A 27-year-old multiparous woman presented to Dr. Bhubaneswar Borooah Cancer Institute, Guwahati, Assam, with complaints of perineal itching and swelling in the genital region for the past one year.

On examination, as shown in Fig. 1A there was a large firm proliferative growth of size 11*7*5 cm lesion involving bilateral labia majora and minora. The lesion involved the clitoris and was 0.5 cm away from the urethra. The lower edge of the lesion was 2 cm away from the anal margin. It was abutting the margin of the vagina bilaterally. Tenderness was noted due to the extensive size of the lesion. Bilateral inguinofemoral lymph nodes were 2 cm in size, firm and mobile in nature. Liquid-based cytology of the cervix was suggestive of negative for intraepithelial lesion or malignancy (NILM). Vulval biopsy showed well-differentiated squamous cell carcinoma. Contrast-enhanced magnetic resonance imaging (MRI) showed a 7*6 cm ulceroproliferative growth abutting the urethral orifice and left lateral wall of the vagina. Fine needle aspiration cytology (FNAC) from the inguinal nodes was suggestive of metastatic squamous cell carcinoma.

Intraoperative procedure of A preoperative photograph, B wide perineal defect and right V–Y plasty, C Doppler assessment of perforators, D skin marking, E raising of ALT flap, (F G H) raising of rectus femoris/sartorius and tunnelling to the perineum

She underwent total deep vulvectomy and bilateral inguinofemoral lymph node dissection as shown in Fig. 1. Using a margin of 1 cm, the entire lesion including bilateral labia majora and the distal 1 cm of the urethra were excised. Post-excision of the mass a large defect of 14*10 cm was present. To reduce the defect size, a V–Y plasty was done on the right side as shown in Fig. 1. Further a residual defect of size 10*8 was left, and a decision to perform a right ALT flap was made.

The perforators for the anterolateral thigh flap which arise from the lateral femoral circumflex artery were marked using a handheld Doppler device. Surface marking was done with a straight line drawn from the anterior superior iliac spine to the central part of the patella. Planning in reverse was done for the defect, and the paddle was marked. The anterior incision was made, and the rectus femoris muscle was identified with its bipinnate nature. No perforator was identified at the required skin paddle. The decision was taken to raise a musculocutaneous flap based on vastus lateralis. The paddle consisting of skin and underlying cuff of vastus lateralis muscle along with the descending branch of the lateral circumflex femoral artery was raised. After skeletonizing the pedicle, the paddle along with the muscle was passed underneath the rectus femoris and sartorius muscles to the perineal defect. After ensuring adequate tunnelling and proper orientation of the pedicle, the flap inset was done. Flap bleeding was confirmed, and the donor site was closed primarily over a negative pressure suction drain as shown in Fig. 2. We used an above-knee brace to ensure the knee was extended in the post-operative period.

A, B Donor site defect and primary closure, C, D Immediate post-operative wound site and gross specimen, E, F Post-op day 2 vulval and leg site wound, G, H Post-op day 28 prior to adjuvant radiotherapy

Post-operative the patient was administered intravenous antibiotics for five days and subcutaneous low molecular weight heparin prophylaxis for 2 weeks. The flap was daily monitored for colour changes, turgor, temperature and sensation. Physiotherapy, ambulation and a soft diet were started by day 2. The ALT drain was removed by day 2. On post-op day 8, there was minimal dehiscence of the VY flap at the vaginal margin. Regular dressing was done and following healing of the wound she was discharged on post-op day 11. The urinary catheter was placed for 3 weeks given the distal urethrectomy.

The final histopathological report showed squamous cell carcinoma with negative margins. However, as one inguinal node out of fourteen nodes removed was positive for malignancy, she was planned for adjuvant radiotherapy in the Disease Management Group meeting. The wound has completely healed, and she is undergoing radiotherapy.