Eur J Orthop Surg Traumatol DOI 10.1007/s00590-015-1599-0
ORIGINAL ARTICLE • PELVIS - TRAUMA
Deep inferior epigastric vessel-pedicled, muscle-sparing rectus abdominis myocutaneous (RAM) flap for reconstruction of soft tissue defects in pelvic area L. Zheng • Z. G. Dong • J. Zheng
Received: 18 September 2014 / Accepted: 31 December 2014 Springer-Verlag France 2015
Abstract Large soft tissue reconstruction in pelvic area is rare but remains challenging. Between August of 2000 and March of 2014, five patients underwent soft tissue reconstruction in pelvic area using deep inferior epigastric vessel-pedicled, muscle-sparing RAM flap. The soft tissue defects located in anterior iliac spine in three cases, lower buttock in one case, contralateral lower buttock and perineal region in one case. The size of the flaps ranged from 13 9 7 cm to 25 9 9 cm. All flaps were harvested in muscle-sparing form. Lateral two-thirds of rectus abdominis muscle and anterior sheath of the rectus abdominis muscle were harvested with the flap in disc or bar shape. All five flaps survived uneventfully. During the follow-up, no ventral hernias occurred in donor sites. Keywords Deep inferior epigastric Rectus abdominis myocutaneous flap Soft tissue defects Pelvic area Reconstruction
Introduction Soft tissue reconstruction in pelvic area remains challenging. The inferiorly based rectus abdominis island flaps were used for resurfacing soft tissue defects in buttock, pelvis, genital region, groin and anterior thigh [1–7]. The pedicled deep inferior epigastric perforator (DIEP) flaps have been used to resurface defects in buttock, groin, genital region and lateral hip [8–14]. But it may be difficult to repair lower and medial parts of buttock with this flap because of the limited length of the pedicle [15]. This article introduces our experience in reconstruction of soft tissue defects in pelvic area using the deep inferior epigastric vesselpedicled, muscle-sparing RAM flap. And the defects involved the lower and medial parts of the buttock in two cases were reconstructed.
Patients and methods
L. Zheng J. Zheng Department of Orthopedics, Henan Provincial People’s Hospital, Zhengzhou 450003, People’s Republic of China e-mail: [email protected] L. Zheng (&) Department of Surgery, Kleinert Kutz Hand Care Center, Christine M. Kleinert Institute for Hand and Microsurgery, School of Medicine, University of Louisville, 225 Abraham Flexner Way, Suite 850, Louisville, KY 40202, USA e-mail: [email protected] Z. G. Dong Department of Orthopedics, Second Xiangya Hospital, Central South University, Changsha 410011, People’s Republic of China e-mail: [email protected]
This study was conducted in accordance with the declaration of Helsinki. This study was conducted with approval from the Ethics Committee of Henan Provincial People’s Hospital. Written informed consent was obtained from all participants. Between August of 2000 and March of 2014, five patients underwent soft tissue reconstruction in pelvic area using the deep inferior epigastric vessel-pedicled muscle-sparing RAM flap. The ages ranged from 12 to 44 years. The soft tissue defects ranged from 11 9 6 cm to 22 9 8 cm. The soft tissue defects located in anterior iliac spine in three cases, lower buttock in one case, contralateral lower buttock and perineal region in one case. The defects were caused by car accident in three cases, caused by soft tissue necrosis after open reduction and internal fixation of iliac fracture in one case, caused by soft tissue
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Eur J Orthop Surg Traumatol
necrosis after tumor resection in one case. All five cases were with bone exposure. One case was with a dead space measured 16 9 2.5 cm in left anterior superior iliac spine. The size of flap ranged from 13 9 7 cm to 25 9 9 cm. The flaps were designed vertically in three cases, obliquely in two cases. The defects located in ipsilateral lower buttock in one case, in contralateral lower buttock and perineal region in another case (details see Table 1).
After the flap was raised, the residual anterior sheath of rectus abdominis muscle was sutured directly to avoid the postoperative ventral hernia, no mesh was used. The flap was then transferred to the recipient site through a subcutaneous tunnel, all donor sites were closed directly without skin graft (Fig. 1d).
Results Operative technique Preoperative Doppler was not done routinely. Under general anesthesia, the patient was in lateral position. After debridement, the flap was designed about 15 % lager than the defects according the shape of the recipient site to avoid the postoperative tension in the flap (Fig. 1a). The flap was elevated from lateral to medial on the surface of the deep fascia. The flap was raised lateral to medial to the lateral border of the anterior sheath of rectus abdominis muscle (point B, Fig. 1b), where two or three perforators were identified. No further intramuscular dissection of the perforators was needed. The dissection of the deep inferior epigastric vessels was performed as caudal as possible. And in cranial direction, the dissection of the deep inferior epigastric vessels was done till to the point where the vessels went into the rectus abdominis muscle (point A, Fig. 1b). No further intramuscular dissection of the vessels was done. Lateral two-thirds of the rectus abdominis muscle and lateral two-thirds of anterior sheath of rectus abdominis muscle between point A and point B were harvested with the flap in disc or bar shape (Fig. 1c). If more muscle was needed to fill the dead space in recipient site, the more lateral two-thirds of the abdominis muscle could be taken.
All five flaps survived uneventfully. The infection was controlled in the two cases. During the follow-up (mean 59.1 months), no ventral hernia was observed (Fig. 2).
Discussion Major soft tissue reconstruction in pelvic area caused by trauma, tumor resection or postoperative soft tissue necrosis is rare but often presents a challenging problem. Small defects with bone exposure can be resurfaced by local or advancement flaps, but they usually do not provide sufficient tissue for large defects [15]. At the sacrifice of some functioning muscles, gracilis flap and rectus myocutaneous flap have been used for scrotal reconstruction and pelvic reconstruction [16, 17]. But the rotation arc of the two procedures is not comparable with the deep inferior epigastric vessel-pedicled muscle-sparing RAM flap. Some free tissue transplantations are used to repair large defects in pelvic area, but sometimes at the sacrifice of the function of the donor site especially when the defects are large. And also the operation time is longer, the microsurgery technique is needed. This deep inferior epigastric vessel-pedicled muscle-sparing RAM flap can provide sufficient tissue to resurface large defects in some pelvic areas. The procedures we used are relative
Table 1 Summary of the patients Patient
Sex
Age (years)
Cause
Recipient site
Features of lesion
Flap size (cm 9 cm)
Complications
1a
F
44
Car accident
Right lower buttock and perineal region
Bone exposure in right ischial tuberosity with infection
25 9 9
No
2
M
36
Car accident
Left anterior iliac spine
Bone exposure in left iliac spine, accompanied with infection and a dead space
17 9 8
No
3
M
12
Soft tissue necrosis after tumor resection
Right lower buttock
Bone exposure in right hip
20 9 9
No
4
F
38
Soft tissue necrosis postpelvic operation
Left anterior iliac spine
Bone exposure in left anterior iliac spine
13 9 7
No
5
M
36
Car accident
Left anterior iliac spine
Bone exposure in left anterior iliac spine
16 9 8
No
a
The flap was designed in contralateral abdominal wall, because of the contusion of ipsilateral abdominal wall
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Eur J Orthop Surg Traumatol
Fig. 1 a Flap design. b, c Lateral two-thirds of rectus abdominis muscle and anterior sheath of rectus abdominis muscle between point A and point B were harvested with the flap. d Flap was transferred to the recipient site through subcutaneous tunnel
simpler compared with free tissue transplantation. The most challenging part of raising the DIEP flap was dissection of the perforators through its intramuscular course [18]. Thus, our procedures are more rapid and safer, because no further intramuscular dissection of the vessels is needed. In the second case, the middle and lateral twothirds parts of the rectus abdominis muscle sized 16 9 2.5 cm in bar shape were harvested with the flap to fill the dead space. The muscle tissue with sufficient blood supply for the dead space, that is good for controlling the infection. Egeberg et al. [19] compared the donor-site morbidity between DIEP and muscle-sparingtransverse RAM (TRAM) flaps for breast reconstructive surgery, their studies found approximately the same risk
of bulge formation between DIEP and TRAM flap patients. Kim reported that a pedicled oblique DIEP flap can be used for the reconstruction of large buttock defects, but it may be difficult to repair the lower and medial parts of the buttock with this flap due to the limited pedicle length [15]. In order to get larger flaps, we designed two flaps in oblique form. In the five cases, the defects involved the lower and medial parts of the buttocks in two cases; the defects were resurfaced by the deep inferior epigastric vessel-pedicled muscle-sparing RAM oblique flaps from ipsilateral or contralateral abdominal wall. The deep inferior epigastric vessel-pedicled muscle-sparing RAM flap in oblique form could be a better choice when a larger flap is required.
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Eur J Orthop Surg Traumatol Fig. 2 a Soft tissue necrosis after tumor resection in right lower buttock. b Flap measuring 20 9 9 cm was designed in oblique form. c Flap was transferred to the recipient site through subcutaneous tunnel. d Two weeks postoperatively
Conclusions The deep inferior epigastric vessel-pedicled muscle-sparing RAM flap is an alternative to reconstruct soft tissue defects in anterior superior iliac spine, ischial tuberosity, perineal region and lower buttock. Besides the advantages such as rapid procedures, robust blood supply, a large arc of rotation and low donor-site morbidity, parts of rectus abdominis muscle could be harvested with the flap if needed. The major disadvantage of this technique is the obvious lineal abdominal scar. Acknowledgments We thank Ross Gibson for his help review and editing of the manuscript. Conflict of interest The authors confirm that they have received no financial assistance relevant to this paper and have no conflict of interest regarding this paper.
References 1. Gu¨rlek A, Demir CY, Askar I, Aydog˘an H, Alaybeyoglu N, Coban YK (2005) A transverse rectus abdominis myocutaneous (TRAM) flap for reconstruction of a large deformity in the buttock: a new indication for a TRAM flap. Scand J Plast Reconstr Surg Hand Surg 39:95–99 2. Evans GR, Goldberg DP, Ames FC (1996) Complex abdominal perineal reconstruction: options after pelvic bone resection. Plast Reconstr Surg 98:735–739
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3. Chen JJ, Giese S, Jeffrey RB et al (1999) Treatment and stabilization of complex wounds involving the pelvic bone, groin, and femur with the inferiorly based rectus abdominis musculocutaneous flap and the use of power color Doppler imaging in preoperative evaluation. Ann Plast Surg 43:494–498 4. Senchenkov A, Thomford NR, Barone FE (2003) Reconstruction of an extensive thigh defect with the paraumbilical TRAM flap. Ann Plast Surg 51:91–96 5. Rufer M, Plock JA, Erni D (2011) One hundred fascia-sparing myocutaneous rectus abdominis flaps: an update. J Plast Reconstr Aesthet Surg 64:209–215 6. Campbell CA, Butler CE (2011) Use of adjuvant techniques improves surgical outcomes of complex vertical rectus abdominis myocutaneous flap reconstructions of pelvic cancer defects. Plast Reconstr Surg 128:447–458 7. Kotti B (2014) Optimizing the pedicled rectus abdominis flap: revised designs and vascular classification for safer procedures. Aesthet Plast Surg 38:387–394 8. Zeng A, Xu J, Yan X, You L, Yang H (2006) Pedicled deep inferior epigastric perforator flap: an alternative method to repair groin and scrotal defects. Ann Plast Surg 57:285–288 9. Gourari A, Quignon R, Tabareau-Delalande F, De Pinieux G, Rosset P, Pucheux J, Samimi M, Lorette G, Goga D, Zakine G (2014) Thigh root reconstruction with a pedicled DIEP flap. Ann Chir Plast Esthet 59:212–214 10. Wang X, Qiao Q, Burd A, Liu Z, Zhao R, Song K et al (2007) A new technique of vaginal reconstruction with the deep inferior epigastric perforator flap: a preliminary report. Plast Reconstr Surg 119:1785–1790 11. Seyhan T, Borman H (2008) Pedicled deep inferior epigastric perforator flap for lower abdominal defects and genital reconstructive surgery. J Reconstr Microsurg 24:405–412
Eur J Orthop Surg Traumatol 12. Fang BR, Ameet H, Li XF, Lu Q, Wang XC, Zeng A, Qiao Q (2011) Pedicled thinned deep inferior epigastric artery perforator flap for perineal reconstruction: a preliminary report. J Plast Reconstr Aesthet Surg 64:1627–1634 13. Ye X, Wang C, Yu Y, Zheng S (2012) Pedicled deep inferior epigastric perforator flap for total phallic reconstruction. Ann Plast Surg 69:64–66 14. Schoeller T, Huemer GM, Otto-Schoeller A, Wechselberger G (2007) Correction of contour deformities of the hip region with a pedicled DIEP flap. Plast Reconstr Surg 119:212–215 15. Kim KS, Kim ES, Hwang JH, Lee SY (2011) Buttock reconstruction using a pedicled deep inferior epigastric perforator flap. Microsurgery 31:237–240
16. Kayikc¸iog˘lu A (2003) A new technique in scrotal reconstruction: short gracilis flap. Urology 61:1254–1256 17. Tobin GR, Day TG (1988) Vaginal and pelvic reconstruction with distally based rectus abdominis myocutaneous flaps. Plast Reconstr Surg 81:62–73 18. Qiu SS, Jurado M, Hontanilla B (2013) Comparison of TRAM versus DIEP flap in total vaginal reconstruction after pelvic exenteration. Plast Reconstr Surg 132:1020–1027 19. Egeberg A, Rasmussen MK, Sørensen JA (2012) Comparing the donor-site morbidity using DIEP, SIEA or MS-TRAM flaps for breast reconstructive surgery: a meta-analysis. J Plast Reconstr Aesthet Surg 65:1474–1480
123
ORIGINAL ARTICLE • PELVIS - TRAUMA
Deep inferior epigastric vessel-pedicled, muscle-sparing rectus abdominis myocutaneous (RAM) flap for reconstruction of soft tissue defects in pelvic area L. Zheng • Z. G. Dong • J. Zheng
Received: 18 September 2014 / Accepted: 31 December 2014 Springer-Verlag France 2015
Abstract Large soft tissue reconstruction in pelvic area is rare but remains challenging. Between August of 2000 and March of 2014, five patients underwent soft tissue reconstruction in pelvic area using deep inferior epigastric vessel-pedicled, muscle-sparing RAM flap. The soft tissue defects located in anterior iliac spine in three cases, lower buttock in one case, contralateral lower buttock and perineal region in one case. The size of the flaps ranged from 13 9 7 cm to 25 9 9 cm. All flaps were harvested in muscle-sparing form. Lateral two-thirds of rectus abdominis muscle and anterior sheath of the rectus abdominis muscle were harvested with the flap in disc or bar shape. All five flaps survived uneventfully. During the follow-up, no ventral hernias occurred in donor sites. Keywords Deep inferior epigastric Rectus abdominis myocutaneous flap Soft tissue defects Pelvic area Reconstruction
Introduction Soft tissue reconstruction in pelvic area remains challenging. The inferiorly based rectus abdominis island flaps were used for resurfacing soft tissue defects in buttock, pelvis, genital region, groin and anterior thigh [1–7]. The pedicled deep inferior epigastric perforator (DIEP) flaps have been used to resurface defects in buttock, groin, genital region and lateral hip [8–14]. But it may be difficult to repair lower and medial parts of buttock with this flap because of the limited length of the pedicle [15]. This article introduces our experience in reconstruction of soft tissue defects in pelvic area using the deep inferior epigastric vesselpedicled, muscle-sparing RAM flap. And the defects involved the lower and medial parts of the buttock in two cases were reconstructed.
Patients and methods
L. Zheng J. Zheng Department of Orthopedics, Henan Provincial People’s Hospital, Zhengzhou 450003, People’s Republic of China e-mail: [email protected] L. Zheng (&) Department of Surgery, Kleinert Kutz Hand Care Center, Christine M. Kleinert Institute for Hand and Microsurgery, School of Medicine, University of Louisville, 225 Abraham Flexner Way, Suite 850, Louisville, KY 40202, USA e-mail: [email protected] Z. G. Dong Department of Orthopedics, Second Xiangya Hospital, Central South University, Changsha 410011, People’s Republic of China e-mail: [email protected]
This study was conducted in accordance with the declaration of Helsinki. This study was conducted with approval from the Ethics Committee of Henan Provincial People’s Hospital. Written informed consent was obtained from all participants. Between August of 2000 and March of 2014, five patients underwent soft tissue reconstruction in pelvic area using the deep inferior epigastric vessel-pedicled muscle-sparing RAM flap. The ages ranged from 12 to 44 years. The soft tissue defects ranged from 11 9 6 cm to 22 9 8 cm. The soft tissue defects located in anterior iliac spine in three cases, lower buttock in one case, contralateral lower buttock and perineal region in one case. The defects were caused by car accident in three cases, caused by soft tissue necrosis after open reduction and internal fixation of iliac fracture in one case, caused by soft tissue
123
Eur J Orthop Surg Traumatol
necrosis after tumor resection in one case. All five cases were with bone exposure. One case was with a dead space measured 16 9 2.5 cm in left anterior superior iliac spine. The size of flap ranged from 13 9 7 cm to 25 9 9 cm. The flaps were designed vertically in three cases, obliquely in two cases. The defects located in ipsilateral lower buttock in one case, in contralateral lower buttock and perineal region in another case (details see Table 1).
After the flap was raised, the residual anterior sheath of rectus abdominis muscle was sutured directly to avoid the postoperative ventral hernia, no mesh was used. The flap was then transferred to the recipient site through a subcutaneous tunnel, all donor sites were closed directly without skin graft (Fig. 1d).
Results Operative technique Preoperative Doppler was not done routinely. Under general anesthesia, the patient was in lateral position. After debridement, the flap was designed about 15 % lager than the defects according the shape of the recipient site to avoid the postoperative tension in the flap (Fig. 1a). The flap was elevated from lateral to medial on the surface of the deep fascia. The flap was raised lateral to medial to the lateral border of the anterior sheath of rectus abdominis muscle (point B, Fig. 1b), where two or three perforators were identified. No further intramuscular dissection of the perforators was needed. The dissection of the deep inferior epigastric vessels was performed as caudal as possible. And in cranial direction, the dissection of the deep inferior epigastric vessels was done till to the point where the vessels went into the rectus abdominis muscle (point A, Fig. 1b). No further intramuscular dissection of the vessels was done. Lateral two-thirds of the rectus abdominis muscle and lateral two-thirds of anterior sheath of rectus abdominis muscle between point A and point B were harvested with the flap in disc or bar shape (Fig. 1c). If more muscle was needed to fill the dead space in recipient site, the more lateral two-thirds of the abdominis muscle could be taken.
All five flaps survived uneventfully. The infection was controlled in the two cases. During the follow-up (mean 59.1 months), no ventral hernia was observed (Fig. 2).
Discussion Major soft tissue reconstruction in pelvic area caused by trauma, tumor resection or postoperative soft tissue necrosis is rare but often presents a challenging problem. Small defects with bone exposure can be resurfaced by local or advancement flaps, but they usually do not provide sufficient tissue for large defects [15]. At the sacrifice of some functioning muscles, gracilis flap and rectus myocutaneous flap have been used for scrotal reconstruction and pelvic reconstruction [16, 17]. But the rotation arc of the two procedures is not comparable with the deep inferior epigastric vessel-pedicled muscle-sparing RAM flap. Some free tissue transplantations are used to repair large defects in pelvic area, but sometimes at the sacrifice of the function of the donor site especially when the defects are large. And also the operation time is longer, the microsurgery technique is needed. This deep inferior epigastric vessel-pedicled muscle-sparing RAM flap can provide sufficient tissue to resurface large defects in some pelvic areas. The procedures we used are relative
Table 1 Summary of the patients Patient
Sex
Age (years)
Cause
Recipient site
Features of lesion
Flap size (cm 9 cm)
Complications
1a
F
44
Car accident
Right lower buttock and perineal region
Bone exposure in right ischial tuberosity with infection
25 9 9
No
2
M
36
Car accident
Left anterior iliac spine
Bone exposure in left iliac spine, accompanied with infection and a dead space
17 9 8
No
3
M
12
Soft tissue necrosis after tumor resection
Right lower buttock
Bone exposure in right hip
20 9 9
No
4
F
38
Soft tissue necrosis postpelvic operation
Left anterior iliac spine
Bone exposure in left anterior iliac spine
13 9 7
No
5
M
36
Car accident
Left anterior iliac spine
Bone exposure in left anterior iliac spine
16 9 8
No
a
The flap was designed in contralateral abdominal wall, because of the contusion of ipsilateral abdominal wall
123
Eur J Orthop Surg Traumatol
Fig. 1 a Flap design. b, c Lateral two-thirds of rectus abdominis muscle and anterior sheath of rectus abdominis muscle between point A and point B were harvested with the flap. d Flap was transferred to the recipient site through subcutaneous tunnel
simpler compared with free tissue transplantation. The most challenging part of raising the DIEP flap was dissection of the perforators through its intramuscular course [18]. Thus, our procedures are more rapid and safer, because no further intramuscular dissection of the vessels is needed. In the second case, the middle and lateral twothirds parts of the rectus abdominis muscle sized 16 9 2.5 cm in bar shape were harvested with the flap to fill the dead space. The muscle tissue with sufficient blood supply for the dead space, that is good for controlling the infection. Egeberg et al. [19] compared the donor-site morbidity between DIEP and muscle-sparingtransverse RAM (TRAM) flaps for breast reconstructive surgery, their studies found approximately the same risk
of bulge formation between DIEP and TRAM flap patients. Kim reported that a pedicled oblique DIEP flap can be used for the reconstruction of large buttock defects, but it may be difficult to repair the lower and medial parts of the buttock with this flap due to the limited pedicle length [15]. In order to get larger flaps, we designed two flaps in oblique form. In the five cases, the defects involved the lower and medial parts of the buttocks in two cases; the defects were resurfaced by the deep inferior epigastric vessel-pedicled muscle-sparing RAM oblique flaps from ipsilateral or contralateral abdominal wall. The deep inferior epigastric vessel-pedicled muscle-sparing RAM flap in oblique form could be a better choice when a larger flap is required.
123
Eur J Orthop Surg Traumatol Fig. 2 a Soft tissue necrosis after tumor resection in right lower buttock. b Flap measuring 20 9 9 cm was designed in oblique form. c Flap was transferred to the recipient site through subcutaneous tunnel. d Two weeks postoperatively
Conclusions The deep inferior epigastric vessel-pedicled muscle-sparing RAM flap is an alternative to reconstruct soft tissue defects in anterior superior iliac spine, ischial tuberosity, perineal region and lower buttock. Besides the advantages such as rapid procedures, robust blood supply, a large arc of rotation and low donor-site morbidity, parts of rectus abdominis muscle could be harvested with the flap if needed. The major disadvantage of this technique is the obvious lineal abdominal scar. Acknowledgments We thank Ross Gibson for his help review and editing of the manuscript. Conflict of interest The authors confirm that they have received no financial assistance relevant to this paper and have no conflict of interest regarding this paper.
References 1. Gu¨rlek A, Demir CY, Askar I, Aydog˘an H, Alaybeyoglu N, Coban YK (2005) A transverse rectus abdominis myocutaneous (TRAM) flap for reconstruction of a large deformity in the buttock: a new indication for a TRAM flap. Scand J Plast Reconstr Surg Hand Surg 39:95–99 2. Evans GR, Goldberg DP, Ames FC (1996) Complex abdominal perineal reconstruction: options after pelvic bone resection. Plast Reconstr Surg 98:735–739
123
3. Chen JJ, Giese S, Jeffrey RB et al (1999) Treatment and stabilization of complex wounds involving the pelvic bone, groin, and femur with the inferiorly based rectus abdominis musculocutaneous flap and the use of power color Doppler imaging in preoperative evaluation. Ann Plast Surg 43:494–498 4. Senchenkov A, Thomford NR, Barone FE (2003) Reconstruction of an extensive thigh defect with the paraumbilical TRAM flap. Ann Plast Surg 51:91–96 5. Rufer M, Plock JA, Erni D (2011) One hundred fascia-sparing myocutaneous rectus abdominis flaps: an update. J Plast Reconstr Aesthet Surg 64:209–215 6. Campbell CA, Butler CE (2011) Use of adjuvant techniques improves surgical outcomes of complex vertical rectus abdominis myocutaneous flap reconstructions of pelvic cancer defects. Plast Reconstr Surg 128:447–458 7. Kotti B (2014) Optimizing the pedicled rectus abdominis flap: revised designs and vascular classification for safer procedures. Aesthet Plast Surg 38:387–394 8. Zeng A, Xu J, Yan X, You L, Yang H (2006) Pedicled deep inferior epigastric perforator flap: an alternative method to repair groin and scrotal defects. Ann Plast Surg 57:285–288 9. Gourari A, Quignon R, Tabareau-Delalande F, De Pinieux G, Rosset P, Pucheux J, Samimi M, Lorette G, Goga D, Zakine G (2014) Thigh root reconstruction with a pedicled DIEP flap. Ann Chir Plast Esthet 59:212–214 10. Wang X, Qiao Q, Burd A, Liu Z, Zhao R, Song K et al (2007) A new technique of vaginal reconstruction with the deep inferior epigastric perforator flap: a preliminary report. Plast Reconstr Surg 119:1785–1790 11. Seyhan T, Borman H (2008) Pedicled deep inferior epigastric perforator flap for lower abdominal defects and genital reconstructive surgery. J Reconstr Microsurg 24:405–412
Eur J Orthop Surg Traumatol 12. Fang BR, Ameet H, Li XF, Lu Q, Wang XC, Zeng A, Qiao Q (2011) Pedicled thinned deep inferior epigastric artery perforator flap for perineal reconstruction: a preliminary report. J Plast Reconstr Aesthet Surg 64:1627–1634 13. Ye X, Wang C, Yu Y, Zheng S (2012) Pedicled deep inferior epigastric perforator flap for total phallic reconstruction. Ann Plast Surg 69:64–66 14. Schoeller T, Huemer GM, Otto-Schoeller A, Wechselberger G (2007) Correction of contour deformities of the hip region with a pedicled DIEP flap. Plast Reconstr Surg 119:212–215 15. Kim KS, Kim ES, Hwang JH, Lee SY (2011) Buttock reconstruction using a pedicled deep inferior epigastric perforator flap. Microsurgery 31:237–240
16. Kayikc¸iog˘lu A (2003) A new technique in scrotal reconstruction: short gracilis flap. Urology 61:1254–1256 17. Tobin GR, Day TG (1988) Vaginal and pelvic reconstruction with distally based rectus abdominis myocutaneous flaps. Plast Reconstr Surg 81:62–73 18. Qiu SS, Jurado M, Hontanilla B (2013) Comparison of TRAM versus DIEP flap in total vaginal reconstruction after pelvic exenteration. Plast Reconstr Surg 132:1020–1027 19. Egeberg A, Rasmussen MK, Sørensen JA (2012) Comparing the donor-site morbidity using DIEP, SIEA or MS-TRAM flaps for breast reconstructive surgery: a meta-analysis. J Plast Reconstr Aesthet Surg 65:1474–1480
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