Versatile Abdominal Perforator Flaps: Tricks and Tips

The evolution of reconstructive techniques has resulted in the development of procedures that restore form and a sense of wholeness, with minimal morbidity and high reconstructive specificity. In recent years, advances in perforator flaps have provided familiarity of the technique required for safe dissection and in turn, this has popularized the use of these ffaps for a wide variety of indications.

Introduction of abdominal flaps based on perforator vessels has established an ideal concept of reconstructive surgery due to the possibility of total muscle preservation. The deep inferior epigastric artery perforator flap (DIEP) was described in 1989 by Koshima as a skin flap without muscle; the technique does not sacrifice any part of the rectus abdominis muscle and aponeurosis, but uses the same amount of tissue from the lower abdomen. The DIEP flap has proven to be very useful in the area of breast and chest wall reconstruction, head and neck, and extremity reconstruction. If both epigastric pedicles are harvested, very large-sized flaps can be harvested to cover major defects. If sensory nerves are reanastomosed, tactile sensation can be restored in the flap, which might be used in breast and head and neck reconstruction. Its applications are not only as a free flap – it is very useful as a pedicled flap to cover large groin or buttock defects.

Many perforator flaps have been described for head and neck reconstruction: anterolateral thigh flaps, deep circumflex iliac perforator flaps, toracodorsal perforator flaps, peroneal perforator flaps, abdominal perforator flaps, and submental perforator flaps. The Taylor extended DIEP flap can provide the largest amount of tissue and the pedicle can be the longest but, on the other hand, it is thicker and the indications for intraoral defects are reduced. Therefore, it is used as a second option when the ALTF cannot be used, or in cases where there is the requirement for coverage of a large defect, or when an extremely long pedicle is needed to reach the contralateral side of the neck or a thoracic vessel.

Following a physiologic and logical approach, if the breast consists of mammary glands and ducts suspended in fat, breast reconstruction should be done with fat and skin alone and without muscle sacrifice. The abdominal perforator flap has become the gold standard for breast reconstruction, and can combine an excellent tissue quality, a minimal donor-site morbidity and, aesthetically, an acceptable abdominal scar.