Split and thinned pedicle deep inferior epigastric perforator (DIEP) flap for vulvar reconstruction

Vulvar defects following tumor extirpation are most commonly closed primarily by the gynecologist but larger and/or radiated defects often require reconstruction with flaps for adequate coverage and wound healing. Recurrence of vulvar carcinomas remains a challenge, so secondary reconstruction becomes increasingly problematic where locoregional flaps (i.e., gracilis, rectus, anterolateral thigh, and gluteal flaps) may have already been utilized, radiated, or have resulted in unacceptable cosmetic or functional morbidity. We present two cases of recurrent vulvar carcinoma following radiation therapy requiring total vulvectomy and a novel approach for soft-tissue reconstruction. Previous authors have reported the use of thinned and split flaps, but we combine these techniques to split and thin a transversely oriented deep interior epigastric artery perforator (DIEP) flap to maximize aesthetic results and minimize donor-site morbidity. The DIEP flap is commonly performed by microsurgeons for autologous free-tissue transfer in breast reconstruction but also serves as a useful option for large vulvar or perineal defects, either in primary or secondary reconstruction.