EXTENDED DEEP INFERIOR EPIGASTRIC ARTERY PERFORATOR FLAP FOR HEAD AND NECK RECONSTRUCTION: A CLINICAL EXPERIENCE WITH 100 PATIENTS 用于头颈部重建的延伸深下腹动脉穿支皮瓣：100 例患者的临床经验
Jaume Masià, MD, PhD, Maria Sommario, MD, Daniele Cervelli, MD, Carmen Vega, MD, Jaume Masià，医学博士，博士， Maria Sommario，医学博士， Daniele Cervelli，医学博士， Carmen Vega，医学博士， Xavier León, MD, PhD, Gemma Pons, MD Xavier León，医学博士，博士， Gemma Pons，医学博士 Department of Plastic Surgery, Hospital de la Santa Creu i Sant Pau (Universitat Autonoma de Barcelona), Sant Antoni M. 圣克鲁圣保罗医院整形外科（巴塞罗那自治大学），圣安东尼 M.Claret 167, 08025 Barcelona, Spain. E-mail: jmasia@santpau.cat Claret 167， 08025 巴塞罗那， 西班牙.电子邮件： jmasia@santpau.cat Department of ENT, Hospital de la Santa Creu i Sant Pau (Universitat Autonoma de Barcelona), 耳鼻喉科，圣保罗圣保罗医院（巴塞罗那自治大学），Sant Antoni M. Claret 167, 08025 Barcelona, Spain Sant Antoni M. Claret 167， 08025 巴塞罗那， 西班牙
Accepted 12 August 2010 录用日期： 2010-08-12
Published online 10 November 2010 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002 / hed.21628 2010 年 11 月 10 日在 Wiley Online Library （wileyonlinelibrary.com） 在线发布。DOI： 10.1002 / hed.21628
Abstract 抽象
Background. The extended deep inferior epigastric perforator (DIEP) artery flap had been described in 1983. For head and neck reconstruction, we have been using a variation of this flap, namely a perforator free flap of the deep inferior epigastric system with a superolateral extension of the skin paddle. 背景。1983 年描述了延伸的深下腹穿支 （DIEP） 动脉瓣。对于头颈部重建，我们一直在使用这种皮瓣的变体，即深下上腹系统的无穿孔皮瓣，皮肤桨的上外侧延伸。
Methods. The purpose of this study was to present our 10year experience in the performance of 102 soft tissue head and neck reconstructions with the extended DIEP flap in 100 patients. 方法。本研究的目的是展示我们在 100 名患者中使用扩展的 DIEP 皮瓣进行 102 次软组织头颈部重建的 10 年经验。
Results. Depending on the reconstructive needs, we used the extended DIEP flap in 3 ways: as a cutaneous perforator flap ( ), as a chimeric perforator flap ( ), and as a myocutaneous perforator flap ( ). The overall flap survival rate was . Three flaps (2.9%) totally necrosed. Partial flap loss occurred in of the cases. 结果。根据重建需求，我们以 3 种方式使用扩展的 DIEP 皮瓣：作为皮肤穿支皮瓣 （ ）、嵌合穿支皮瓣 （ ） 和作为肌穿支皮瓣 （ ）。皮瓣总存活率为 。三个皮瓣（2.9%）完全坏死。 这些病例中发生了部分皮瓣丢失。
Conclusion. The extended DIEP flap is reliable, has a safe vascular supply, and has a long pedicle. Its versatility makes it suitable for reconstruction of moderate to large head and neck reconstruction. @ 2010 Wiley Periodicals, Inc. Head Neck 33: 1328-1334, 2011 结论。扩展的 DIEP 皮瓣可靠，具有安全的血管供应，并且具有长蒂。它的多功能性使其适用于中度至大型头颈部重建的重建。@ 2010 Wiley Periodicals， Inc. Head Neck 33： 1328-1334， 2011
Keywords: extended DIEP flap; perforator flap; head and neck reconstruction; microsurgical reconstruction; head and neck cancer 关键词：扩展 DIEP 皮瓣;穿孔器襟翼;头颈部重建;显微外科重建;头颈癌
Management of patients after ablative head and neck surgery often presents challenging reconstruction of complex 3-dimensional defects. The extended deep inferior epigastric perforator (DIEP) artery flap was described by Taylor et in 1983 . 头颈部消融手术后的患者管理通常具有挑战性的复杂三维缺损重建。延伸的深下腹穿支 （DIEP） 动脉瓣由 Taylor 等人 于 1983 年描述。
Regardless of the size, such defects can have a dramatic effect on cosmesis, speech, respiration, and alimentation and may significantly impact the patient's quality of life. 无论大小，这些缺陷都会对美容、言语、呼吸和营养产生巨大影响，并可能显着影响患者的生活质量。
In this setting, the ultimate goal of the reconstructive surgeon is to achieve adequate functional and morphological rehabilitation of the treated area, matching shape, tissue type, and volume of the surgical defect as closely as possible. At the same time, any compromise of the remaining normal tissue function must be minimized. 在这种情况下，重建外科医生的最终目标是在治疗区域实现充分的功能和形态康复，尽可能匹配手术缺损的形状、组织类型和体积。同时，必须尽量减少对剩余正常组织功能的任何损害。
To achieve better postoperative functional and aesthetic outcomes, and to provide a reasonable quality of life, microvascular free tissue transfers are now the first choice in many cases for head and neck reconstruction. 为了获得更好的术后功能和美学结果，并提供合理的生活质量，微血管游离组织移植现在是许多情况下头颈部重建的首选。
A number of free flap donor sites have been described in the literature for the head and neck; these include rectus abdominis, latissimus dorsi, serratus and gracilis for myocutaneous flaps, radial forearm, ulna, lateral arm, temporoparietal, anterolateral thigh, deep inferior epigastric perforator, superficial inferior epigastric artery, and superficial circumflex iliac artery for fasciocutaneous flaps, jejunum for visceral flap, fibula, radial forearm, scapula, and iliac crest for osteocutaneous flaps. 在头部和颈部的文献中描述了许多游离皮瓣供体部位;这些包括用于肌皮瓣的腹直肌、背阔肌、锯肌和股纤毛、桡前臂、尺骨、外臂、颞顶、大腿前外侧、深下腹穿支、浅表上腹下动脉和用于筋膜皮瓣的回旋髂浅动脉、用于内脏皮瓣的空肠、腓骨、桡前臂、肩胛骨和用于骨皮瓣的髂嵴。
With the development of perforator flaps, another safe and reliable surgical option has become available for reconstructive surgeons. Since Taylor and Palmer introduced the concept of angiosomes, we know that a single perforator vessel of adequate caliber can nourish tissues contained within its angiosome, and also within neighboring angiosomes by means of choke vessels. The pedicle of a perforator flap originates from a main vessel, runs through a muscle and/or intermuscular septum to the fascia, and ramifies at a suprafascial level in the subcutaneous fat. The main advantage in the use of these flaps is lower donor site morbidity, as the muscle through which the perforators pass is spared. 随着穿支皮瓣的发展，重建外科医生可以使用另一种安全可靠的手术选择。自从泰勒和帕尔默 引入血管体的概念以来，我们知道一个足够口径的穿支血管可以滋养其血管体内的组织，也可以通过窒息血管滋养邻近血管内的组织。穿支皮瓣的椎弓根起源于主血管，穿过肌肉和/或肌间隔到达筋膜，并在皮下脂肪的筋膜上水平分支。使用这些皮瓣的主要优点是降低供体部位的发病率，因为穿孔器通过的肌肉可以幸免。
Concerning the application of perforator flaps in soft-tissue head and neck reconstruction, the 关于穿支皮瓣在软组织头颈部重建中的应用，
FIGURE 1. (A) Preoperative design of the skin flap. (B) Flap and pedicle dissection through the paramedian skin incision. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] 图 1.（A）皮瓣的术前设计。（B） 通过旁正中皮肤切口进行皮瓣和椎弓根夹层。[彩色图可在 wileyonlinelibrary.com 在线刊物中查看。
anterolateral thigh (ALT) perforator flap, described and widely applied by Wei et and Koshima et al, has become the work-horse in this setting over the last 10 years. Wei 等人 和 Koshima 等人描述并广泛应用的大腿前外侧 （ALT） 穿支皮瓣在过去 10 年 中已成为这种情况的主力军。
In 1999, we started to incorporate perforator flaps into our routine head and neck reconstruction surgery. For small defects located in the neck and buccal floor, we preferably use the internal mammary artery perforator flap, transferred with the propeller method. In case of wider defects, we usually use free perforator flaps, such as the superficial circumflex iliac artery perforator flap, the ALT perforator flap, and the extended DIEP flap, these last 2 being our first choices. 1999 年，我们开始将穿支皮瓣纳入我们的常规头颈部重建手术中。对于位于颈部和颊底的小缺损，我们优选使用乳内动脉穿支皮瓣，用螺旋桨方法转移。 在缺陷较宽的情况下，我们通常使用游离穿支皮瓣，例如浅回旋髂动脉穿支皮瓣、ALT 穿支皮瓣和扩展 DIEP 皮瓣，最后 2 个是我们的首选。
The extended deep inferior epigastric artery flap was first described by Taylor et in 1983. This versatile flap of the upper-lateral portion of the abdomen is supplied by a reliable cluster of periumbilical perforators of the deep inferior epigastric artery and connected by means of choke vessels with the anterior branches of the lateral intercostal vessels. 延伸的深上腹下动脉瓣由 Taylor 等人 于 1983 年首次描述。腹部上外侧的这种多功能皮瓣由上腹下动脉的可靠脐周穿支簇提供，并通过阻塞血管与肋间外侧血管的前支连接。
In this article, we describe our 10 years' experience using the perforator variation of the extended deep inferior epigastric artery flap in soft tissue head and neck reconstruction. We report the reliability and versatility of this flap, showing its high effectiveness in meeting our surgical needs in this setting. 在本文中，我们描述了我们在软组织头颈部重建中使用延伸的深下腹动脉瓣穿支器变化的 10 年经验。我们报告了这种皮瓣的可靠性和多功能性，表明它在这种情况下可以很好地满足我们的手术需求。
MATERIALS AND METHODS 材料与方法
We retrospectively reviewed 102 cases of soft tissue head and neck reconstruction with the extended DIEP flap, carried out in 100 patients. All operations were performed at our institution by the same surgical team from June 1999 to June 2009. There were 73 male patients and 27 female patients, with a mean age of 58 years old. Follow-up ranged from 2 months to 10 years. 我们回顾性回顾了 102 例在 100 例患者中进行的延长 DIEP 皮瓣软组织头颈部重建。从1999年6月到2009年6月，所有手术均由同一外科团队在我们机构进行。男性患者73例，女性患者27例，平均年龄58岁。随访时间从2个月到10年不等。
All patients were preoperatively submitted to perforator mapping. Until October 2003, this was performed by means of a Doppler ultrasound scan. As of this date, we performed the mapping with the aid of multidetector-row CT, a technique with high sensitivity and specificity that proved to be very useful in evaluating perforating vessels, and, therefore, in planning abdominal perforator flaps. 所有患者术前均接受穿支器标测。直到 2003 年 10 月，这是通过多普勒超声扫描进行的。截至目前，我们在多排 CT 的帮助下进行了标测，这是一种具有高灵敏度和特异性的技术，被证明在评估穿孔血管方面非常有用，因此在规划腹部穿支皮瓣时也非常有用。
To describe our operative technique, we first draw the axis of the flap from the umbilicus to the inferior tip of the scapula, parallel to the ribs, at a 45 degree angle to the anterior axillary line. The skin paddle is then traced by placing the main perforator, preoperatively located, centrally at its base. The flap extends from the midline upward and laterally and can reach the anterior axillary line, if required. Its width is determined by the laxity of local soft tissues, using the "pinch test" (Figure 1). 为了描述我们的手术技术，我们首先绘制皮瓣的轴线，从脐部到肩胛骨下端，平行于肋骨，与腋前线成 45 度角。然后通过将术前位于其底部的主穿孔器放在其底部的中央来追踪皮肤桨。皮瓣从中线向上和横向延伸，如果需要，可以到达腋前线。它的宽度由局部软组织的松弛度决定，使用“捏合测试”（图1）。
Dissection begins at the distal end of the flap and proceeds along a suprafascial plane toward the lateral border of the rectus muscle. When the anterior rectus sheath is reached, careful dissection is performed over this fascia until the best perforator is encountered. The perforator is then carefully evaluated at the suprafascial level and subsequently dissected. 解剖从皮瓣的远端开始，沿筋膜上平面向直肌的外侧缘进行。当到达前直肌鞘时，对该筋膜进行仔细解剖，直到遇到最佳穿孔器。然后在筋膜上水平仔细评估穿孔器，随后解剖。
On continuation, the flap is harvested along the upper, medial, and inferior borders of the skin paddle, skirting the umbilicus, and the adipocutaneous flap is isolated. At these levels, the rectus sheath is opened around the main perforator, so as to spare the fascia as much as possible and to facilitate donor site repair. 在继续时，沿着皮桨的上缘、内侧和下缘收获皮瓣，绕过脐部，并分离脂肪皮瓣。在这些水平上，直肌鞘在主穿孔器周围打开，以便尽可能地保留筋膜并促进供体部位修复。
To facilitate the intramuscular dissection, we perform a cutaneous incision opening the subcutaneous fat and fascia over the rectus abdominis muscle. If a muscle-sparing procedure is chosen, the rectus muscle is split and freed from the perforator and the deep inferior epigastric pedicle, taking care not to damage the segmental motor nerves which allow its function. 为了便于肌内解剖，我们进行了一个皮肤切口，打开腹直肌上的皮下脂肪和筋膜。如果选择保留肌肉的手术，则直肌被分开并从穿孔器和深部上腹弓根中释放出来，注意不要损伤允许其功能的节段性运动神经。
Depending on reconstructive needs, another option is to dissect a muscular branch of the deep inferior epigastric vessels and the cutaneous perforator, to incorporate a separate muscular component in the flap. Both these components are supplied by a common vascular source, providing a "chimeric" perforator flap. 根据重建需要，另一种选择是解剖上腹下部血管和皮肤穿支的肌肉分支，以在皮瓣中加入单独的肌肉成分。这两种组件都由一个共同的血管源提供，提供一个“嵌合”穿孔器瓣。
We can also leave a small portion of muscle and fascia around the selected perforator to give major projection to the flap, as a musculocutaneous flap. 我们还可以在选定的穿孔器周围留下一小部分肌肉和筋膜，以使皮瓣主要突出，作为肌肉皮肤皮瓣。
After completing the pedicle dissection, we wait for 10 minutes to ascertain skin paddle perfusion. The flap is then transposed to the recipient site and anastomosed. With this technique, we preserve the integrity of muscle, muscular fascia, and innervation, thereby facilitating direct defect closing. 完成椎弓根解剖后，我们等待 10 分钟以确定皮肤桨灌注。然后将皮瓣转位到受体部位并吻合。通过这种技术，我们保持了肌肉、肌肉筋膜和神经支配的完整性，从而促进了直接的缺损闭合。
RESULTS 结果
We used the extended DIEP flap as a cutaneous perforator flap in 54 cases ( ), as a "chimeric" perforator flap in 7 cases ( ), and as a myocutaneous perforator flap in 41 cases ( ). 我们在 54 例 （ ） 中使用扩展的 DIEP 皮瓣作为皮肤穿支皮瓣，在 7 例 （ ） 中用作“嵌合”穿支皮瓣，在 41 例 （ ） 中用作肌穿支皮瓣 。
Skin paddle size ranged from 11 to in length (mean, ) and from 7 to in width (mean, ). 皮肤桨的长度范围从11 到（平均值） 和宽度从7 到宽度（平均值， ）。
The overall flap survival rate was (99 of 102). There were 3 flap losses ( ) due to postoperative complications, represented by hematoma due to a cervical vessel bleeding during the first 24 hours of the postoperative period in radiated patients. These were repaired with an extended DIEP flap of the contralateral side in 2 cases and with an ALT flap in the third. 总皮瓣存活率为 （102 例中有 99 例）。有 3 例皮瓣丢失 （ ） 由术后并发症引起，表现为放射患者术后前 24 小时内颈血管出血引起的血肿。在 2 例病例中，这些用对侧的扩展 DIEP 皮瓣修复，在第三例中用 ALT 皮瓣修复。
Necrosis occurred in 6 cases; it involved only a small area, about 1 to , and it affected the distal edge of the flap. The patients with necrosis were smokers. All had a very wide skin paddle, of almost , going beyond the costal margin. There was no association with increased abdominal wall fat. All necroses were successfully treated by suture or medication (Figures 2-4). 坏死6例;它只涉及一小块区域，大约1到 ，它影响了皮瓣的远端边缘。坏死患者为吸烟者。所有人都有一个非常宽的皮肤桨，几乎 超出了肋缘。与腹壁脂肪增加无关。所有坏死均通过缝合或药物成功治疗（图2-4）。
DISCUSSION 讨论
The use of Taylor's flap as a free flap for reconstruction of the head and neck has been described in very few articles to date. Taylor et applied this flap to repair complex head and neck defects, Gottlieb et al used it for wound closure and nasal reconstruction after a total rhinectomy and ethmoidectomy, and Lee and Dumanian provided a case in which the flap was used for a face reconstruction. In all 3 cases, the 迄今为止，很少有文章描述使用泰勒皮瓣作为自由皮瓣重建头部和颈部。Taylor 等人 将这种皮瓣用于修复复杂的头颈部缺损，Gottlieb 等人 将其用于全鼻切除术和筛骨切除术后的伤口闭合和鼻重建，Lee 和 Dumanian 提供了一个将皮瓣用于面部重建的案例。在所有 3 种情况下，
FIGURE 2. (A) Preoperative design of the skin flap for the tongue reconstruction. (B) Cutaneous perforator flap with pedicle. (C) Result of tongue reconstruction after 6 months. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] 图2.（A）舌头重建皮瓣的术前设计。（B） 带椎弓根的皮肤穿支皮瓣。（C） 6个月后舌头重建的结果。[彩色图可在 wileyonlinelibrary.com 在线刊物中查看。
flap was used as a non-perforator, muscle, myocutaneous, or myosubcutaneous flap. 皮瓣用作非穿孔器、肌肉、肌皮或肌皮下皮瓣。
Koshima and Soeda were the first to provide the report of a DIEP flap, describing an inferior epigastric artery skin flap without rectus abdominis muscle Koshima 和 Soeda 是第一个提供 DIEP 皮瓣报告的人，描述了没有腹直肌的下腹动脉皮瓣
FIGURE 3. (A) A 68-year-old man with full-thickness left cheek mucosa squamous cell carcinoma. (B) Preoperative design of the chimeric perforator flap. (C) Residual defect after wide resection of tumor and left hemimandibulectomy. (D) Chimeric perforator flap and pedicle dissection. (E) Chimeric perforator flap with 2 skin paddles based on 2 distinct cutaneous perforators of the deep inferior epigastric artery. One skin paddle is for cheek mucosa reconstruction and the other for cheek skin reconstruction. An abdominis rectus muscle portion is taken with the skin paddle for skin cheek reconstruction. (F) The chimeric perforator flap is positioned on the defect. The mandible was not reconstructed because in view of the patient's poor prognosis the multidisciplinary head and neck committee decided to perform a soft tissue reconstruction only. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] 图3.（A） 一名 68 岁男性，患有全层左颊黏膜鳞状细胞癌。（B）嵌合穿孔皮瓣的术前设计。（C）肿瘤广泛切除术和左半下颌骨切除术后残留缺损。（D）嵌合穿支皮瓣和椎弓根解剖术。（E） 嵌合穿支皮瓣，带有 2 个基于上腹深动脉 2 个不同皮肤穿孔器的皮肤穿孔器。一个皮肤桨用于脸颊粘膜重建，另一个用于脸颊皮肤重建。腹直肌部分与皮肤桨一起进行皮肤脸颊重建。（F） 嵌合穿孔器瓣位于缺陷上。下颌骨没有重建，因为鉴于患者预后不良，多学科头颈部委员会决定仅进行软组织重建。[彩色图可在 wileyonlinelibrary.com 在线刊物中查看。
FIGURE 4. Result after 6 months. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] 图4.6个月后结果。[彩色图可在 wileyonlinelibrary.com 在线刊物中查看。
pedicled on perforators of the deep inferior epigastric system. They later described the periumbilical perforator variation of this flap. 在深下上腹系统的穿孔器上扎根。他们后来描述了这种皮瓣的脐周穿孔器变化。
In our experience in free-flap reconstruction of the head and neck, we prefer to use a perforator variation of Taylor's flap, that is, an extended DIEP flap. We use this flap in 3 different ways. The first is as a cutaneous perforator flap without the corresponding muscular portion. The second is as a "chimeric" perforator flap where the cutaneous and muscular components can be separately placed because each is supplied by a distinct branch of the common source, that is, the pedicle. The third is as a myocutaneous perforator flap. In this case, the 2 components are not separated because 根据我们在头部和颈部自由皮瓣重建方面的经验，我们更喜欢使用泰勒皮瓣的穿孔器变体，即加长的 DIEP 皮瓣。我们以 3 种不同的方式使用这个翻盖。第一种是皮肤穿支皮瓣，没有相应的肌肉部分。第二种是作为“嵌合”穿孔皮瓣，其中皮肤和肌肉成分可以单独放置，因为每个成分都由公共来源的不同分支（即椎弓根）提供。第三种是作为肌穿支皮瓣。在这种情况下，2 个组件不会分开，因为
CUTANEOUS PERFORATOR FLAP 皮肤穿支皮瓣
FIGURE 5. Cutaneous perforator flap. DIEA, deep inferior epigastric artery. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] 图5.皮肤穿支皮瓣。DIEA，深下腹动脉。[彩色图可在 wileyonlinelibrary.com 在线刊物中查看。
MYOCUTANEOUS PERFORATOR FLAP 肌皮穿支皮瓣
FIGURE 6. Myocutaneous perforator flap. DIEA, deep inferior epigastric artery. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] 图6.肌皮肤穿支皮瓣。DIEA，深下腹动脉。[彩色图可在 wileyonlinelibrary.com 在线刊物中查看。
the perforator is not dissected in its initial intramuscular portion (Figures ). 穿孔器在其初始肌内部分未被解剖（图）。
The DIEP flap with the transverse skin paddle (a design that is often used in breast reconstruction) has also been described by several authors for head and neck reconstruction. In this setting, however, we consider it could be advantageous to opt for other skin paddle designs as less tissue is generally required than in breast reconstruction. 几位作者还描述了带有横向皮肤桨叶的 DIEP 皮瓣（一种经常用于乳房重建的设计）用于头颈部重建。然而，在这种情况下，我们认为选择其他皮肤桨设计可能是有利的，因为通常比乳房重建需要更少的组织。
We also prefer to harvest the DIEP flap on periumbilical perforators, but we use the superolateral extension of the skin paddle, as described by Taylor. With this modification, the distal part of the flap is placed on the upper-lateral portion of the abdomen toward the anterior chest wall. Skin and subcutaneous tissues are often hairless, pliable, and relatively thinner in this area than in the periumbilical region. This feature can be particularly useful, especially in cases of detailed reconstructions, such as for molding the tip of a reconstructed tongue after a partial or total glossectomy, and for buccal floor reconstruction. 我们也更喜欢在脐周穿孔器上收获 DIEP 皮瓣，但我们使用皮肤桨的上外侧延伸，如 Taylor 所述。通过这种修改，皮瓣的远端部分位于腹部的上外侧，朝向前胸壁。该区域的皮肤和皮下组织通常无毛、柔韧且比脐周区域相对较薄。此功能可能特别有用，尤其是在详细重建的情况下，例如在部分或全部舌切除术后塑造重建的舌尖，以及用于颊底重建。
The vascular anatomy of the extended DIEP flap has been well studied. 扩展的 DIEP 皮瓣的血管解剖结构已得到充分研究。
The inferior epigastric vessels give rise to large (greater than diameter) periumbilical perforators which communicate with the anterior branches of the lateral intercostal vessels by means of choke vessels. This constant vascular network means the flap is always well vascularized, even in smokers and older patients with vascular disorders. This property allows us to extend the skin paddle to the anterior 下腹血管产生大（大于 直径）的脐周穿孔，通过阻塞血管与外侧肋间血管的前支相通。这种恒定的血管网络意味着皮瓣始终血管化良好，即使在吸烟者和患有血管疾病的老年患者中也是如此。该特性使我们能够将皮肤桨延伸到前部
CHIMERIC PERFORATOR FLAP 嵌合穿孔器襟翼
FIGURE 7. Chimeric perforator flap. DIEA, deep inferior epigastric artery. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] 图7.嵌合穿孔器襟翼。DIEA，深下腹动脉。[彩色图可在 wileyonlinelibrary.com 在线刊物中查看。
FIGURE 8. (A and B) Preoperative study of supraumbilical perforators with multidetector CT of the patient in Figure 2 . [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] 图8.（A 和 B）脐上穿孔器与多排 CT 患者的术前研究如图 2 所示。[彩色图可在 wileyonlinelibrary.com 在线刊物中查看。
axillary line to restore large defects if required. Choosing a cranial paraumbilical perforator, the extended DIEP flap has one of the longest pedicles in the human body. We know from the literature that the DIEP flap pedicle has an average length of 10.3 and a mean caliber of 如果需要，腋窝线可以恢复大缺陷。选择颅脐旁穿孔器，加长的 DIEP 皮瓣具有人体最长的椎弓根之一。我们从文献中知道，DIEP 皮瓣蒂的平均长度为 10.3 ，平均口径为
The use of high periumbilical perforators implies that the mean pedicle length of the extended DIEP is greater. In our experience, the average length is 16.8 . 使用高脐周穿孔器意味着延长的 DIEP 的平均椎弓根长度更大。根据我们的经验，平均长度为 16.8 .
We compared the length of the extended DIEP flap pedicle with that of the ALT flap pedicle. 我们比较了延长的 DIEP 皮瓣蒂的长度与 ALT 皮瓣蒂的长度。
As described by Shieh et al, the average length of vascular pedicle of the ALT flap is . The pedicle of the extended DIEP flap is, therefore, longer. This feature is particularly helpful for reconstruction in patients with radiated necks. 正如 Shieh 等人所描述的， ALT 皮瓣的血管蒂的平均长度为 。因此，延长的 DIEP 皮瓣的椎弓根更长。此功能对颈部放射患者的重建特别有帮助。
In this setting, there is a recipient vessel deficit so contralateral vessels should be used if those of the omolateral side are not suitable. This flap provides good quality vessels for anastomoses far from the treated area. The recipient arteries generally used are: superior thyroid artery, facial artery, and lingual artery. 在这种情况下，受体血管缺损，因此如果外侧的血管不合适，则应使用对侧血管。该皮瓣为远离治疗区域的吻合口提供优质血管。一般使用的受体动脉有：甲状腺上动脉、面动脉和舌动脉。
The recipient veins are either a vein of the thyroid-lingual-facial trunk or the external jugular vein. Nowadays, with preoperative perforator planning using a multidetector CT scan, we can determine where the most reliable perforator is and therefore, can optimize our flap design directly (Figure 8). 受体静脉是甲状腺-舌-面干的静脉或颈外静脉。如今，通过使用多排 CT 扫描进行术前穿孔规划，我们可以确定最可靠的穿孔器位置，因此可以直接优化我们的皮瓣设计（图 8）。
Due to its versatility, the extended DIEP flap can be used for the reconstruction of a great variety of head and neck defects, particularly medium-sized and large defects. It can provide bulky tissue if a portion of the rectus muscle is raised with the flap and it can allow simple flap molding and insetting if the cutaneous and muscular components are separated. 由于其多功能性，扩展的 DIEP 皮瓣可用于重建各种头部和颈部缺损，尤其是中型和大型缺损。如果用皮瓣抬起一部分直肌，它可以提供笨重的组织，如果皮肤和肌肉成分分开，它可以允许简单的皮瓣成型和嵌入。
Extended DIEP flap dissection is relatively fast and straightforward. It can be done with the patient in a supine position, allowing 2 surgical teams to operate comfortably at the same time. Finally, the donor site can be closed as a linear scar with direct repair of the rectus sheath. 扩展 DIEP 皮瓣清扫术相对快速且直接。它可以在患者仰卧位的情况下完成，允许 2 个手术团队同时舒适地操作。最后，供体部位可以作为线性瘢痕闭合，直接修复直肌鞘。
We think that this flap is excellent because it has a lot of advantages compared to other flaps commonly used for head and neck reconstruction. First the radial flap, like the extended DIEP flap, can provide a large skin paddle but an important artery (the radial artery) is sacrificed. Besides, a graft may be needed to cover the defect in the forearm as this area is more commonly exposed than the abdomen. Furthermore, the extended DIEP flap offers either a thin or thick flap depending on reconstructive needs, whereas the radial technique provides only a thin flap. 我们认为这种皮瓣非常出色，因为与其他常用于头颈部重建的皮瓣相比，它具有很多优点。首先，桡动脉皮瓣与延长的 DIEP 皮瓣一样，可以提供大的皮肤桨，但牺牲了一条重要的动脉（桡动脉）。此外，可能需要移植物来覆盖前臂的缺损，因为该区域比腹部更常暴露。此外，扩展的 DIEP 皮瓣可根据重建需求提供薄或厚的皮瓣，而径向技术仅提供薄皮瓣。
Second, the extended DIEP flap is not better than the ALT flap but it is a very good alternative because it has a longer pedicle. Also, an abdominal scar is generally more widely accepted than a thigh scar, above all in women. 其次，加长的 DIEP 皮瓣并不比 ALT 皮瓣好，但它是一个非常好的选择，因为它的椎弓根更长。此外，腹部疤痕通常比大腿疤痕更广泛地被接受，尤其是在女性中。
The extended DIEP flap is preferable to the transverse rectus abdominus myocutaneous flap because in the myocutaneous variation it involves a smaller quantity of muscle and, therefore, less morbidity. The muscle is only needed to give more projection to the flap such as in buccal floor reconstruction. 扩展的 DIEP 皮瓣优于腹直肌横肌皮瓣，因为在肌皮变异中，它涉及的肌肉量较少，因此发病率较低。只需要肌肉来给皮瓣更多的投影，例如在颊底重建中。
Third, the extended DIEP flap is preferable to the superficial circumflex iliac artery perforator flap because its vascular anatomy is constant and it provides a long pedicle. 第三，延长的 DIEP 皮瓣优于浅回旋髂动脉穿支皮瓣，因为它的血管解剖结构是恒定的，并且它提供了一个长蒂。
The disadvantages of the DIEP flap should also be taken into account. First, an abdominal scar is less aesthetic than a transverse lower abdominal approach. Moreover, the periumbilical portion of the flap may be excessively bulky in an obese patient. Occasionally, however, this can be advantageous such as when a high projection flap is needed, for example, after a total glossectomy. Another drawback is that dissection of the perforator can be somewhat tedious, especially with the cutaneous and "chimeric" variations of the flap. Furthermore, there is a potential risk of abdominal wall weakness and herniation if a portion of the muscle is harvested with the flap. We did not encounter this complication in our series, but it has been reported in the literature. 还应考虑 DIEP 皮瓣的缺点。首先，腹部瘢痕不如横向下腹部入路美观。此外，在肥胖患者中，皮瓣的脐周部分可能过于笨重。然而，有时这可能是有利的，例如当需要高投影皮瓣时，例如，在全舌切除术后。另一个缺点是穿孔器的解剖可能有些乏味，尤其是皮瓣的皮肤和“嵌合”变化。此外，如果用皮瓣收获部分肌肉，则存在腹壁无力和疝气的潜在风险。我们在系列中没有遇到这种并发症，但文献中已经报道过。
CONCLUSION 结论
With all its variations, the flap described here provides a reliable and safe vascular supply and the versatility of its design makes it suitable for any type of head and neck defect. 通过其所有变化，这里描述的皮瓣提供了可靠和安全的血管供应，其设计的多功能性使其适用于任何类型的头颈部缺损。
As the goal of the reconstructive surgeon is to achieve a postoperative result that will ensure a maximum quality of life, the extended DIEP flap should be considered a valuable resource in the armamentarium of ablative head and neck surgery. 由于重建外科医生的目标是获得确保最高生活质量的术后结果，因此扩展的 DIEP 皮瓣应被视为消融头颈部手术武器库中的宝贵资源。
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Correspondence to: . Masià 对应于： 。马西亚
This work was presented at the XLIII Congreso Nacional de la Sociedad Española de Cirugía Plástica Reparadora y Estética, Zaragoza, Spain, June 18-21, 2008; Congresso Nazionale della Società Italiana di Chirurgia Plastica Ricostruttiva ed Estetica, Napoli, Italy, September 24-27, 2008; and XXIII Congresso Nazionale della Società Italiana di Microchirurgia, First Atlanto-Pacific Microsurgery Conference, Modena, Italy, October 1-3, 2009. 这项工作于2008年6月18日至21日在西班牙萨拉戈萨举行的第四十三届西班牙社会国家会议上发表; 2008年9月24日至27日，意大利那不勒斯国家社会大会，意大利那不勒斯;2009 年 10 月 1 日至 3 日，在意大利摩德纳举行的第一届大西洋-太平洋显微外科会议，第二十三届意大利国家微手骨外科大会。
