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Deep inferior epigastric artery perforator free flaps in head and neck reconstruction
头颈部重建中的深部下腹动脉穿支游离皮瓣

Bin Zhang *, De-zhi Li, Zhen-gang Xu, Ping-zhang Tang
张斌*， 李德志， 徐振刚， 唐平章Department of Head and Neck Surgery, Cancer Hospital, Chinese Academy of Medical Sciences,
中国医学科学院肿瘤医院头颈外科Peking Union Medical College, Beijing 100021, China
北京协和医学院， 北京100021， 中国

Received 19 March 2008; accepted 4 April 2008
收稿日期： 2008-03-19;录用日期：2008年4月4日
Available online 14 July 2008
2008年7月14日可在线查阅

KEYWORDS 关键字

Free flap; 自由襟翼;
Head and neck cancer reconstruction;
头颈癌重建;
Deep inferior epigastric artery free flaps
深部上腹下动脉游离皮瓣

Abstract 抽象

Summary The advantage of free perforator flaps versus free musculocutaneous flaps is the reduced morbidity of the donor site with preservation of nerves, muscles and deep fascia. In this study, we evaluated the reconstruction results of deep inferior epigastric artery perforator (DIEAP) free flaps in the head and neck.
摘要 游离穿支皮瓣与游离肌皮瓣相比，游离皮瓣的优点是降低了供体部位的发病率，并保留了神经、肌肉和深筋膜。在这项研究中，我们评估了头颈部深部上腹动脉穿支器 （DIEAP） 游离皮瓣的重建结果。

A retrospective review was performed of 12 patients with head and neck tumor ablation defects that were reconstructed with the deep inferior epigastric artery perforator (DIEAP) free flaps between January 2004 and December 2006. Reconstruction outcomes and complications were measured.
回顾性回顾了 2004 年 1 月至 2006 年 12 月期间使用 DIEAP 下腹动脉穿孔器 （DIEAP） 游离皮瓣重建的 12 例头颈部肿瘤消融缺损患者。测量了重建结果和并发症。

Recipient sites were subdivided into defects of total or subtotal glossectomy , threedimensional defects of midface , through and through defects of the cheek , and anterior skull base resection with an external skin component defect ( ). The overall free flap success rate was (11/12). One DIEAP free flap was lost because the draining jugular vein thrombosed. No complications were observed in the donor site, including abdominal bulge or hernia.
受体部位细分为全或次全舌切除术缺损 、中面 三维缺损、脸颊贯穿和贯穿缺损 ，以及具有外部皮肤成分缺损的前颅底切除术 （ ）。总体游离皮瓣成功率为 （11/12）。由于引流颈静脉血栓形成，丢失了 1 个 DIEAP 游离皮瓣。在供体部位未观察到并发症，包括腹部隆起或疝气。

Due to the advantage of minimum donor site morbidity, the DIEAP free flap is a new and reliable reconstruction choice for head and neck surgical defects.
由于供体部位发病率最低的优点，DIEAP游离皮瓣是头颈部手术缺损的一种新的可靠重建选择。

© 2008 Elsevier Ltd. All rights reserved.
© 2008 爱思唯尔有限公司保留所有权利。

Introduction 介绍

The use of free flaps for reconstruction of head and neck oncological defects is currently the first choice of reconstruction methods. The rectus abdominis musculocutaneous free flap was one of the most frequently used free flaps in this region. Removal of one rectus abdominis along with a portion of its overlying fascia creates a potential weakness
使用游离皮瓣重建头颈部肿瘤缺损是目前首选的重建方法。腹直肌皮肤游离皮瓣是该区域最常用的游离皮瓣之一。 切除一个腹直肌及其上覆筋膜的一部分会产生潜在的弱点
in the anterior abdominal wall that may predispose the patient to ventral herniation or a midline bulge. Most of the data are derived from the transverse rectus abdominis musculocutaneous free flaps (TRAM) that were used for breast reconstruction. The Deep inferior epigastric artery perforator (DIEAP) free flap is a relatively new flap that has been developed as a modification of the rectus abdominal musculocutaneous free flap and has been widely used in breast reconstruction instead of TRAM flaps for the least donor site morbidity associated with rectus abdominis harvest. However, there were only limited reports of the use of DIEAP free flaps in the head and neck region. In this article, we present the primary results of 12 consecutive DIEAP free flaps for head and neck reconstruction.
在前腹壁，可能使患者易患腹侧疝或中线隆起。大多数数据来自用于乳房重建的腹直肌肌皮肤游离皮瓣 （TRAM）。 深下腹动脉穿支器 （DIEAP） 游离皮瓣是一种相对较新的皮瓣，是作为腹直肌肌肉皮肤游离皮瓣的改良型而开发的，并已广泛用于乳房重建，而不是 TRAM 皮瓣，用于与腹直肌收获相关的供体部位发病率最低。 然而，关于在头部和颈部区域使用 DIEAP 游离皮瓣的报道有限。 在本文中，我们介绍了 12 个连续 DIEAP 游离皮瓣用于头颈部重建的主要结果。

Materials and methods 材料与方法

Study subjects 研究对象

Between January of 2004 and of December 2006, 12 consecutive patients with head and neck cancer underwent reconstruction with the free DIEAP flap after tumor ablation. All the cases were performed at the Cancer Hospital of the Chinese Academy of Medical Sciences in Beijing and the reconstructive procedure was done by a single surgeon (Zhang). Among the 12 flaps (Table 1), six flaps were used to reconstruct total or subtotal glossectomy defects, three were used for three-dimensional defects of the midface, two were used to repair through and through cheek defects, and one to repair the defect following anterior skull base resection with an external skin component defect.
2004 年 1 月至 2006 年 12 月期间，连续 12 例头颈癌患者在肿瘤消融后接受了游离 DIEAP 皮瓣重建。所有病例均在北京中国医学科学院肿瘤医院进行，重建手术由一名外科医生（张）完成。在 12 个皮瓣（表 1）中，6 个皮瓣用于重建全或次全舌切除术缺损，3 个用于中面部三维缺损，2 个用于通过和通过脸颊缺损进行修复，1 个用于修复前颅底切除术后的缺损。
The average age of patients was 48 years (range, years). All 12 patients were males. Among them, were nine who had recurrent tumor, and had received radiotherapy and /or surgery previously (Table 1 ).
患者的平均年龄为48岁（范围， 岁）。12例患者均为男性。其中，有9例肿瘤复发，之前接受过放疗和/或手术（表1）。

Surgical technique 手术技术

Preoperatively, potential flap perforators were identified using Doppler ultrasound, and the flap was designed to include the larger vessels, generally found in the peri-umbilical area. The patient is placed in the supine position. All flaps are elevated at the time of the tumor ablation, and all were raised in an oblique direction (see Fig. 1). The skin-fat island is then elevated off the external oblique fascia laterally until the lateral row of perforators is encountered. The median side is then elevated beyond the linea alba to expose the medial row of perforators. Flap perforators are carefully identified during elevation. The largest vessel is selected and dissected along its course through the rectus muscle down to the deep inferior epigastric vessels. Numerous fine muscular branches are coagulated by using bipolar forceps. The deep inferior epigastric pedicle is dissected down to the external iliac vessels to obtain adequate length (see Fig. 2). The pedicle is divided and pulled through the split in the rectus muscle. The flap is transferred and sutured into the head and neck defect. The microanastomoses are completed. The anterior sheath of the rectus muscle is closed primarily using silk interrupted sutures. There is usually no need for donor site drainage or abdominal bandage. Patients are encouraged to walk gradually the day after surgery.
术前，使用多普勒超声识别潜在的皮瓣穿孔器，皮瓣设计为包括较大的血管，通常位于脐周区域。患者被置于仰卧位。在肿瘤消融时，所有皮瓣都升高，并且所有皮瓣都向倾斜方向升高（见图 1）。然后将皮肤脂肪岛从外斜筋膜外侧抬高，直到遇到外侧穿孔。然后将正中侧抬高到白线之外，以暴露穿孔的内侧行。在抬高过程中仔细识别襟翼穿孔器。选择最大的血管并沿着其路线通过直肌向下解剖到深部上腹下血管。使用双极镊子凝固许多细小的肌肉分支。将深下腹蒂解剖至髂外血管，以获得足够的长度（见图2）。椎弓根被分开并穿过直肌的分裂。皮瓣被转移并缝合到头颈部缺损处。微吻合术完成。直肌的前鞘主要使用 丝断缝合线闭合。通常不需要供体部位引流或腹部绷带。鼓励患者在手术后的第二天逐渐行走。

Recipient and donor site
受助者和捐赠者网站

Recipient arteries were the superior thyroid ( ), the facial , and the lingual . All were anastomosed end-to-end. The recipient veins were the internal jugular , the facial , and the external jugular . Except for the internal jugular vein, which was anastomosed end-to-side, the others were anastomosed end-to-end Postoperatively, flaps were monitored by color, and by cap
受体动脉是甲状腺上动脉 （ ）、面部 动脉和舌动脉 。所有这些都是端到端的吻合。受体静脉是颈内静脉 、面部 静脉和颈外静脉 。除了颈内静脉是端对侧吻合的，其他的都是端到端吻合术 术后，皮瓣通过颜色和帽进行监测
Table 1 Characteristic of 12 patients
表1 12例患者特征
Patient no. 患者编号 Age /sex 年龄/性别 Primary tumor 原发性肿瘤 Previous therapy 既往治疗 Surgery of primary site
原发部位手术
 缺陷尺寸
Defect
size
Complications 并发症
1 48/M 48/米 T3N2MO ACC base of tongue
T3N2MO ACC 舌根		 None 没有 Total glossectomy 全舌切除术 None 没有
2 T3N2MO SCC oral tongue
T3N2MO 鳞状细胞癌口腔舌		 None 没有 Total glossectomy 全舌切除术 Fistula 瘘管
3 54/M 54/米 Recurrent SCC oral tongue
复发性鳞状细胞癌口腔舌		 S&R (70 Gy) S&R （70 Gy） Total glossectomy 全舌切除术 Flap necrosis 皮瓣坏死
4 Recurrent SCC oral tongue
复发性鳞状细胞癌口腔舌		 S&R (63 Gy) S&R （63 吉） Subtotal glossectomy 舌次全切除术 None 没有
5 Recurrent SCC base of tongue
复发性舌根鳞状细胞癌		 Gy Subtotal glossectomy 舌次全切除术 None 没有
6 T3N1MO ACC base of tongue
T3N1MO ACC舌根		 None 没有 Subtotal glossectomy 舌次全切除术 tongue necrosis 舌坏死
7 Recurrent Sarcoma cheek 复发性肉瘤脸颊 S&R (65 Gy) S&R （65 Gy）

脸颊切除术
Cheek through and
through resection
None 没有
8 Recurrent SCC cheek 复发性鳞状细胞癌脸颊 S&R (65 Gy) S&R （65 Gy）

脸颊切除术
Cheek through and
through resection
None 没有
9 Recurrent Sarcoma sinonasal
复发性鼻窦肉瘤		 S&R (70 Gy) S&R （70 Gy）

中面部 3 维切除术
Midface 3-dimension
resection
None 没有
10 Recurrent ACC sinonasal 复发性 ACC 鼻窦

中面部 3 维切除术
Midface 3-dimension
resection
None 没有
11 72/M 72/米 Recurrent SCC sinonasal 复发性鳞状细胞癌鼻窦 S&R (70 Gy) S&R （70 Gy）

中面部 3 维切除术
Midface 3-dimension
resection
None 没有
12 Recurrent SCC sinonasal 复发性鳞状细胞癌鼻窦 S&R (70 Gy) S&R （70 Gy）

颅面皮肤切除术
Craniofacial resection
with skin
None 没有
Figure 1 The design of DIEAP free flap.
图1 DIEAP自由襟翼的设计。
Figure 2 The DIEA flap is isolated on the musculocutaneous perforator and pedicle (arrow) (RA: rectus abdominis).
图 2 DIEA 皮瓣隔离在肌肉皮肤穿支和椎弓根（箭头）（RA：腹直肌）上。
illary re-flush. If there were any signs of compromised blood circulation of the flaps, re-exploration was carried out.
Illary 重新冲洗。如果有任何皮瓣血液循环受损的迹象，则进行重新探查。
In this series, eight flaps were elevated on one perforator. Four flaps were elevated on two perforators where two skins paddles needed to be folded to reconstruct midface or cheek three-dimensional defects.
在这个系列中，一个穿孔器上抬高了八个襟翼。在两个穿孔器上抬高了四个皮瓣，其中需要折叠两个皮肤桨以重建面部中部或脸颊三维缺陷。

Results 结果

The average overall operating time and flap harvest time were 418 and , respectively. Flap sizes in this series ranged from to .
平均总操作时间和襟翼收获时间分别为 418 和 。该系列的襟翼尺寸范围从 到 。
Eleven of 12 flaps survived completely. One patient (patient 3) was returned to the operating theatre because of venous congestion. Re-exploration of the vascular anastomosis revealed that the recipient internal jugular vein was thrombosed and the flap was totally lost despite thrombec-
12 个襟翼中有 11 个完全幸存下来。1例患者（患者3）因静脉淤血被送回手术室。对血管吻合的重新探查显示，受体颈内静脉血栓形成，尽管血栓形成，皮瓣完全丢失。
Figure 3 Oral view of patient 6 . Four weeks after DIEAP free flap reconstruction of subtotal glossectomy. The residual oral tongue became necrotic and had been removed.
图 3 患者 6 的口腔视图。DIEAP后4周，舌次全切除术的游离皮瓣重建。残留的口腔舌头坏死并被切除。
tomy and revision. This patient was salvaged with a pectoralis major musculocutaneous flap and, unfortunately, died two and half months later due to local recurrence and lung metastases. Early complications are listed in Table 1
tomy 和修订。该患者被胸大肌皮瓣抢救，不幸的是，两个半月后因局部复发和肺转移而死亡。早期并发症见表1
Five of six patients who underwent total or subtotal glossectomy resumed total oral feeding and decannulation in an average of 16 days (see Fig. 3). These five patients had intelligible speech postoperatively. The only patient (patient 3) who failed to resume oral feeding and speech was the same patient who had flap loss and tumor recurrence thereafter.
在接受全或次全舌切除术的 6 例患者中，有 5 例在平均 16 天内恢复了全口服喂养和脱管（见图 3）。这 5 例患者术后言语清晰。唯一未能恢复经口喂养和言语的患者（患者 3）是此后出现皮瓣丢失和肿瘤复发的同一患者。
There were no complications in the donor site, such as abdominal wound infection, dehiscence, hernia, or bulge.
供体部位没有并发症，如腹部伤口感染、裂开、疝气或隆起。

Discussion 讨论

Free flap transfer has revolutionized the reconstruction of large head and neck defects after tumor ablation by providing better cosmetic and functional outcomes than local and regional flaps. The past two decades have witnessed a proliferation of a multitude of free flap options for head and neck reconstruction. These offer options to the reconstructive surgeon so that he may select the flap that provides the best tissue match with minimal resultant donor site morbidity. Traditionally, the myocutaneous rectus abdominis free flap was the most commonly used flap for large defects in the head and neck region to restore bulk volume. However, the associated donor site morbidity for this site is well established. Mizgala and colleagues tested 150 patients years postoperatively to define the long-term abdominal consequences of the TRAM flap procedure. Their finding showed decreased abdominal strength and sit-up performance, abdominal laxity and bulging, and increased back pain. The denervated muscle tissue incorporated into the musculocutaneous flap will atrophy to an unpredictable degree after the elevation, leading to further uncertainty about the final volume of the reconstruction, and therefore produces an unpredictable result. The DIEAP flap spares the whole rectus abdominis muscle, includes skin and fat only, and therefore, preserves adequate abdominal wall compe-
游离皮瓣转移通过提供比局部和区域皮瓣更好的美容和功能结果，彻底改变了肿瘤消融后大型头颈部缺损的重建。在过去的二十年中，用于头颈部重建的多种自由皮瓣选择激增。这些为重建外科医生提供了选择，以便他可以选择提供最佳组织匹配且供体部位发病率最小的皮瓣。传统上，肌直肌游离皮瓣是头颈部大缺损恢复体积最常用的皮瓣。然而，该部位的相关供体部位发病率已得到充分证实。 Mizgala及其同事 在术后数年对150名患者 进行了测试，以确定TRAM皮瓣手术的长期腹部后果。他们的发现显示腹部力量和仰卧起坐表现下降，腹部松弛和隆起，背痛增加。掺入肌皮瓣的去神经支配肌肉组织在抬高后会萎缩到不可预测的程度，导致重建的最终体积进一步不确定，因此会产生不可预测的结果。 DIEAP皮瓣保留了整个腹直肌，仅包括皮肤和脂肪，因此保留了足够的腹壁
tence. The study of abdominal strength by Futter and coworkers showed that the TRAM flap group had significantly more abdominal weakness than the DIEAP and control group, although the DIEAP group showed weaker abdominal strength than the control group. Postoperatively, DIEAP free flap patients were reported to have a decreased need for morphine and may even have a slightly reduced hospital stay compared with TRAM flap patients. Although most studies of functional and aesthetic postoperative advantages of DIEAP over TRAM flap procedures were conducted in the field of breast reconstruction, it would be reasonable to assume that the reduced morbidity seen in breast reconstruction patients would also be seen in head and neck reconstruction patients having essentially the same operation. In this series, donor site morbidity was not observed. These patients do not need either drainage or abdominal bandage which is usually used after rectus abdominal musculocutaneous free flap elevation, and they begin early ambulation postoperatively.
因此。Futter 及其同事 对腹部力量的研究表明，尽管 DIEAP 组的腹部力量比对照组弱，但 TRAM皮瓣组的腹肌无力明显高于 DIEAP 和对照组。术后，据报道，与 TRAM 皮瓣患者相比，DIEAP 游离皮瓣患者对吗啡的需求减少，甚至可能略微缩短住院时间。 尽管大多数关于DIEAP术后功能和美学优势的研究都是在乳房重建领域进行的，但可以合理地假设，乳房重建患者的发病率降低也将在具有基本相同手术的头颈部重建患者中看到。在该系列研究中，未观察到供体部位的发病率。这些患者不需要引流或腹部绷带，通常在腹直肌皮肤游离皮瓣抬高后使用，术后开始早期活动。
Most flaps in our series were obliquely oriented on one side of the midline, in the peri-umbilical region, therefore placing the flap in zones 1 and 2 of the DIEAP circulation. This orientation of the DIEAP free flap provides a longer pedicle than the transverse DIEAP free flap, which is generally necessary in head and neck reconstruction. Closing the primary donor site is also easy because less tissue is required in head and neck repair compared to breast reconstruction.
我们系列中的大多数皮瓣都斜向在中线的一侧，即脐周区域，因此将皮瓣放置在DIEAP环流的1区和2区。DIEAP游离皮瓣的这种方向提供了比横向DIEAP游离皮瓣更长的椎弓根，这在头颈部重建中通常是必需的。关闭主要供体部位也很容易，因为与乳房重建相比，头颈部修复所需的组织更少。
The indication for the DIEAP flap is the need for a bulky flap in head and neck reconstruction. The most common defect reconstructed is total or subtotal glossectomy in this series, followed by midface three-dimensional defects, and through and through cheek defects. We prefer to use the DIEAP free flap in male patients rather than in females for the following reasons: (1) in most instances the DIEAP free flap is too bulky in females for head and neck reconstruction. In the female group the anterolateral thigh flap is the choice for head and neck reconstruction ; (2) The average diameter of the deep inferior epigastric artery (DIEA) is smaller in Chinese than in Westerners. According to the anatomic study of 15 Chinese cadavers by Shao et al. , the average diameters of the DIEA were only . However, the average diameter of the DIEA was in a series of 25 cadaver dissections reported by Boyd et al. Empirically, the DIEA of the female is even smaller than the male, making anastomosis much more difficult.
DIEAP皮瓣的适应症是在头颈部重建中需要一个大块的皮瓣。该系列中最常见的重建缺损是全或次全舌切除术，其次是中面部三维缺损，以及贯穿和贯穿脸颊缺损。我们更倾向于在男性患者而不是女性患者中使用 DIEAP 游离皮瓣，原因如下：（1） 在大多数情况下，女性 DIEAP 游离皮瓣对于头颈部重建来说过于笨重。在女性组中，大腿前外侧皮瓣是头颈部重建 的首选;（2）中国人上腹深下动脉（DIEA）的平均直径小于西方人。根据Shao等人对15具中国尸体的解剖学研究 ，DIEA的平均直径仅 为。然而，DIEA的平均直径是在 Boyd等人 报道的一系列25具尸体解剖中，根据经验，雌性的DIEA甚至比雄性还要小，这使得吻合变得更加困难。
One DIEAP (patient 3) free flap failed because of recipient internal jugular vein thrombosis. Potential internal jugular vein thrombosis is reported following modified neck dissection, but flap compromise following internal jugular vein thrombosis is rare. Miyasaka et al. reported four free flaps developed congestion due to internal jugular vein thrombosis in a survey of 756 patients, representing a rate of for the entire series. Early exploration and thrombectomy of the internal jugular vein are crucial for salvage.
一个 DIEAP（患者 3）游离皮瓣因受体颈内静脉血栓形成而失败。据报道，经改良颈部夹层后可能出现颈内静脉血栓形成，但颈内静脉血栓形成后皮瓣受损的情况很少见。 Miyasaka 等人在一项针对 756 名患者的调查 中报告了由于颈内静脉血栓形成导致的 4 个游离皮瓣发生充血，代表了整个系列的发生率。 颈内静脉的早期探查和血栓切除术对于挽救至关重要。
As previously reported, dissection of the perforator vessel is tedious, and requires meticulous dissection of the musculocutaneous perforator passing through the underlying muscle. The average time for flap harvest is about in this series. Because these flaps are raised synchronously with the head and neck tumor ablation, two teams of surgeons working at the same time are required to accomplish the simultaneous removal of the tumor and the elevation of the flap. This does not increase the overall operating time.
如前所述，穿支血管的解剖是繁琐的，需要细致地解剖穿过下层肌肉的肌肉皮肤穿孔。 襟翼收获的平均时间大约 在这个系列中。由于这些皮瓣与头颈部肿瘤消融术同步抬高，因此需要两组外科医生同时工作才能同时完成肿瘤切除和皮瓣抬高。这不会增加整体运行时间。
In conclusion, the DIEAP free flap is a reliable and useful flap for head and neck reconstruction, particularly when additional tissue bulk is required. This flap spares the whole rectus abdominis muscle and sheath, and therefore, lessens donor site morbidity.
总之，DIEAP游离皮瓣是一种可靠且有用的头颈部重建皮瓣，特别是当需要额外的组织体积时。该皮瓣可保留整个腹直肌和鞘，从而降低供体部位的发病率。

Conflict of interest statement
利益冲突声明

None declared. 没有宣布。

Acknowledgment 确认

The authors thank Loring W. Pratt, MD of Maine, USA for English revising.
作者感谢美国缅因州医学博士 Loring W. Pratt 的英语修订。

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    • Corresponding author. Address: Department of Head and Neck Surgery, Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, P.O. Box 2258, Beijing 100021, China. Tels.: +86 1087787190 (office), +86 1064716924 (home); fax: +86 1067759100 .
      通讯作者。地址：北京协和医学院附属中国医学科学院肿瘤医院头颈外科，邮政信箱2258，北京100021，中国电话：+86 1087787190（办公室），+86 1064716924（家庭）;传真： +86 1067759100 .
    E-mail address: docbinzhang@hotmail.com (B. Zhang).
    电邮地址：docbinzhang@hotmail.com（B. Zhang）。