Use of Translocated Deep Inferior Epigastric Vessels for Free Flap Reconstruction of Gluteal Defect

Sir:

Reconstruction of large defects in the gluteal region remains challenging. Although regional flaps (eg, anterolateral thigh flap) or myocutaneous flaps (eg, tensor fasciae latae) are options, extensive scarring after multiple surgeries or heavy irradiation renders these options unavailable. In such situations, free flap transfer is often the last resort. Because the gluteal region suffers from insufficient vascular pedi cles, finding reliable recipient vessels is challenging. We herein present a method for reconstructing a large defect in the gluteal region using deep inferior epigastric (DIE) vessels as free flap recipients.

A 70-year-old man suffered from recurrent myxoid liposarcoma in the left gluteal region. Multiple tumor resections and radiation therapy (60 Gy, 3x) resulted in a large soft tissue defect (20 × 8 cm). To reconstruct the defect, a free latissimus dorsi myocutaneous (LDM) flap was elevated in the lateral position. Simultaneously, DIE vessels were isolated until they entered the rectus abdominis muscle as a vascular pedicle using a longitudinal abdominal incision. The pedicle was then translocated through a subcutaneous tunnel for anastomosis (Fig. 1). Microsurgical anastomosis was accomplished with ease behind the anterior superior iliac spine in the same position, and the defect was closed with the LDM flap in combination with a skin graft (Fig. 2). The postoperative course was uneventful, and the patient remains ulcer-free after 5 months.

Fig. 1.

DIE vessels were isolated until they entered the rectus abdominis muscle as a vascular pedicle. The pedicle was translocated through a subcutaneous tunnel for anastomosis (arrow).

Fig. 2.

After vascular anastomosis in the lateral position, the gluteal defect was closed with a free LDM flap in combination with a skin graft.

The selection of recipient vessels is a critical decision that impacts the success of free tissue transfer. However, options are limited in the gluteal region. Superior and inferior gluteal vessels have been previously used as recipients for free flap reconstruction of a lumbosacral defect.^1,2 Although these vessels typically have a sufficient diameter for anastomosis and are near the defect, they can be damaged by multiple surgeries and irradiation, as in the present case. Moreover, because they are very deep seated, dissection and anastomosis can be challenging. Transfer of the LDM flap with interpositional vein grafts³ or the use of posteriorly translocated deep femoral vessels⁴ has also been reported. However, disadvantages with these techniques include an increased risk of thrombosis with vein grafts and the sacrifice of major vessels.

As recipients, DIE vessels have several advantages. First, operative procedures are simple, as DIE vessels are anatomically stable and have sufficient diameters for anastomosis, even in the distal segment. Second, flap harvest and recipient preparation can be simultaneously performed in the lateral position, thereby reducing operative time. Third, the anastomotic site is pressure unloaded in the supine position, decreasing the risk of postoperative compression of pedicles and simplifying postoperative care. Although the anastomotic site and defect are separated to a certain extent, anastomosis can be performed without tension using a flap with a long pedicle, such as the LDM flap.

DISCLOSURE

The authors have no competing financial interests to declare in relation to the content of this article. The Article Processing Charge was paid by the authors.