JOURNAL OF PHYSIOLOGY AND PHARMACOLOGY 2008, 59, Suppl 5, 59–67

www.jpp.krakow.pl

H. LEONHARDT1, R. MAI1, W. PRADEL1, J. MARKWARDT1,

T. PINZER2 , A. SPASSOV3, G. LAUER1

FREE DIEP-FLAP RECONSTRUCTION OF TUMOUR

RELATED DEFECTS IN HEAD AND NECK

1Department of Oral and Maxillofacial Surgery University, Hospital Carl Gustav Carus
Dresden, Germany; 2Department of Neurosurgery University Hospital Carl Gustav Carus
Dresden, Germany; 3Department of Orthodontics, Preventive and Pediatric Dentistry, Ernst-
Moritz-Arndt University Greifswald, Germany

The free deep inferior epigastric perforator flap (DIEP) is a well-established therapy
for plastic reconstruction of the breast or defects of the lower extremity without
distinct donor site morbidity. Because of its particular qualities we started to apply the
DIEP-flap also in reconstruction of defects in the cranio-maxillofacial area. A series
of 10 consecutive patients, who received a DIEP-flap for reconstruction of large soft
tissue defects after ablative tumour surgery, was reviewed. Nine of the 10 flaps
survived and uneventfully healing was observed in 8 of the 10 flaps. Primary layered
closure of the abdominal wall was achieved in all cases and no complications at the
donor site were observed. In our experience the DIEP may serve as a well
considerable alternative to the rectus abdominis flap and the latissimus dorsi flap for
bridging extensive reconstructions in the cranio-maxillofacial region. It offers the
possibility for flap elevation simultaneously to the surgical procedures in the head and
neck area. A special advantage of the DIEP-flap is the very low donor site morbidity.

K e y w o r d s : DIEP-flap, head and neck reconstruction, microsurgery, donor site morbidity

INTRODUCTION

The use of microvascular-anastomosed flaps has become the gold standard for
reconstruction of extended defects after tumour ablation in head and neck area.
Mainly applied flaps are the radial forearm flap (rff), the lateral upper arm flap
(luaf), the lateral thigh flap (ltf), the latissimus dorsi flap (ldf) and the rectus
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abdominis flap (raf) (1- 4). The advantage of the raf is that an extended tissue
volume consisting of muscle, subcutaneous fat and a variable big skin area with a
reliable pedicle is available. The skin area including the fat is nutrified via separate
perforator vessels. These perforators are branches of the deep inferior epigastric
artery and vein. Therefore, the harvest of the deep inferior epigastric perforator
(DIEP) flap with extended skin-areas without sacrificing the rectus abdominis
muscle is possible (5). High rates of successful reconstruction and little donor site
morbidity were pointed out in breast reconstruction with the DIEP (6, 7). However
there is very little experience with the DIEP in head and neck reconstruction (8).
We describe the technique of the DIEP for reconstruction of extensive voluminous
facial defects after ablative tumour surgery and its outcome in 10 cases.

PATIENTS AND METHODS

DIEP flap reconstruction for primary and secondary repair of large defects after ablative tumour
surgery was performed in 10 cases between 2001 and 2004 (follow up between 12 and 47 month).
The defect-locations, diagnoses of the tumours and recipient vessels are specified in Table 1 and 2.
The resected skin surface ranged between 40 and 180 cm2. The Ethic Committe of Dresden
University approved this study and informed consent was obtained from each patient.

Operation Technique
Preoperatively a Doppler flow imaging of the epigastric vessels was performed. Hereby, the
location and the calibre of the perforator vessels were assessed and marked on the skin (Fig. 1). Skin

Table. 1.

Case Age Gender Diagnoses Localisation

1 55 M SCC Mandible right

2 60 M ChS Mandible middle

Floor of Mouth,
3 48 M SCC
Tongue
4 71 M NS Temporal+orbital left

5 74 M SCC Periorbital+nose right

6 58 M SCC Temporal left

7 59 M SCC Orbita left+infraorbital

8 37 F AcC Infraorbital+Nose right

9 60 F FS Temporal right

10 52 F FS Temporal left

Legend: SCC - squamous cell carcinoma, NS - neurosarcoma, ChS - chondrosarcoma, AcC -

adenoidcystic carcinoma, FS - myxofibrosarcoma
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Table. 2.
Perforator
Case Flap Size Vessels Recipient Vessels

1 7 x 9 cm 3 A. carotis ext., V. jugularis int.

2 5 x 8 cm 4 A. & V. thyroidea sup.

3 5 x 8 cm 4 A. & V. facialis

4 8 x 10 cm 4 A. & V. facialis

5 9 x 9 cm 4 A. facialis, V. jugularis int.

6 10 x 17 cm 3 A. & V. facialis

7 8 x 10 cm 3 A. facialis, V. jugularis int.

8 6 x 15 cm 2 A. thyroidea sup., V. jugularis int.

9 8 x 14 cm 2 A. facialis, V. jugularis int.

10 12 x 12 cm 1 A. thyroidea sup., V. jugularis ext.

Fig. 1. Flap design and DIEP vessels outlined after Doppler-flow ultrasound investigation.

incision will then start at the lateral part of the abdominal wall cutting through subcutaneous fat
staying on the fascia of the abdominal muscles. Without resecting any fascia the dissection moves
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Fig. 2. Dissection of one large periumbilical perforator vessel embedded in a collar of the anterior
rectus fascia.

towards the midline. Once the selected periumbilical perforators are identified (Fig. 2), the anterior
rectus fascia is incised to form separate collars around the tiny gaps to protect the perforating
vessels. The incision is then extended towards the groin to dissect the main stem of the inferior
epigastric vessels and to follow it to the level of the lateral border of the rectus abdominis muscle.
Then the branches leading from the inferior epigastric stem to the perforator vessels are exposed by
blunt dissection along the muscle-fibres towards the tiny gaps in the fascia (Fig. 3). Thereby the
motor-nerves are identified and because the pedicle is dissected deep to motor nerves they can be
mostly preserved. If this is not possible divided branches are to suture. Thus, after completely
developing the flap consisting of ligated vessel pedicle, subcutaneous fat and skin, it is raised and
transferred to the recipient site. After the flap is sutured into the defect, the A. and V. epigastica
inferior are connected to the recipient vessels by microsurgery. Before wound closure at the donor-
site the rectus abdominis muscle and the anterior rectus sheath are inspected and potential surgical
damages to the structures is repaired by coaptation.

RESULTS

Nine of the 10 DIEP survived completely, 8 flaps healed uneventfully and

without any complication. A sufficient wound closure and aesthetically pleasing
coverage of the large facial defects could be achieved (Fig. 4). A sufficient
healing also occurred in the 2 cases of secondary mandibular reconstruction.
Metal plates and free iliac bone grafts restored the continuities of the mandibles
and the DIEPs filled the extraoral soft tissue defects without complications (Fig.
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Fig. 3. Recipient sites of

DIEP-reconstruction
(Patient 1 to 10).

5). In the patient who underwent a subtotal glossectomy a total flap loss was
encountered after thrombosis of the venous pedicle. It had occurred after
reintubation, necessitated by the threat of suffocation after pharyngeal swelling.
In one other patient primary skin closure of the tumour defect with the flap could
not be achieved due to bulky subcutaneous fatty tissue. The risk to compress the
vessel pedicle was avoided by temporarily covering a part of the subcutaneous
fatty tissue with Syspurderm® as artificial surface. After healing of the flap for 3
weeks, the adipose subcutaneous tissue was reduced by liposuction and the
defect area was closed completely. Primary layered closure of the abdominal
wall led in all cases to functional and good aesthetic results of the donor sites.
Abdominal wall complications like bulking, herniation or functional deficits
were not observed.
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Fig. 4. Operation situs showing the vessel pedicle and a perforator leading into the flap.

Fig. 5. Primary DIEP-flap reconstruction after resection of a myxofibrosarcoma in the left

temporal region
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Fig. 6. DIEP-flap for soft tissue cover of free iliac bone graft in secondary reconstruction of the
mandible after resection and radiation of a fibrosarcoma.

DISCUSSION

Although the muscle-sparing DIEP-flap is widely used in breast

reconstruction surgery this report is one of the few of its application for large
facial or head and neck defect reconstruction (8-10). In general DIEP-flaps are
very suitable for the rehabilitation of large volume defects due to their pliable
character with a certain amount off subcutaneous tissue (9). The perforators
provide a good nutrition as a precondition for uneventful wound healing after
successful microvascular anastomosis at the recipient site. The importance of the
perforators blood supply is clearly demonstrated by the DIEP failure in this study,
which was encountered in the early postoperative interval. However,
Moolenburgh et al. even described a DIEP failure 3 years after transplantation
due to pedicle diversion (11). In contrast to total flap loss Nahabedian et al.
reported a rate of about 10% of fat necrosis related to breast reconstruction with
DIEP-flaps (12) and Kroll et al. described a close relation between the size of the
perforators and fat necrosis (13). These facts relate to our experience with the
case of delayed primary defect closure after the liposuction. It suggests that
extensive subcutaneous fatty tissue due to adipositas should be encountered as a
risk factor for flap survival even when large perforators exist that guaranteed well
nutrified DIEP-flaps. All patients were satisfied with the aesthetic results of the
reconstruction and none of the patients showed functional disturbances of the
abdominal wall. The low donor site morbidity of the DIEP-flap except the skin
scar matches with the results of Blondeel et al. who assessed the function of the
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abdominal wall by clinical examinations, physical exercises and a questionnaire

after DIEP-and TRAM-flap elevation (14). However, the low donor-site
morbidity of the DIEP-flap is associated with a longer operation time, due to the
delicate dissection of the perforators to the stem of the deep inferior epigastric
vessels. This slight disadvantage is matched by the simultaneous two-team
approach for parallel flap harvesting and tumour-surgery as no patient
repositioning is required (15). Taken all this into account, we advocate the DIEP
as a reliable and save transplant for head and neck reconstruction.
The application of the DIEP-flap is in particular an alternative for primary and
secondary reconstruction of large tumour associated defects in the head and neck
area. Especially the pliability together with a certain volume, the long and reliable
vascular pedicle and the texture of the flap make the DIEP suitable for the
aesthetically challenging reconstruction of large facial defects after ablative
tumour surgery. The preservation of the rectus abdominis muscle and the fascia
guarantees a very little donor site morbidity. The simultaneous two-team
approach for tumour surgery and flap harvesting makes the application of the
DIEP very comfortable also for craniomaxillofacial or head and neck surgery.

Conflicts of interest statement: None declared.

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R e c e i v e d : July 24, 2008

A c c e p t e d : October 15, 2008

Author’s address: Dr. Henry Leonhardt, Department of Oral and Maxillofacial Surgery,
University Hospital Carl Gustav Carus, Fetscherstraße 74, Dresden, D - 01307, Germany; phone:
+49 351 458 5205; fax: +49 351 458 5382; e-mail: guenter.lauer@uniklinikum-dresden.de