Buried Deep Inferior Epigastric Perforator Flaps for Complex Head and Neck Contour Defects 埋藏深部上腹下穿支皮瓣治疗复杂的头颈部轮廓缺陷
Mark W. Clemens, M.D., and Steven P. Davison, M.D., D.D.S., F.A.C.S. Mark W. Clemens，医学博士和 Steven P. Davison，医学博士、D.D.S.、F.A.C.S.
Abstract 抽象
The deep inferior epigastric perforator (DIEP) flap is presented as a potential source of tissue for head and neck reconstruction. It has been sparingly reported for pharyngeal reconstruction and to provide a large bulk of skin but not previously described for buried contour defects. We present a retrospective study of a consecutive series of six buried DIEP flaps performed between 2005 and 2007 with a review of their indications, results, and complications. Three patient defects had previous radiation. All flaps were used in the delay setting as secondary reconstructions. Soft tissue defects addressed in this study were the result of a variety of different pathologies, including temporal fossa meningioma, fibrous dysplasia of the skull and orbit, nasopharyngeal carcinoma, neck scar repair, sinus cancer, and osteomyelitis. We report a success rate with primary flap survival, secondary contouring, minimal donor site, provision of moldable bulk soft tissue fill, and ability to fillet and redistribute. Patient-reported satisfaction at 6 months and 1 year was good to excellent in all cases. We concluded that in select cases, the functional and aesthetic advantages of the DIEP flap for head and neck reconstruction of soft tissue defects are superior to implants, fillers, and nonvascularized fat grafts. During revisions, these flaps are amendable to liposuction as a contouring tool with portions that can be redistributed on pedicles. The subcutaneous fat of the DIEP flap has resilience that tends to last and retain its shape with maintenance of residual volume over muscle flaps. 深部下腹穿孔 （DIEP） 皮瓣是头颈部重建的潜在组织来源。它很少被报道用于咽部重建和提供大量皮肤，但以前没有描述过埋藏的轮廓缺损。我们对 2005 年至 2007 年间连续进行的 6 例埋藏式 DIEP 皮瓣进行了回顾性研究，并回顾了它们的适应症、结果和并发症。三名患者既往接受过放射治疗。在延迟设置中，所有襟翼都用作二次重建。本研究中涉及的软组织缺损是多种不同病理的结果，包括颞窝脑膜瘤、颅骨和眼眶纤维发育不良、鼻咽癌、颈部疤痕修复、鼻窦癌和骨髓炎。我们报告了 原发性皮瓣存活率、次级轮廓、最小供体部位、提供可塑性散装软组织填充以及切片和重新分布的能力。在所有病例中，患者在 6 个月和 1 年时报告的满意度均为良好至极好。我们得出的结论是，在特定情况下，DIEP 皮瓣用于软组织缺损头颈部重建的功能和美学优势优于植入物、填充剂和非血管化脂肪移植物。在翻修期间，这些皮瓣可以修改为吸脂术，作为一种轮廓工具，其部分可以重新分布在椎弓根上。DIEP 皮瓣的皮下脂肪具有弹性，倾向于持续并保持其形状，并维持肌肉皮瓣上的残余体积。
KEYWORDS: DIEP flap, contour defects, head and neck reconstruction 关键词：DIEP 皮瓣、轮廓缺损、头颈部重建
patient burden. Despite successful tumor extirpation for benign or malignant disease, patients are deeply concerned with a true restoration. To patients, reconstruction means restoration. As the art of microsurgery advances, the demands are changing. No longer is the emphasis on anastomosis, but rather the focus has turned to the donor site and the final functional and aesthetic result. A prime example of this is head and 患者负担。尽管良性或恶性疾病的肿瘤切除成功，但患者对真正的恢复深感担忧。对患者来说，重建意味着恢复。随着显微外科技术的进步，需求也在发生变化。重点不再是吻合口，而是重点转向供体部位以及最终的功能和美学结果。一个典型的例子是头部和
neck reconstruction. The expectation now is for a result that no longer fills a hole but restores shape, dimension, and patient confidence. John Winston Siebert's longitudinal work with facial atrophy exemplifies this philosophy. Head and neck defects contribute a significant degree of associated psychological trauma to an individual's sense of self, body integrity, and selfesteem. As in breast reconstruction, the restoration of appearance can be as important to the patient as function, and the final aesthetic outcome can become paramount. 颈部重建。现在的期望是，结果不再是填补漏洞，而是恢复形状、尺寸和患者信心。约翰·温斯顿·西伯特（John Winston Siebert）对面部萎缩的纵向研究体现了这一理念。 头部和颈部缺陷对个人的自我意识、身体完整性和自尊心造成很大程度的相关心理创伤。 与乳房重建一样，外观的恢复对患者来说与功能一样重要，最终的美学结果可能变得至关重要。
The three main goals in head and neck reconstruction are (1) to close defects, which includes isolating adjacent structures such as nose/brain, mouth/nose, cheek/mouth, and so on; (2) to maintain function, whether speech, deglutition, or orbit support; and (3) to restore as nearly as possible how the patient looked originally. This goal ultimately becomes the patient's main focus. 头颈部重建的三个主要目标是：（1）闭合缺损，包括隔离相邻结构，如鼻子/大脑、嘴巴/鼻子、脸颊/嘴巴等;（2）维持功能，无论是言语、排泄还是轨道支持;（3）尽可能恢复患者原来的样子。这个目标最终成为患者的主要关注点。
Several different free flaps have been used for head and neck cancer, all with the objective of providing a pliable substitute tissue with a long pedicle and large-diameter vessels. A common criticism of the radial forearm flap is the associated donor site morbidity. The anterior lateral thigh flap is a good alternative for face, neck, and intraoral defects, but it may not provide a sufficient amount of bulk tissue. Significant advancements have been made in the deep inferior epigastric perforator (DIEP) flap, and its popularity has increased in breast reconstruction. At our institution, we have seen an increase of 10 DIEP flap surgeries per year in 2004 to 125 per year in 2007. The DIEP flap has been presented as a potential source of tissue for head and neck reconstruction. has been sparingly reported for pharyngeal reconstruction and to provide a large bulk of skin, but it is not previously described for buried contour defects. The purpose of this study was to present the DIEP flap as an excellent option as a buried perforator flap. In select patients, it is an ideal alternative to other flaps, fillers, and implants in providing the bulk of soft tissue restoration in the head and neck. 几种不同的游离皮瓣已被用于头颈癌，所有这些都是为了提供具有长蒂和大直径血管的柔韧替代组织。 对桡侧前臂皮瓣的常见批评是相关的供体部位发病率。 大腿前外侧皮瓣是面部、颈部和口内缺损的良好替代方法，但它可能无法提供足够数量的散装组织。深下腹穿支 （DIEP） 皮瓣取得了重大进展，其在乳房重建中的普及程度也有所增加。 在我们机构，我们看到 2004 年每年 10 例 DIEP 皮瓣手术增加到 2007 年的每年 125 例。DIEP 皮瓣已被证明是头颈部重建的潜在组织来源。 对于咽部重建和提供大量皮肤的报道很少，但以前没有报道过它用于埋藏的轮廓缺损。本研究的目的是将 DIEP 皮瓣作为埋入式穿孔器皮瓣的绝佳选择。在特定患者中，它是其他皮瓣、填充剂和植入物的理想替代品，可提供头部和颈部的大部分软组织修复。
PATIENTS AND METHODS 患者和方法
We present a retrospective study of a consecutive series of six buried DIEP flaps performed between 2005 and 2007 with a review of their indications, results, and complications (Table 1). Average age was 57.4 years (range, 24 to 77 years). Three (50%) patient defects had previous radiation. DIEP flaps were used for functional scar repair, bulk fill, and soft tissue fill of contour defects. Four flaps were used in the delay setting because secondary reconstructions and one flap were designed with a monitor paddle of skin. Despite the buried nature of flaps, postoperative monitoring was possible in all cases by directed Doppler evaluation of anastomotic vessels. Three (50%) patients went on to receive secondary contouring work either by lipoaspiration or by filleting the flap in a butterfly technique. Follow-up ranged from 12 to 26 months (mean, 16.2 months). 我们对 2005 年至 2007 年间连续进行的 6 例埋藏式 DIEP 皮瓣进行了回顾性研究，并回顾了它们的适应症、结果和并发症（表 1）。平均年龄为57.4岁（范围为24至77岁）。3 例 （50%） 患者既往接受过放射治疗。DIEP 皮瓣用于功能性疤痕修复、大量填充和轮廓缺损的软组织填充。在延迟设置中使用了四个襟翼，因为二次重建和一个襟翼设计有监视器皮肤桨。尽管皮瓣具有掩埋性质，但通过对吻合口血管进行定向多普勒评估，在所有情况下都可以进行术后监测。三名 （50%） 患者继续通过脂肪抽吸或蝴蝶技术切片皮瓣进行二次轮廓塑造工作。随访时间为12至26个月（平均16.2个月）。
TECHNIQUE 技术
Unlike a DIEP flap for breast reconstruction, the flap design is custom shaped. A towel template of the soft tissue defect is made and transferred to the abdomen. Previous incisions are incorporated. A vertical laparotomy scar can be included rather than avoided. A lower transverse excision over the pelvis without mobilization of the umbilicus similar to a mini abdominoplasty is possible. Scars within the abdominal wall are taken into account when designing how the DIEP flap will be raised. For example, abdominal incisions may either be vertical, horizontal, periumbilical, or low horizontal so as to incorporate a previous Pfannenstiel incision. Flaps that are completely crossed by a scar should not be raised 与用于乳房重建的 DIEP 皮瓣不同，皮瓣设计是定制形状的。制作软组织缺损的毛巾模板并转移到腹部。合并了以前的切口。垂直剖腹手术疤痕可以包括在内，而不是避免。在不活动脐部的情况下，可以在骨盆上进行下横切除术，类似于小型腹部整形术。在设计如何抬起 DIEP 皮瓣时，会考虑腹壁内的疤痕。例如，腹部切口可以是垂直的、水平的、脐周的或低水平的，以便结合先前的 Pfannenstiel 切口。完全被疤痕穿过的皮瓣不应抬起
Table 1 Patient Summary 表1 患者总结
患者年龄/性别）
Patient
Age/Gender)
Lesion 病变
Defect 缺陷
Perforator 穿孔器
接收容器
Recipient
Vessel
跟进时间
Follow-up
Time
并发症/修订
Complications/
Revisions
Osteomyelitis 骨髓炎
Neck with radiation 颈部有辐射
DIEP
颈总动脉 ，颈内动脉
Common carotid ,
internal jugular
18 months 18个月
修订版：DIEP 襟翼蝴蝶脱落
Revision: DIEP flap
butterflied out
Sinus CA 鼻窦 CA
眼眶和上颌骨重建
orbit and maxilla
reconstruction
DIEP
浅表颞叶 AN
Superficial
temporal AN
14 months 14个月
None 没有
24/M 24/米
Torticollis 斜颈
鼻咽 CA 既往颈部夹层、放疗、大块组织丢失
Nasopharyngeal CA
with previous neck
dissection, radiation,
loss of bulk tissue
DIEP
面部 ， 颈 内
Facial , internal
jugular
26 months 26个月
None 没有
Meningioma 脑膜 瘤
软组织缺损颞窝、脑底部、顶叶，伴脑脊液漏
Soft tissue defect
temporal fossa, base
of brain, parietal lobe,
with CSF leak
DIEP
Facial AN 面部 AN
14 months 14个月
修订版：DIEP 襟翼蝴蝶脱落
Revision: DIEP
flap butterflied
out
纤维性发育不良
Fibrous
dysplasia
R orbit, skull, and soft tissue R 眼眶、颅骨和软组织
DIEP
浅表颞叶 AN
Superficial
temporal AN
13 months 13个月
None 没有
24/M 24/米
腮腺黑色素瘤
Parotid
Melanoma
颊颧区腔伴辐射
cheek malar region
cavity with radiation
DIEP
颈总动脉 ，颈内动脉
Common carotid ,
internal jugular
12 months 12个月
蝴蝶瓣二次吸脂术
Secondary liposuction
with butterfly flap
because this would unacceptably compromise vascular supply. Because medial row periumbilical perforators are usually dominant, a short transverse scar over a dominant Doppler-capable perforator may be ideal. The resultant donor defect is minimal and can be tailored subsequently with secondary liposuction. The dominant perforator is identified with a Doppler. The anterior rectus fascia is split, and the DIEP pedicle is dissected to a main vessel of adequate length and caliber. Because vessel length is key to get out of the zone of injury, the vessel is traced to the external iliacs and harvested at a full of length. Primary repair of the fascia is completed without mesh repair. Layered closure of Scarpa's fascia, deep dermis, and skin complete the donor defect. 因为这会不可接受地损害血管供应。由于内侧排脐周穿孔通常占主导地位， 因此在具有多普勒能力的显性穿支上出现短横向瘢痕可能是理想的选择。由此产生的供体缺陷是最小的，随后可以通过二次吸脂术进行定制。显性穿支器由多普勒识别。将前直肌筋膜劈开，并将 DIEP 椎弓根解剖到足够长度和口径的主血管上。由于血管长度是离开损伤区域的关键，因此将血管追踪到髂外侧，并以全 长采集。 筋膜的初级修复无需补片修复即可完成。Scarpa筋膜、真皮深层和皮肤的分层闭合完成了供体缺陷。
It is important to establish and identify the recipient vessels early. The damage from either previous surgical resections or radiation as a single factor is seldom a problem, but both together create an inhospitable zone of injury that is better to generously explore around. Superficial temporal vessels explored deep in the parotid from their origin off the deep maxillary artery are preferable to those in the temporoparietal fascia. The vein is larger and the artery less spastic. Note that an experienced surgeon should use this strategy with caution to minimize risk to the facial nerve. The neck vessels, including branches of the external carotid and end to side on the jugular, are good recipients. 及早建立和识别受体血管非常重要。先前的手术切除或放疗造成的损害很少成为问题，但两者共同造成了一个不适宜居住的损伤区域，最好慷慨地探索周围。从上颌深动脉的起源处探查腮腺深处的浅颞血管比颞顶筋膜中的颞浅血管更可取。静脉较大，动脉痉挛较少。请注意，有经验的外科医生应谨慎使用此策略，以尽量减少对面神经的风险。颈部血管，包括颈外动脉的分支和颈静脉的首尾相连，是良好的受体。
Figure 1 A 24-year-old man with a history of parotid melanoma, status post left parotidectomy and lymph node dissection and subsequent radiation and interferon treatment. Note presenting left lower face soft tissue defect. (Top) The patient received a deep inferior epigastric perforator flap subcutaneously buried to the left cheek malar region. (Middle) Secondary reconstruction was performed at 8 months where he received lipoaspiration with butterflying of the flap. (Bottom) One year postoperatively. 图 1 一名 24 岁男性，有腮腺黑色素瘤病史，左腮腺切除术和淋巴结清扫术以及随后的放疗和干扰素 治疗后状态。注意显示左下面部软组织缺损。（返回顶部）患者接受了皮下埋在左颊颧骨区域的深下腹穿支皮瓣。（中）在 8 个月时进行了二次重建，在那里他接受了脂抽吸和皮瓣的蝴蝶。（底部）术后一年。
Figure 2 (A) Intraoperative photo of patient from case 1. Original incision was used for access to the common carotid artery and internal jugular vein recipient vessels. Note that the extent of the undermining for flap placement is marked in pen on the patient's skin. (B) Healed lower abdominal donor site at 1 year. 图2（A）病例1患者术中照片。原始切口用于进入颈总动脉和颈内静脉受体血管。请注意，皮瓣放置的破坏程度用笔标记在患者的皮肤上。（B） 1 年时下腹部供体部位愈合。
When inserting the flap, "marionette" sutures are very useful. The pocket is made slightly larger than the flap and a 2-0 polydioxanone (PDS II) suture (Ethicon, Somerville, NJ) is used as a percutaneous stitch to position the flap. The sutures are not tied but instead taped with Steri-Strips (3M, St. Paul, MN). 插入皮瓣时，“牵线木偶”缝合线非常有用。口袋比皮瓣略大，并使用 2-0 聚二恶烷酮 （PDS II） 缝合线（Ethicon，Somerville，NJ）作为经皮缝线来定位皮瓣。缝合线没有绑扎，而是用 Steri-Strips（3M，圣保罗，明尼苏达州）粘贴。
RESULTS 结果
Soft tissue defects addressed in this study were the result of a variety of different pathologies, including temporal fossa meningioma, fibrous dysplasia of the skull and orbit, nasopharyngeal carcinoma, neck scar repair, sinus cancer, and osteomyelitis. The surgical defects all had the following indications in common: subcutaneous contour deformity, whether bone or soft tissue; overlying intact skin; and loss of bulk tissue. In this series, six of six flaps survived initial procedures for a primary flap survival rate. All patients demonstrated minimal donor site morbidity, provision of moldable bulk soft tissue fill. Overall, the average hospital stay was 4.6 days (range, 3 to 6 days). Three patients ( ) received secondary contouring emphasizing the flaps amenability to lipoaspiration and butterfly technique, filleting, and redistributing. Patient-reported satisfaction at 6 months and 1 year follow-up was good to excellent in all. 本研究中涉及的软组织缺损是多种不同病理的结果，包括颞窝脑膜瘤、颅骨和眼眶纤维发育不良、鼻咽癌、颈部疤痕修复、鼻窦癌和骨髓炎。手术缺陷均具有以下共同适应症：皮下轮廓畸形，无论是骨还是软组织;覆盖完整的皮肤;和散装组织的损失。在该系列研究中，六个皮瓣中有六个在初始手术中幸存下来， 获得了初级皮瓣存活率。所有患者均表现出最低的供体部位发病率，提供可塑的散装软组织填充物。总体而言，平均住院时间为 4.6 天（范围为 3 至 6 天）。三名患者 （ ） 接受了二次轮廓塑造，强调皮瓣适合脂肪抽吸和蝴蝶技术、切片和再分布。患者报告的 6 个月和 1 年随访的满意度总体上为良好至优秀。
Case 1 案例 1
A 24-year-old man presented with a history of parotid melanoma, status post left parotidectomy and lymph 一名 24 岁男性，有腮腺黑色素瘤病史、左腮腺切除术和淋巴后状态
Figure 3 Drawing demonstrating the "butterfly" filleting of a deep inferior epigastric perforator flap during secondary contouring and revision. Attention to the direction of the vascular flow is important in designing the pedicles. 图 3 在二次轮廓和翻修过程中，展示了深下腹穿支皮瓣的“蝴蝶”圆角。在设计椎弓根时，注意血管流动的方向很重要。
node dissection in 1999. The patient had received radiation and interferon treatment. His initial resection left him with a concavity and facial deformity of the left cheek malar region (Fig. 1). The patient received a DIEP flap subcutaneously buried to the left cheek malar region (Fig. 2). Secondary reconstruction was performed at 8 months when he received lipoaspiration of the anterior aspect of the parotid region and further definition of the contoured jaw using a cannula. Additionally, the original skin flap was raised, and the excess DIEP flap was butterflied, turned down, and used to contour the anterior aspect of the neck (Fig. 3). The patient tolerated all procedures well with no complications and reports excellent satisfaction with the result. 1999年淋巴结清扫术。病人接受了放疗和干扰素 治疗。他最初的切除术使他的左颊颧部区域凹陷和面部畸形（图1）。患者接受了皮下埋藏在左颊颧部区域的 DIEP 皮瓣（图 2）。在 8 个月时进行了二次重建，当时他接受了腮腺区域前部的脂肪抽吸术，并使用 套管进一步定义了下颌轮廓。此外，将原来的皮瓣抬高，多余的 DIEP 皮瓣被蝴蝶化、向下翻转，并用于勾勒颈部前部的轮廓（图 3）。患者对所有手术的耐受性良好，没有并发症，并报告对结果非常满意。
Figure 4 A 48-year-old woman after resection of a large oral cancer for which she later received radiation. She subsequently received an iliac crest flap and a fibula free flap for reconstruction but continued to have significant soft tissue defects. (Top) The patient received a buried deep inferior epigastric perforator (DIEP) flap to her neck. (Middle) Secondary revision was performed at 6 months by butterflying the excess DIEP flap. (Bottom) Fourteen months postoperatively. 图 4：一名 48 岁的女性在切除大面积口腔癌后接受了放射治疗。随后，她接受了髂嵴皮瓣和腓骨游离皮瓣进行重建，但仍有明显的软组织缺损。（返回顶部）患者颈部埋藏深下腹穿孔 （DIEP） 皮瓣。（中）在 6 个月时通过蝴蝶飞过多余的 DIEP 皮瓣进行二次翻修。（底部）术后14个月。
Figure 5 Intraoperative photos of the 49-year-old woman from case 2. Note deep inferior epigastric perforator flap with vessels prior to inset (A) and inset with anastomosis to common carotid artery and internal jugular vein for recipient vessels (B). 图5 病例2中49岁女性的术中照片。注意深下腹穿支皮瓣，在插入 （A） 之前有血管，并插入颈总动脉和颈内静脉 （B） 的吻合口。
Figure 6 A 62-year-old woman after resection of fibrous dysplasia from her right orbit and skull, with significant soft tissue loss. Note the considerable deformity of the right forehead and skull. (Top) A buried deep inferior epigastric perforator flap was inset to the superficial temporal artery and vein for recipient vessels. (Bottom) Thirteen months postoperatively. 图 6 一名 62 岁的女性从右眼眶和颅骨切除纤维发育不良后，软组织明显丢失。注意右前额和头骨的严重畸形。（返回顶部）将埋藏的深部上腹下穿支皮瓣嵌入受体血管的颞浅动脉和静脉。（底部）术后13个月。
Table 2 Advantages of Buried Deep Inferior Epigastric Perforator (DIEP) Flaps in Head and Neck Reconstruction 表2 埋藏深下上腹穿孔（DIEP）皮瓣在头颈部重建中的优点
Buried DIEP flaps have high survival with no resorption or atrophy 埋藏的 DIEP 皮瓣具有高存活率，不会吸收或萎缩
Excellent bulk for bony or soft tissue defects 出色的体积，适用于骨或软组织缺损
Amendable to secondary contouring 可修改为二次轮廓
techniques such as lipoaspiration 脂肪抽吸等技术
Case 2 案例 2
A 49 -year-old woman presented in 2002 with a large oral and maxillary squamous cell carcinoma for which she received excision and radiation by otolaryngology. She subsequently underwent two free flap reconstructions of her left face, including an iliac crest flap to the left lateral aspect of the premaxillary area and a fibula free flap for a mandibular defect second to osteomyelitis. She received postoperative radiation. These procedures left the patient with significant soft tissue defects, including collapse of the left lateral aspect of the neck, pain and tenderness, a facial contour deficit, and trismus (Fig. 4). She also developed osteoradionecrosis and an oral-cutaneous fistula. The patient received a buried DIEP flap to her neck using the common carotid artery and internal jugular vein for recipient vessels. Intraoperatively, the common carotid artery was partially cross-clamped using a side-biting Satinsky clamp. Postoperatively, the patient demonstrated significant improvement in the soft tissue deficit with near complete resolution of the trismus. Secondary reconstruction was performed at 6 months where the original skin flap was raised and the excess DIEP flap was butterflied, turned down, and the transition smoothed between the native and flap tissue (Fig. 5). The patient tolerated all the procedures well with no complications and reports excellent satisfaction with the result. 一名 49 岁的女性于 2002 年因口腔和上颌大面积鳞状细胞癌就诊，为此她接受了耳鼻喉科切除和放疗。随后，她接受了两次左脸游离皮瓣重建术，包括上颌前区左侧外侧的髂嵴皮瓣和继发于骨髓炎的下颌缺损的腓骨游离皮瓣。她接受了术后放疗。这些手术使患者出现明显的软组织缺损，包括颈部左侧塌陷、疼痛和压痛、面部轮廓缺陷和牙关紧闭（图 4）。她还出现了放射性骨坏死和口腔皮肤瘘。患者使用颈总动脉和颈内静脉作为受体血管在她的颈部接受了埋藏的 DIEP 皮瓣。术中，使用侧咬 Satinsky 夹对颈总动脉进行部分交叉夹紧。术后，患者软组织缺损明显改善，牙关紧闭几乎完全消退。在 6 个月时进行二次重建，将原来的皮瓣抬高，将多余的 DIEP 皮瓣蝴蝶化、向下翻转，并在天然组织和皮瓣组织之间平滑过渡（图 5）。患者对所有手术的耐受性良好，没有并发症，并报告对结果非常满意。
CONCLUSIONS 结论
Reconstructive techniques for head and neck defects are always evolving. In select cases, we report the functional and aesthetic advantages of the DIEP flap for head and neck reconstruction of soft tissue defects as superior to implants, fillers, and nonvascularized fat grafts (Fig. 6; Table 2). 头颈部缺损的重建技术一直在不断发展。在特定病例中，我们报告了 DIEP 皮瓣在软组织缺损头颈部重建方面的功能和美学优势优于植入物、填充剂和非血管化脂肪移植物（图 6;表2）。
Donor site defects are remote and minimized, with no muscle loss. They are well accepted by patients, and mild contour revisions of the abdomen are possible at secondary surgery. Rectus muscle flaps are generally accepted to have a deep inferior epigastric vessel length of from origin to entrance into the rectus muscle. When using neck vessels, this pedicle length can be insufficient for reconstruction of the upper midface, forehead, and cranial base and may require the addition of vein grafts. Radiation to soft tissues and bone in the head and neck creates significant challenges for later free tissue transfer. A zone of injury exists after radiation injury to surrounding tissue with deleterious effects on possible recipient vessels. The DIEP flap has a longer pedicle than most commonly used free flaps, with an average pedicle length of 8 to and diameter of 2 to , allowing the surgeon to place the anastomosis well outside of the zone of injury. 供体部位缺损是远程的，并且最小化，没有肌肉损失。它们被患者很好地接受，并且在二次手术中可以对腹部进行轻微的轮廓修正。直肌皮瓣通常被认为 具有从起点到进入直肌的深下腹血管长度。 当使用颈部血管时，这种椎弓根长度可能不足以重建上中面、前额和颅底，可能需要添加静脉移植物。对头部和颈部软组织和骨骼的辐射给以后的游离组织转移带来了重大挑战。对周围组织进行辐射损伤后存在损伤区域，对可能的受体血管产生有害影响。DIEP 皮瓣的椎弓根比最常用的自由皮瓣长，平均椎弓根长度为 8 至 ，直径为 2 至 ，允许外科医生将吻合口放置在损伤区域之外。
The subcutaneous fat of the DIEP flap has resilience that tends to last reliably and retain its shape with no atrophy as seen in muscle flaps. We observe maintenance of residual volume over muscle flaps that, once denervated, tend to shrink with time. Hence the procedure's immediate result more closely predicts the long-term result. During revisions, these flaps are amendable to secondary remodeling with lipoaspiration as a contouring tool. This allows for closed revisions using micro-liposuction. Alternately, the surgeon may choose an open approach to the revision and the flaps may be butterflied with portions redistributed on pedicles and flipped over to smooth transition margins. DIEP 皮瓣的皮下脂肪具有弹性，往往能够可靠地持续并保持其形状，而不会像肌肉皮瓣那样萎缩。我们观察到肌肉皮瓣的残余体积维持，一旦去神经化，往往会随着时间的推移而缩小。因此，该程序的直接结果更接近于预测长期结果。在翻修过程中，这些皮瓣可以修改为二次重塑，以脂肪抽吸作为轮廓工具。这允许使用微吸脂术进行封闭式翻修。或者，外科医生可以选择开放式翻修方法，并且可以将皮瓣部分重新分布在椎弓根上并翻转以平滑过渡边缘。
This technique of buried DIEP flaps represents a fusion between cosmetic and reconstructive surgery, and it is superior to current alternative solutions for providing tissue bulk in head and neck contour defects. 这种埋藏式 DIEP 皮瓣技术代表了整容手术和重建手术的融合，它优于目前为头部和颈部轮廓缺损提供组织体积的替代解决方案。
ACKNOWLEDGMENTS 确认
A special thank you to Jennifer G. Seither, R.N., for medical illustration. 特别感谢 Jennifer G. Seither， RN 提供医学插图。
Presented at the 2008 annual meeting of the American Society for Reconstructive Microsurgery, Beverly Hills, California, January 12-15, 2008. 2008 年 1 月 12 日至 15 日在加利福尼亚州比佛利山庄举行的美国重建显微外科学会 2008 年年会上发表。
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Department of Plastic Surgery, Georgetown University Medical Center, Washington, District of Columbia. 乔治敦大学医学中心整形外科，华盛顿，哥伦比亚特区。
Address for correspondence and reprint requests: Mark W. Clemens, M.D., Department of Plastic Surgery, Georgetown University Medical Center, 3800 Reservoir Road NW, Washington, DC 20007 (e-mail: clemensmd@gmail.com) 通信和重印请求的地址：Mark W. Clemens， M.D.， Department of Plastic Surgery， Georgetown University Medical Center， 3800 Reservoir Road NW， Washington， DC 20007（电子邮件：clemensmd@gmail.com）
J Reconstr Microsurg 2009;25:81-88. Copyright (C) 2009 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: 584-4662. 显微外科研究杂志 2009;25：81-88。版权所有 （C） 2009 Thieme Medical Publishers， Inc.， 333 Seventh Avenue， New York， NY 10001， USA。电话： 584-4662。
Received: February 24, 2008. Accepted after revision: May 30, 2008. Published online: October 15, 2008. 收稿日期： 2008-02-24.修改后接受：2008年5月30日。在线发布：2008年10月15日。
DOI 10.1055/s-0028-1090601. ISSN 0743-684X. DOI： 10.1055/s-0028-1090601.国际标准刊号：ISSN 0743-684X。
