Use of intraflap and extraflap microvascular anastomoses in combination for facilitating bipedicled DIEP/SIEA free flap for reconstruction of circumference soft tissue defect of extremity

Abstract

Dear Editor, We were reading with great interest the article by Oni, Nabulyato, and Malata (2018). In the article, the author introduced their experience in the breast reconstruction using the bipedicled DIEP/SIEA free flap. They have highlighted that it was possible to harvest the entire lower abdomen and maximize the volume of tissue by combining intraflap and extraflap microvascular anastomoses. We applaud the authors for their work. The use of this technique is also possible to repair circumference soft tissue defect in the extremity. We would like to share our own experience on using bipedicled DIEP/SIEA free flap to reconstruct circumference soft tissue defect in the extremity through combining intraflap and extraflap microvascular anastomoses. A 35-year-old female suffered with a chronic ulcer in the left leg (Figure 1A). Radical debridement left a large circumference soft tissue defect. We have performed a successful reconstruction using a free bipedicled DIEP and SIEA flap (Figure 1B). The SIEA was anastomosed onto an arterial branch of the right DIEP pedicle, and the right DIEP pedicle was connected with the posterior tibia vessel, whereas the left DIEP pedicle was anastomosed to the medial sural vessel (Figure 1B). The primary closure of donor site was achieved in the patient. The wounds healed uneventfully (Figure 1D–F). Reconstruction of circumference soft tissue defect of the extremity is always a challenging problem. The challenge in this type of reconstruction is not only to resurface the large soft tissue defect, but also not be readily available to harvest enough healthy recipient vessels around the defect for free flap transfer. A variety of options including multiple flaps transfer and a super-long flap have been reported to address the issue. However, more than one pair of recipient vessels and donor site is required for multiple flaps transfer. In this situation, we prefer to choose a super-long flap for reconstruction of circumference soft tissue defect. An extended bilateral DIEP flap was one of most commonly procedure to obtain a super-long flap because of its large cutaneous area, long vascular pedicle, and acceptable donor-site morbidity. However, intraflap or extraflap microvascular anastomoses is necessary to reestablish the vascular supply for the super-long flap due to limits of perfusion (Numajiri et al., 2013; Puhaindran, Sebastin, & Peng, 2007; Teven, Ooi, Chang, & Song, 2016). Yoshimatsu, Yamamoto, Hayashi, and Iida (2018) present a case in which a 72-cm long DIEP free flap was successfully harvested through extraflap microvascular anastomoses. As we shown in the present case, an extended bilateral DIEP/SIEA flap successful achieved a significant length to resurface the circumference soft tissue defect through intraflap and extraflap microvascular anastomoses.