Preliminary experience in reconstruction of the vulva using the pedicled vertical deep inferior epigastric, perforator flap

Large vulva reconstructions are usually accomplished by means of musculocutaneous, often bilateral, flaps. The VRAM flap has demonstrated excellent reliability as a skin carrier, but because of the major functional and aesthetic donor area morbidity, it is indicated only when the transverse rectus abdominis musculocutaneous (TRAM) flap is not available. When muscle component is not needed, the TRAM flap is nowadays replaced by the deep inferior epigastric perforator. In some cases, however, it might not be available because of the midline scar. In our experience, we have progressively reduced the rectus muscle needed to raise a VRAM flap and have finally clinically demonstrated the possibility of raising a large vertical skin flap, including both the upper and lower abdominal skin, supplied by the deep inferior epigastric perforator vessels via subcutaneous connections with the superior epigastric system (the vertical DIEP flap). The vertical DIEP flap was used three times as a pedicled transfer for different types of vulva reconstructions with satisfactory results. All but one patient healed uneventfully; that patient experienced a distal 2- to 3-cm necrosis along a large, 37 x 11-cm flap. We demonstrated clinically that the vascular territory of the deep inferior epigastric perforator vessels extends superiorly well above the umbilicus, which can safely support very long, vertically orientated abdominal skin flaps. In large vulva reconstructions, it is an excellent flap that includes the umbilicus for the distal urethra. It can be used as a free transfer or an island pedicle flap with a 360-degree arc of rotation around its axis for urogenital or proximal thigh reconstructions. Due to scar morbidity in the donor area, the vertical deep inferior epigastric perforator (VDIEP) flap is indicated in patients with a previous midline scar impairing use of the deep inferior epigastric perforator. It is preferred in hairy men more than it is in women. ©2007American Society of Plastic Surgeons.