Abdominoplasty as the Impetus for Selection of the Deep Inferior Epigastric Artery Perforator Free Flap for Non-breast Reconstruction

Fig. 26.1

(a) Following skin grafting of most of the right lower extremity in this young woman, some instability still persisted around the patella. (b) Shrinkage of the popliteal grafts prohibited full knee extension while also causing an equinus deformity of the foot

Fig. 26.2

Tentative abdominoplasty design about the deep inferior epigastric perforators marked “x” in periumbilical region, with the superior border actually moved several centimeters above the umbilicus to encompass them. The lowest lower boundary markings would have been used if the superficial inferior epigastric system was found to be adequate, but that was not the case

In order to insure adequate vascularization to both lower hemi-abdomens needed to cover as much of the right lower extremity as possible, both deep inferior epigastric pedicles and their perforators were harvested (Fig. 26.3). After release of the popliteal contracture, the popliteal vessels served in end-to-side fashion as the microvascular recipient site. Full knee extension was then possible (Fig. 26.4), with modest improvement of the quality and contour of her right thigh. The lower abdomen donor site was closed to give the typical abdominoplasty appearance and improvement (Fig. 26.5).

Fig. 26.3

Huge lower abdomen apron free flap based on bilateral deep inferior epigastric vessels (DIEV) that in turn each supplied two cutaneous perforators. The left DIEV were anastomosed to its right counterpart, and then the latter to the popliteal recipient site

Fig. 26.4

Healthy DIEP free flap that replaced the popliteal skin grafts and relieved the knee flexion contracture

Fig. 26.5

Abdominoplasty closure of the lower abdomen donor site

26.4 Discussion

The DIEP free flap, except as indicated for breast reconstruction, has been rarely described for other reconstructive purposes. Those meager reports have included DIEP flap use for defects of the lower leg [9, 10] and as a local rotation flap for groin coverage [11]. This author has also added a small series when the DIEP free flap was used for traumatic knee wounds, encompassing a group of women who all actually wanted an abdominoplasty more than they did limb salvage [4]! The reason for the limited versatility of the DIEP flap, of course, is the usual extreme bulk of the flap that might impede joint movement or wearing of clothing depending on the location of the recipient site. Note that Van Landuyt et al. [9] performed “liposculpture” for DIEP flap debulking only on a delayed basis for 100 % of their female patients, who all had had a non-breast DIEP flap with additional costs incurred. Koshima et al. [12] and others [13] have performed immediate thinning of these abdominal flaps to avoid any added expense; but as Rozen et al. [14

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