2020;136(1):e1–e14. doi:10.1097/AOG.0000000000003944