Journal of Plastic, Reconstructive & Aesthetic Surgery (2011) 64, 1238e1241

CASE REPORT

Recycling delayed perforator flap: Deep inferiorepigastric artery perforator-based propeller flapfrom a prior vertical rectus abdominismusculocutaneous flap

Ju Young Go, So Young Lim, Goo Hyun Mun, Sa Ik Bang, Kap Sung Oh,Jai Kyong Pyon*

Department of Plastic Surgery, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Ilwon-dong 50,Gangnam-gu, Seoul 135-710, Republic of Korea

Received 18 June 2010; accepted 26 January 2011

KEYWORDSVertical rectusabdominis flap;Flap recycling;Perforator flap

* Corresponding author. Tel.: þ82 20036.

E-mail address: pspriest.pyon@sam

1748-6815/$-seefrontmatterª2011Bridoi:10.1016/j.bjps.2011.01.020

Summary This article reports a case of re-elevating a prior vertical rectus abdominis muscu-locutaneous flap as a deep inferior epigastric artery perforator-based propeller flap to covera recurrent chest wall defect. This case demonstrates that a conventional musculocutaneousflap tissue with a preserved perforator can be recycled as a perforator flap. Furthermore, thistechnique can be a promising new surgical option for recurring abdominal and chest defects.ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published byElsevier Ltd. All rights reserved.

Sequential flap coverage may be required for recurrentdefects and adjacent tissues or tissues from the contralat-eral side that have not been used previously as a flapresource. Moreover, reusing a prior flap can also be analternative method for providing coverage to a relapsinglesion. A biceps femoris myocutaneous flap for ischial ulcers,a tensor fascia lata myocutaneous flap for trochantericulcers and gluteal myocutaneous or fasciocutaneous flap for

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sung.com (J.K. Pyon).

tishAssociationofPlastic,Reconstruc

sacral ulcers are examples of reusable flaps in the repair ofrecurrent pressure ulcers.1 However, there are few reportson the reuse of a flap as a perforator-based propeller flap,which had been elevated within the boundaries of theprevious flap.2 Here, we introduce the concept of recyclinga previous myocutaneous flap as a perforator flap througha case study of recurrent chest wall defects.

Case report

A 57-year-old female presented with a right anterolateralchest wall mass that had been diagnosed as a liposarcoma

tiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.

Recycled perforator flap 1239

by a fine needle aspiration. A wide excision of the lesionwith the underlying muscle and 6th to 8th rib was per-formed. A skeletal reconstruction was achieved usinga Composix mesh and 11 � 11 cm-sized muscle defect wascovered with a latissimus dorsi muscle flap. After surgery,she underwent adjuvant radiotherapy. The postoperativecourse was uneventful until the findings indicated a relapseof the lesion 3 years after the previous operation.

The patient revisited our clinic due to a recurrentsarcoma on the same site. A wide excision including theremnant 7th rib was performed again and the exposedpleural space was covered with 2-mm Gore-Tex. As a result,13 � 15 cm-sized musculocutaneous defect was formed. Anipsilateral superiorly based vertical rectus abdominis mus-culocutaneous flap with a 14 � 7 cm-sized skin paddle wasdesigned precisely to be rotated clockwise 120� to coverthe defect (Figure 1).

The patient returned with the complaint of wounddehiscence in the upper flap margin 2 months after adju-vant chemotherapy. Minimal debridement and woundclosure were performed in an outpatient clinic. Neverthe-less, the wound dehiscence recurred and the lesion size anddepth were aggravated. Moreover, fibrous changes in thewound margin and bed occurred secondary to radiotherapyand reoperation scarring (Figure 2A).

The wound margin was debrided and a 5 � 4 cm defectwas formed. A hand-held Doppler showed that a perforator,which was previously the right deep inferior epigastricartery, was localised within the previous rectus abdominismusculocutaneous flap. After confirming good blood flow of

Figure 1 (A) Prior vertical rectus abdominis muscu-locutanous flap (B) Immediate postoperative photography.

the perforator pedicle, an incision was made along the flapboundary. The dissection was started on the anterior chestwall through the suprafascial plane. The perforator, whichwas localised with the Doppler, was visualiseddirectly(Figure 2B). As the flap was totally elevated,a further intramuscular dissection of the pedicle wascarried out through the rectus abdominis muscle to provideadequate mobility for advancement. This perforator flapwas re-rotated 180� clockwise and was advanced moreposteriorly to cover the defect and closed in a VeY fashion.Complete coverage of the chest wall defect was possiblewith minimal tension on the flap and intact blood circula-tion of the flap was confirmed. In the 2nd postoperativeweek, a seroma under the flap was evacuated and minimaldebridement was performed again in the area of flapnecrosis, which healed uneventfully.

During the 12-month follow-up period, there were noadditional wound problems or evidence of relapse(Figure 2C).

Discussion

A repeated defect formed in an area where a reconstruc-tion had previously been performed using flaps is a greatchallenge to surgeons because of the limitation of potentialdonor sites and local tissues. Several solutions have beenproposed to overcome the issue of limited donor sites. Forexample, reuse of the same myocutaneous flap for thetreatment of recurrent lesions in difficult second opera-tions of the head and neck region has been reported.3 Forpressure ulcers in the sacral, ischial or trochanteric area,VeY re-advancement flaps have been the key for managingrecurrent lesions.1 Previous reports on the repetitive use ofa prior flap focused mainly on myocutaneous or fas-ciocutaneous flaps.

There are several reports on propeller-islanded perfo-rator flaps based on the DIEP (deep inferior epigastricperforator) and SEA (superior epigastric artery) to recon-struct abdominal defects.4,5 The vascular territories of thesuperior and deep inferior epigastric arteries were examinedin various studies.6,7 The superior and the deep inferiorepigastric arteries were united by choke vessels in thesegment of themuscle above theumbilicus. The supply to thevarious transverse and vertical skin flaps from the deepsuperior epigastric artery was defined as a series of capturedanatomic territories bound by choke vessels.8 For a breastreconstruction, it would appear that a prior ligation of thedeep inferior epigastric artery would be an advantage whenelevating the lower abdominal skin on a superiorly basedrectus abdominis musculocutaneous flap.9

In this case, the first flap was actually raised as a standardvertical rectus abdominis flap where the distal skin flaprelied on retrograde filling of the deep inferior epigastricartery perforators. Furthermore, the second flap was raisedas a perforator, which had originally been supplied by thedeep inferior epigastric artery but now by a continuation ofthe superior epigastric artery. This means that the perfo-rator flap previously raised as a propeller flap was raised ona perforating vessel that had originally been supplied by thedeep inferior epigastric system. However, it is now suppliedby the superior system because that system is no longer

Figure 2 (A) Lateral view of the right chest wall showing upper lateral flap margin dehiscence and a soft tissue deficit withextensive scarring. (B) The perforator was visualized and the perforator flap was completely raised. (C) No recurrence or woundproblems were observed 12 months after the recycled perforator flap surgery.

1240 J.Y. Go et al.

connected. A dilatation of choke vessels and reorientation ofvessels caused by a prior division of the deep inferiorepigastric artery might explain this phenomenon.10

In this case, re-advancement of the flap could beattempted in the same fasciocutaneous manner. However,an increase in lateral tension on the wound would be inevi-table due to the reduced movability of the soft tissues in there-advancement. A satisfactory range and unrestricteddirection of advancement can be ensured by dissecting theperforator to obtain a lengthy pedicle and elevate and rotatethe flap as an island flap. An intramuscular perforator

dissection could be performed, a perforator-based flapwithin the boundaries of the previous flap could be elevatedand the flap could be rotated as a propeller flap.

This case demonstrates that despite ligation of the deepinferior epigastric system, it is still possible to raise perfo-rator flaps within pre-existing musculocutaneous superiorlybased vertical rectus abdominis flaps. This suggests thata prior flap can be re-elevated and re-transferred asa perforator flap when a reliable perforator is preserved inthe supramuscular layer and is identified within the tissuesof the musculocutaneous unit of a previously transferred

Recycled perforator flap 1241

flap. This concept of recycling a previous musculocutaneousor fasciocutaneous flap as a subsequent perforator flap willbe very useful and applicable to recurring defects in manyother locations. Therefore, reconstructive surgeons shouldconsider this potential option.

Funding

None.

Conflict of interest

None.

References

1. Kroll SS, Hamilton S. Multiple and repetitive uses of theextended hamstring VeY myocutaneous flap. Plast ReconstrSurg 1989;84:296e302.

2. Mun GH. Recycled free septocutaneous perforator flap. AnnPlast Surg 2008;60:37e40.

3. Havlik R, Ariyan S. Repeated use of the same myocutaneousflap in difficult second operations of the head and neck. PlastReconstr Surg 1994;93:481e8.

4. Woo KJ, Pyon JK, Lim SY, Mun GH, Bang SI, Oh KS. Deepsuperior epigastric artery perforator ‘propeller’ flap forabdominal wall reconstruction: a case report. J Plast ReconstrAesthet Surg 2010;63:1223e6.

5. AngGG,RozenWM,ChauhanA,AcostaR. Thepedicled ‘propeller’deep inferior epigastric perforator (DIEP) flap for a large abdom-inal wall defect. J Plast Reconstr Aesthet Surg; 2010.

6. Boyd JB, Taylor GI, Corlett R. The vascular territories of thesuperior epigastric and the deep inferior epigastric systems.Plast Reconstr Surg 1984;73:1e16.

7. Moon HK, Taylor GI. The vascular anatomy of rectus abdominismusculocutaneous flaps based on the deep superior epigastricsystem. Plast Reconstr Surg 1988;82:815e32.

8. Hallock GG. The superior epigastric (RECTUS ABDOMINIS)muscle perforator flap. Ann Plast Surg 2005;55:430e2.

9. Atisha D, Alderman AK, Janiga T, Singal B, Wilkins EG. Theefficacy of the surgical delay procedure in pedicle TRAM breastreconstruction. Ann Plast Surg 2009;63:383e8.

10. Yim HY, Park YJ. Clinical application of the delayed procedurein the distally based sural flap. J Korean Soc Plast ReconstrSurg 2010;37(6):775e8.