Local Skin Flaps for Lichen Sclerosus Sequelae
Local flaps can provide coverage after release of selected vulvar scars or contractures when direct closure would recreate narrowing. Surgery addresses an anatomical consequence of lichen sclerosus (LS); it does not reliably eliminate the underlying inflammatory disease. The 2026 S3 guideline suggests de-adhesion, perineoplasty or anatomical vulvoplasty for persistent introital stenosis causing urinary or sexual mechanical problems despite appropriate topical treatment.[1]
Local flaps are not a compulsory intermediate step between Perineoplasty and De-Adhesion and aOAP Flap Reconstruction. Choose the reconstruction according to the actual defect, adjacent tissue, previous surgery and the patient's goals. Comparative evidence establishing a preferred sequence is lacking.[1][2]
Assessment before reconstruction
- Confirm the cause of symptoms. Distinguish mechanical narrowing or recurrent fissuring from active inflammation, genitourinary syndrome of menopause, pelvic floor overactivity and other pain disorders. Surgery alone may not resolve coexisting pain.
- Treat active LS and check treatment use. Review application site, amount, adherence and response before labeling medical treatment unsuccessful. Suspicious persistent or new hyperkeratotic, eroded or ulcerated lesions require assessment and biopsy where indicated before reconstructive planning.
- Define a meaningful functional goal. This may be comfortable voiding, examination, hygiene or desired sexual activity; penetrative intercourse is not the only relevant outcome. Offer pelvic floor and sexual-health support, with partner involvement if the patient wants it.
- Plan continuing care. The S3 guideline recommends explaining and agreeing on topical treatment before and after surgery, alongside interdisciplinary counseling.[1][3]
Choosing a local flap
| Tissue problem | Possible approach and limitation |
|---|---|
| A localized scar band with adequate healthy adjacent tissue | Scar release with an advancement or rearrangement design may avoid re-closing the same tight line. |
| A broader deficit after release | A rotational or transposition flap may bring additional tissue into the defect. |
| Extensive disease, complex previous surgery, or inadequate local tissue | Obtain specialist reconstructive input; regional or perforator reconstruction may be needed. |
A historical mixed-vulvar series described 207 flaps in 191 women: sliding designs were commonly used for contractures and pivoting designs for tissue deficits. This illustrates selection by anatomy; it does not prove that one flap class is superior for LS. Much of the broader vulvar-flap literature concerns oncologic resections and cannot supply LS-specific complication or recurrence rates.[2][4]
Preserve vascularity and avoid tension, distortion of the urethral meatus or introitus, and unnecessary injury to sensate tissue. Discuss wound separation, infection, altered sensation, persistent pain, recurrent stenosis and possible revision. The choice and extent of release should be tailored to the functional problem, rather than used to excise every visible area of LS.[1][2]
What the long-term evidence shows
Rangatchew 2017: local-flap reconstruction
This retrospective series included 38 women treated between 1990 and 2013. Before surgery, 33 reported dyspareunia, including 24 unable to have intercourse. Mean follow-up differed by assessment: 10 months for the early review, 7.6 years for the survey and 8.4 years for the later clinical examination. Survey and clinical follow-up rates were 87% and 78%, respectively.[5]
Reported early pain improved, but seven patients had an unknown early outcome. At the long-term survey, 20 of 24 women in the reported dyspareunia subgroup still had pain. The authors nevertheless reported benefit and satisfaction for many participants, with some able to have intercourse despite recurrent symptoms.[5]
Do not turn this into a universal “88% relapse at eight years” prediction or an “85% restoration of intercourse” rate. The assessments used different follow-up groups, dyspareunia is not synonymous with inability to have intercourse, and the abstract does not resolve the denominators for its minor/severe relapse percentages. This uncontrolled historical experience supports counseling about recurrent disease and persistent pain, not a precise contemporary prognosis.[5]
Other surgical and patient-reported evidence
| Study | Useful finding | Limitation |
|---|---|---|
| Rouzier 2002, perineoplasty | Of 64 operated patients, 50 answered the outcome questionnaire; 45/50 reported improved dyspareunia and 43/50 improved quality of intercourse. | Respondent outcomes, not success in all 64 patients; no comparison with local flaps. |
| Lauber 2021, perineoplasty/de-adhesion | 41 of 70 invited patients responded at median 2.3 years; symptoms and satisfaction generally improved, but 10/27 who answered the dyspareunia item still reported pain during intercourse. | Substantial nonresponse and an item-specific denominator; does not establish superior durability. |
| Brauer 2016, qualitative interviews | Among 19 interviewed women, 13 reported less sexual pain, including only four who were pain-free. | Selected interviews describe experience rather than provide a population success rate. |
| Caretto 2024, capillary-perforator perineal flaps | In a retrospective 13-patient/29-flap series (10 LS, three post-cancer stenosis), the authors reported no postoperative complication or recurrent stenosis at one year among included patients.[9] | Single-center, no comparator, small selected cohort and one-year follow-up; the paper's specific Doppler/tunnel protocol is not a universal requirement. |
These studies help explain the difference between anatomical improvement, reduced pain and satisfaction. They do not provide a valid cross-procedure ranking.[3][6][7][9]
Maintenance and follow-up
Potent or ultrapotent topical corticosteroids remain standard LS treatment. Do not withhold appropriate treatment solely because of a general assertion that it impairs healing. Agent, potency and frequency should be individualized to disease control and tolerability. The guideline does not require every patient to use the same indefinite clobetasol schedule. Use the topical corticosteroid hub for medication detail.[1]
In Lee's prospective cohort of 507 women, individualized preventive treatment and adherence were associated with less scarring and fewer combined SCC or vulvar intraepithelial neoplasia events: 0/357 adherent versus 7/150 partially adherent patients over mean 4.7 years. This was an observational association, not proof that treatment eliminates cancer. Reported steroid-associated atrophy was uncommon and reversible.[8]
Review postoperative healing, residual narrowing, pain, urinary symptoms and treatment response. Continue regular LS follow-up and prompt reassessment of suspicious lesions; the S3 guideline gives example intervals of every three to six months initially and annually once stable. A new lesion, worsening symptoms or treatment failure warrants earlier review.[1]
See also
References
1. Kirtschig G, Woelber L, Günthert A, et al. Evidence- and consensus-based guideline on lichen sclerosus. J Dtsch Dermatol Ges. 2026;24:566–584. doi:10.1111/ddg.70000
2. Reid R. Local and distant skin flaps in the reconstruction of vulvar deformities. Am J Obstet Gynecol. 1997;177(6):1372–1383. doi:10.1016/S0002-9378(97)70078-4
3. 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
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. 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
6. 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
7. 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
8. Lee A, Bradford J, Fischer G. Long-term management of adult vulvar lichen sclerosus: a prospective cohort study of 507 women. JAMA Dermatol. 2015;151(10):1061–1067. doi:10.1001/jamadermatol.2015.0643
9. Caretto AA, Garganese G, Fragomeni SM, et al. Local perineal capillary perforator flaps: a minimally invasive technique for the correction of vulvar stenosis. J Pers Med. 2024;14(6):617. doi:10.3390/jpm14060617