The Pedicled Deep Inferior Epigastric Perforator (DIEP) Flap for Vulva Reconstruction

Case Report

Austin J Clin Case Rep. 2021; 8(2): 1196.

The Pedicled Deep Inferior Epigastric Perforator (DIEP) Flap for Vulva Reconstruction

Bachleitner K*, Ndhlovu M, Schoeller T, Amr A and Weitgasser L

Department of Hand, Breast and Reconstructive Microsurgery, Teaching Hospital of the University of Tubingen Germany

*Corresponding author: Kathrin Bachleitner, Department of Hand, Breast, and Reconstructive Microsurgery of the Center for Plastic Surgery at the Marienhospital Stuttgart, Teaching Hospital of the University of Tubingen, Boheimstr 37, 70199 Stuttgart, Germany

Received: February 12, 2021; Accepted: March 01, 2021; Published: March 08, 2021


Pain, scar contracture and soft tissue defects are common late sequel of acne inversa and Fournier’s gangrene. Aesthetical as well as functional reconstruction of the external vulva and labia majora can be very challenging. We present two cases where a pedicled Deep Inferior Epigastric Perforator (DIEP) flap for vulva reconstruction was implemented. In order to reconstruct both labia majora, we partially split the flap and raised a bilaterally pedicled DIEP flap. Many local flap techniques have been published on vulvar reconstruction. The aim of this paper is a discussion of the present literature and a review of current strategies for soft tissue restoration with the DIEP flap for vulva reconstruction. Wepresent and discuss two cases which were successfully reconstructed using the described surgical technique

Keywords: Vulva reconstruction; Pedicled flap; Hemi-DIEP; DIEP flap; Fournier gangrene; Acne inversa


Most partial or full thickness soft tissue defects of the vulva are repaired with local flaps from the groin, the gluteal region or the inner thigh. In cases where these donor sites are already scarred or do not offer enough soft tissue for reconstruction, surgeons need to be more creative and need to seek alternative options. Only few publications have shown alternatives to local random pattern advancement or rotation flaps [1-3]. In patients with excess abdominal tissue the DIEP flap represents a favourable donor site for vulva reconstruction. Excess literature has been published about the free DIEP flap for breast and extremity reconstruction [4,5]. Only very few studies examined the pedicled DIEP flap for reconstruction of defects localized in close proximity to the lower abdomen, including the hip, groin and vulva so far. A standardized flap harvest as well as a controlable and favourable donor site morbidity represent outstanding advantages of the DIEP flap, which now represents the gold standard for autologous breast reconstruction. Opposed to breast-, vulva reconstruction can be more challenging due to the heterogeneity of each individual defect as well as the complexity and shape of the anatomy, which needs to be reconstructed. Several aspects such as sexual intercourse, micturition, cosmetic resurfacing, and replenishing dead space need to be carefully considered when choosing a flap and it’s donor site for reconstruction. Adjuvant radiotherapy or previous operations and scarring significantly increase complication rates, reduce healing capacity and can burn bridges for straightforward reconstructions with local flaps. Here we would like to discuss the current available literature on vulvar reconstruction with DIEP flap and present two cases of full thickness total vulvar reconstructions with bilaterally pedicled DIEP flaps.

Search Strategy and Inclusion Criteria of Literature Review

Literature research reporting on the use of the DIEP-flap for vulva reconstruction was done in PubMed (US National Library of Medicine, Bethesda, MD). We included articles using the DIEP flap for reconstruction of defects in the vulvar and vaginal region. The literature research was performed using the terms “DIEP-flap for vulva reconstruction” and “vulvar reconstruction”. The “related articles” feature was used to find additional articles and the references of the selected articles were screened for further publications.

Results of Literature Review

8 papers were found fulfilling our criteria. The reports were published between 2004 and 2015. To date only 29 reports of patients receiving a vulva reconstruction with the DIEP flap were identified. Patients were aged 19 to 77 years with an average of 56 years. The dimensions of the defects successfully reconstructed with DIEP flap ranged from 9 to 15 cm, whereas the maximal flap length measured 37 cm. Total flap necrosis did not occur in any patients whereas 2 partial flap necrosis, requiring reoperations were noted (6, 9%). Other complications included haematoma (3, 4%) and wound dehiscence (3, 4%). Altogether complications occurred in 17, 2% of patients.

Muneuchi [6] was 2005 among the first who described vulvar reconstruction with a pedicled DIEP flap. A present longitudinal scar in the midline of the lower abdomen from additional procedures, such as hysterectomy and salpingectomy necessitated a vertical flap design (15x8 cm). The flap was transferred through a subcutaneous tunnel into the defect. The transferred flap was then thinned by taking down the layer of fat to scarpa’s fascia in order to match the thickness to the surrounding thin skin.

Fang et al. [7] reported about 12 cases of thinned DIEP-flaps for perineal reconstruction. Debulking was performed initially after anatomy was analysed by preoperatively CT-scan. According to the authors, this step furthermore reduced the overall flap harvesting time. Here, the flap was thinned in a plane deep to the superficial inferior epigastric vein, also correlating to scarpa’s fascia. In the reported series a partial necrosis of the distal flap tip occurred in only a relatively large transverse flap measuring 24x8.5 cm.

Negosanti [8] proposed that all kinds of vulvar defects can be repaired either by a DIEP flap or a Lotus pedicled flap. According to their classification especially in type II resections (resections of vulvar and vagina), when more tissue to fill the pelvic dead space is required, a pedicled DIEP flap is preferred. The mean size of the defect reconstructed with aDIEP flap was 14.4x10.4x4.6 cm; All patients reported satisfactory results, both functionally and aesthetically.

Bodin [9] was the first who reported a Hemi-DIEP flap with two vascular pedicles for vulva reconstruction. This technical modification provides multiple benefits. Harvesting two pedicles offeresimproved blood supply of the DIEP flap angiosome, therefore avoiding distal flap necrosis, especially when the full width of the abdominal skin is required. Additionally flap modelling is more easily achievable with two hemi-abdominal flaps. The surgical procedure however is more time consuming and requires two rectus abdominis muscle dissections, which can increase the overall donor site morbidity and risk for postoperative lower abdominal bulging (Table1).