Vaginal reconstruction after anterior pelvectomy by deep inferior epigastric perforator flap (DIEP)

Muscle sparing technique is one of the latest improvements of rectus abdominis flaps harvesting. It minimizes donor site morbidity by preserving the abdominal wall. The deep inferior epigastric perforator flap (DIEP) provides reliable tissues for vaginal reconstruction with local low morbidity. We describe the surgical technique and flap-related specific complications. This technique is safe and useful in the vaginal reconstruction especially following a radiotherapy.     

腹壁下动脉穿支皮瓣修复腹部创面

目的探讨应用腹壁下动脉穿支皮瓣修复腹部创面的方法。方法2001年12月至2006年12月,对9例腹部创面,其中3例伴腹壁缺损的患者,用腹壁下动脉穿支皮瓣进行修复,供区直接缝合。结果本组9例腹壁下动脉穿支皮瓣全部Ⅰ期愈合。随访6~12个月,外形良好,均无腹壁疝和腹内疝的发生。结论腹壁下动脉穿支皮瓣是修复腹部创面合理、可靠的新方法,手术简单,易于普及推广。     

腹壁下动脉穿支皮瓣修复腹部创面

目的探讨应用腹壁下动脉穿支皮瓣修复腹部创面的方法。方法2001年12月至2006年12月,对9例腹部创面,其中3例伴腹壁缺损的患者,用腹壁下动脉穿支皮瓣进行修复,供区直接缝合。结果本组9例腹壁下动脉穿支皮瓣全部Ⅰ期愈合。随访6-12个月,外形良好,均无腹壁疝和腹内疝的发生。结论腹壁下动脉穿支皮瓣是修复腹部创面合理、可靠的新方法,手术简单,易于普及推广。     

Lower abdominal bulge after deep inferior epigastric perforator flap (DIEP) breast reconstruction

The etiology of lower abdominal bulge following breast reconstruction with the DIEP flap is uncertain. Most studies report an incidence that ranges from 0.7% to 5%. The purpose of this study was to review a set of factors that may predispose to a lower abdominal bulge. This was a retrospective review of 123 women who had breast reconstruction with the DIEP flap over a 4-year period. The reconstruction was unilateral in 93 women and bilateral in 30 women, totaling 153 flaps. Etiologic factors that were evaluated included patient age, diabetes mellitus, tobacco use, previous abdominal operations, unilateral or bilateral reconstruction, previous childbirth, aponeurotic plication to improve the natural abdominal contour, and use of Marlex mesh. A lower abdominal bulge occurred in 5 of the 123 women (4%), 2 following 30 bilateral reconstructions (6.6%) and 3 following 93 unilateral reconstructions (3.2%). Analysis of the factors for all women demonstrated diabetes mellitus in 1 (0.8%), tobacco use in 9 (7.3%), a prior abdominal operation in 55 (44.7%), previous childbirth in 95 (77%), aponeurotic plication in 49 (40%), and use of Marlex mesh in 4 (3.3%). Statistical analysis did not show any significant association between the explanatory factors and the occurrence of a lower abdominal bulge, except for a weak trend in women who had not been pregnant (P = 0.08). The results of this study demonstrate that the occurrence of a lower abdominal bulge following the DIEP flap is a random event that can occur in anyone. Pregnancy may confer a preventative effect as the collagen fibers strengthen to overcome the stretching forces. Techniques for prevention and treatment include intraoperative assessment of the anterior rectus sheath, use of an adjuvant material for reinforcement if unstable, and vertical plication for bulge repair.     

Buttock reconstruction using a pedicled deep inferior epigastric perforator flap

Although deep inferior epigastric perforator (DIEP) flaps are mainly used for breast reconstruction as free flaps, they are also useful as pedicled island flaps. However, DIEP flaps have seldom been used for reconstructions in the lateral hip region. Furthermore, to the best of our knowledge, no report has been issued on the use of this flap for buttock reconstruction. The authors describe the successful use of a pedicled oblique DIEP flap for the reconstruction of a severe scar contracture in the buttock. The pedicled DIEP flap can be a useful option for the reconstruction of large buttock defects, and if a transverse DIEP flap is unavailable, an oblique DIEP flap should be considered an alternative.     

Glans penis reconstruction with the pedicled deep inferior epigastric artery perforator flap

This is a report on a novel technique of neoglans reconstruction in a patient with an amputated glans penis as a result of a gunshot injury. A pedicled deep inferior epigastric artery perforator (DIEAP) flap measuring 7 x 4 cm and centralizing the uppermost perforators in the right abdominal region was used. The distal penile skin was used to elongate the urethra. A subcutaneous tunnel was created alongside the penis and underneath the mons pubis. The flap was passed through this tunnel, fashioned into the shape of a glans, and secured in place around the neourethra. The patient had a satisfactory neoglans and a functional urethra at 4-month follow-up. The pedicled DIEAP flap is a suitable option for reconstruction of the glans penis.     

应用腹壁下动脉穿支游离皮瓣移植乳房再造

目的 通过应用腹壁下动脉穿支游离皮瓣移植进行乳房再造的手术方法，总结应用该方法进行乳房再造的临床经验。方法 切取以腹壁下动静脉为蒂的穿支游离皮瓣，将腹壁下动静脉与胸廓内动静脉相吻合，进行乳房再造。结果 自2000年以来，临床应用腹壁下动脉穿支皮瓣再造乳房共15例，10例皮瓣100％成活，2例皮瓣远端局部皮肤坏死，1例皮瓣远端脂肪硬结，2例皮瓣完全坏死。随访6个月至1年，再造乳房外形满意，供区无腹壁疝、腹壁膨出、腹壁薄弱等并发症发生。结论 腹壁下动脉穿支游离皮瓣是下腹部横行腹直肌肌皮瓣(TRAM皮瓣)的技术改良与发展，该皮瓣具有血运丰富、组织量大、易于塑形、供区损伤小等优点，是一种安全可靠的乳房再造方法。     

游离腹壁下深动脉穿支皮瓣一期重建乳房

目的　行乳癌改良根治术同时应用游离腹壁下深动脉穿支 (deepinferiorepigastricper forator,DIEP)皮瓣行一期乳房再造 ,以降低术后并发症的发生率。方法　 2 0 0 1年 12月～ 2 0 0 3年 1月对 12例患单侧乳癌的女性患者 ,在行乳癌改良根治术的同时用游离DIEP皮瓣行一期乳房再造 ,受区血管采用胸背动、静脉或胸廓内动、静脉。结果　本组 12例DIEP皮瓣中有 1例因为下腹部多条瘢痕 ,术后整块皮瓣坏死 ,其余 11例全部存活。 11例再造乳房和对侧乳房大小基本一致 ,术后无一例发生腹壁薄弱、腹部包块、腹壁疝等。结论　DIEP皮瓣是利用自体组织一期重建乳房合理可靠的新方法 ,较TRAM皮瓣 ,术后供区的并发症明显降低 ,康复快 ,但手术较复杂、时间较长 ,对外科技术的要求较高。     

Immediate skin-sparing mastectomy reconstruction with deep inferior epigastric perforator (DIEP) flap. Technical aspects and outcome

Although breast reconstruction with deep inferior epigastric perforator (DIEP) flap is a well-described technique, few publications have specifically reported the technical aspects and the outcome following skin-sparing mastectomy (SSM). The aim of this study is to analyse the feasibility of its immediate application and to describe the operative planning, outcome and complications after SSM. 27 patients underwent 30 DIEP flap breast reconstructions with all immediate and 3 bilateral. Mean time of follow-up was 29 months. Breast skin, DIEP Flap and donor-site complications were evaluated. Information on patient satisfaction was collected. 70% had tumors measuring 2 cm or less (T1) and 74% were stage 0 and I according to American Joint Committee on Cancer. Breast skin complications occurred in 7.4%, all represented by small areas of skin necrosis. Partial losses were observed in two (7.4%) patients (less than 15% of total area) and total DIEP loss in 1 (3.7%). Donor-site complications represented by bulging occurred in only one patient (3.7%). The majority of patients were either very satisfied or satisfied. One local recurrence was observed. All complications except 2 were treated by a conservative approach. The DIEP flap is a reliable technique for SSM reconstruction. Success depends on patient selection, coordinated planning with the oncologic surgeon and careful intraoperative and postoperative management. The main advantage is that patients can safely undergo dual procedures with the added aesthetic benefits in breast and abdominal donor site.     

Anterolateral thigh flap salvage following failed deep inferior epigastric artery perforator breast reconstruction

The deep inferior epigastric artery perforator flap is an option for women desiring autologous tissue breast reconstruction. If this reconstruction fails, other autologous tissue flaps, including the gluteal artery perforator and latissimus dorsi flaps, may be used for salvage. The anterolateral thigh (ALT) flap offers adequate tissue volume for breast reconstruction, acceptable fat quality and a long vascular pedicle. Other advantages include obviating the need for intraoperative position changes and harvesting tissue outside of the radiation field. Two cases involving ALT flaps used in the setting of deep inferior epigastric artery perforator failure are presented with favourable results. A review of the anatomy of the ALT flap is included.     

Maxillary reconstruction using a free deep inferior epigastric perforator (DIEP) flap combined with vascularised costal cartilages.

In this article, we describe a case of maxillary carcinoma requiring reconstruction in which we used a free deep inferior epigastric perforator (DIEP) flap combined with vascularised costal cartilages. The DIEP flap was harvested with a rectus abdominis muscle in its cranial side. Eighth and ninth costal cartilages were harvested and connected with the muscle. The Zygomaticomaxillary buttress was reconstructed using vascularised costal cartilages. Nasal and oral lining were reconstructed with a DIEP flap. The viability of grafted bone was proved in bone scintigraphy and three-dimensional computed tomography after six months. Cosmetically the result was good. Compared with other methods, this flap can be thinned easily to match a defect and vascularised cartilages connected with rectus muscle can be nourished by the same vascular pedicle. This is a first report of perforator flap combined with vascularised cartilage. This flap has a possibility to be used for a lot of reconstruction that needs bone reconstruction with perforator flap.     

纵行腹壁下动脉穿支皮瓣阴道再造术

目的 探讨应用腹壁下动脉穿支皮瓣行阴道再造的新术式. 方法 2007年6月至2008年4月,为5例先天性无阴道、1例阴道癌全切即刻阴道再造患者,应用纵行腹壁下动脉穿支皮瓣行阴道再造术.术前应用增强CT技术选择优势穿支,根据该结果设计皮瓣,大小为(5～6)cm×(18～24)cm. 结果 所有转移皮瓣完全成活.5例患者术后恢复顺利,1例出现会阴切口感染,伤口部分裂开,予以换药愈合.围手术期无明显其他并发症发生.随访1～8个月(平均4个月),再造阴道外口通畅,患者对再造效果满意. 结论 应用纵行腹壁下动脉穿支血管再造阴道是一种安全、可靠的手术方法.     

Objective evaluation of fat tissue induration after breast reconstruction using a deep inferior epigastric perforator (DIEP) flap

Problems in breast reconstruction with deep inferior epigastric perforator (DIEP) flaps include postoperative fat induration and necrosis. A resulting clinical symptom is palpable indurated tissue, but it is difficult to measure the stiffness of transplanted fat tissues objectively at a deep site. The ability to perform shear-wave elastography (SWE) was recently added to some common ultrasonic echo devices, enabling objective three-dimensional measurements of tissue stiffness. In this study, we measured the stiffness of transplanted DIEP flaps using SWE to examine the effects of measurement sites, flap size and perforator patterns on stiffness. The subjects were 26 patients who showed induration of a transplanted flap on palpation in follow-up observation performed more than 6?months after breast reconstruction with a DIEP flap. The effects of the weight of the transplanted flap, and the diameter, number and location of the perforators on the stiffness of fat tissue were also analyzed. Within each zone, distal regions showed higher values, but in Zone II, significantly higher stiffness was also found in the proximal region. Multivariate regression analysis including all measurement sites, the weight of transplanted flap, and diameter, number and location of perforators showed that the stiffness of fat tissue was significantly higher in subjects with a larger weight flap. For safe reconstruction, it will be useful to examine the stiffness of fat tissue in individual regions of a transplanted flap retrospectively, because the examination results can be used in actual clinical practice.     

利用腹壁下动脉穿支皮瓣阴茎再造的临床研究

目的 探讨腹壁下动脉穿支(DIEP)皮瓣阴茎再造手术方法的临床疗效.方法 2003年12月至2006年11月收治体外热疗致阴茎严重烧伤2例、假两性畸形1例、动物咬伤致阴茎大部缺损1例.患者平均年龄31岁.术前残余阴茎常态下长度0.5～1.5 cm.应用DIEP皮瓣及第12肋骨植入行一期阴茎再造术.结果 4例手术均成功,皮瓣完全成活,术后未发生感染、尿道狭窄等并发症.3例术后随访5～32个月,再造阴茎外形逼真,阴茎定型长度7.5～11.0 cm,排尿正常,未发生严重感染及尿道狭窄,皮肤感觉与勃起功能良好.1例近期手术者随访3个月阴茎感觉仍在恢复中.结论 该手术方法设计合理,手术一期完成,术后再造阴茎形态功能良好,能满足患者及配偶性生活的要求.供区损伤小,是比较理想的阴茎再造方法.     

Bilateral breast reconstruction with the deep inferior epigastric perforator (DIEP) flap: an experience with 280 flaps

Bilateral prophylactic mastectomy can reduce the incidence of breast cancer by 87 to 93% in high-risk individuals and is an appealing option for many patients if reconstruction can be provided with acceptable morbidity and outstanding esthetic results. Autogenous breast reconstruction techniques have evolved over the last 20 years to meet this goal. Familiarity with the deep inferior epigastric perforator (DIEP) flap led us to carry out simultaneous bilateral breast reconstruction with acceptable morbidity and superior esthetic outcome in 3 patient groups: (1) after bilateral prophylactic mastectomy, (2) after therapeutic and contralateral prophylactic mastectomy, and (3) after explantation of bilateral implant failures. A retrospective review of our experience with 280 flaps in 140 patients was performed. Average operating times, including time for implant removal or mastectomy and reconstruction, was 7.3 hours. Average hospitalization was 3.9 days. Significant perioperative complications occurred in 9 patients (6.4%); all returned to the operating room. This included 7 microvascular complications, 1 hematoma, 1 seroma, and 1 DVT. Less significant complications were divided into early and late. The early complications included 1.8% partial flap necrosis, 4.2% abdominal apron necrosis greater than 5 cm2, 2.9% seromas that required intervention, and 5.7% partial breast flap dehiscence. Late complications included 12.5% fat necrosis of any size and 2.1% hernia formation. Smoking, obesity, age, history of chest wall radiation, and flap size were evaluated as risk factors for increased morbidity.     

改良腹壁下动脉穿支皮瓣的临床应用

目的 探讨腹壁下动脉穿支皮瓣(deep inferior epigastric perforator flap,DIEP皮瓣)切取方式的改进,扩大DIEP皮瓣的临床应用范围.方法 采用双腹壁下血管蒂仅带肌袖的DIEP皮瓣(并可通过筋膜蒂携带髂骨或肋骨)修复四肢大面积软组织缺损,其中前臂缺损5例,手腕部缺损6例,创面面积为10.0 cm×5.0 cm～45.0cm×20.0 cm,均为急诊修复.结果 术后11例皮瓣中全部存活10例,大部分存活1例.随访时间3～61个月,皮瓣愈合良好,手功能恢复满意.所有供区均未发生腹壁疝.结论 改良DIEP皮瓣是修复大面积皮肤缺损的首选皮瓣之一.