Annals of Burns and Fire Disasters - vol. XII - n. 1 - March 1999

RECONSTRUCTION OF VULVA IN A FEMALE PATIENT HAVING LONGSTANDING GENITAL BURN CONTRACTURE WITH SEVERE WEB AND MARJOLIN'S ULCER: A CASE REPORT

Sonmez Ergun S, lscen Cek D, Ulay M.

Department of Plastic and Reconstructive Surgery, Vakif Gurepa Hospital, Istanbul, Turkey

SUMMARY. In this report, a 17-year-old female patient with a post-burn genital contracture that caused severe deformity and squarnous cell carcinoma and the results of the genital web release and vulva reconstruction with our flap design are presented.

Burn injuries involving the genital area are rarely seen owing to the anatomical features of the region. The elasticity and laxity of the skin in this region are very important. The characteristics of the skin after thermal injury may be lost so that extensive contractures may occur. The diagnosis and treatment of this type of burn sequela are frequently delayed owing to the patients' ignorance or shyness. This delay can be extended until puberty and sometimes even later in females.

A 17-year-old white was female admitted to our department with an ulcerovegetant tumoral mass on the superornedial side of the left thigh. She had undergone thermal burn injury ten years previously. The wounds were treated conservatively, but severe scars, involving the pubic area, both inguinal and in the upper thigh anteriorly and posteriorly, developed. The web in the inguinal area caused walking, sitting, urination and defecation difficulties. The ulcerovegetant tumoral mass on the superomedial side of the left thigh was 12 x 12 cut in size with progressive enlargement in the last 8 months. A soft, mobile, painless lymph node 0.5 x 0.5 cm in size was palpated in the ipsilateral inguinal area. Systemic examination revealed no additional pathology (Fig. 1).
Ablation of the tumoral mass, nodal biopsy, and web release with skin grafting were planned.

Fig. la - Pre-operative anterior view. Fig. 1b - Pre-operative posterior view. Fig. lc - Pre-operative lateral view.

The tumoral mass was excised with a 2 cm intact margin and the node was extirpated. The histopathological examination revealed that the tumoral mass was a welldifferentiated squarrious cell carcinoma; the surgical margins were reported to be turnour-free. The diagnosis of the nodal biopsy was reactive hyperplasia.
Incising bilaterally, 2 cm caudal and parallel to both inguinal creases and joining at the inferior border of the web, two flaps were formed. The genital web was released in such a manner that the tissue forming the abdominal side of the web was utilized for pubic reconstruction as a flap with superior pediele, while the perineal side was used for the upper part of the vulvar reconstruction in Zplasty fashion (Fig. 2).

The secondary defects after turnoral mass excision and the release in both the inguinal and the upper thigh area were reconstructed by STSG harvested from the posterolateral thigh (Figs. 3, 4). The patient did well post-operatively. In the follow-up period, no recurrence or metastasis was found up to two years postoperatively.

Fig. 3a - Post-operative anterior view. Fig. 3b - Post-operative posterior view. Fig. 3c - Post-operative lateral view. Fig. 4 - Late result after one year.

Burn injuries involving the genital area are seen rarely, probably due to the anatomically hidden location. These injuries may occur as part of the extensive burns of the lower trunk and thighs. In secondary healed cases, severe contractures and bridges may occur.
Since the contracture is not in a stabilized position, recurrent ulcerations may occur, and in exceptional cases Marjolin's ulcer may develop, as in our patient. Treatment of Marjolin's ulcer is entirely surgical, sometimes with a combination of radiotherapy and chemotherapy according to the stage of the tumour. Surgical treatment is wide monoblock resection.
The overall incidence of regional lymph node metastases in the trunk and extremities appears to be 25%, but the controversy regarding prophylactic nodal dissection still exists. Further information is needed to establish the validity of predictive factors such as size and depth of invasion.
Clinically enlarged regional lymph nodes were subjected to biopsy and patients with biopsy-proved nodal metastases were treated by nodal dissection radiation and chemotherapy if necessary. Proper initial treatment of burns, with early use of skin grafts, might prevent the development of these potentially serious tumours.
In conservatively treated cases, many of the problems - severe contractures and web formation causing difficulties with walking, sitting, urination and defecation - may be encountered as a result of the natural trend of thigh adduction. The abnormal appearance and the contracture may prevent the patients having a normal sexual life, with consequent psychological problems. Thus, in the management of burn sequelae of the area and especially in vulvar reconstruction, not only the functional aspect but also the cosmetic appearance should be primary aims. Reconstruction should be performed in harmony with anatomical factors.
Various surgical procedures have been suggested and utilized for the release and reconstruction of post-burn webs in the genital area. These range from simple release and skin grafting to a number of different flap procedures, including Z-plasty, V-Y plasty, 5-flap plasty, doubleopposing Z-plasty, and other local flap uses. Tissue expansion can be utilized.
In our patient, after release of the web with the flap elevated anteriorly, the pubic area presented an almost normal anatomical appearance. Also, tailoring of the posterior side of the genital web in Z-plasty fashion relieved the retraction involving upper parts of the labia majora, resulting in the vulva having a normal anatomical appearance.
This method minimizes the necessity of grafting. A natural appearance of the pubic and vulvar areas was obtained that cannot be observed with other procedures.
We conclude that a highly acceptable functional and aesthetic result was achieved by our flap design.

RESUME. Les Auteurs présentent le cas d'une patiente de 17 ans atteinte d'une contracture génitale due à des brûlures qui a causé une déformation sévère et un carcinome épidermoide. Les résultats, de la reconstruction de la vulve effectuée moyennant notre système sont présentés, avec une revue de la littérature en rapport.

BIBLIOGRAPHY

1. Alghanem A.A., McCauley R.L., Robson M.C., Rutan R.L., Herndon D.N.: Management of pediatric perineal and genital burns: twentyyear review. J. Burn Care Rehabil., 11: 308, 1990.
2. Joucdar S., Kismoune H., Boudjemia F., Bacha D., Abchiche M.: S&quelles de br6lures abdomino-p6rin6ales - ~ propos de trente cas. Ann. Medit. Burns Club., 8: 103, 1995.
3. Luce E.A.: Oncologic considerations in nonmelanotic skin cancer. Clin. Plast. Surg., 22: 39, 1995.
4. Broadland D.G., Zitelli J.A.: Surgical margins for excision of primary cutaneous squamous cell carcinoma. J. Am. Acad. Dermatol., 27: 108, 1992.
5. Shin M.H., Chu F., Fortner J.G.: Treatment of regionally advanced epidermoid carcinoma of the extremity and trunk. Surg. Gynecol. Obstet., 150: 558, 1980.
6. Bangma C.V., van der Molen A.B.M., Boxma H.: Burns to the perineal and genitals - management, results and 'function of the thermally injured perineum in a 5-year review. Ent. J. Plast. Surg., 18: 111, 1995.
7. Cek C.I., Ergun S.S., Cek M., Akbay S., Guneren E.: Genital ve bolge yaniklari. Turk. Plast. Rekonstr. Cerrahi Derg., 4: 159, 1996.
8. Muir I.F.K., Morgan B.D.G.: Burns of genitalia and perineum. "Plastic and Reconstructive Surgery of the Genital Area", Horton C.G., Little Brown G., 447, 1993.