The deep inferior epigastric artery perforator flap: a narrative review on its various uses in non-breast reconstruction

Introduction

Free tissue transfers have revolutionized the reconstruction of soft tissue defects. Since Hartrampf first described the transverse rectus abdominis muscle (TRAM) flap in 1982, the abdomen has been recognized as an invaluable source of autologous donor tissue (1). In 1989, Koshima and Soeda (2) published the first case of inferior epigastric skin flaps without the rectus abdominis muscle and subsequently, described the paraumbilical perforator variation. This came to be known as the deep inferior epigastric artery perforator (DIEP) flap, which was then popularized by Allen and Treece in 1994 (3). It has since become the gold standard in autologous breast reconstruction (4). Indeed, it is considered to be the most reliable flap for this type of reconstruction, even in the elderly population (5), with published flap failure rates ranging from less than 1 to 4 percent (6). With further progress, the goal of DIEP breast reconstruction has evolved from flap success to minimizing complications and maximizing aesthetic outcomes and operative efficiency. Despite the DIEP flap’s well-established usage in breast reconstruction, its application in the reconstruction of other body areas remains uncommon and is not usually a first-choice option in other reconstructive settings. Mayo-Yáñez et al. (7) have published a systematic evaluation on the use, applications, and outcomes of the DIEP flap in the head and neck region, which reflects growing interest in such non-breast applications. Their review found that the DIEP flap could be an alternative for treating complex, three-dimensional head and neck abnormalities while maintaining low donor site morbidity. They also examined the DIEP flap’s advantages and disadvantages.

Therefore, we examined the usage of the DIEP free flap for all non-breast reconstructions to provide a more comprehensive report. In this context, we analyzed the benefits and drawbacks of the DIEP flap in comparison to alternative flaps, depending on the target body region. We present the following article in accordance to the Narrative Review reporting checklist (available at https://atm.amegroups.com/article/view/10.21037/atm-22-2623/rc).

Methods

The authors first conducted a comprehensive literature search for articles published up to February 2022 using PubMed. We used the following key words: “DIEP flap” OR “deep inferior epigastric perforator flap”. We then expanded these terms to include the corresponding Medical Subject Headings and EMTREE subject headings. The search terminology is listed in Table 1 (search strategy summary). A total of 1,692 articles were identified. After removing duplicates, two reviewers (CG and ECT) separately screened the individual articles by reviewing the titles and abstracts to eliminate those unrelated to the current study. The same two reviewers then reviewed the full text of the remaining articles based on our inclusion and exclusion criteria: we included articles that (I) were in English or French and (II) where the DIEP flap was defined as an inferior epigastric artery skin flap without rectus abdominis muscle, used as a free flap or pedicled on the muscle perforators and the proximal deep inferior epigastric artery. Articles on breast reconstruction, and those that did not have the full-text available were excluded. Reference lists in the remaining articles were screened manually to identify potentially relevant studies that were not found during the initial search. Overall, 1,692 articles were identified, of which 105 fulfilled the inclusion criteria for this review.

The authors then conducted a second search with the same key words AND “breast” and found 1,129 articles.

Results

DIEP flap in breast reconstruction versus DIEP in non-breast reconstruction

Firstly, the literature search on DIEP flap for breast reconstruction retrieved 1,129 articles. These articles were compared with the 105 articles detailing the use of the DIEP flap for other anatomical areas of reconstruction.

Figure 1 showed that the vast majority (92%) of the current literature was on the use of the DIEP flap for breast reconstruction.

Figure 1 Available literature on DIEP flap for breast reconstruction compared to other anatomical areas. Only 105 articles were on the use of the DIEP flap in non-breast reconstruction (8%) compared to 1,129 articles on its use in breast reconstruction (92%). DIEP, deep inferior epigastric perforator.

Figure 2 categorized the different anatomical regions for usage of the DIEP flap for non-breast reconstruction based on the available literature. When an article presented cases on several anatomical sites, it was counted for separately in each region. The most frequent anatomical regions were the head and neck region with 28 articles (21%) and the lower limb with 26 articles (19%). This was followed by its use in gynecological reconstruction (21 articles, 16%), the upper limb (17 articles, 13%), and the thigh and hip (12 articles, 9%). Ten articles quoted its use in penoscrotal reconstruction (7%) and 8 detailed its use in groin reconstruction (6%). The remaining articles described its use in the reconstruction of sternal wounds (6 articles), buttocks, or the abdomen (6 articles).

Figure 2 Anatomical distribution of the use of the DIEP flap in non-breast reconstruction. The most common anatomical regions were the head and neck region (28 articles, 21%) and the lower limb with 26 articles (19%). This is followed by its use in gynecological reconstruction (21 articles, 16%), the upper limb (17 articles, 13%), and the thigh and hip (12 articles, 9%). Ten articles proposed its use in penoscrotal reconstruction (7%) and 8 articles were on its use in the groin region (6%). The remaining articles detailed its use in the reconstruction of sternal wounds (6 articles), buttocks, or the abdomen (6 articles). If an article discussed several cases of reconstruction in different anatomical areas, it is individually counted for in each area. DIEP, deep inferior epigastric perforator.

Lower limb

Twenty seven articles were on the use of the DIEP flap in lower limb reconstruction. Most were case series (16 articles, 135 patients) (8-23) and case reports (7 articles, 7 patients) (24-30). There were also four retrospective reviews (112 patients) (31-34).

Microsurgical reconstruction of the lower extremity is associated with a greater risk of flap failure than anywhere else in the body. This is because of suboptimal vascularity in the distal part of the lower limb and the continuous weight-bearing forces (32). Nevertheless, microsurgical advances are such that muscle flaps are no longer the only reconstructive option (35,36). Of the included articles, the reported total flap failure rate was up to 13% and partial flap necrosis up to 20%, mostly attributed to venous outflow issues (8-22).

The use of the DIEP flap in lower limb reconstruction has been reported in the context of trauma (11,18,19,21,23,30) and burns (18,23), oncology (18,33), aesthetics (27), infection (23,28), venous ulcers (19) and diabetes (9,17). Interestingly, such use is not limited to adults with good outcomes (13,15,23,26,31,34) but also reported in the pediatric population. Indeed, it has been noted that the relative size of the pedicle vessels in children are larger than that in adults (23). We reported in Table 2 the advantages and disadvantages of the DIEP flap in lower limb reconstruction.

The extended, bipedicled DIEP flap is one of—if not the—largest flap in the human body

The extended bilateral DIEP flap is commonly harvested (20,21,26,27) to maximize the length of the flap. According to Mahajan et al. (20), a bipedicled DIEP flap provides the equivalent of two or three perforator flaps with a single donor site scar. Ou et al. showed that it can be particularly useful in cases of extensive soft tissue loss such as in treating circumferential wounds (14). Yoshimatsu et al. (29) presented a case in which a 72-cm long DIEP free flap was successfully harvested with extra flap microvascular anastomoses for reconstruction of a lower leg with no suitable recipient vessels around the injury zone, and still achieved primary closure of the donor site. This very long flap allowed them to avoid using cross-leg free flaps, vein grafts, arteriovenous loops and their potential complications.

The DIEP flap can provide sufficient and well-vascularized tissue which is especially useful in patients with diabetes (9) and other vascular pathologies. Indeed, it avoids sacrificing major vessels such as the lateral circumflex femoral system which provides important collateral blood supply to ischemic extremities.

To further increase the available tissue size, pre-expansion of DIEP flaps has also been described (18,26,27). Melnikov et al. (27) described the use of a prefabricated bilateral DIEP flap in the reconstruction of a large tissues defect (50×25 cm²) after the excision of a giant pigmented nevus in the lower limb, with satisfactory results. In another case, Grinsell et al. (26) chose a pre-expanded DIEP flap over a pre-expanded anterolateral thigh (ALT) flap because the use of tissue expansion in the abdominal region has a lower risk of complications compared to the lower extremity (such as pre-expanded ALTs) (37).

The vascular anatomy of the abdomen is especially useful in the setting of the lower limb for venous drainage

Venous drainage issues often complicate lower limb reconstruction (38). Due to the unique vascular anatomy of the legs, it is important to account for venous congestion by positioning the flap appropriately to achieve a through-flow of venous blood. In this regard, abdominal tissue has inherent advantages when it comes to flap mobilization due to its relatively constant anatomy, an excess of tissue available for transfer, and a rich venous drainage system (superficial and deep) (27). Distal perfusion of the DIEP flap could be augmented by supercharging and superdraining via the superficial circumflex iliac artery (SCIA) system if needed (24).

The DIEP flap design can be versatile

The horizontal DIEP flap is the most commonly used design in breast reconstruction because it offers the secondary advantage of an abdominoplasty which can improve the patient’s body habitus. In lower limb reconstruction, this advantage has been highlighted by Hallock et al. (22), where three female patients chose the DIEP flap solely for this reason, while fully understanding the potential need for later flap revision to optimize the appearance and function of the flap at the recipient site. Other skin paddle designs have been described in the literature. These include the oblique (16,18) and vertical designs (12,19). The oblique design is similar to the deep inferior epigastric artery with inferior rectus abdominis flap as originally described by Taylor in 1984 (39), with the added advantage of minimizing donor site morbidity by preserving the rectus muscle. On the other hand, in the case of the vertical design, the operating time may be shorter compared to the classical transverse technique as it eliminates the need for a more extensive dissection. It also avoids unnecessary sacrifice of the contralateral flap (19). Nevertheless, the vertical/oblique donor site scar is not as aesthetically acceptable. In addition, the existence of multiple perforators allows a large flap to be raised (via intra-flap anastomoses of perforators from each abdominal side), while allowing surgeons to use ipsilateral perforators to harvest multiple skin paddles. Luo et al. (15) described a “kiss design” DIEP flap with two skin paddles, each on a different perforator, that can be rotated or translated to create various shapes and achieve good aesthetic and functional results.

The DIEP flap among other flaps for thigh and lower limb reconstruction

A retrospective review of 563 flaps by Abdelfattah et al. (32) showed that among the different laps used for lower limb reconstruction, the DIEP flap not only provides the largest size (836.2±210.3 cm²) and the longest pedicle (11.7±1.4 cm) but is also the thickest (11.1±3.9 mm). The ALT flap is a very popular free flap option for lower limb reconstruction. It can be raised from the contralateral limb without any need for intra-operative repositioning and can be taken as a thin flap (or thinned primarily after raising) to provide an acceptable profile in reconstructing soft tissue defects around the foot and ankle. Other commonly used fasciocutaneous free flap options include those from the radial forearm (for smaller defects), scapular and parascapular region (40).

A study by Cao et al. (31) compared the ALT perforator flap to the DIEP flap in pediatric patients. Their study showed that an ALT perforator flap may yield better results than a DIEP flap in terms of short- and long-term complications, scarring, and morpho-functional outcomes for pediatric patients undergoing reconstruction of foot and ankle defects. They showed that the ALT group have a significantly lower operative blood loss than the DIEP group and a lower flap necrosis rate (5.3% vs. 24.4%). In long-term follow-up, the ALT group showed a lower late complication rate and a better cosmetic and functional outcome than the DIEP group (P<0.05). Another article from the same authors (19) compared the DIEP flap to the circumflex scapular artery perforator (CSAP) flap for foot and ankle reconstruction of moderate-sized defects in pediatric patients. They concluded that the CSAP flap has a shorter operating and flap harvest time, lower fat hyperplasia rate, and better long-term cosmetic outcomes than the DIEP flap. They noticed that most DIEP flaps gained various degrees of bulkiness as patients grew and gain weight, despite the immediate smooth contour post-operatively.

Our study however, did not find any article comparing the CSAP flap to the DIEP flap in adult patients. When it comes to lower limb reconstruction, preservation of the femoral system provides an advantage. Other free flap options such as the latissimus dorsi perforator flap or scapular flap do preserve this femoral system as opposed to the ALT but they cannot be raised in the supine position, unlike the DIEP flap that has these two advantages (17). Besides that, the scapular flap uses skin of the back that is somewhat thick for foot coverage and does not match skin texture on the dorsum of the foot (21).

Hip and thigh reconstruction

There were eight articles on thigh reconstruction using the DIEP flap, five of which were isolated case reports (41-44); the remaining three were case series (5 patients) (45-47).

All were reconstruction cases after sarcoma resection (41-45,48). All authors used the DIEP flap in pedicled fashion (41,43,47-49) except Bota et al. (42), who described raising an abdominoplasty-like paddle and transferred it as a free flap. Scaglioni et al. (41). reported a case of a pedicled, split, extended vertical DIEP flap for reconstruction of the medial thigh compartment after sarcoma resection. In his report, the cranial part of the flap was de-epithelialized and used as an adipo-dermal thigh flap to fill the dead space, while the caudal part was used for skin closure. Fernández Garrido et al. (43) described a turbocharged bi-pedicled DIEP flap for reconstruction of the thigh without recipient vessels and coverage of a femoropopliteal bypass.

In a more recent literature review, Kotick (50) proposed the pedicled ALT perforator flap as the gold standard for reconstruction of the groin and complex, upper medial thigh defects. Among the pedicled perforator flaps employed in this area, the DIEP flap was not a common choice (41). However, it should be noted that an ideal flap for the reconstruction of soft tissue defects after radiotherapy at these anatomical regions should provide robust, non-irradiated tissue for the coverage of important structures such as blood vessels, nerves, and bone. The pedicled DIEP flap could thus be a good candidate that fulfills these criteria.

In hip reconstruction, three articles described the use of the pedicled DIEP flap (19,51) following trauma, infected hip prosthesis and for aesthetic reasons.

Upper limb

The main objectives in soft tissue reconstruction of the upper extremity are to restore function, with emphasis on avoiding prolonged immobilization that can cause joint stiffness, tendon adhesion, scar contractures, and ultimately, loss of function. There are some local flap options available, such as pedicled flaps based on the radial and ulnar arteries, which have their limitations when it comes to resurfacing larger defects. In addition, the use of local flaps could further compromise blood flow to an already injured upper extremity (52).

We found 17 articles describing the use of the DIEP flap in upper extremity reconstruction. Most of these were clinical series (9 articles) (10,13,15,18,36,53-56) and case reports (5 articles) (28,57-60). There were two retrospective reviews (52,61) (4 patients) comparing the use of the DIEP flap in upper limb reconstruction with other flap options such as the ALT, SCIA, superficial inferior epigastric artery (SIEA) and thoracodorsal perforator flaps. There was also a prospective study (18 patients) looking at consecutive DIEP flaps in the reconstruction of burns or scar contracture wounds of the upper extremity (61). The DIEP flap has been used in the context of trauma (11,18-21,23,29,30,54-56,59,61) and burns (55,57,58,60). Other uses are in cases of meningococcal (55) and mucormycosis (28) infections.

Most of the articles discussed the use of the DIEP flap in adult patients, with only two articles (5 patients, mean age =8 years) discussing the use of the DIEP flap in pediatric patients (14,23). We reported in Table 3 the advantages and disadvantages of the DIEP flap in upper limb reconstruction.

The DIEP flap design can be versatile

All articles described the use of the DIEP flap as a free flap, except three articles where it was used as pedicled flap. The pedicled DIEP flaps were used for elbow (56) and hand (60) reconstruction in two stages. There was also an article that described islanding of the DIEP flap to close the donor site after harvesting a superficial inferior epigastric artery flap for hand defect resurfacing (58).

For the upper extremity, the skin paddle design could be transverse, vertical or oblique. The flap could be harvested either above or below the level of the umbilicus (55). A trefoil-shaped flap was also described by Chew et al. (57) to reconstruct a right hand defect. The flap was raised from the left lower hemi-abdomen (17 cm × 13 cm) to resurface soft tissue defects at the volar aspect of the first webspace, the whole dorsal metacarpal area while the third part of the flap was sited at the dorsum of the first webspace.

Pre-expanded DIEP flaps were also used by Shang et al. (60) to resurface one or both sides of the hand after burn contracture excision. Simultaneous reconstruction of the thumb and first webspace using a DIEP flap has been reported in five cases by Li et al. (54). This is achieved by combining a free second toe transfer and a DIEP flap, where both arterial pedicles were anastomosed to the same recipient artery. A further case described the use of a laparoscopically-assisted, chimeric, peritoneal DIEP flap to provide coverage of exposed tendons in the hand and lower limb (10).

The DIEP flap amongst other flaps for upper limb reconstruction: better in large proximal upper arm defects than in the hand?

A review by Wang et al. (61) compared the ALT, SCIA, deep inferior epigastric perforator, superficial inferior epigastric artery, and flow-through flaps for upper extremity defects. The authors highlighted the fact that these flaps share several qualities: a well-concealed donor site, preservation of major arteries responsible for providing inflow to the distal extremity, and the potential for a concurrent two-team approach. These flaps also have the potential to be sensate, which is particularly important in the hand. According to the authors, the DIEP flap could be a feasible option for large, proximal upper arm defects. The bulkiness of these free flaps may require additional revision procedures such as liposuction to improve the contour. However, significant weight gain could lead to a subsequent increase in flap bulk on the upper extremity. For distal upper limb defects such as on the dorsum of the hand and wrist, the thin SCIA, groin or ALT flaps are preferred.

A separate paper by Hamdi et al. echoed the notion but advocates that the DIEP flap could be used for the reconstruction of dorsal hand defects by immediate flap thinning to obtain a better contour (55). This could be a viable option if other flap options such as the thoracodorsal artery perforator (TDAP) flap are unavailable (62). Chen et al. (53) reviewed four cases on the use of the DIEP flap for reconstruction of the thumb and first webspace, palm, dorsum of the hand, wrist, and forearm defects, comparing it to other free flaps such as the ALT and thoracodorsal perforator flaps. They concluded that DIEP flaps are generally at least 5 mm thick—more than other flap options. The authors thus suggested primary thinning with prior insertion of a silastic sheet at the lateral border of the rectus abdominis muscle one week prior to flap elevation, or defatting of the flap. Nevertheless, the authors acknowledged that while the DIEP flap may be more suitable for proximal upper limb defects, the ALT flap is otherwise a superior option in most cases of upper extremity reconstruction.

Head and neck

Immediate reconstruction of head and neck defects after oncological resection is now considered the gold standard of care. Reconstruction with vascularized tissue transfer minimizes postoperative complications by eliminating communication between the neck defect and the oral cavity by filling the dead space.

A systematic review on the use of the DIEP flap in head and neck reconstruction was recently published by Mayo-Yáñez et al. (7) in 2020. They reviewed 31 articles with 185 flaps and reported a 95% flap survival rate. In concordance with our findings in the current study, the authors agreed that the DIEP flap is the gold standard in breast reconstruction, but its use remains anecdotal in the head and neck. Their methodology and inclusion criteria are similar to our findings—of 31 articles included, 20 (64.52%) were case series, 9 (29.03%) case reports and 2 (6.45%) were preclinical studies. In the current study, we excluded three of the articles (cadaveric, preclinical and porcine) that were used in their review.

The most frequent sites of reconstruction were the tongue (30.51%) (63-72) and maxillary region (26.27%) (46,73,74). Several designs have been described, but most followed that described by Koshima (2), or with slight modifications according to the flap shape required. The preferred flap design was oblique or vertical based on the ipsilateral side, in the peri-umbilical region. This orientation of the DIEP flap provides a longer pedicle than the transverse orientation with the advantage of increased thickness, which is often a better fit for head and neck reconstruction (67,68,75). The abdominoplasty-like transverse design is also proposed in some of the articles (18,76,77) although some variations exist. Yano et al. (65) described a DIEP flap that has three lobes and a single perforator. Adding a shallow incision on the surface between the second and third lobe helps in creating a crease for three-dimensional spatial flap in-setting. This design could also be used to separate the DIEP flap into several smaller “islands”, similar to that previously used by Koshima et al. (63) with their “accordion” modification (66,78). Wisecarver et al. (79), proposed a four-lobe DIEP flap with flow-through intra-flap anastomosis. Miyamoto et al. (48) suggested a vertical peanut-shaped design for post-maxillectomy defects where the cephalic part of the skin paddle was used for nasal lining or the palate while the rest of the flap was de-epithelized for volume restoration to achieve a better facial contour. Other articles reported burying of the de-epithelized flap (80,81). The concept of tissue expansion prior to raising the DIEP flap has also been described by some of the papers to increase the final size of the raised flap (18,76,82,83).

In summary, the relatively constant vascular anatomy of the DIEP flap with its high flap survival rate and relatively low donor site morbidity makes it a great option for reconstructing complex head and neck defects (62). It is a feasible option in laryngopharyngeal reconstruction, although the ALT and radial forearm free (RFAF) flap remain the most common options for reconstructing these defects (63,64). The DIEP flap provides adequate bulk for reconstructing the orbital and maxillary regions, in addition to providing vascularized tissues that are sufficiently wide to provide coverage to the skull and exposed brain tissues if necessary.

We reported the advantages and disadvantages of the DIEP flap in head and neck reconstruction in Table 4.

Genito-crural reconstructions

Vaginal reconstruction

Vaginal reconstruction is usually performed for congenital vaginal agenesis, post-oncological resection, and in gender reassignment. Vaginal defects post-oncological resection is often challenging due to the need for adjuvant chemotherapy and radiotherapy. It requires careful planning to minimize the risk of delayed wound healing which could be detrimental. The primary goals of vaginal reconstruction are to improve the patients’ quality of life, return of sexual function and minimize the risk of developing empty pelvis syndrome (84).

Our literature review found 13 articles on vaginal reconstruction, consisting of four case series (84-87), two single case reports (88,89), three technical notes (90-92), two experimental studies (87,93), a review (94) and a letter to editor (95).

The first description of a pedicled DIEP flap for vaginal reconstruction was described in 2006 (96) for reconstruction of the external genitalia in a case of congenital vaginal agenesis. It has been described in a few other cases of congenital agenesis since (86,87,94,97). Apart from these unusual cases, this flap was used mostly in the context of oncological reconstruction (85-87,90,93,97) after primary resection (85) or in cases of recurrence (94). We reported in Table 5 the advantages and disadvantages of the DIEP flap in vaginal reconstruction. The advantages and disadvantages of the DIEP flap in vaginal reconstruction were reported in Table 6.

The pedicled DIEP flap is safe in vaginal reconstruction

The relative long length of the pedicle renders the DIEP flap a feasible and robust pedicled option for vaginal reconstruction. This obviates the need for microvascular anastomosis, as in the case of free flap. For perineal reconstruction, Fang et al. described the use of the DIEP flap as a pedicled island flap (87), thus reducing the risks inherent to free tissues transfer, such as anastomotic thrombosis.

Interestingly, loss of the pedicled DIEP flap has not been reported for vaginal reconstruction after pelvic exenteration, likely due to the relatively small number of cases and appropriate patient selection (85). In a study comparing the DIEP to the TRAM flap by Qiu et al. (93), 40 patients underwent vaginal reconstruction, 21 with TRAM flaps and seven with DIEP flaps: all DIEP flaps survived while three TRAM flaps were lost because of total necrosis, and another five developed partial flap necrosis.

The DIEP flap can form an effective neo vagina

The design of its skin paddle is versatile and follows the principles of propeller flaps. The orientation can be oblique (9,87,90) or vertical (85,86,88,89,91-93), depending on the availability of excess tissue for a neovagina. It is then folded onto itself and fashioned in a spiral orientation, with the epithelial surface as the inner lining of the neovagina.

The pedicled DIEP flap could be too bulky for vaginal reconstruction (86). For this reason, several articles have proposed thinning of the flap as part of the primary procedure (87,97). The authors concluded that the DIEP flap can provide a reliable and adequate soft tissue paddle for perineal reconstruction and that it can be thinned without damaging the tissues inferior to the superficial epigastric vein. This thinning allows the creation of a wider neovagina, while giving a more natural perineal appearance (87).

The DIEP flap could be the preferred flap after pelvic exenteration

Three types of pedicled flaps have been used frequently in vaginal reconstruction: the Singapore or pudendal thigh flap, the vertical rectus abdominis myocutaneous (VRAM) flap, and the gracilis flap. Of these, the most frequently used reconstruction technique is the muscle-sparing VRAM flap, which is generally easier to perform than DIEP reconstruction but has a higher incidence of abdominal wall complications. A 21% incidence of incisional hernias was reported with the VRAM as compared to less than 3% with the DIEP flap (93).

More recently, there has been a shift towards using the DIEP flap for circumferential vaginal reconstruction after pelvic exenteration compared to the VRAM (85,88,93). Similarly, the gracilis flap can achieve satisfactory results in perineal reconstruction, with the main disadvantage being that of sacrificing a functioning muscle. In addition, according to Wang et al. (86), the DIEP flap has the added advantage of being hairless (compared to the Singapore flap), odorless (skin paddle forming the neovagina), less contracture and stenosis, and provides reliable harvest due to its constant anatomy.

The DIEP flap addresses volume defects associated with pelvic tissue losses while protecting visceral and vascular structures. It also reduces the incidence of wound infections and fistula formation in irradiated areas (90). Nevertheless, its routine use in congenital agenesis is more debatable. Indeed, for some authors, the use of an insensate DIEP flap for vaginoplasty in congenital vaginal agenesis is unacceptable due to its inability to achieve a normal sex life in young patients (95). Some authors argue that this flap should be strictly limited to cases of vaginal reconstruction post oncological resection, or in extensive trauma; otherwise, rectosigmoid vaginoplasty is preferred.

Vulvar reconstruction

Our literature review found nine articles on vulvar reconstruction, consisting of four single case reports (98-101), three case series (87,102,103), a retrospective study (104) and a short communication with a video describing a surgical technique (105).

Vulvar defects following oncological resection are usually closed primarily by the gynecologist. Nevertheless, in cases of larger defects and irradiated vulvar tissues, reconstruction is usually achieved with musculocutaneous flaps, often bilateral. In addition, recurrence of vulvar carcinomas remains a difficult issue with up to 50% of women requiring a second surgical intervention within the first 14 months of diagnosis (106), and a 5-year recurrence rate of up to 33% (107,108). Secondary reconstruction becomes even more challenging when locoregional flaps have already been used or if the patient has had adjuvant radiotherapy.

Flap design and thinning

For vulvar reconstruction, a vertically oriented DIEP flap has been described by a few authors (99,100). On the other hand, a bilateral, transverse pedicled DIEP flap was used for extended vulvar reconstruction (98,101). Cheng et al. (102) described splitting and thinning of a transversely oriented DIEP flap to help with contouring and optimizing aesthetic outcomes. Santanelli et al. (100) described using the umbilicus for reconstruction of the distal urethra. The convexity of the mons pubis and vulva can be satisfactorily recreated simply and safely by thinning the adipose tissue beneath Scarpa’s fascia. This does not require the same extensive thinning compared to cases of vaginal and scrotal reconstruction. This anatomical region also has a relative paucity of linking vessels so removal of this tissue is unlikely to affect flap perfusion (102).

The DIEP flap is a useful tool in extensive vulvar reconstruction

The ideal flap for vulvar reconstruction has the characteristics of providing a large volume of well-vascularized tissue of matching tissue thickness. It should provide restoration of both function and sensation, as well as a normal appearance and an inconspicuous donor site scar with minimal donor-site morbidity (102).

Negosanti et al. (103) proposed a reconstructive algorithm based on the topography of the external vulvar defect. According to the proposed algorithm, all external vulvar defects without any vaginal involvement can be repaired with lotus petal flaps. In cases of wider resection, including other pelvic organs, the algorithm suggests the use of the DIEP flap for reconstructive purposes. Similarly, other authors (100) have also suggested limiting the use of the DIEP flap to cases with extensive vulvar defects, where the distal third of the vagina or the anus are involved.

Advantages of the DIEP flap include the robustness and reliability of its vascular pedicle, even after radiotherapy; its ability to provide a skin island with plenty of subcutaneous tissue that can be tailored to fill in dead space, and it does not involve an intra-operative change of patient position. It can be harvested transversely or vertically, and in cases with a previous midline laparotomy, without additional donor site scars. The donor site can also be closed primarily (103). Furthermore, in comparison to flaps raised from the thigh and other musculocutaneous options, the DIEP flap enables early post-operative mobilization and can reduce the length of hospital stay (100).

Penoscrotal and groin reconstruction

Penoscrotal

Our literature search returned five cases series (87,109-112) on penile reconstruction, after circumcision complications and penile amputation (109,111), for false hermaphroditism (109) (matching chromosomal and gonadal tissue sex, but mismatching external genitalia) and cases of penoscrotal Paget’s disease (87,112). For scrotal reconstruction, five articles were included: there were two case series (47,112), a commentary (113), and two case reports on reconstruction after Fournier’s gangrene (114,115). One of the cases required coverage of a soft tissue defect measuring 36 cm × 18 cm involving the testes, both sides of the groin, the left medial thigh, and perianal skin. This was successfully reconstructed using a left DIEP and bilateral ALT flaps (115).

The main goal of penile reconstruction is to achieve a watertight urethra with sufficient penile stiffness, and to provide a sensate penis for normal sexual function.

Ye et al. found that the neopenis tends to become tactile and erogenous six months after penile reconstruction (109). The intercostal nerves commonly found running alongside the perforating vessels of deep inferior epigastric vessels, if preserved, could provide sensate skin (116). In all cases of penile reconstruction, the DIEP flap was harvested as a pedicled flap with either a low abdominal skin paddle and additional costal cartilage graft (109), or a vertical skin paddle with (110) or without cartilage graft (87,111). Immediate flap ischaemia and flap loss was reported in one case, likely due to the pedicle having undue tension (111). The contralateral DIEP was then used without further complications. In the two cases reported by Ye et al. (109), one patient reported full sensation along the entire length of the neophallus, while the other reported partial sensory recovery of a 2-cm area near the pedicle at 1-year follow-up. A fistula occurred in one case that was then resected and redone at six months (109). No meatal stenosis was reported in these cases. Even though the flap was usually thinned primarily, several authors (87,113) still reported that the DIEP flap remains too bulky for penoscrotal reconstruction. Nevertheless, this disadvantage could be acceptable among elderly patients, considering the advantages of early ambulation provided by the pedicled DIEP flap as compared to skin grafting (112,113). We reported in Table 7 the advantages and disadvantages of the DIEP flap in penoscrotal reconstruction.

Groin reconstruction

We included seven articles on the DIEP flap for groin reconstruction. Kotick et al. (50) reported a case of groin scar contracture following a pedicled DIEP flap. Three out of their 105 reviewed cases used the DIEP flap for groin reconstruction (112,117,118) in lymphatic malformation, burn scar contracture release and coverage after resection of a Paget’s carcinoma. The authors found that in most cases, a pedicled flap was used, with the ALT flap being the most common. Our literature review found four other case reports or case series (47,48,117,119). All cases utilized the DIEP flap in pedicled fashion.

Scaglioni et al. (119) reported a case of total groin defect reconstruction with a lymphatic flow-through, pedicled DIEP flap using its superficial veins for lymphovenous anastomosis with good outcomes. This article suggests that the lymphatic flow- through DIEP flap might be a new solution in cases requiring both dead space obliteration and lymphatic drainage restoration in regions such as the groin due to its proximity to the inguinal lymph nodes where seroma, lymphocele, and lymphedema are often unavoidable complications.

Other reconstructions

Buttock reconstruction

Our literature review found two case reports on buttock reconstruction, one of which used the DIEP flap as a pedicled flap (120), while the other used it as a free flap (121). Both articles reported satisfactory results suggesting that the DIEP flap could be used for reconstruction of large buttock defects.

Abdominal reconstruction

We included four articles (111,122-124) on abdominal reconstruction with the DIEP flap where it was used as a pedicled flap. In these articles, the authors proposed that the long and robust vascular pedicle of the DIEP flap is ideal for its use in islanded, local advancement or ‘propeller’ rotation to adjacent abdominal wall defects. These cases used the DIEP flap for oncological reconstruction except a case by Monsivais et al. (123), where the flap was pre-expanded for burn resurfacing.

Sterno-thoracic reconstruction

Six articles on sterno-thoracic reconstructions were included. Three free DIEP flaps were used by Angrigiani et al. (125) to treat restricted chest wall expansion secondary to burn contracture. Several cases have been reported where the DIEP flap was used for the protection of underlying critical structures, such as the heart and lungs. Manley et al. (126) reported a case of a de-epithelized free DIEP flap for filling of dead space after resection of postpneumonectomy empyema. In another case reported by Inatomi et al., a bilobed pedicled DIEP flap was used (127) to prevent intestinal prolapse through an omental flap after heart transplantation. Sharma et al. (128). also used a bilateral pedicled DIEP flap in a case of chondrosarcoma of the sternum requiring wide local excision of the full thickness of the chest wall. A bilobed DIEP flap, extended with a superficial circumflex iliac artery perforator (SCIP) flap was used to reconstruct the soft tissue defect following resection of a refractory ulcer on the torso, was reported by Yoshimatsu et al. (33). Finally, Miyamoto et al. (48) reported a case of free DIEP reconstruction for an anterior chest wall defect after dermatofibrosarcoma excision.

Discussion

In the late 1970s and early 1980s, musculocutaneous flaps were popularized for pedicled flap reconstruction of large soft tissue defects. The success of musculocutaneous flaps is often attributed to the robust blood supply to the muscle and its usefulness in providing bulk for volume defect (129).

When first described in 1994, the use of the free DIEP flap for breast reconstruction was considered new and unconventional. However, over time, the DIEP flap has become the gold standard in autologous breast reconstruction (130). The abdominal region is a robust donor site for free tissue transfers, offering relatively large skin and soft tissues for reconstructive use. Partial necrosis of the flap is always an existing risk, especially for longer flaps, and is mostly attributed to venous outflow issues but can be prevented by supercharging and superdraining via the SCIA system if needed. The laxity of abdominal skin also minimizes the risks of donor site morbidity and it can almost always be closed primarily. It has been used successfully in a variety of anatomical regions, especially for larger defects but not only, and the authors believe that its use in regions other than the breast could become more common thanks to the numerous advantages associated with this flap.

Most of the reports were case reports and the small number of reports could introduce publication bias, presenting only successful cases of reconstruction with the DIEP flap. In many case series, the various types of DIEP flaps were reported but not explained in detail. As previously reported in a head and neck review by Mayo-Yáñez et al. (7), the workgroup with the largest number of publications on the use of DIEP flap is Koshima’s (2,25,63,64). It is also worth noting that non-breast reconstruction using the DIEP flap is not a common technique employed by most reconstructive surgeons. Those who publish the different reports are usually from the same working groups [Yano et al. (65,66), Zhang et al. (67,75,104) or Kostakoğlu et al. (18,76)].

It is also interesting to note that the versatility of DIEP flap for use in non-breast reconstruction was first proposed as early as 1999 by Classen (47) but has only gained some traction in the past decade. We hope that this review will provide a useful summary of the pros and cons of the DIEP flap in non-breast reconstruction and raise awareness amongst our colleagues, in the hope of benefiting our future patients.

Conclusions

The DIEP flap can be used as a pedicled flap in the reconstruction of pelvic, ischial, perineal and thigh regions up to the lower third or as a free flap when needed. It is a good option for reconstruction of the ventral part of the body, especially when the patient is supine. The DIEP flap is also useful when the reconstruction does not require a particularly thin flap, although some authors have suggested that it can be safely thinned primarily or in secondary procedures. The DIEP flap’s size can be increased as necessary by utilizing pre-expansion. The feasibility and safety of doing so has been previously demonstrated. Furthermore, its reliable vascular anatomy and long pedicle make it particularly useful when no reliable vascular recipient is available adjacent to the defect such as in trauma or post-radiation cases. Its versatile skin paddle designs can address a variety of defect sizes and contours specific to different anatomical regions. From the traditional horizontal, abdominoplasty-like paddle to an oblique design and a vertical, customized skin paddle, possibilities with the DIEP flap are limitless. Additionally, by incorporating multiple perforators, it allows the creation of different skin paddles that can be rotated or tailor-matched to specific defect shapes and sizes.

As was the case when it was first introduced and considered anecdotal, we believe that the use of the DIEP flap in reconstruction of other regions will gradually become more accepted and mainstream. Hence, Plastic Surgeons should familiarize themselves with this flap as it will most likely become an indispensable reconstructive tool in future beyond breast reconstruction. This is particularly applicable to the reconstruction of large, proximal upper and lower limb defects. With regard to head and neck defects, it provides adequate bulk for volume defects of the orbit and maxilla, besides providing protection for the skull or exposed brain tissues. For genital reconstructions, the DIEP flap is safe and effective in vaginal reconstruction and useful in extensive external vulvar defects when the vagina is also involved. We do not believe however, that the DIEP flap should be used for penoscrotal reconstruction due to the flap being bulky, even after primary thinning. It may be considered acceptable for elderly patients with more emphasis on functional rather than aesthetic outcomes as it allows for early ambulation when compared to resurfacing with skin grafts.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://atm.amegroups.com/article/view/10.21037/atm-22-2623/rc

Peer Review File: Available at https://atm.amegroups.com/article/view/10.21037/atm-22-2623/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://atm.amegroups.com/article/view/10.21037/atm-22-2623/coif). AGL serves as an unpaid editorial board member of Annals of Translational Medicine from December 2020 to November 2022. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Hartrampf CR, Scheflan M, Black PW. Breast reconstruction with a transverse abdominal island flap. Plast Reconstr Surg 1982;69:216-25. [Crossref] [PubMed]
2. Koshima I, Soeda S. Inferior epigastric artery skin flaps without rectus abdominis muscle. Br J Plast Surg 1989;42:645-8. [Crossref] [PubMed]
3. Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg 1994;32:32-8. [Crossref] [PubMed]
4. Blondeel PN. One hundred free DIEP flap breast reconstructions: a personal experience. Br J Plast Surg 1999;52:104-11. [Crossref] [PubMed]
5. Dejean MF, Dabi Y, Goutard M, et al. Deep inferior epigastric perforator free flap in elderly women for breast reconstruction: The experience of a tertiary referral center and a literature review. Breast J 2021;27:700-5. [Crossref] [PubMed]
6. Kelley BP, Ahmed R, Kidwell KM, et al. A systematic review of morbidity associated with autologous breast reconstruction before and after exposure to radiotherapy: are current practices ideal? Ann Surg Oncol 2014;21:1732-8. [Crossref] [PubMed]
7. Mayo-Yáñez M, Rodríguez-Pérez E, Chiesa-Estomba CM, et al. Deep inferior epigastric artery perforator free flap in head and neck reconstruction: A systematic review. J Plast Reconstr Aesthet Surg 2021;74:718-29. [Crossref] [PubMed]
8. Duffy FJ Jr, Brodsky JW, Royer CT. Preliminary experience with perforator flaps in reconstruction of soft-tissue defects of the foot and ankle. Foot Ankle Int 2005;26:191-7. [Crossref] [PubMed]
9. Ozkan O, Coşkunfirat OK, Ozgentaş HE. Reliability of free-flap coverage in diabetic foot ulcers. Microsurgery 2005;25:107-12. [Crossref] [PubMed]
10. Guo E, Xie Q, Zhu Z, et al. Laparoscopy-assisted Chimeric Peritoneal-deep Inferior Epigastric Perforator Flap for Reconstruction of Hand and Foot. Wounds 2018;30:36-40.
11. Ayestaray B, Elbaz M, Lelievre H, et al. Reconstruction of post-traumatic drop foot deformity by the chimeric deep inferior epigastric artery perforator free flap associated with a composite quadriceps osteotendinous graft. Microsurgery 2016;36:334-8. [Crossref] [PubMed]
12. Akdag O, Karamese M, Yıldıran GU, et al. Foot and ankle reconstruction with vertically designed deep inferior epigastric perforator flap. Microsurgery 2018;38:369-74. [Crossref] [PubMed]
13. Tang J, Fang T, Song D, et al. Free deep inferior epigastric artery perforator flap for reconstruction of soft-tissue defects in extremities of children. Microsurgery 2013;33:612-9. [Crossref] [PubMed]
14. Ou Q, Wu P, Zhou Z, et al. Algorithm for covering circumferential wound on limbs with ALTP or/and DIEP flaps based on chain-linked design and combined transplantation. Injury 2021;52:1356-62. [Crossref] [PubMed]
15. Luo Z, Qing L, Zhou Z, et al. Reconstruction of Large Soft Tissue Defects of the Extremities in Children Using the Kiss Deep Inferior Epigastric Artery Perforator Flap to Achieve Primary Closure of Donor Site. Ann Plast Surg 2019;82:64-70. [Crossref] [PubMed]
16. Van Landuyt K, Blondeel P, Hamdi M, et al. The versatile DIEP flap: its use in lower extremity reconstruction. Br J Plast Surg 2005;58:2-13. [Crossref] [PubMed]
17. Ohta M, Ikeda M, Togo T, et al. Limb salvage of infected diabetic foot ulcers with free deep inferior epigastric perforator flaps. Microsurgery 2006;26:87-92. [Crossref] [PubMed]
18. Kostakoğlu N, Keçik A. Deep inferior epigastric artery (DIEA) skin flap: clinical experience of 15 cases. Br J Plast Surg 1998;51:25-31. [Crossref] [PubMed]
19. Tan O. Versatility of the vertical designed deep inferior epigastric perforator flap. Microsurgery 2009;29:282-6. [Crossref] [PubMed]
20. Mahajan AL, Van Waes C, D'Arpa S, et al. Bipedicled DIEAP flaps for reconstruction of limb soft tissue defects in male patients. J Plast Reconstr Aesthet Surg 2016;69:920-7. [Crossref] [PubMed]
21. Masuoka T, Nomura S, Yoshimura K, et al. Deep inferior epigastric perforator flap for foot reconstruction using an external pedicle. J Reconstr Microsurg 2005;21:231-4. [Crossref] [PubMed]
22. Hallock GG. Abdominoplasty as the patient impetus for selection of the deep inferior epigastric artery perforator free flap for knee coverage. Microsurgery 2014;34:102-5. [Crossref] [PubMed]
23. Van Landuyt K, Hamdi M, Blondeel P, et al. Free perforator flaps in children. Plast Reconstr Surg 2005;116:159-69. [Crossref] [PubMed]
24. Qing LM, Tang JY. Use of intraflap and extraflap microvascular anastomoses in combination for facilitating bipedicled DIEP/SIEA free flap for reconstruction of circumference soft tissue defect of extremity. Microsurgery 2019;39:190-1. [Crossref] [PubMed]
25. Koshima I, Nanba Y, Tsutsui T, et al. Perforator flaps in lower extremity reconstruction. Handchir Mikrochir Plast Chir 2002;34:251-6. [Crossref] [PubMed]
26. Grinsell D, Saravolac V, Rozen WM, et al. Pre-expanded bipedicled deep inferior epigastric artery perforator (DIEP) flap for paediatric lower limb reconstruction. J Plast Reconstr Aesthet Surg 2012;65:1603-5. [Crossref] [PubMed]
27. Melnikov DV, Starceva OI, Ivanov SI, et al. A Unique Case of Lower Limb Soft Tissue Reconstruction with a Prefabricated Bipedicled Deep Inferior Epigastric Artery Flap. Plast Reconstr Surg Glob Open 2020;8:e2976. [Crossref] [PubMed]
28. Reinbold C, Derder M, Hivelin M, et al. Using free flaps for reconstruction during infections by mucormycosis: A case report and a structured review of the literature. Ann Chir Plast Esthet 2016;61:153-61. [Crossref] [PubMed]
29. Yoshimatsu H, Yamamoto T, Hayashi A, et al. Use of a 72-cm-long extended bilateral deep inferior epigastric artery perforator free flap for reconstruction of a lower leg with no suitable recipient vessel around the injury zone: A case report. Microsurgery 2018;38:89-93. [Crossref] [PubMed]
30. Zeltzer AA, Van Landuyt K. Reconstruction of a massive lower limb soft-tissue defect by giant free DIEAP flap. J Plast Reconstr Aesthet Surg 2012;65:e42-5. [Crossref] [PubMed]
31. Cao ZM, Du W, Qing LM, et al. Reconstructive surgery for foot and ankle defects in pediatric patients: Comparison between anterolateral thigh perforator flaps and deep inferior epigastric perforator flaps. Injury 2019;50:1489-94. [Crossref] [PubMed]
32. Abdelfattah U, Power HA, Song S, et al. Algorithm for Free Perforator Flap Selection in Lower Extremity Reconstruction Based on 563 Cases. Plast Reconstr Surg 2019;144:1202-13. [Crossref] [PubMed]
33. Yoshimatsu H, Hayashi A, Karakawa R, et al. Combining the superficial circumflex iliac artery perforator flap with the superficial inferior epigastric artery flap or the deep inferior epigastric artery perforator flap for coverage of large soft tissue defects in the extremities and the trunk. Microsurgery 2020;40:649-55. [Crossref] [PubMed]
34. Sui X, Cao Z, Pang X, et al. Reconstruction of moderate-sized soft tissue defects in foot and ankle in children: Free deep inferior epigastric artery perforator flap versus circumflex scapular artery perforator flap. J Plast Reconstr Aesthet Surg 2019;72:1494-502. [Crossref] [PubMed]
35. Cho EH, Shammas RL, Carney MJ, et al. Muscle versus Fasciocutaneous Free Flaps in Lower Extremity Traumatic Reconstruction: A Multicenter Outcomes Analysis. Plast Reconstr Surg 2018;141:191-9. [Crossref] [PubMed]
36. Yazar S, Lin CH, Lin YT, et al. Outcome comparison between free muscle and free fasciocutaneous flaps for reconstruction of distal third and ankle traumatic open tibial fractures. Plast Reconstr Surg 2006;117:2468-75; discussion 2476-7. [Crossref] [PubMed]
37. Pandya AN, Vadodaria S, Coleman DJ. Tissue expansion in the limbs: a comparative analysis of limb and non-limb sites. Br J Plast Surg 2002;55:302-6. [Crossref] [PubMed]
38. Dodd SX, Morzycki A, Nickel KJ, et al. One or two venous pedicles by anastomoses for free flaps in reconstruction of the lower extremity: A systematic review and meta-analysis. Microsurgery 2021;41:792-801. [Crossref] [PubMed]
39. Taylor GI, Corlett RJ, Boyd JB. The versatile deep inferior epigastric (inferior rectus abdominis) flap. Br J Plast Surg 1984;37:330-50. [Crossref] [PubMed]
40. Shehan Hettiaratchy JC. Lower limb trauma - an overview. Rich's Vascular Trauma (Fourth Edition); 2022.
41. Scaglioni MF, Giunta G, Barth AA, et al. A pedicled split extended vertical deep inferior epigastric (s-vDIEP) flap and an adipo-dermal thigh local flap for the reconstruction of the medial thigh compartment after sarcoma resection: A case report. Microsurgery 2020;40:65-9. [Crossref] [PubMed]
42. Bota O, Spindler N, Sauber J, et al. Double-Pedicled Free Deep Inferior Epigastric Perforator Flap for the Coverage of Thigh Soft-Tissue Defect. Plast Reconstr Surg Glob Open 2017;5:e1372. [Crossref] [PubMed]
43. Fernández Garrido M, Pereira N, López Fernández S, et al. Turbocharged bilateral pedicled DIEP flap for reconstruction of thigh defect without recipient vessels: A case report. Microsurgery 2018;38:324-7. [Crossref] [PubMed]
44. Gourari A, Quignon R, Tabareau-Delalande F, et al. Thigh root reconstruction with a pedicled DIEP flap. Ann Chir Plast Esthet 2014;59:212-4. [Crossref] [PubMed]
45. Faramarz FK, Martin E, Paraskevas A, et al. Coverage of pelvis and thigh region by pedicled perforator flap like deep inferior epigastric perforator (DIEP). Ann Chir Plast Esthet 2005;50:733-8. [Crossref] [PubMed]
46. Miyamoto S, Arikawa M, Fujiki M. Deep inferior epigastric artery perforator flap for maxillary reconstruction. Laryngoscope 2019;129:1325-9. [Crossref] [PubMed]
47. Classen D. The extended deep inferior epigastric flap: a case series. Ann Plast Surg 1999;42:137-41. [Crossref] [PubMed]
48. Miyamoto S, Arikawa M, Kagaya Y. The use of lower abdominal perforator flaps in soft-tissue reconstruction after sarcoma resection. Microsurgery 2020;40:353-60. [Crossref] [PubMed]
49. Ruffenach L, Boeri C, Ronde Oustau C, et al. A pedicled deep inferior epigastric flap to cover a hip arthroplasty infection. Ann Chir Plast Esthet 2022;67:101-4. [Crossref] [PubMed]
50. Kotick JD, Sandelin RS, Klein RD. Deep Inferior Epigastric Perforator Free Flaps for Use in Complicated Groin Wound Repair: A Case Report of Severe Groin Scar Contracture and Review of Pedicled and Free Flaps in Groin Wound Repair. J Hand Microsurg 2017;9:101-6. [Crossref] [PubMed]
51. Schoeller T, Huemer GM, Otto-Schoeller A, et al. Correction of contour deformities of the hip region with a pedicled DIEP flap. Plast Reconstr Surg 2007;119:212-5. [Crossref] [PubMed]
52. Chim H, Ng ZY, Carlsen BT, et al. Soft tissue coverage of the upper extremity: an overview. Hand Clin 2014;30:459-73. vi. [Crossref] [PubMed]
53. Chen HC, Tang YB, Mardini S, et al. Reconstruction of the hand and upper limb with free flaps based on musculocutaneous perforators. Microsurgery 2004;24:270-80. [Crossref] [PubMed]
54. Li XJ, Tong J, Wang Y. Combined free toe and free deep inferior epigastric perforator flap for reconstruction of the thumb and thumb web space. J Reconstr Microsurg 2000;16:427-36. [Crossref] [PubMed]
55. Hamdi M, Van Landuyt K, Monstrey S, et al. A clinical experience with perforator flaps in the coverage of extensive defects of the upper extremity. Plast Reconstr Surg 2004;113:1175-83. [Crossref] [PubMed]
56. Seitchik SH, Granick MS, Solomon MP, et al. Posttraumatic upper extremity wound coverage utilizing the extended deep inferior epigastric flap. Ann Plast Surg 1992;28:465-71. [Crossref] [PubMed]
57. Chew BK, Chew DY, Kirkpatrick JJ, et al. The free thin DIEP flap in microsurgical reconstruction of severe hand contractures following burn injury. J Plast Reconstr Aesthet Surg 2008;61:1266-7. [Crossref] [PubMed]
58. Liu Y, Song B, Zhu S, et al. Reconstruction of the burned hand using a super-thin abdominal flap, with donor-site closure by an island deep inferior epigastric perforator flap. J Plast Reconstr Aesthet Surg 2010;63:e265-8. [Crossref] [PubMed]
59. Kim KS, Kim ES, Kim DY, et al. Resurfacing of a totally degloved hand using thin perforator-based cutaneous free flaps. Ann Plast Surg 2003;50:77-81. [Crossref] [PubMed]
60. Shang Z, Zhao Y, Ding H, et al. Repair of hand scars by a dilated deep inferior epigastric artery perforator flap. J Plast Surg Hand Surg 2011;45:102-8. [Crossref] [PubMed]
61. Wang HD, Alonso-Escalante JC, Cho BH, et al. Versatility of Free Cutaneous Flaps for Upper Extremity Soft Tissue Reconstruction. J Hand Microsurg 2017;9:58-66. [Crossref] [PubMed]
62. Hamdi M, Salgarello M, Barone-Adesi L, et al. Use of the thoracodorsal artery perforator (TDAP) flap with implant in breast reconstruction. Ann Plast Surg 2008;61:143-6. [Crossref] [PubMed]
63. Koshima I, Moriguchi T, Soeda S, et al. Free thin paraumbilical perforator-based flaps. Ann Plast Surg 1992;29:12-7. [Crossref] [PubMed]
64. Koshima I, Hosoda M, Moriguchi T, et al. New multilobe "accordion" flaps for three-dimensional reconstruction of wide, full-thickness defects in the oral floor. Ann Plast Surg 2000;45:187-92. [Crossref] [PubMed]
65. Yano T, Okazaki M, Kawaguchi R, et al. Tongue reconstruction with minimal donor site morbidity using a deep inferior epigastric perforator (DIEP) free flap in a 6-year-old girl. Microsurgery 2013;33:487-90. [Crossref] [PubMed]
66. Yano T, Sakuraba M, Asano T, et al. Head and neck reconstruction with the deep inferior epigastric perforator flap: a report of two cases. Microsurgery 2009;29:287-92. [Crossref] [PubMed]
67. Zhang B, Li DZ, Xu ZG, et al. Deep inferior epigastric artery perforator free flaps in head and neck reconstruction. Oral Oncol 2009;45:116-20. [Crossref] [PubMed]
68. López-Arcas JM, Arias J, Morán MJ, et al. The deep inferior epigastric artery perforator (DIEAP) flap for total glossectomy reconstruction. J Oral Maxillofac Surg 2012;70:740-7. [Crossref] [PubMed]
69. Li R, Zhang R, He W, et al. The Use of Venous Coupler Device in Free Tissue Transfers for Oral and Maxillofacial Reconstruction. J Oral Maxillofac Surg 2015;73:2225-31. [Crossref] [PubMed]
70. Leonhardt H, Mai R, Pradel W, et al. Free DIEP-flap reconstruction of tumour related defects in head and neck. J Physiol Pharmacol 2008;59:59-67.
71. Beausang ES, McKay D, Brown DH, et al. Deep inferior epigastric artery perforator flaps in head and neck reconstruction. Ann Plast Surg 2003;51:561-3. [Crossref] [PubMed]
72. Woodworth BA, Gillespie MB, Day T, et al. Muscle-sparing abdominal free flaps in head and neck reconstruction. Head Neck 2006;28:802-7. [Crossref] [PubMed]
73. Marchetti C, Gessaroli M, Cipriani R, et al. Use of "perforator flaps" in skull base reconstruction after tumor resection. Plast Reconstr Surg 2002;110:1303-9. [Crossref] [PubMed]
74. Sekido M, Yamamoto Y, Makino S. Maxillary reconstruction using a free deep inferior epigastric perforator (DIEP) flap combined with vascularised costal cartilages. J Plast Reconstr Aesthet Surg 2006;59:1350-4. [Crossref] [PubMed]
75. Zhang B, Wan JH, Wan HF, et al. Free perforator flap transfer for reconstruction of skull base defects after resection of advanced recurrent tumor. Microsurgery 2014;34:623-8. [Crossref] [PubMed]
76. Ağaoğlu G, Mavili E, Kostakoğlu N. Hair transplantation using a freely transferred nonhair-bearing skin flap. Ann Plast Surg 1999;43:649-52. [Crossref] [PubMed]
77. Guerra AB, Lyons GD, Dupin CL, et al. Advantages of perforator flaps in reconstruction of complex defects of the head and neck. Ear Nose Throat J 2005;84:441-7.
78. Masià J, Sommario M, Cervelli D, et al. Extended deep inferior epigastric artery perforator flap for head and neck reconstruction: a clinical experience with 100 patients. Head Neck 2011;33:1328-34. [Crossref] [PubMed]
79. Wisecarver IR, Mundinger GS, Tarakji MS, et al. Microsurgical Engineering: Bilateral Deep Inferior Epigastric Artery Perforator Flap with Flow-Through Intraflap Anastomosis. Plast Reconstr Surg Glob Open 2018;6:e1554. [Crossref] [PubMed]
80. Clemens MW, Davison SP. Buried deep inferior epigastric perforator flaps for complex head and neck contour defects. J Reconstr Microsurg 2009;25:81-8. [Crossref] [PubMed]
81. Hanasono MM, Skoracki RJ, Silva AK, et al. Adipofascial perforator flaps for "aesthetic" head and neck reconstruction. Head Neck 2011;33:1513-9. [Crossref] [PubMed]
82. Margulis A, Adler N, Eyal G. Expanded deep inferior epigastric artery perforator flap for reconstruction of the posterior neck and the upper back in a child with giant congenital melanocytic nevus. J Plast Reconstr Aesthet Surg 2010;63:e703-5. [Crossref] [PubMed]
83. Yanko-Arzi R, Gur E, Margulis A, et al. The role of free tissue transfer in posterior neck reconstruction. J Reconstr Microsurg 2014;30:305-12. [Crossref] [PubMed]
84. Johnson YL, West MA, Gould LE, et al. Empty pelvis syndrome: a systematic review of reconstruction techniques and their associated complications. Colorectal Dis 2022;24:16-26. [Crossref] [PubMed]
85. Ferron G, Gangloff D, Querleu D, et al. Vaginal reconstruction with pedicled vertical deep inferior epigastric perforator flap (diep) after pelvic exenteration. A consecutive case series. Gynecol Oncol 2015;138:603-8. [Crossref] [PubMed]
86. Wang X, Qiao Q, Burd A, et al. A new technique of vaginal reconstruction with the deep inferior epigastric perforator flap: a preliminary report. Plast Reconstr Surg 2007;119:1785-90. [Crossref] [PubMed]
87. Fang BR, Ameet H, Li XF, et al. Pedicled thinned deep inferior epigastric artery perforator flap for perineal reconstruction: a preliminary report. J Plast Reconstr Aesthet Surg 2011;64:1627-34. [Crossref] [PubMed]
88. Sawan D, Bosc R, La Padula S, et al. Immediate vaginal reconstruction following pelvic exenteration using the pedicled vertical Deep Inferior Epigastric Perforator (DIEP) flap: A technical note. Ann Chir Plast Esthet 2020;65:e1-5. [Crossref] [PubMed]
89. Dupré PF, Legoupil D, Vigouroux C, et al. Laparoscopy-assisted immediate vaginal reconstruction with a vertical pedicled deep inferior epigastric perforator flap for primary melanoma of the vagina. Clin Case Rep 2021;9:e04183. [Crossref] [PubMed]
90. Binder JP, Méria P, Desgrandchamps F, et al. Vaginal reconstruction after anterior pelvectomy by deep inferior epigastric perforator flap (DIEP). Ann Urol (Paris) 2006;40:192-202. [Crossref] [PubMed]
91. Belhadia M, Narducci F, Leblanc E, et al. How I do… to use indocyanine green to check the flap viability in vaginal reconstruction. Gynecol Obstet Fertil Senol 2019;47:484-6. [Crossref] [PubMed]
92. Angeles MA, Martínez-Gómez C, Martinez A, et al. Vaginal reconstruction after pelvic exenteration with a vertical deep inferior epigastric perforator flap in 10 steps. Int J Gynecol Cancer 2020;30:2015-6. [Crossref] [PubMed]
93. Qiu SS, Jurado M, Hontanilla B. Comparison of TRAM versus DIEP flap in total vaginal reconstruction after pelvic exenteration. Plast Reconstr Surg 2013;132:1020e-7e. [Crossref] [PubMed]
94. Angeles MA, Martínez-Gómez C, Migliorelli F, et al. Novel Surgical Strategies in the Treatment of Gynecological Malignancies. Curr Treat Options Oncol 2018;19:73. [Crossref] [PubMed]
95. Perovic SV. Re: a new technique of vaginal reconstruction with the deep inferior epigastric perforator flap: a preliminary report. Eur Urol 2008;53:856-7. [Crossref] [PubMed]
96. Wang X, Qiao Q, Burd A. Deep inferior epigastric perforator flap for vaginal reconstruction. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2006;20:537-9.
97. Ang Z, Qun Q, Peirong Y, et al. Refined DIEP flap technique for vaginal reconstruction. Urology 2009;74:197-201. [Crossref] [PubMed]
98. Bodin F, Robert E, Dissaux C, et al. Extended vulvar immediate reconstruction using the bilateral transverse pedicled DIEP flap. J Plast Reconstr Aesthet Surg 2015;68:745-7. [Crossref] [PubMed]
99. Muneuchi G, Ohno M, Shiota A, et al. Deep inferior epigastric perforator (DIEP) flap for vulvar reconstruction after radical vulvectomy: a less invasive and simple procedure utilizing an abdominal incision wound. Ann Plast Surg 2005;55:427-9. [Crossref] [PubMed]
100. Santanelli F, Paolini G, Renzi L, et al. Preliminary experience in reconstruction of the vulva using the pedicled vertical deep inferior epigastric perforator flap. Plast Reconstr Surg 2007;120:182-6. [Crossref] [PubMed]
101. Garví Morcillo J, Lara Peñaranda R, Martínez Cendán JP. Squamous cell carcinoma of the vulva together with vulvar lymphangiomatosis: vulvectomy and reconstruction (DIEP). Arch Gynecol Obstet 2021;303:1625-7. [Crossref] [PubMed]
102. Cheng A, Saint-Cyr M. Split and thinned pedicle deep inferior epigastric perforator (DIEP) flap for vulvar reconstruction. J Reconstr Microsurg 2013;29:277-82. [Crossref] [PubMed]
103. Negosanti L, Sgarzani R, Fabbri E, et al. Vulvar Reconstruction by Perforator Flaps: Algorithm for Flap Choice Based on the Topography of the Defect. Int J Gynecol Cancer 2015;25:1322-7. [Crossref] [PubMed]
104. Zhang W, Zeng A, Yang J, et al. Outcome of vulvar reconstruction in patients with advanced and recurrent vulvar malignancies. BMC Cancer 2015;15:851. [Crossref] [PubMed]
105. Rei M, Mota R, Paiva V, et al. Recurrence of vulvar carcinoma: A multidisciplinary approach. Gynecol Oncol Rep 2019;29:38-9. [Crossref] [PubMed]
106. Jones RW, Rowan DM, Stewart AW. Vulvar intraepithelial neoplasia: aspects of the natural history and outcome in 405 women. Obstet Gynecol 2005;106:1319-26. [Crossref] [PubMed]
107. Rouzier R, Haddad B, Plantier F, et al. Local relapse in patients treated for squamous cell vulvar carcinoma: incidence and prognostic value. Obstet Gynecol 2002;100:1159-67. [Crossref] [PubMed]
108. Gonzalez Bosquet J, Magrina JF, Gaffey TA, et al. Long-term survival and disease recurrence in patients with primary squamous cell carcinoma of the vulva. Gynecol Oncol 2005;97:828-33. [Crossref] [PubMed]
109. Ye X, Wang C, Yu Y, et al. Pedicled deep inferior epigastric perforator flap for total phallic reconstruction. Ann Plast Surg 2012;69:64-6. [Crossref] [PubMed]
110. Davies DM, Matti BA. A method of phalloplasty using the deep inferior epigastric flap. Br J Plast Surg 1988;41:165-8. [Crossref] [PubMed]
111. Seyhan T, Borman H. Pedicled deep inferior epigastric perforator flap for lower abdominal defects and genital reconstructive surgery. J Reconstr Microsurg 2008;24:405-12. [Crossref] [PubMed]
112. Zeng A, Xu J, Yan X, et al. Pedicled deep inferior epigastric perforator flap: an alternative method to repair groin and scrotal defects. Ann Plast Surg 2006;57:285-8. [Crossref] [PubMed]
113. Morris SF. Invited discussion: pedicled deep inferior epigastric perforator flap: an alternative method to repair groin and scrotal defects. Ann Plast Surg 2006;57:685-6. [Crossref] [PubMed]
114. Makino Y, Matsumine H, Fujimaki H, et al. Reconstruction of the Necrotic Scrotum with Hydrosurgery System and Pedicle DIEP Flap: A Case Report of Fournier Gangrene. Plast Reconstr Surg Glob Open 2020;8:e3135. [Crossref] [PubMed]
115. Kadota H, Momii K, Hanada M, et al. Simultaneous deep inferior epigastric and bilateral anterolateral thigh perforator flap reconstruction of an extended perineoscrotal defect in Fournier's gangrene: A case report. Microsurgery 2019;39:263-6. [Crossref] [PubMed]
116. Yap LH, Whiten SC, Forster A, et al. The anatomical and neurophysiological basis of the sensate free TRAM and DIEP flaps. Br J Plast Surg 2002;55:35-45. [Crossref] [PubMed]
117. Guerra AB, Metzinger SE. Use of the deep inferior epigastric perforator flap in a 15-month-old boy after resection of lymphatic malformation. J Pediatr Surg 2004;39:1428-31. [Crossref] [PubMed]
118. Eo S, Kim D, Jones NF. Microdissection thinning of a pedicled deep inferior epigastric perforator flap for burn scar contracture of the groin: case report. J Reconstr Microsurg 2005;21:447-50; discussion 451-2. [Crossref] [PubMed]
119. Scaglioni MF, Meroni M, Fritsche E, et al. Total groin defect reconstruction by lymphatic flow-through (LyFT) pedicled deep inferior epigastric artery perforator (DIEP) flap resorting to its superficial veins for lymphovenous anastomosis (LVA): A case report. Microsurgery 2022;42:170-5. [Crossref] [PubMed]
120. Kim KS, Kim ES, Hwang JH, et al. Buttock reconstruction using a pedicled deep inferior epigastric perforator flap. Microsurgery 2011;31:237-40. [Crossref] [PubMed]
121. Thomas A, Branford OA, Floyd D. Sitting on a gold mine: optimal autologous reconstruction of a significant cosmetic contour defect of the buttock using a deep inferior epigastric artery perforator free flap. J Plast Reconstr Aesthet Surg 2012;65:e153-5. [Crossref] [PubMed]
122. Ang GG, Rozen WM, Chauhan A, et al. The pedicled 'propeller' deep inferior epigastric perforator (DIEP) flap for a large abdominal wall defect. J Plast Reconstr Aesthet Surg 2011;64:133-5. [Crossref] [PubMed]
123. Monsivais SE, Webster ND, Wong S, et al. Pre-expanded Deep Inferior Epigastric Perforator Flap. Clin Plast Surg 2017;44:109-15. [Crossref] [PubMed]
124. Di Lorenzo S, Zabbia G, Corradino B, et al. A Rare Case of Giant Basal Cell Carcinoma of the Abdominal Wall: Excision and Immediate Reconstruction with a Pedicled Deep Inferior Epigastric Artery Perforator (DIEP) Flap. Am J Case Rep 2017;18:1284-8. [Crossref] [PubMed]
125. Angrigiani C, Artero G, Castro G, et al. Reconstruction of thoracic burn sequelae by scar release and flap resurfacing. Burns 2015;41:1877-82. [Crossref] [PubMed]
126. Manley K, Gelvez S, Meldon CJ, et al. Free deep inferior epigastric perforator flap used for management of post-pneumonectomy space empyema. Ann Thorac Surg 2013;95:e83-5. [Crossref] [PubMed]
127. Inatomi Y, Kadota H, Kaku K, et al. Omental and deep inferior epigastric artery perforator flap coverage after heart transplantation to manage wide left ventricular assist device exposure with pocket infection. J Artif Organs 2018;21:466-70. [Crossref] [PubMed]
128. Sharma RK, Mehrotra S, Dhaliwal RS. 'Extended deep inferior epigastric artery flaps' for reconstruction after excision of chondrosarcoma sternum. Br J Plast Surg 2005;58:1004-6. [Crossref] [PubMed]
129. Geddes CR, Morris SF, Neligan PC. Perforator flaps: evolution, classification, and applications. Ann Plast Surg 2003;50:90-9. [Crossref] [PubMed]
130. Depypere B, Herregods S, Denolf J, et al. 20 Years of DIEAP Flap Breast Reconstruction: A Big Data Analysis. Sci Rep 2019;9:12899. [Crossref] [PubMed]