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FREE DEEP INFERIOR EPIGASTRIC ARTERY PERFORATORFLAP FOR RECONSTRUCTION OF SOFT-TISSUE DEFECTSIN EXTREMITIES OF CHILDREN
JUYU TANG, M.D., PH.D.,1* TAOLIN FANG, M.D., PH.D.,2,3 DAJIANG SONG, M.D., PH.D.,1 JIEYU LIANG, M.D., PH.D.,1
FANG YU, M.D., PH.D.,1 and CONGYANG WANG1
The deep inferior epigastric artery perforator (DIEP) flap has been a valuable tool in breast reconstruction, but seldom in extremity recon-struction. The aim of this report is to present our experience on the use of the DIEP flap for reconstruction of soft-tissue defects in theextremities of pediatric patients. From January 2007 to February 2011, 22 consecutive free DIEP flap transfers were performed for recon-struction of complex soft-tissue defects in the extremities of children with a mean age of 5.7 years old (ranging 2–10 years old). The flapdesign included transverse, oblique, and irregular DIEP flaps, containing one to three perforators in the flap. The flap size ranged from 73 4 cm to 18 3 17 cm. Primary donor-site closure was accomplished in all of patients. The postoperative course was uneventfully inmost of cases. The venous congestion was observed in two cases. One case of venous congestion was caused by flap inset with tension.The other case with venous thrombosis ended with partial loss of the flap after salvage procedure. There was one total flap loss due tothe arterial thrombosis. The flap survival rate was 95.5%. The mean follow-up was 12 months (ranging 6–36 months). All reconstructedextremities had satisfactory aesthetic and functional outcomes except two cases undergoing the secondary debulking procedures. Thedonor sites healed well in all cases without complications. Our experience showed that the free DIEP flap could be an alternative forreconstruction of soft-tissue defects in the extremities of children. VC 2013 Wiley Periodicals, Inc. Microsurgery 33:612–619, 2013.
Complex soft-tissue defects of extremities in children
pose a difficult challenge for the reconstructive surgeons.
Free flap transfer has become the preferred treatment
option for reconstruction of the extremities in many cen-
ters.1–5 It has been shown that the free flap transfer for
extremity reconstruction in children in various clinical
situations has success rates comparable to that of the
adult patients.6–8 The rectus abdominis muscle flap and
the free latissimus dorsi flap with their sizable areas and
large vascular pedicles are the most commonly per-
formed. The disadvantages of these flaps are the sacrifice
of important muscles that may lead to functional deficit
and potential donor site morbidity.9
The deep inferior epigastric artery perforator (DIEP)
flap has been a valuable tool in breast reconstruction
since its first description by Koshima et al.10,11 The free
DIEP flap can provide a huge amount of skin and soft
tissue, with the advantage of minimal donor-site morbid-
ity, relatively rapid dissection and flap elevation.12–14
There have also been reports on using the free DIEP flap
in extremity reconstruction, including foot and ankle
resurfacing, thumb reconstruction, and repair of massive
lower limb soft-tissue defect.15–21 Yet there was only one
author reported a small series of cases of free DIEP flaps
for reconstruction of the soft-tissue defect in the extrem-
ities in pediatric patients.22,23 It was thought that the
technical challenges and complexities in these younger
patients are greater than that in adults.24
The purpose of the present report is to present our
experience on the use of the free DIEP flap for recon-
struction of soft-tissue defects in the extremities of pedi-
atric patients.
PATIENTS AND METHODS
From January 2007 until February 2011, 22 children
underwent reconstruction of the soft-tissue defect with
exposed tendons and/or bones in the extremities using
free DIEP flaps at our center. There were 19 boys and 3
girls with a mean age of 5.7 years old (ranging from 2
to 10 years). Twenty children presented with soft-tissue
defects in the lower limbs, and the remaining two in the
hands. All the soft-tissue defects were traumatic injuries,
including 20 cases caused by traffic accident, one by ex-
plosive injury and one by crush injury. Initial debride-
ment was conducted before the patients being referred to
our center for reconstruction. The patients’ information is
shown in Table 1.
Surgical Technique
Preoperatively, the perforators were detected and
marked with the help of a hand-held Doppler. The design
of the flap was based on the size and three-dimensional
features of the defect, including transverse, oblique, and
1Department of Hand and Microsurgery, Xiangya Hospital of Central SouthUniversity, Changsha, China2Department of Orthopaedic Surgery, Zhongshan Hospital, Fudan Univer-sity, Shanghai, China3Department of Plastic Surgery, University of Mississippi Medical Center,Jackson, MS
*Correspondence to: Juyu Tang, M.D., Ph.D, Department of Hand and Micro-surgery, Xiangya Hospital of Central South University, 87 Xiangya Road,Changsha, China 410008. E-mail: [email protected]
Received 15 March 2013; Revised 25 March 2013; Accepted 29 March2013
Published online 11 July 2013 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22127
� 2013 Wiley Periodicals, Inc.
Tab
le1.
Patients
’C
hara
cte
ristics
and
Outc
om
es
Patient
Age
(year)
/gender
Cause
of
inju
ryLoca
tion
of
defe
ct
Dim
ensio
nof
the
flap
(cm
)D
esig
n
No.
of
perf
ora
tors
Recip
ient
vesse
ls
Outc
om
e
of
flaps
Com
plic
ation
Secondary
pro
cedure
s
15
/MTra
ffic
acci
dent
Dors
um
of
left
foot
18
37
Obliq
ue
1A
nte
rior
tibia
lS
urv
ival
No
Debulk
ing
26/M
Tra
ffic
acci
dent
Dors
um
of
left
foot
16
36
Tra
nsve
rse
2D
ors
alis
pedis
Surv
ival
Venous
com
pre
ssio
n
No
36/M
Tra
ffic
acci
dent
Rig
ht
heel
10
36
Tra
nsve
rse
1T
he
bra
nch
of
poste
rior
tibia
l
Surv
ival
No
No
46/M
Tra
ffic
acci
dent
Dors
um
of
left
foot
and
media
lm
alle
olu
s
17
36
Obliq
ue
2P
oste
rior
tibia
lS
urv
ival
No
Debulk
ing
55/F
Tra
ffic
acci
dent
Left
dis
talle
g15
35.5
Obliq
ue
2P
oste
rior
tibia
lS
urv
ival
No
No
68/M
Tra
ffic
acci
dent
Left
heel
24
38
Obliq
ue
1P
oste
rior
tibia
lS
urv
ival
No
No
72/F
Tra
ffic
acci
dent
Dors
um
of
left
foot
14
39
Obliq
ue
2A
nte
rior
tibia
lP
art
iallo
ss
Venous
thro
mbosis
No
84/M
Tra
ffic
acci
dent
Dors
um
of
right
foot
and
1st
toe
17
35.5
Obliq
ue
2A
nte
rior
tibia
lS
urv
ival
No
No
92/M
Tra
ffic
acci
dent
Dors
um
of
right
foot
and
1st-
4th
toe
toes
83
6.5
Irre
gula
r1
Dors
alis
pedis
Surv
ival
No
No
10
8/F
Tra
ffic
acci
dent
Rig
ht
leg
and
foot
18
37
Irre
gula
r2
Ante
rior
tibia
lS
urv
ival
No
No
11
5/M
Tra
ffic
acci
dent
Rig
ht
leg
12
36
Tra
nsve
rse
1P
oste
rior
tibia
lS
urv
ival
No
No
12
8/M
Tra
ffic
acci
dent
Rig
ht
late
ralm
alle
olo
us
and
foot
18
317
Irre
gula
r3
Pero
neal
Surv
ival
No
No
13
4/M
Tra
ffic
acci
dent
Left
heel
11
35
Tra
nsve
rse
1P
oste
rior
tibia
lS
urv
ival
No
No
14
5/M
Tra
ffic
acci
dent
Dors
um
of
right
foot
16
36
Obliq
ue
1A
nte
rior
tibia
lS
urv
ival
No
No
15
4/M
Tra
ffic
acci
dent
Dors
um
of
left
foot
12
37
Obliq
ue
1Late
ralta
rsal
Surv
ival
No
No
16
2/M
Cru
sh
inju
ryR
ight
hand
83
4Tra
nsve
rse
2R
adia
lart
ery
/
cephalic
vein
Surv
ival
No
No
17
6/M
Explo
siv
ein
jury
Rig
ht
hand
73
4Tra
nsve
rse
1R
adia
lart
ery
/
cephalic
vein
Surv
ival
No
No
18
6/M
Tra
ffic
acci
dent
Left
heel
18
37
Obliq
ue
2P
oste
rior
tibia
lTota
llo
ssA
rterial
thro
mbosis
No
19
8/M
Tra
ffic
acci
dent
Dors
um
of
left
foot
20
38
Obliq
ue
2D
ista
lante
rior
tibia
lS
urv
ival
No
No
20
10/M
Tra
ffic
acci
dent
Rig
ht
heel
12
36
Tra
nsve
rse
1P
oste
rior
tibia
lS
urv
ival
No
No
21
5/M
Tra
ffic
acci
dent
Dors
um
of
right
foot
14
36
Tra
nsve
rse
2A
nte
rior
tibia
lS
urv
ival
No
No
22
6/M
Tra
ffic
acci
dent
Dors
um
of
left
foot
15
37.5
Obliq
ue
2D
ors
alis
pedis
Surv
ival
No
No
Reconstruction of Soft-tissue Defects in Extremities of Children 613
Microsurgery DOI 10.1002/micr
irregular. Subsequently, the flap was dissected above the
deep fascia from lateral to medial. A careful dissection
was performed to preserve the perforators near the lateral
border of the rectus sheath. All of perforators were iden-
tified and the largest perforator was chosen as the vascu-
lar pedicle. After that, the anterior rectus sheath was
incised about 1 mm around the chosen perforator. Then
the sheath was incised longitudinally without injuring the
rectus muscle and the muscle was split in the direction
of its fibers. Under a 103 magnification, a deep intra-
muscular separation was performed along the perforator
until the trunk of deep inferior epigastric vessels was
exposed. The deep inferior epigastric vessels were then
isolated from the outer rectus abdominis muscle. A sec-
ond perforator could be included into the flap if it was
located on the same row and near each other. If the per-
fusion from one perforator was ascertained, other perfora-
tors were ligated. When a large flap was needed, more
than two perforators were included. The pedicle was dis-
sected to its required length and the flap was then har-
vested. When the venous outflow was inadequate, the
superficial epigastric vein was dissected to its origin for
an additional venous outflow. The nerves of the rectus
muscle should be preserved well. The end-to-end micro-
anastomoses were performed to the recipient vessels with
10/0 or 11/0 nylon sutures. A dose of 100 mL of Dex-
tran-40 was administered intravenously during operation.
The donor site was closed primarily.
Postoperatively, the drains were removed on day 3.
Antibiotics were used for 3 days. Intravenous Dextran-40
was administered 100–200 mL/per day, for 5–7 days.
RESULTS
A total of 22 free DIEP flaps were performed in the
series. The size of the DIEP flaps ranged from 7 3 4 cm
to 18 3 17 cm. There were 10 cases containing one per-
forator, 11 cases containing two perforators, and one
case containing three perforators.
Primary donor-site closure was accomplished in all
of patients. The postoperative course was uneventfully
in most of cases. The venous congestion was observed
in two cases after surgery. Among them, the compres-
sion of venous outflow was found in one case due to
the foot swelling and high tension of flap inset, which
was released after removal of several stitches. In
another case, the venous thrombosis was identified after
re-exploration. The thrombus was removed and re-anas-
tomosis was performed. This flap ended with partial
loss and wound healed by secondary intention. There
was one total flap loss due to the arterial thrombosis,
and the wound was covered using a cross-leg flap with-
out complication. The overall flap survival rate was
95.5%.
The mean follow-up was 12 months (ranging 6–36
months). All reconstructed extremities had satisfactory
aesthetic and functional outcomes except for the two
cases undergoing the debulking procedures. The donor
sites healed well in all cases without complications. All
cases were left with a linear donor site scar, whereas the
scars of the oblique and irregular designed flaps were
more noticeable than that of transverse designed flaps.
CASE REPORTS
Case 1
A 6-year-old boy was involved in a motor vehicle
accident and presented in our center on day 7 after injury
with a skin defect of 8 3 5 cm and partial necrosis of
Achilles tendon (Fig. 1A). A 10 3 6 cm transverse
designed DIEP flap was harvested and transferred for
coverage after thorough debridement (Figs. 1B, 1C and
1D). The arterial pedicle of flap was end-to-end anasto-
mosed to the medial malleolus branch of posterior tibial
artery. The venous pedicle was end-to-end anastomosed
to the concomitant vein of the medial malleolus branch
of posterior tibial artery. The partial necrotic Achilles
tendon was removed without compromising the structural
integrity of the tendon. The donor site was closed pri-
marily. The flap survived completely. Six months postop-
eratively, the patient restored full ankle mobility and a
slightly noticeable linear scar was left on the abdominal
wall (Figs. 1E and 1F).
Case 2
A 2-year-old boy suffered from the skin defect of the
distal dorsum of the right foot and the loss of the first to
fourth toes in a motorcycle accident (Fig. 2A). After
debridement, the skin defect on the dorsum of the right
foot was covered by an 8 3 6.5 cm irregular designed
DIEP flap (Figs. 2B and 2C). The end-to-end anastomo-
sis was performed between the deep inferior epigastric
artery and the dorsalis pedis artery. The concomitant
vein of the deep inferior epigastric artery was anasto-
mosed to that of the dorsalis pedis artery. The donor site
was closed primarily. The flap survived without compli-
cations. At the 18-month follow-up, the patient did not
present a bulky appearance of the foot (Fig. 2D). The
gait and shoe-wear were both normal. A relative obvious
scar was left on the abdominal wall after operation (Fig.
2E).
Case 3
A 5-year-old boy was a victim of a car accident,
which resulted in a skin defect on the dorsum of the
right foot, exposure of the metatarsal bones, and a defect
of the extensor tendons (Fig. 3A). A reconstructive pro-
cedure was performed 7 days after injury. After thorough
614 Tang et al.
Microsurgery DOI 10.1002/micr
debridement of necrotic tissue, the skin defect on the dor-
sum of right foot and lateral malleolus was repaired with
a 16 3 6 cm oblique designed DIEP flap based on one
perforator (Figs. 3B, 3C and 3D). The deep inferior epi-
gastric artery was anastomosed to the dorsalis pedis artery,
followed by the anastomoses of the concomitant vein of
the donor and recipient arteries. The donor site was closed
primarily. Six months later, the extensor tendons were
reconstructed with the tendon allografts. At the 12-month
follow-up evaluation, the flap had a good contour without
bulky appearance and the toe extension and dorsiflexion
were restored. The patient regained function with a normal
gait and wear normal shoes (Fig. 3E). A noticeable scar
was left on the abdominal wall (Fig. 3F).
DISCUSSION
Soft-tissue defects of the extremities in children put
forward a delicate problem for the reconstructive
surgeons,25 especially when nerves, vessels, bones, and
tendons are exposed. Some regional flaps have been used
to reconstruct the extremity.26 The inferior epigastric
artery-based rectus abdominis muscle flap and the latissi-
mus dorsi flap are two most commonly performed flaps
for resurfacing these wounds due to their reliable vascu-
lar supply and powerful abilities to resist infection.
Nevertheless, sacrifice of the functional muscle, bulkiness
and the donor morbidities are major disadvantages of the
use of these two flaps for reconstruction.27
There are many advantages of the DIEP flaps.13,18,24
There is no need to sacrifice the abdominal musculature,
which significantly decrease the donor morbidities. The
free DIEP flap also provides a longer pedicle, which
allows tension-free anastomoses, and has a reliable and
safe vascular supply as well as the versatility of its
design. The free DIEP flap is suitable for any type of
head, neck and extremities defect. The donor site can be
closed primarily with the closure of the rectus sheath. In
Figure 1. (A) A skin defect in right heel and partial necrosis of Achilles tendon. (B) Design of a transverse DIEP flap. (C) Preparation of
the branch of posterior tibial artery located 6 cm proximally to the medial malleolus at the recipient site. (D) Transfer the DIEP flap. (E,F)
Postoperative view of the recipient and donor sites at 6 months follow-up. [Color figure can be viewed in the online issue, which is avail-
able at wileyonlinelibrary.com.]
Reconstruction of Soft-tissue Defects in Extremities of Children 615
Microsurgery DOI 10.1002/micr
addition, the harvest of DIEP flap can be performed on
the patient in a supine position, allowing two surgical
teams at the same time.
However, the literatures are limited about using the
DIEP flap for reconstruction of extremities in pediatric
population with concerns about smaller vascular diameter
and perfusion of flap. Based on our experiences, the
blood supply of free DIEP flap is reliable in pediatric
population as is in adult. The sizes of the deep inferior
epigastric artery and its perforators could be small, but
those vessels were usually found relatively larger at dis-
section. In addition, the artery has better vascular flexi-
bility in children. Therefore the free DIEP flaps could be
performed in children if surgeons had excellent techni-
ques of perforator dissection and microvascular
anastomosis.
There was only one group that have reported a series
of free DIEP flaps for reconstruction of the soft-tissue
defect in the extremities of children.22,23 The authors pre-
sented nine free DIEP flaps in a series of 23 consecutive
free perforator flaps. In their report, only one case
included two perforators in the flap, while the other cases
included one perforator. Moreover, the flap designs were
not shown in detailed in their report. In our series, more
than half of the cases included two or three perforators
to supply the flaps. In addition, we listed three different
flap designs in our series, including transverse, oblique,
and irregular. In our series, transverse design was used in
eight cases, oblique in 11 cases, irregular in three cases
based on the different wound situations. From our experi-
ence, the transverse design was more suitable for the
DIEP flaps smaller than 6 3 12 cm. As described by
Scheflan and Dinner,28 the abdomen midline divides the
lower abdominal flap in two hemi-abdominal flaps. These
are ideally divided in two halves, thus resulting four
zones, which are numbered from I to IV based on their
perfusion. Zone I is the most perfused zone being the
one corresponding to the selected perforator. Zone IV is
the most distant one and usually poorly perfused. We
found that the distance between the umbilicus and the
pubic symphysis in children was small (only 5–6 cm
under 10 years old) and the flap would extend to zone
Figure 2. (A) A skin defect on the dorsum of the right foot and the loss of the first to fourth toes. (B) Design of an irregular DIEP flap. (C)
Raise of the DIEP flap. (D) Postoperative view of the recipient site at 18 months follow-up. (E) Postoperative view of the donor site at 18
months follow-up. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
616 Tang et al.
Microsurgery DOI 10.1002/micr
IV if the flap length was over 12 cm. To maximize the
total length of the flap with adequate perfusion, most of
flaps in our series were of oblique design. Irregular
design was only used to cover irregular wound of recipi-
ent. Considering the possibility of leaving noticeable scar
on donor site, we did not use vertical design in our
cases.
It was believed that the flap viability should be
directly correlated to the presence of adequate perfusion.
To ensure the viability of the DIEP flaps, many micro-
surgeons have tried to include two or more perforators
into the flap.23,29 However, Hallock, et al. compared the
blood flow and relative flap viability of a conventional
TRAM flap, multiple perforator DIEP flaps, and a soli-
tary perforator DIEP flap in a rat model. They found that
a solitary musculocutaneous perforator with adequate size
could routinely allow the survival of the entire ventral
abdominal flap.30 Most of clinical applications have also
corroborated this finding, as only one to three perforators
are commonly used to support the DIEP flap.30–33 Gill
et al. found that the more number of applied perforators
included, the higher incidence of complications.13 They
believed that even one perforator, compared with two or
three perforators, could provide an adequate blood supply
to DIEP flap.
From our experience, one perforator was adequate to
provide a blood supply to a flap with dimensions of up
to 24 3 8 cm. Therefore, if the perforator had a large
diameter, one was enough to ensure the safety and
reliability of the flap, but more perforators should be
required when harvesting a larger flap. Furthermore, as
the perforator diameter in children is smaller than that of
adult, a second or third perforator should be included if
the main perforator is not big enough.
The dissection of perforators is the key to achieve the
successful free DIEP flap transfer in children. The accu-
rate allocation of perforator before surgery is required as
it can not only facilitate the flap design but also avoid
unexpected injury of the perforators. Currently the Ultra-
sound Doppler is still the most effective and economic
Figure 3. (A) A skin defect on the dorsum of the right foot with exposure of the metatarsal bones and defect of the extensor tendons. (B)
Design of an oblique DIEP flap. (C) Harvest of the DIEP flap. (D) Inset of the flap. (E) Postoperative view of the recipient site at 12
months follow-up. (F) Postoperative view of the donor site at 12 months follow-up. [Color figure can be viewed in the online issue, which
is available at wileyonlinelibrary.com.]
Reconstruction of Soft-tissue Defects in Extremities of Children 617
Microsurgery DOI 10.1002/micr
method to allocate the perforators. In our series, the flap
was elevated from lateral to medial above the deep fas-
cia, which would help explore the perforators and avoid
unexpected injury as well. After the largest perforator
was exposed, the anterior rectus sheath was incised about
1 mm around the chosen perforator. Then the rest of dis-
section could be finished with assistance of an operating
microscope. If the flap had a large single perforator, it
could be easily harvested without nerve or muscle sacri-
fice. However, when flaps required multiple perforators
from both the medial and lateral row, segmental nerves
and the central muscle may be sacrificed. Medial row
perforators were far from these motor nerves, and using
these perforators as pedicle of the DIEP flap could be
ideal for preserving the motor nerves.34 Conventionally,
both of the medial and lateral row perforators needed
splitting the rectus abdominis muscle so that the flap
could pass it before cutting off the vessel pedicle. In our
series, to minimize the injury of rectus abdominis mus-
cle, only a little muscular separation was performed. The
vessel pedicles were cut off first and then were extracted
from the split rectus abdominis muscle.
There have been some reports on using the free DIEP
flap in extremity reconstruction in adult patients,15–21 but
most of them were reports of single case or small series
with up to five cases. There was only one larger series
on using DIEP in extremity reconstruction presented by
Van Landuyt et al.23 The survival rate of that series was
96 %. In our series, the overall flap survival rate was
95.5 %, which is comparable to the survival rate from
the literature.
The venous outflow is easier to be compromised
because of its slower flow and thin vessel wall. As two
cases with venous congestion, one survived after re-inter-
vention and another case ended with partial loss. There-
fore we suggest to use the superficial epigastric vein to
add an additional venous drainage for the large flap that
may have venous insufficiency.35
Some of disadvantages of the free DIEP flap in pedi-
atric patients are inevitable. First, the fat hypertrophy is
still a problem. When the patients grow up and get fat,
the flap at the repair site may become bulky. In this
series, two cases underwent a secondary debulking proce-
dure because of the later fat hypertrophy. We only had
an average 12 months follow-up. The need of flap
debulking may be increased. Second disadvantage is the
scar left on the abdominal wall. We also concerned about
the consequence of scar, which may bring at girl’s preg-
nancy in the future. For this reason, we changed surgical
plans to perform the thoracodorsal artery perforator flap
or the circumflex scapular artery perforator flap for
reconstruction in three cases (Data was not shown).
The free DIEP flap in children may have better skin
and vessels flexibility and reliable blood supply. The
children are normally with thin subcutaneous fat and
underdeveloped rectus abdominis muscle that makes dis-
section of perforators even easier. Moreover, all donor
sites can be directly closed, especially in the cases of
transverse designed. We did not encounter abdominal
wall weakness and herniation as it has been reported in
the literature.13,36 In conclusion, the free DIEP flap could
be an alternative for reconstruction of soft-tissue defects
in the extremities of children.
REFERENCES
1. Serletti JM, Schingo VA, Jr., Deuber MA, Carras AJ, Herrera HR,Reale VF. Free tissue transfer in pediatric patients. Ann Plast Surg1996;36(6):561–568.
2. Parry SW, Toth BA, Elliott LF. Microvascular free-tissue transfer inchildren. Plast Reconstr Surg 1988;81(6):838–840.
3. Arnez ZM, Hanel DP. Free tissue transfer for reconstruction of trau-matic limb injuries in children. Microsurgery 1991;12(3):207–215.
4. Canales F, Lineaweaver WC, Furnas H, Whitney TM, Siko PP,Alpert BS, Buncke GM, Buncke HJ. Microvascular tissue transfer inpaediatric patients: Analysis of 106 cases. Br J Plast Surg1991;44(6):423–427.
5. Lin CH, Mardini S, Wei FC, Lin YT, Chen CT. Free flap recon-struction of foot and ankle defects in pediatric patients: Long-termoutcome in 91 cases. Plast Reconstr Surg 2006;117(7):2478–2487.
6. Banic A, Wulff K. Latissimus dorsi free flaps for total repair ofextensive lower leg injuries in children. Plast Reconstr Surg1987;79(5):769–775.
7. Yu ZJ. The use of bilateral latissimus dorsi myocutaneous flaps tocover large soft tissue defects in the lower limbs of children.J Reconstr Microsurg 1988;4(2):83–88.
8. Arslan H, Cinar C, Bingol UA, Yucel OA. Subacute and delayedperiod microsurgical management of traumatic extremity injuries inpediatric population. Microsurgery 2012;32(7):527–532.
9. Chang DW, Youssef A, Cha S, Reece GP. Autologous breast recon-struction with the extended latissimus dorsi flap. Plast Reconstr Surg2002;110(3):751–759.
10. Koshima I, Soeda S. Inferior epigastric artery skin flaps without rec-tus abdominis muscle. Br J Plast Surg 1989;42(6):645–648.
11. Cubitt J, Barber Z, Khan AA, Tyler M. Breast reconstruction withdeep inferior epigastric perforator flaps. Ann R Coll Surg Engl2012;94(8):552–558.
12. Allen RJ, Treece P. Deep inferior epigastric perforator flap for breastreconstruction. Ann Plast Surg 1994;32(1):32–38.
13. Gill PS, Hunt JP, Guerra AB, Dellacroce FJ, Sullivan SK, Boraski J,Metzinger SE, Dupin CL, Allen RJ. A 10-year retrospective reviewof 758 DIEP flaps for breast reconstruction. Plast Reconstr Surg2004;113(4):1153–1160.
14. Fodor L, Bota IO, Filip CI, Grecea D, Fodor M, Dindelegan G,Motocu R, Ciuce C. New trends in breast reconstruction. Chirurgia2011;106(4):485–489.
15. Duffy FJ Jr., Brodsky JW, Royer CT. Preliminary experience withperforator flaps in reconstruction of soft-tissue defects of the footand ankle. Foot Ankle Int 2005;26(3):191–197.
16. Ohta M, Ikeda M, Togo T, Suzuki S. Limb salvage of infected dia-betic foot ulcers with free deep inferior epigastric perforator flaps.Microsurgery 2006;26(2):87–92.
17. Masuoka T, Nomura S, Yoshimura K, Ohmori K. Deep inferior epi-gastric perforator flap for foot reconstruction using an external pedi-cle. J Reconstr Microsurg 2005;21(4):231–234.
18. Koshima I, Nanba Y, Tsutsui T, Takahashi Y, Itoh S. Perforatorflaps in lower extremity reconstruction. Handchir Mikrochir PlastChir 2002;34(4):251–256.
618 Tang et al.
Microsurgery DOI 10.1002/micr
19. Li XJ, Tong J, Wang Y. Combined free toe and free deep inferiorepigastric perforator flap for reconstruction of the thumb and thumbweb space. J Reconstr Microsurg 2000;16(6):427–436.
20. Ozkan O, Coskunfirat OK, Ozgentas HE. Reliability of free-flap cov-erage in diabetic foot ulcers. Microsurgery 2005;25(2):107–112.
21. Zeltzer AA, Van Landuyt K. Reconstruction of a massive lowerlimb soft-tissue defect by giant free DIEAP flap. J Plast ReconstrAesthet Surg 2012;65(2):e42–e45.
22. Van Landuyt K, Hamdi M, Blondeel P, Tonnard P, Verpaele A,Monstrey S. Free perforator flaps in children. Plast Reconstr Surg2005;116(1):159–169.
23. Van Landuyt K, Blondeel P, Hamdi M, Tonnard P, Verpaele A,Monstrey S. The versatile DIEP flap: Its use in lower extremityreconstruction. Br J Plast Surg 2005;58(1):2–13.
24. Upton J, Guo L, Labow BI. Pediatric free-tissue transfer. PlastReconstr Surg 2009;124(6 Suppl).
25. Aydin OE, Tan O, Kuduban SD, Barin EZ. Nerve sparing-distallybased sural flap. Microsurgery 2011;31(4):276–280.
26. Townsend PL. An inferiorly based soleus muscle flap. Br J PlastSurg 1978;31(3):210–213.
27. Tan O, Algan S, Denktas Kuduban S, Cinal H, Zafer Barin E, UlviH. Versatile use of the muscle and nerve sparing latissimus dorsiflap. Microsurgery 2012;32(2):103–110.
28. Scheflan M, Dinner MI. The transverse abdominal island flap: PartII. Surgical technique. Ann Plast Surg 1983;10(2):120–129.
29. Lindsey JT. Integrating the DIEP and muscle-sparing (MS-2) freeTRAM techniques optimizes surgical outcomes: Presentation of analgorithm for microsurgical breast reconstruction based on perforatoranatomy. Plast Reconstr Surg 2007;119(1):18–27.
30. Hallock GG, Rice DC. Comparison of TRAM and DIEP flap physi-ology in a rat model. Plast Reconstr Surg 2004;114(5):1179–1184.
31. Nahabedian MY, Momen B, Galdino G, Manson PN. Breast Recon-struction with the free TRAM or DIEP flap: Patient selection, choiceof flap, and outcome. Plast Reconstr Surg 2002;110(2):466–475.
32. Kroll SS. Fat necrosis in free transverse rectus abdominis myocuta-neous and deep inferior epigastric perforator flaps. Plast ReconstrSurg 2000;106(3):576–583.
33. Craigie JE, Allen RJ, DellaCroce FJ, Sullivan SK. Autogenousbreast reconstruction with the deep inferior epigastric perforator flap.Clin Plast Surg 2003;30(3):359–369.
34. Rozen WM, Ashton MW, Murray AC, Taylor GI. Avoiding denerva-tion of rectus abdominis in DIEP flap harvest: The importance ofmedial row perforators. Plast Reconstr Surg 2008;122(3):710–716.
35. Enajat M, Rozen WM, Whitaker IS, Smit JM, Acosta R. A singlecenter comparison of one versus two venous anastomoses in 564consecutive DIEP flaps: Investigating the effect on venous conges-tion and flap survival. Microsurgery 2010;30(3):185–191.
36. Conroy K, Malata CM. Epigastric hernia following DIEP flap breastreconstruction: Complication or coincidence? J Plast Reconstr Aes-thet Surg 2012;65(3):387–391.
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