Vulvar Reconstruction
This page hosts the Decision Framework and Treatment Database for non-gender-affirming vulvar reconstruction — vulvar cancer, extramammary Paget disease (EMPD), VIN, lichen sclerosus / lichen planus sequelae, FGM/C reconstruction, trauma, vulvar hidradenitis suppurativa, and GSM-related fat-grafting. Feminizing gender-affirming vulvoplasty / vaginoplasty lives at 04k Gender-Affirming Surgery.
Decision Framework
Vulvar reconstruction restores form and function of a composite three-dimensional structure — labia majora and minora, clitoral hood / clitoris, vestibule, posterior fourchette, and perineal body — with a rich pudendal-arterial network and pudendal-nerve sensory supply that must be respected at every step.[2][3] The dominant indications are vulvar cancer (post-radical-vulvectomy reconstruction), extramammary Paget disease (EMPD), vulvar intraepithelial neoplasia (VIN), lichen sclerosus / lichen planus (sequelae rather than primary disease — surgery is reserved for refractory complications), FGM/C (an estimated 200+ million women globally), trauma (obstetric, sexual assault, accidental), Fournier's-gangrene extension, and genitourinary syndrome of menopause / vulvar atrophy (an emerging fat-grafting indication). The contemporary anchors are the Höckel & Dornhöfer 2008 Lancet Oncol comprehensive defect-classification system, the Toulouse Algorithm (Ricotta 2025 IJGC) location-based perforator-flap-first algorithm, the Han 2023 Ann Plast Surg vulvo-thigh-junctional-crease 2-flap algorithm, the Caretto 2023 Front Oncol secondary-reconstruction algorithm, the Kwong 2025 BJOG prospective vulval-flap reconstruction series (sexual activity 9.3% → 24.4% at 12 mo, p = 0.04; urinary continence 48.1% → 80.4%, p = 0.004; 88.9% reported reconstruction helped diagnostic acceptance), the O'Dey 2024 Plast Reconstr Surg FGM/C anatomical-reconstruction series (n = 119), the Almadori 2024 BJOG scoping review of FGM reconstructive surgery, the Confalonieri 2017 V-Y-vs-LPF comparative series (LPF tunneled superior cosmetically), and the Eseme 2022 Cancers VRAM-vs-gracilis donor-site meta (16% vs 57.6%).[2][4][5][6][7][8][9][10][11][12][13][14]
Assess Clinical Context
| Variable | Sub-Categories |
|---|---|
| Etiology | Vulvar cancer (most common indication) / EMPD (44.7% of one surgical cohort) / VIN (occult cancer in 31% at skinning vulvectomy) / lichen sclerosus (sequelae only) / lichen planus (erosive vaginal synechiae) / FGM/C / trauma (obstetric, sexual assault) / Fournier's gangrene / vulvar HS / GSM / vulvar atrophy |
| Defect characteristics | Location (anterior commissure / lateral hemivulva / posterior / total) — depth (superficial vs deep) — size — adjacent-structure involvement (vagina / urethra / anus / groin / mons pubis) |
| Primary vs secondary reconstruction | Prior surgery / flaps used; prior radiation; recurrent disease |
| Patient factors | Age, BMI, smoking, diabetes, radiation history, comorbidities, fertility goals (preservation if oncologic) |
| Functional goals | Sexual function (FSFI), continence, ambulation, body image — 88.9% of women reported that reconstruction helped acceptance of their cancer diagnosis (Kwong 2025) |
Determine If Reconstruction Is Needed
International guidelines (NCCN, ESGO) recommend reconstruction always be considered when it will guarantee better functional / cosmetic results or when wound closure under tension is likely.[5][6] Flap reconstruction significantly improves sexual function, urinary continence, and quality of life vs primary closure under tension; the Kwong 2025 prospective series documents 92.6% of flaps with none-to-mild complications at 7 days and all flaps healed/healing at 30 days.[4]
Technique Selection by Defect Type
| Defect Type | First-Line | Alternative(s) | Avoid |
|---|---|---|---|
| Small, anterior or posterior commissure | Limberg (rhomboid) flap or primary closure when laxity allows | Anterior- or posterior-based labial flap | Closure under tension at the posterior fourchette (introital stenosis) |
| Moderate, lateral (hemivulvectomy) | V-Y medial-thigh flap (workhorse) or lotus petal flap (LPF) | Internal pudendal-artery perforator (IPAP) flap (Han 2023 vulvo-thigh-junctional-crease algorithm — IPAP for medial defects) | LPF when tunneled-variant donor scar would cross radiation field |
| Moderate, posterior | Gluteal V-Y flap or lotus petal (lower-petal variant) with scar in gluteal fold | Genito-crural island perforator flap (Commenge 2025 n = 27 / 46 flaps; complete healing) | Posterior closure under tension |
| Total vulvectomy | Bilateral V-Y + bilateral LPF combinations; pubolabial V-Y flap can reconstruct the entire vulva with a single flap | Combined flap algorithms per Höckel-Dornhöfer 11-procedure taxonomy | Pubolabial V-Y when groin dissection has extended medially |
| Extended with inguinal involvement | Pedicled ALT flap (Gentileschi 2017 first choice for extended defects, especially with inguinal involvement or prior radiation) | Tensor fasciae latae (TFL) flap when soft-tissue defect includes inguinal region | Mons pubis flap when groin dissection has compromised the superficial external pudendal artery |
| Extended, posterior (perianal / gluteal) | Gluteal-thigh flap (inferior gluteal artery; ideal for posterior orientation) | Gracilis myocutaneous flap | VRAM when posterior orientation is dominant |
| Extended, anterior (suprapubic) | VRAM (large pelvic dead-space filling) or pedicled DIEP (rectus-sparing alternative) | ALT flap | VRAM in patient at high abdominal-hernia risk; consider DIEP |
| Vulvar + vaginal (Negosanti Type II) | Pedicled DIEP flap (Negosanti 2015 algorithm — Type II requires tissue volume) | VRAM; tubularized gracilis or ALT for neovagina | Skin grafts alone for combined vulvovaginal defects |
| Superficial (VIN / Paget — skinning vulvectomy) | STSG (scalp / thigh / buttock donor) — enables full histologic examination of specimen; occult cancer 31% (Lavoué 2013 n = 13) | FTSG from groin crease (limited role) | STSG when deep defect requires bulk |
| Secondary reconstruction (recurrence) | Choice driven by available unused flaps + radiation field — Caretto 2023 algorithm: ALT, DIEP, V-Y, free flap as needed | Free flap when all pedicled options exhausted | Re-using already-radiated flap territory |
| FGM/C clitoral / vulvovestibular reconstruction | Foldès technique (95% of published series; significant reduction in dyspareunia + improvement in clitoral sensation / orgasm; meta-analytic OR 79.67 for pain reduction) ± omega-domed (OD) preputial reconstruction | aOAP flap for vulvovestibular reconstruction (O'Dey 2024 — 36% of FGM cohort) or vaginal mucosal graft (Mañero 2018 FSFI 16 → 29) | Surgery without preoperative + postoperative psychosexual counseling |
| Lichen sclerosus with introital stenosis | Perineoplasty / de-adhesion after failed maximum-potency topical-corticosteroid therapy (Lauber 2021 significant complaint reduction at 2.3 yr) | aOAP flap for refractory disease (O'Dey 2024 n = 61); fat grafting | Surgery without exhausting medical management; relapse rate 38–50% requires lifelong topical maintenance |
| GSM / vulvar atrophy | Microfat / nanofat grafting (Menkes 2021 VHI / FSD significantly improved at 1 + 3 mo) | Combined PRP + fat grafting (Casabona 2023 LS framework adaptable) | Surgery as first-line; counsel as regenerative / adjunctive only |
Perforator vs Musculocutaneous Flap Sub-Comparison
| Feature | Perforator / Fasciocutaneous (LPF / V-Y / IPAP / ALT-perforator / Genito-Crural) | Musculocutaneous (VRAM / Gracilis) |
|---|---|---|
| Donor-site morbidity | Low | Higher — VRAM 57.6%, gracilis 16.0% (Eseme 2022 meta)[14] |
| Tissue bulk for pelvic dead space | Insufficient for large pelvic defects | Excellent — VRAM, gracilis with muscle |
| Irradiated recipient bed | Adequate if perforator preserved | Preferred — muscle bulk improves healing |
| Sensation preservation | Superior — local perforator flaps retain pudendal-nerve innervation | Insensate (VRAM); partially sensate (thigh flaps) |
| Aesthetic outcome | Superior — thinner, better contour match | Bulkier; may require staged debulking |
| Surgical complexity | Generally simpler; shorter operative time | More complex; longer operative time |
| Best evidence | Confalonieri 2017 LPF vs V-Y (LPF tunneled superior cosmetically); Han 2023 IPAP (12.9% wound-complication vs 37.5% PAP/TUG); Huang 2015 perforator-flap series[15][7][16] | Eseme 2022 meta (donor-site morbidity favors gracilis); Stein 2019 n = 88 direct VRAM vs gracilis (no significant complication-rate differences); Singh 2016 gracilis OR data (obesity OR 7.5 / smoking OR 9.3)[14][18][1] |
Special Decision Branch — Clitoral / Vulvovestibular Reconstruction Post-FGM/C
The principle: the clitoral body is never fully excised during FGM/C — deeper portions remain intact beneath scar tissue and can be surgically liberated.[19]
| Step | Operation | Anchor |
|---|---|---|
| 1 | Longitudinal incision over clitoral stump → excision of scar tissue → identification of remnant clitoral body | Foldès (95% of published series) |
| 2 | Division of suspensory ligament → downward mobilization of clitoral stump | O'Dey 2024 PRS technique[13] |
| 3 | Anchor clitoral stump to bulbocavernosus muscles with overcorrection (≥ 5 mm projection) to compensate for retraction | O'Dey 2024 PRS[13] |
| 4 | Optional Omega-Domed (OD) preputial flap for clitoral hood reconstruction (85% of O'Dey series) | O'Dey 2024 PRS[13] |
| 5 | Optional aOAP flap for vulvovestibular reconstruction in severe cases (36% of O'Dey FGM cohort) | O'Dey 2024 JPRAS / O'Dey 2024 PRS[10][13] |
| 6 | Pre- and postoperative psychosexual counseling is mandatory; multidisciplinary team essential | Almadori 2024 BJOG scoping review[14] |
| Alternative | Vaginal mucosal graft for clitoral / labial reconstruction — Mañero 2018 FSFI 16 → 29 | Mañero 2018 Obstet Gynecol[15] — note: see Vulvar Reconstruction database |
Special Decision Branch — Surgical Management of Lichen Sclerosus
LS surgery is reserved for complications refractory to medical therapy — surgery does not treat the disease itself, and topical-corticosteroid maintenance must continue lifelong.[8][17]
| Indication | First-Line | Alternative | Caveat |
|---|---|---|---|
| Introital stenosis with dyspareunia / apareunia after failed topical therapy | Perineoplasty / de-adhesion (Lauber 2021 n = 41; significant complaint reduction at 2.3 yr) | Local skin flap | Continue topical clobetasol; relapse 38–50% |
| Severe refractory LS with sexual dysfunction | aOAP flap (O'Dey 2024 JPRAS n = 61; significant dyspareunia + intercourse-ability improvement at 1 yr) | Skinning vulvectomy + aOAP flap | Relapse risk requires lifelong dermatologic surveillance |
| LS sequelae after multiple failed interventions | Local skin flaps (Rangatchew 2017 mean 8.4 yr follow-up; 75% surgical benefit; 74% cosmetic satisfaction; 58% improved sexual life — but 38% severe LS relapse with recurrent apareunia) | Repeated topical therapy; counseling | Counsel patients explicitly on the relapse rate |
Concurrent Procedures
| Procedure | When |
|---|---|
| Inguinofemoral lymphadenectomy | Through separate incisions from vulvectomy; may limit availability of groin-based flaps |
| Sentinel lymph-node biopsy | For unifocal tumors < 4 cm with negative-imaging groins |
| Vaginal reconstruction | If vaginal resection is included — sigmoid-colon vaginoplasty (preferred for circumferential vaginal defects) or tubularized gracilis / ALT flap |
| Urethral reconstruction | If urethral meatus is involved — careful repositioning to prevent stenosis or spraying |
| Psychosexual counseling | Essential for all etiologies, particularly FGM/C — pre- and postoperative |
| Adjuvant radiotherapy | Flap reconstruction does not delay initiation of adjuvant vulvar radiotherapy (Kwong 2025) |
Postoperative Management & Surveillance
- Wound dehiscence is the most common complication (17–31% across flap types; managed with local wound care).
- Sexual rehabilitation — Kwong 2025: sexual activity 9.3% pre-op → 24.4% at 12 mo (p = 0.04); FSFI improvement is achievable across reconstructive modalities.
- Urinary continence — Kwong 2025: 48.1% pre-op → 80.4% at 12 mo (p = 0.004) after flap reconstruction.
- Oncologic surveillance — local recurrence 14.9% at 2 yr across flap types (no significant difference by flap type); 58.3% recurrence at median 5 mo for advanced / recurrent disease (Zhang 2015).
- LS-specific — high relapse (38–50%) after surgical correction; mandatory continued topical-corticosteroid maintenance.
- FGM/C-specific — multidisciplinary follow-up (sexual health, psychology, dermatology, urogynecology); long-term FSFI tracking is the standard PRO.
Treatment Database
| Procedure | Domain | Notes |
|---|---|---|
| Primary Closure (small defects with adequate laxity) | Primary Closure / Graft | Feasible after radical local excision with adequate surrounding tissue laxity. Risk: introital stenosis with closure under tension at posterior fourchette. Wound complication rates with primary closure alone in radical vulvectomy reach 40–50% — major driver of flap-based approaches. |
| Split-Thickness Skin Graft (STSG) — Skinning Vulvectomy | Primary Closure / Graft | Primary indication: VIN or Paget disease. Superficial excision of vulvar skin + preserved subcutaneous tissue + STSG. Donor: scalp (hidden), thigh, buttock. Lavoué 2013 *EJSO* n=13: no QOL difference vs general population on MOS SF-36; normal sexual function on FSFI; **occult cancer 31%**; mean DFS 58 mo. Recurrence up to 50% regardless of margin status. Enables full histologic examination of the specimen. |
| Full-Thickness Skin Graft (FTSG) | Primary Closure / Graft | Groin-crease donor (hidden scar). Better elasticity / color match than STSG. Limited role — most vulvar defects requiring reconstruction are better served by flaps. |
| Limberg (Rhomboid) Flap | Local Random / Fasciocutaneous | Small defects of the anterior or posterior vulvar commissure. Random vascularization; rhomboid design per local tension lines. Base width must be ≥50% of flap length. Simple and reliable for small defects; can be designed unilaterally or bilaterally. |
| V-Y Advancement — Medial Thigh | Local Random / Fasciocutaneous | Workhorse flap for hemivulvectomy defects. Advanced laterally to medially. Confalonieri 2017 V-Y vs LPF n=234 V-Y series: complication rate 21%; not statistically different from LPF (p=0.588). Can be raised with underlying fascia / muscle (gracilis, gluteus maximus) to extend reach. |
| V-Y Advancement — Gluteal | Local Random / Fasciocutaneous | Fin 2019 *Int Wound J* n=30 patients / 59 flaps: minor complications in 23% (14% of flaps); 1 ostial stenosis; full flap sensitivity restored at 24 mo; scars hidden in natural folds. Advanced from caudolateral position for posterior / lateral defects. |
| V-Y Advancement — Pubolabial (Single-Flap Total Vulva) | Local Random / Fasciocutaneous | Cranial (mons-pubis) advancement combining downward advancement with bilateral medial rotation. Can reconstruct the **entire vulva** with a single flap. Cannot be used when groin dissection has extended medially. |
| Lotus Petal Flap (LPF / Pudendal-Thigh / Singapore) | Local Random / Fasciocutaneous | Internal-pudendal-artery terminal-branch axial pattern with perineal-anastomotic supply. Multiple petal designs along the genitocrural sulcus. Confalonieri 2017 n=106 LPF: complication rate **13%**; tunneled variant superior to V-Y for primary vulvar malignancy. Sensate, thin, pliable, color-matched, donor scar hidden in natural crease. |
| Genito-Crural Island Perforator Flap | Local Random / Fasciocutaneous | Commenge 2025 *IJGC* n=27 / 46 flaps: complete healing < 30 days in 100% of fully-evaluable patients. Simple, reliable, rapid recovery; routinely used at tertiary cancer centers. |
| Internal Pudendal Artery Perforator (IPAP) Flap | Local Random / Fasciocutaneous | Han 2023 *Ann Plast Surg* simplified algorithm — IPAP for defects medial to the vulvo-thigh junctional crease. Wound complications **only 12.9%** vs 37.5% for PAP / TUG flaps (p=0.04). Dominant first-line for medial defects per the Han 2-flap framework. |
| Anterior- or Posterior-Based Labial Flap | Local Random / Fasciocutaneous | Anterior labial flap = bulbocavernosus / Martius flap (superficial / deep external pudendal artery; used in VVF / RVF interposition + small vulvar defects). Posterior labial flap = posterior labial artery (terminal branch IPA). |
| Mons-Pubis Flap | Local Random / Fasciocutaneous | Superficial-external-pudendal-artery-based flap. Provides pliable, hair-bearing skin matching labia majora. Requires modified groin-dissection technique to preserve nourishing vessels. |
| Pedicled Anterolateral Thigh (ALT) Flap | Regional Pedicled | Lateral-circumflex-femoral perforator-based. **First choice for extended vulvar defects, especially with inguinal involvement or prior radiation** (Gentileschi 2017 *Microsurgery* n=large). Versatile: unilateral, split (transverse / longitudinal), fenestrated, combined. O'Brien 2021 split ALT for total vulvectomy. Zhang 2015 advanced/recurrent vulvar cancer n=36: ALT used in 58.3%; complications 30.6%; 5-yr survival 53.8%. |
| Gracilis Myocutaneous Flap (Standard or Short-Gracilis Variant) | Regional Pedicled | Medial-circumflex-femoral pedicle (dominant) or terminal obturator-artery (short variant). Provides muscle bulk for dead-space obliteration. Eseme 2022 *Cancers* meta: donor-site complications **16.0%** (significantly lower than VRAM 57.6%). Stein 2019 n=88 direct comparison: minor complications 44% vs 48% (p=0.8); major 19% vs 13% (p=0.53); time to healing 68 vs 67 d (p=0.19). Singh 2016 risk factors: obesity OR 7.5, smoking OR 9.3, neoadjuvant chemoradiation OR 21.4. |
| Vertical Rectus Abdominis Myocutaneous (VRAM) Flap | Regional Pedicled | Deep-inferior-epigastric-artery-based. Large reliable skin paddle; excellent for filling pelvic dead-space after exenteration. Donor-site complication 57.6% (Eseme 2022 meta) — significantly higher than gracilis. Risk of abdominal-wall hernia. Insensate. Indication: anteriorly extended vulvar defects; combined vulvovaginal + pelvic reconstruction after exenteration. |
| Pedicled DIEP Flap (Deep Inferior Epigastric Perforator) | Regional Pedicled | Negosanti 2015 *IJGC* algorithm — **Type II defect (vulvar + vaginal resection)** first-line because of large tissue volume needed to fill pelvic dead space. Spares rectus abdominis muscle (vs VRAM). Negosanti 2015 + DIEP/LPF n=22: no major complications; satisfactory functional / aesthetic results. |
| Tensor Fasciae Latae (TFL) Flap | Regional Pedicled | Ascending branch of lateral-circumflex-femoral artery. **First choice when soft-tissue defect includes the inguinal region.** |
| Gluteal-Thigh Flap | Regional Pedicled | Inferior-gluteal-artery-based. Indication: extended vulvar defects with **posterior orientation** including perianal and gluteal regions. Galbraith 2023 *Int J Surg* n=122 advanced pelvic resection: comparable outcomes to VRAM and thigh flaps; lower infection rates in flap group despite higher radiotherapy rates (p < 0.05). |
| Free ALT Flap (Single Split Flap for Total Vulvectomy) | Free Tissue Transfer | Used when pedicled ALT cannot reach. O'Brien 2021 *Microsurgery* — split design allows total-vulvectomy reconstruction with a single free flap. Reserved primarily for secondary / tertiary reconstruction when prior pedicled flaps have been used. |
| Free DIEP Flap (Secondary Reconstruction) | Free Tissue Transfer | Caretto 2023 *Front Oncol* simplified secondary-reconstruction algorithm — used when prior abdominal-based pedicled flaps are unavailable or radiation has compromised pedicled options. |
| Foldès Clitoral Reconstruction (± OD Preputial Flap) | FGM/C Reconstruction | Used in 95% of published FGM/C reconstructive series. Principle: clitoral body never fully excised — deep portions remain intact. Steps: longitudinal incision over clitoral stump → scar excision → identification of remnant clitoral body → suspensory-ligament division → downward mobilization → bulbocavernosus anchoring with **≥ 5 mm overcorrection** → wound closure. O'Dey 2024 *PRS* n=119: significant reduction in dysmenorrhea / dysuria / dyspareunia; significant improvement in clitoral sensation + orgasm. Meremikwu 2026 *IJGO* SR meta-OR 79.67 for pain reduction. OD preputial flap performed in 85% (clitoral hood reconstruction). |
| Vaginal Mucosal Graft for Clitoral / Labial Reconstruction (Mañero) | FGM/C Reconstruction | Mañero 2018 *Obstet Gynecol* n=32: FSFI improved from 16 → 29 (p < 0.001). Alternative to Foldès when clitoral remnant is severely scarred or atypical anatomy. |
| Anterior Obturator Artery Perforator (aOAP) Flap — Vulvovestibular | FGM/C Reconstruction | O'Dey 2024 *PRS* FGM/C n=119: aOAP performed in 36% for comprehensive vulvovestibular reconstruction. Significant improvement in all sexual-function parameters. Also indicated for severe refractory lichen sclerosus. |
| Fat Grafting for FGM/C Vulvar Scars | FGM/C Reconstruction | Almadori 2025 *Aesthet Plast Surg* n=13: significant improvement in VASS (p < 0.05) — minimally invasive option for scar / sensation issues; potential global-impact alternative when full Foldès reconstruction is not available. |
| Autologous Fat Grafting for Vulvar Lichen Sclerosus | Regenerative / Fat Grafting | Boero 2015 *Gynecol Oncol* n=36: 94% improved vulvar trophism; 75% improved introital caliber / elasticity; 50% reduced clitoral burying; 83% increased labial volume; 95% stopped routine topical corticosteroids; significant DLQI + FSFI improvement (p < 0.001). |
| Combined PRP + Fat Grafting for Vulvar LS | Regenerative / Fat Grafting | Casabona 2023 *Eur J Dermatol* n=72: significant improvement in Skindex-29, FSFI, CSS, DLQI, and IGA (all p < 0.05). Adjunct to topical-corticosteroid maintenance; not a disease-modifying replacement. |
| Microfat / Nanofat Grafting for GSM (Vulvar Atrophy) | Regenerative / Fat Grafting | Menkes 2021 *Aesthet Surg J* n=50: VHI + FSD scores significantly improved at 1 + 3 mo (p < 0.05). Emerging option for vulvar atrophy with regenerative-medicine focus rather than structural reconstruction. |
| Perineoplasty / De-Adhesion (LS Introital Stenosis) | Lichen Sclerosus — Surgical | Lauber 2021 *EJOGRB* n=41 median 2.3-yr follow-up: significant reduction in general complaints (p < 0.05). Indicated when introital stenosis causes dyspareunia / apareunia despite adequate topical-corticosteroid therapy. Mandatory continued topical-clobetasol maintenance after surgery; relapse 38–50%. |
| Skinning Vulvectomy + aOAP Flap (Severe Refractory LS) | Lichen Sclerosus — Surgical | O'Dey 2024 *JPRAS* n=61: significant reduction in dyspareunia and improved ability to have intercourse at 1 yr (p < 0.001). Reserved for sexual dysfunction refractory to all conservative measures. |
| Local Skin Flaps for LS Sequelae (Long-Term Outcomes) | Lichen Sclerosus — Surgical | Rangatchew 2017 *JPRAS* n=38 mean 8.4-yr follow-up: 75% reported surgical benefit; 74% satisfied with cosmetic results; 58% reported improved sexual lives; **38% had severe LS relapse causing recurrent apareunia** — counsel patients explicitly on relapse rate. |
References
1. Singh M, Kinsley S, Huang A, et al. Gracilis-flap reconstruction of the perineum: an outcomes analysis. J Am Coll Surg. 2016;223(4):602–610. doi:10.1016/j.jamcollsurg.2016.06.383
2. Höckel M, Dornhöfer N. Vulvovaginal reconstruction for neoplastic disease. Lancet Oncol. 2008;9(6):559–568. doi:10.1016/S1470-2045(08)70147-5
3. Pavlov A, Bhatt N, Damitz L, Ogunleye AA. A review of reconstruction for vulvar cancer surgery. Obstet Gynecol Surv. 2021;76(2):108–113. doi:10.1097/OGX.0000000000000866
4. 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
5. Ricotta G, Russo SA, Ferron G, Meresse T, Martinez A. The Toulouse algorithm: vulvar cancer location-based reconstruction. Int J Gynecol Cancer. 2025;35(4):100065. doi:10.1016/j.ijgc.2024.100065
6. National Comprehensive Cancer Network. Vulvar Cancer (NCCN Clinical Practice Guidelines). Updated 2026-01-06.
7. Han WY, Kim Y, Han HH. A simplified algorithmic approach to vulvar reconstruction according to various types of vulvar defects. Ann Plast Surg. 2023;91(2):270–276. doi:10.1097/SAP.0000000000003597
8. Lavoué V, Lemarrec A, Bertheuil N, et al. Quality of life and female sexual function after skinning vulvectomy with split-thickness skin graft in women with vulvar intraepithelial neoplasia or vulvar Paget disease. Eur J Surg Oncol. 2013;39(12):1444–1450. doi:10.1016/j.ejso.2013.09.014
9. Rettenmaier MA, Berman ML, DiSaia PJ. Skinning vulvectomy for the treatment of multifocal vulvar intraepithelial neoplasia. Obstet Gynecol. 1987;69(2):247–250.
10. 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
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. American College of Obstetricians and Gynecologists. Diagnosis and management of vulvar skin disorders: ACOG Practice Bulletin Summary, Number 224. Obstet Gynecol. 2020;136(1):222–225. doi:10.1097/AOG.0000000000003945
13. O'Dey DM, Kameh Khosh M, Boersch N. Anatomical reconstruction following female genital mutilation/cutting. Plast Reconstr Surg. 2024;154(2):426–438. doi:10.1097/PRS.0000000000011026
14. Almadori A, Palmieri S, Coho C, et al. Reconstructive surgery for women with female genital mutilation: a scoping review. BJOG. 2024;131(12):1604–1619. doi:10.1111/1471-0528.17886
15. Negosanti L, Sgarzani R, Fabbri E, et al. Vulvar reconstruction by perforator flaps: algorithm for flap choice based on the topography of the defect. Int J Gynecol Cancer. 2015;25(7):1322–1327. doi:10.1097/IGC.0000000000000481
16. 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
17. Gentileschi S, Servillo M, Garganese G, et al. Versatility of pedicled anterolateral thigh flap in gynecologic reconstruction after vulvar cancer extirpative surgery. Microsurgery. 2017;37(6):516–524. doi:10.1002/micr.30077
18. Caretto AA, Servillo M, Tagliaferri L, et al. Secondary post-oncologic vulvar reconstruction — a simplified algorithm. Front Oncol. 2023;13:1195580. doi:10.3389/fonc.2023.1195580
19. Meremikwu C, Oringanje C, Moses C, et al. Clitoral reconstructive surgery in women and girls living with female genital mutilation: a systematic review. Int J Gynaecol Obstet. 2026;172 Suppl 1:81–94. doi:10.1002/ijgo.70760