MODUL READING

HARVESTING
VASCULARIZED FIBULA FLAP &
DEEP INFERIOR EPIGASTRIC PERFORATORS (DIEP)

I GUSTI AYU PUTRI

PURWANTHI
VASCULARIZED FIBULA FLAP
VASCULARIZED FIBULA FLAP
ANATOMY
ANATOMY
 PRE-OPERATIVE ASSESMENT

• Both lower extremities must be evaluated  signs of peripheral

vascular disease and the anterior and posterior tibial pulses are
palpated, modified Allen's test  may detect proximal vessel
obstruction.
• Preoperative angiography in young, healthy patients with a
normal physical examination  controversy. Our tendency has
been to obtain preoperative angiograms as a guide. MRI or CT
angiography can also be used in many circumstances.
 FLAP HARVEST

• The patient is placed in the supine position with a bump under the ipsilateral hip to
lessen the need for excessive internal rotation of the lower leg. 
• A well padded tourniquet is placed on the thigh and the leg from the knee down is
prepped and draped.  The proximal and distal fibula are marked and the axis of
the bone is drawn.  
• The axis of the skin paddle is drawn at the posterior border of the fibula.  The
paddle is outlined a few centimeters below the neck of the fibula and 5 to 5
centimeters above the medial malleolus. 
• If no skin paddle is needed, the incision is simply made along the axis of the bone
 FLAP HARVEST

• The anterior flap is elevated just above the muscle and deep to
the muscular fascia.  The septum is approached by elevating the
fascia from anterior to posterior.  Septal perforators can usually
be seen from this anterior approach. 
• If no perforators are visible, muscular perforators near the
septum posteriorly must be preserved and harvested in a
perforator flap fashion to the posterior tibial vessels to preserve
skin paddle viability. This requires dissection through the
anterior aspect of the soleus muscle.
• The skin paddle is raised from
the posterior approach noting and
preserving muscular perforators if
adequate septal perforators were
not visible from the anterior
approach.
• If septal perforators were present,
the muscular perforators are
ligated and the septal vessels are
preserved. Attention is then turned
to the fibula bone.
 FLAP HARVEST

• A small cuff of muscle - a millimeter or less - is left

attached to the fibular bone as the surgeon proceeds
medially from the anterior approach.  Army-Navy
retractors help provide countertraction as the muscle is
peeled away leaving behind a cuff of muscle overlying
periosteum on bone.
 POST – OPERATIVE CARE

• The ankle is splinted in neutral and the patient is

allowed to ambulate in a cast shoe at about a week after
surgery, usually with an ace wrap to prevent edema. 
• At all other times the foot is kept elevated.  The donor
site can heal slowly if closed under tension or in the
elderly patient.  
DEEP INFERIOR EPIGASTRIC
PERFORATORS (DIEP)
DEEP INFERIOR EPIGASTRIC PERFORATORS (DIEP)
 □ Zone I is the zone of
greatest vascularity,
with the main
perforator underlying
the area. Zone II was
the contralateral area
(across the midline)
adjacent to the
perforator. Zone III
was therefore the
ipsilateral adjacent
zone to zone I and
zone IV the
Diagram of traditional Hartrampf contralateral lateral
zones as per Hartrampt, Scheflan and zone, furthest away
Dinner from the perforator.

19
 ANATOMY

The deep inferior epigastric artery arises

from the external iliac artery and runs from
lateral to medial under the rectus muscle. It can
enter the substance of the muscle or run deep to
it, while sending branches into the muscle and
through the muscle.

Perforators often travel through the tendinous

inscriptions of the rectus muscle, making their
dissection somewhat more difficult. In most
patients the DIEP and its venae can supply
adequate circulation for zones 1-3, making the
territory of perfusion larger than that of the
SIEA flap.
FLAP DESIGN

• The abdominal skin island is designed with

the lower aspect of the incision transversely
placed above the pubic bone, in line with the
typical transverse Cesarean section incision.
It extends laterally with a gentle curve
superior to the inguinal ligament finishing
adjacent to the anterior superior iliac spines.
• The upper incision is placed above the
umbilicus and gently curves laterally to meet
the lower transverse incision marking. With
the patient in the supine position and the
knees slightly flexed.
 OPERATIVE PROCEDURE

• The patient is prepped and draped

supine with the arms stretched out on an
arm board. The abdominal tissue can be
pinched to determine the tightness of
postoperative closure and markings can be
adjusted accordingly. This is best done
with the knees and hips slightly flexed.
• Perforators can optionally be assessed
with the pencil Doppler. If bilateral flaps
are to be harvested, the Doppler signals can
be marked on the contralateral side as well.
This is a good practice even in unilateral
flaps to find the largest and loudest
perforators.
 OPERATIVE PROCEDURE

• The flap is usually elevated from lateral to medial and the search for
perforators is begun when the territory of the rectus sheath over the lateral
rectus muscle is reached. This dissection can be performed with the
electrocautery on a low setting, or with bipolar forceps and scissors.

• If bilateral flaps are being prepared, the midline incision can be made
and the flap traced from medial to lateral as well, in order to help
surround the perforators. Note that the attachment of the flap to the rectus
fascia in the midline is much more adherent and the plane is more difficult to
dissect at this level.
 OPERATIVE PROCEDURE

• As larger perforators are identified, smaller ones may be

ligated. Usually the single flap can be supported on one major
perforator. Occasionally, if the perforators are small, a second
perforator may be used as well, as long is it is in a similar
longitudinal plane with its counterpart. Two different longitudinal
planes would result in excess muscle transection. The whole
point of the DIEP flap is to preserve abdominal muscles. 
• The umbilicus is separated from the flap with a periumbilical
incision, leaving the stalk attached to the abdominal wall. When
the abdomen is re draped, the umbilicus is brought through an
new incision.
OPERATIVE PROCEDURE
 OPERATIVE PROCEDURE

• When a large dominant perforator is

isolated, the rectus fascia is incised
longitudinally, around the perforator.
Great care is required so as to not
injure the vessels, especially the vein,
which can be quite delicate.
• The fascia is opened for 10 to 12
centimeters and the perforator is
traced through the muscle, using gentle
retraction of the muscle and the bipolar
electrocautery. Small branches of the
perforator are coagulated or clipped as
they sprout into the muscle and the
perforator is traced to the DIEA and
the venae commitans.
OPERATIVE PROCEDURE
 OPERATIVE PROCEDURE

• The DIEA vessels are then traced back to near their origin while
retracting the muscle away from the deep abdominal contents. When
the entire flap is isolated on the perforator and DIEA/DIEV, and the
recipient area is ready, the DIEA and the venae can be ligated and divided.
The rectus sheath is closed with a running large caliber non-braided suture.
• The abdominal wall is undermined to the costal margin and the
abdominal incision is closed in layers over suction drains with the hips
flexed and knees bent in a semi-Fowler position. The umbilicus is
brought through the abdominal wall and sutured into position. The patient
is allowed to mobilize when clinically indicated for the recipient area.
The patient ambulates with the hips flexed until the tension of the
closure slowly resolves.
OPERATIVE PROCEDURE
 THANK YOU

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