Autologous Free Tissue Transfer Research Articles

A retrospective unicentric cohort study, evaluating the impact of tranexamic acid on autologous free flap tissue reconstruction

The use of tranexamic acid (TXA) has been shown to be effective in reducing haemorrhage and mortality in numerous surgical settings. However, its use in plastic surgery has been limited due to misconceptions related to increased thrombotic events in microsurgery. We performed a retrospective single-centre cohort study including any patients who underwent autologous free flap tissue transfer at Lister Hospital, Stevenage, from 1 January 2016-20 April 2022. The Chi-squared test was used to determine if there were any significant differences between the proportion of patients who developed any evidence of microvascular thrombosis, flap failure, or return to theatre, and univariate logistic regression was used to calculate odds ratio. The treatment group (N = 160) received TXA (1 g intravenous) at the time of general anaesthetic induction as per the senior author's routine practice, while the control group (N = 80) did not receive TXA at any point of the hospital admission, according to the normal practice of other surgeons. No differences were found between the proportion of patients who developed microvascular thrombotic complications between the TXA and control group, contributing evidence that TXA is safe to use in microvascular surgery. TXA may have a role in improving outcomes in plastic surgery procedures by reducing the need for blood transfusions and through anti-inflammatory effects. Our study shows that TXA administration did not increase microvascular thrombosis in free flap reconstructive surgery, contributing evidence that TXA is safe to use in microvascular surgery, however further larger studies are required to improve the power of this study.

544 Effect of Tranexamic Acid on Microvascular Thrombosis in Autologous Free Tissue Transfer

Abstract Aim The use of Tranexamic Acid (TXA) has been shown to be effective in reducing haemorrhage and mortality in numerous surgical settings and has a wide range of proposed benefits linked to anti-inflammatory effects which promotes healing and reduces pain and discomfort. However, the surgical community has been reluctant to incorporate TXA use into mainstream practices in microvascular surgery due to possible risk of thromboembolic events. Hence, we aim to report our experience with the use of TXA in microsurgical reconstruction. Method We performed a retrospective single-centre cohort study including any patients who underwent autologous free flap tissue transfer at a district general hospital, from 1 January 2016 to 20 April 2022. The Chi-squared test was used to determine if there were any significant differences between the proportion of patients who developed any evidence of microvascular thrombosis, flap failure, or return to theatre. Univariate logistic regression was used to calculate odds ratio. Results The treatment group (N = 160) received TXA (1g intravenous) at the time of general anaesthetic induction as per the senior author’s routine practice, while the control group (N = 80) did not receive TXA at any point of the hospital admission, according to the normal practice of other surgeons. No differences were found between the proportion of patients who developed flap failure, venous congestion or were returned to theatre between the TXA and control group. Conclusions Our study shows that TXA administration did not increase microvascular thrombosis in free flap reconstructive surgery, contributing evidence that TXA is safe to use in microvascular surgery.

Management after flap failure: a narrative review

Autologous free tissue transfer for breast reconstruction is a well-established and reliable form of reconstruction for women undergoing mastectomies. These surgeries are performed with high rates of success; however, the consequences of flap failure can be devastating to patients and surgeons. Breast reconstruction decision making following flap loss is a uniquely individualized process, based on considerations of safety, patient goals and preferences, as well as the surgeon’s skillset. The first priority following flap failure is to provide thoughtful patient counseling and support through this difficult time. The aims of reconstruction salvage after flap loss are to excise unhealthy tissue and restore a breast mound of normal anatomical shape. We present an algorithm as a possible approach to managing flap failures. We also review the management of breast reconstruction following free flap failure, including the role of hematologic investigation, anticoagulation recommendations and secondary or tertiary reconstruction with both prosthetic and autologous techniques.

Diagnosis, management and prevention of thrombotic complications in microsurgical breast reconstruction: a review of the literature

Autologous free tissue transfer is a safe and effective option for breast reconstruction. It is an increasingly utilized technique with well-demonstrated improved patient satisfaction and quality of life. Microvascular thrombosis is a rare but significant complication of microsurgical breast reconstruction, often resulting in flap failure. Proper diagnosis and timely management of this complication are essential to free flap salvage. While microvascular thrombosis poses a threat to flap survival, several methods may be employed to mitigate its more devastating effects. Here, we present a comprehensive review of arterial and venous thrombotic complications in both the intraoperative and postoperative settings. We discuss preoperative risk assessment, methods for flap monitoring, and operative and medical management of thrombotic complications. We present an updated algorithm for the intraoperative management of microvascular thrombosis adapted to reflect the most recent literature and our novel algorithm for the postoperative management of microvascular thrombosis.

Using a Business Model (the 4 Disciplines of Execution) to Improve Consistency, Efficiency, and Length of Stay in Microvascular Autologous Breast Reconstruction.

Autologous free tissue transfer is a common method of breast reconstruction in the United States, but it involves many care teams and can incur a large cost on an institution. The consistency and efficiency of performing these procedures can be improved with a method called the 4 disciplines of execution (4DX). Patients that underwent autologous breast reconstruction between 2015 and 2020 were included. Midway through the collection period, several preoperative and intraoperative interventions were implemented using the 4DX. Then, 2 cohorts of patients were analyzed for differences in operative times, length of stay (LOS), and major complications. Thirty-two total patients were included. The median operative time before interventions were implemented was 828 minutes, and the median operative time after interventions was 619 minutes (P < 0.05). The median LOS in days before interventions was 5 days, and the median LOS after interventions was 3 days (P < 0.05). There were no statistically significant differences in complications before or after the interventions. The 4DX successfully improved consistency and efficiency in the process of performing autologous breast reconstruction at our institution, as evidenced by a faster median operative time and shorter patient LOS in the hospital.

Closed-Incision Negative Pressure Therapy Prevents Major Abdominal Donor-Site Complications in Autologous Breast Reconstruction.

Outcomes in autologous breast reconstruction continue to improve with refinements in microsurgical techniques; however, donor-site morbidity remains a concern. Closed-incision negative pressure therapy (ciNPT) has been shown to reduce wound complications. Limited evaluation in abdominal donor sites has shown promising results. We hypothesize that ciNPT will reduce abdominal donor-site complications. A retrospective chart review was performed of patients who underwent abdominally based autologous free tissue transfer for breast reconstruction by 4 microsurgeons at an academic institution from 2015 to 2020. The application of a commercial ciNPT for donor-site management was at the discretion of the operating surgeon. Demographics, operative details, and management of donor-site complications were analyzed. Four hundred thirty-three patients underwent autologous breast reconstruction; 212 abdominal donor sites were managed with ciNPT and 219 with standard dressings. Demographics were statistically similar between groups. Abdominal wound healing complications were noted in 30.2% of ciNPT patients (64/212) and 22.8% of control patients (50/219, P = 0.08); however, overall wound complications were attributed to obesity on multivariable analysis. Closed-incision negative pressure therapy significantly decreased complications requiring reoperation (ciNPT 6.2%, 4/64; control 26.5%, 13/51; P = 0.004). There were no significant differences in surgical site infection rates (P = 0.73) and rates of abdominal scar revisions (ciNPT 11.8%, 25/212; control 9.1%, 20/219; P = 0.37). Use of ciNPT in abdominal donor-site management significantly decreases the incidence of delayed wound healing requiring surgical intervention, with one major wound healing complication prevented for every 6 donor sites managed with ciNPT.

Autologous free tissue transfer in paediatric patient with a univentricular heart.

We report on the case of a 30-month-old boy who developed severe deep cervical necrosis after bypass surgery for total cavopulmonary connection, followed by low-cardiac output and extracorporeal life support. As several bedside debridements failed to result in sufficient wound healing, a 2-stage necrectomy followed by autologous reconstruction with a free anterolateral thigh-flap was required. Due to impaired circulation, postoperative flap monitoring was extremely difficult. To ensure flap perfusion, mean arterial pressure had to be raised by catecholamines over 7 days.

Designing an evidence-based free-flap pathway in head and neck reconstruction.

BackgroundThe use of autologous free‐tissue transfer is an increasingly utilized tool in the ladder of reconstructive options to preserve and restore function in patients with head and neck cancer. This article focuses on the evidence surrounding perioperative care that optimizes surgical outcomes and describes one tertiary center's approach to standardized free‐flap care.Data SourcesThis article examines English literature from PubMed and offers expert opinion on perioperative free‐flap care for head and neck oncology.ConclusionFree‐flap reconstruction for head and neck cancer is a process that, while individualized for each patient, is best supported by a comprehensive and standardized care pathway. Surgical optimization begins in the preoperative phase and a thoughtful approach to intraprofessional communication and evidence‐based practice is rewarded with improved outcomes.

Free Flap Surgery Outcome Related to Antithrombotic Treatment Regime: An Analysis of 1000 Cases

Background:Autologous free tissue transfer is today an integral part of reconstructive plastic surgery, but still lacks generally accepted guidelines regarding antithrombotic agents. We hypothesized that the overuse of antithrombotic agents could be a risk factor for free flap complications and therefore studied a treatment protocol adjustment.Methods:Consecutive free flaps between 2005 and 2020 at a single center were analyzed for complications in relation to the use of pre- and intraoperative treatment with three different antithrombotic agents. The use of preoperative low molecular weight heparin (LMWH), intraoperative heparin, and dextran were analyzed in relation to outcome variables, thromboembolic events, or reexploration for hematoma.Results:Nine hundred thirty-one patients underwent 1000 microvascular free flaps for breast (n = 487), head and neck (n = 365), and extremity (n = 148) reconstruction. Within the first postoperative week, 44 cases had a thromboembolic event and 58 cases underwent hematoma-related reexploration. In the multivariate analysis, thromboembolic events were associated with extremity reconstruction (P = 0.02) and smoking (P = 0.02). Hematoma-related reexploration was more common with triple antithrombotic therapy compared with all other treatment regimes (P < 0.05). The number of antithrombotic agents used perioperatively was linearly decreased, from three to none, over the elapsed time period (P < 0.001).Conclusions:Hematoma was the most common reason for reexploration and was further associated with the use of multiple antithrombotic agents. Cessation of triple treatment was associated with less hematomas and further reduction of antithrombotic agents did not result in any increase of thromboembolic events. Evidence-based guidelines are warranted for antithrombotic regimes in standard free flap surgery.

Management of postoperative microvascular compromise and ischemia reperfusion injury in breast reconstruction using autologous tissue transfer: Retrospective review of 2103 flaps.

Although rates of microvascular thrombosis following free-flap breast reconstruction are low, debate persists about the optimal methods to restore blood flow and prevent ensuing flap shrinkage or fibrosis. Here we evaluate our management of microvascular compromise, including both a review of our approach for restoring blood flow and addressing the ensuing inflammatory changes following ischemia reperfusion. We conducted a retrospective review of autologous free tissue transfer breast reconstructions from 1/2010 to 1/2020. Patients who had flaps requiring take-back for salvage were identified. Management of microvascular compromise and ischemia reperfusion injury were recorded. Of 2103 flaps were used in the breast reconstructions, 47 flaps required take-back for microvascular compromise (2.2%). Most flaps were either completely salvaged (n=29, 61.7%) or partially salvaged (n=5, 10.6%). Thirteen (27.7%) were a total flap loss, for an overall rate of 0.8% (including 3 flaps with no salvage attempt). Management of microvascular compromise most often included revision of the anastomosis (n=33, 70.2%), thrombectomy (n=27, 57.4%), tissue plasminogen activator administration (n=26, 55.3%), and vein grafts (n=18, 38.3%). Management of ischemia reperfusion included intraoperative steroids (n=33, 70.2%), postoperative steroids (n=17, 38.6%), and postoperative therapeutic anticoagulation (n=27, 61.3%). Of 34 salvaged flaps, 5 (14.7%) had partial flap loss and/or fat necrosis on clinical examination at an average follow-up of 2.7 ± 2.8 years. Salvage of microvascular compromise in autologous breast reconstruction should include restoration of blood flow and management of ischemia reperfusion injury. Attention to both is paramount for successful outcomes.

945 Elective Autologous Free Tissue Transfer for Breast Reconstruction During the Covid-19 Pandemic: A Comparative Analysis of Outcomes

Abstract Introduction The demand placed on the National Health Service by Covid-19 has led to increased delays on elective surgery. Despite these challenges, our unit was the first centre in the UK to recommence elective breast reconstruction following the development of an evidence-based pathway to select low-risk patients. An enhanced recovery protocol was introduced to reduce length of stay. The aim of this study was to compare post-operative outcomes between our Pre-Covid group and our Covid-group of free tissue transfer breast reconstruction. Method We retrospectively reviewed autologous free tissue transfer breast reconstruction within our department between January 15th and September 27th 2020. Comparative data was split into two groups. A ‘pre-Covid group’ from 15th January to 12th March 2020 and a ‘Covid group’ from 3rd June to 27th September 2020. Both groups contained 15 patients. Operative notes and case notes were reviewed. Length of stay, haematoma-rate, flap failure, infection, fat necrosis, ischaemic time, re-do anastomosis and return-to-theatre were compared. Results Average length of stay was reduced from 4 to 3 days amongst our Covid group, haematoma rate was 7% pre-Covid and 13% during Covid. There was no evidence of flap failure, fat necrosis and donor site dehiscence in either group. Infection and flap dehiscence were 7% pre-Covid and 0% during Covid. Re-do anastomosis was 20% pre-Covid and 7% during Covid. Conclusions No statistically significant changes in outcomes were identified. This early review suggests that elective breast reconstructive surgery can still be achieved with comparable outcomes, despite the added challenges of Covid-19.

Breast reconstruction during the COVID-19 pandemic: A systematic review.

Background:The novel coronavirus disease 2019 (COVID-19) has changed people's way of life and posed great challenges to plastic surgery. Most of plastic surgeries are considered elective surgeries and are recommended to be delayed. But breast reconstruction in plastic surgery is special. Doctors’ associations from different countries have different rules on whether breast reconstruction surgery should be delayed. For the controversial topic of immediate breast reconstruction in the COVID-19 pandemic, we conducted this study.Methods:We searched English databases such as PubMed, Cochrane Library, and Embase. The publication time of papers was set to be from the establishment of the databases to February 2021. All studies on immediate breast reconstruction in the COVID-19 pandemic were included in our study.Results:A total of 6 studies were included in this study. Four studies recommended the use of breast implants or tissue expansion for breast reconstruction surgery and had good results in their clinical practice. In addition, 1 study planned to use autologous free tissue transfer for breast reconstruction, and 1 study planned to use microsurgical techniques for breast reconstruction. But these 2 technologies are still in the planning stage and have not yet been implemented.Conclusions:In our opinion, breast cancer surgery belongs to confine operation, and breast reconstruction surgery should be performed immediately after the completion of breast cancer surgery. We recommend the use of breast implants for breast reconstruction surgery during the COVID-19 epidemic. Due to the limitations of the study, our proposed protocol for breast reconstruction surgery during the COVID-19 epidemic needs to be further validated in clinical studies.

Osteocutaneous radial forearm free flap for anterior cranial base reconstruction: Technical note

The reconstruction of anterior skull base defects after carcinologic surgery is challenging. Large defects can require the use of autologous free tissue transfer. Currently, most reconstructions use soft-tissue flaps. We describe the use of an osteocutaneous radial forearm free flap to reconstruct a large defect secondary to a malignant paraganglioma extending into the anterior cranial fossa and both orbits. The surgical resection required endonasal and transcranial approaches. We reconstructed the defect with a free osteocutaneous radial forearm flap. We laid the bone flap across the defect, resting on the orbital roof on each side, and sutured the soft component to the edge of the dura. The pedicle was funnelled from the craniotomy to a prepared cervicotomy and the micro-anastomoses were performed onto the facial artery and two satellite veins. Potential indications and major drawbacks of this technique are briefly discussed. Osteocutaneous radial forearm free flaps can be a valuable reconstructive option for patients with a large defect of the anterior skull base, needing both rigid support and a watertight closure.

Facial Gunshot Wounds.

Craniomaxillofacial gunshot injuries, resulting from assault, suicide attempts, and accidental trauma, represent a major public health dilemma in the United States. Due to the extent of injury and resulting osseous and soft tissue loss, facial gunshot wounds pose a unique challenge to the reconstructive surgeon. Initial management should use advanced trauma life support principles with the goal of patient stabilization. Acute operative management should center around wound decontamination, debridement, and temporary closure. Historically, definitive surgical management focused on delayed reconstruction secondary to high rates of wound infections, necrosis, and ischemia. With improvements in imaging modalities, the advent of virtual surgical planning, and the popularization of microvascular free flaps, contemporary methods have shifted toward earlier more definitive reconstruction. Autologous free tissue transfer has resulted in a decrease in hospital stay and the number of overall surgeries. Importantly, due to the variability in injury pattern and complexity in reconstruction, a systematic approach toward intervention is needed to mitigate complications and optimize overall functional and aesthetic outcomes.

Prevention of radiotherapy-induced arterial inflammation by interleukin-1 blockade.

AimsRadiotherapy-induced cardiovascular disease is an emerging problem in a growing population of cancer survivors where traditional treatments, such as anti-platelet and lipid-lowering drugs, have limited benefits. The aim of the study was to investigate vascular inflammatory patterns in human cancer survivors, replicate the findings in an animal model, and evaluate whether interleukin-1 (IL-1) inhibition could be a potential treatment.Methods and resultsIrradiated human arterial biopsies were collected during microvascular autologous free tissue transfer for cancer reconstruction and compared with non-irradiated arteries from the same patient. A mouse model was used to study the effects of the IL-1 receptor antagonist, anakinra, on localized radiation-induced vascular inflammation. We observed significant induction of genes associated with inflammasome biology in whole transcriptome analysis of irradiated arteries, a finding supported by elevated protein levels in irradiated arteries of both, pro-caspase and caspase-1. mRNA levels of inflammasome associated chemokines CCL2, CCL5 together with the adhesion molecule VCAM1, were elevated in human irradiated arteries as was the number of infiltrating macrophages. A similar pattern was reproduced in Apoe−/− mouse 10 weeks after localized chest irradiation with 14 Gy. Treatment with anakinra in irradiated mice significantly reduced Ccl2 and Ccl5 mRNA levels and expression of I-Ab.ConclusionAnakinra, administered directly after radiation exposure for 2 weeks, ameliorated radiation induced sustained expression of inflammatory mediators in mice. Further studies are needed to evaluate IL-1 blockade as a treatment of radiotherapy-induced vascular disease in a clinical setting.

The Urogenital Epithelium and Corporal Tissues Are the Primary Targets of Rejection in Penile Vascularized Composite Allotransplantation: A New Real-Time Tissue-Based Monitoring System.

Although significant surgical advances have been made in the form of microvascular surgery and autologous free tissue transfer, penile reconstruction still poses several difficult challenges. Although interest in penile vascularized composite allotransplantation has grown since the first attempted transplant in 2006, little is known regarding the kinetics of rejection and subsequent function of penile allografts. The penis contains multiple tissue types that are not qualified by the Banff 2007 vascularized composite allotransplantation classification system, including urogenital mucosal epithelium and erectile tissues. In this study, the authors investigate the propagation of rejection and the resultant function following rejection in rat and human penile tissues. Rejected human and rat penile tissues were examined using an ex vivo real-time tissue-based derivative of the classic mixed lymphocyte reaction assay to determine the interactions occurring between en bloc penile tissues and peripheral blood mononuclear cells (autologous and allogeneic). Correlative in vivo heterotopic rat penile vascularized composite allotransplantation was used to correlate ex vivo findings. In both human and rat ex vivo systems and in vivo rat vascularized composite allotransplantation, the urethral mucosa was the first to undergo rejection-associated apoptosis. The urethral mucosa was the most immunogenic and led to the highest level of peripheral blood mononuclear cell proliferative generations in all systems, whereas the neural tissues of the penis remained immune privileged. These findings are the first to describe the kinetics of rejection in both human and rat penile vascularized composite allotransplantation and that the urethral mucosa is the most antigenic, suffering the highest level of rejection-associated apoptosis and peripheral blood mononuclear cell proliferative aggregation.

A Retrospective Analysis of Secondary Revisions after Face Transplantation: Assessment of Outcomes, Safety, and Feasibility

Face transplantation has emerged as a viable option for certain patients in the treatment of devastating facial injuries. However, as with autologous free tissue transfer, the need for secondary revisions in face transplantation also exists. The authors' group has quantified the number of revision operations in their cohort and has assessed the rationale, safety, and outcomes of posttransplantation revisions. A retrospective analysis of prospectively collected data of the authors' seven face transplants was performed from April of 2009 to July of 2015. The patients' medical records, preoperative facial defects, and all operative reports (index and secondary revisions) were critically reviewed. The average number of revision procedures was 2.6 per patient (range, zero to five procedures). The median time interval from face transplantation to revision surgery was 5 months (range, 1 to 10 months). Most interventions consisted of debulking of the allograft, superficial musculoaponeurotic system plication and suspension, and local tissue rearrangement. There were no major infections, allograft skin flap loss, or necrosis. One patient suffered a postoperative complication after autologous fat grafting in the form of acute rejection that resolved with pulse steroids. Secondary revisions after face transplantation are necessary components of care, as they are after most conventional free tissue transfers. Secondary revisions after face transplantation at the authors' institution have addressed both aesthetic and functional reconstructive needs, and these procedures have proven to be safe in the context of maintenance immunosuppression. Patient and procedure selection along with timing are essential to ensure patient safety, optimal function, and aesthetic outcomes. Therapeutic, V.

Secondary Revisions After Facial Transplantation

INTRODUCTION: Facial transplantation (FT) has emerged as a viable option in treating devastating facial injuries.1-3 The benefits of near normal restoration of multiple functional and aesthetic units in previously non-reconstructable defects have been reported in the literature and media.1-2 However, as with autologous free tissue transfer, the need for secondary revisions in FT also exists.3-4 We aimed to quantify the outcomes of secondary revisions and assess the safety and feasibility of such procedures in our cohort. METHODS: A retrospective review of our face transplant recipients was performed from April 2009 to March 2015. The patients’ histories, pre-operative facial defects and all operative reports were critically reviewed. Functional outcomes and aesthetic appearance were also evaluated in the context of secondary revisions. RESULTS: A total of five patients have undergone secondary revisions after FT. The time interval from FT to revisional surgery ranged from 1 – 10 months (mean: 5.4 months). The mean number of secondary revisions was 3.2 per patient. The mean follow-up time from latest revision ranged from 5-47 months (mean: 20.4 months). Most interventions have consisted of debulking of soft tissues, SMAS plication and suspension, and local tissue rearrangement for contour abnormalities and excess soft tissue. There were no major infections, hematomas, skin flap loss or necrosis, and most importantly, there were no allograft losses. One patient suffered a post-operative complication after fat grafting in the form of acute rejection that resolved with pulse steroids. CONCLUSION: Secondary revisions after FT may become standard of care as they are now after conventional free tissue transfer.4 Secondary revisions after FT at our institution have addressed both aesthetic and functional aspects and have proven to be safe and introduce minimal complications in the context of maintenance immunosuppression. Our understanding of the effects of rejection and volumetric changes of facial allografts continues to evolve. The natural history and evolution of facial allografts will influence and impact the appropriateness and selection of secondary revisions after FT. As such, patient and procedure selection along with timing are paramount to ensure patient safety and optimal functional and aesthetic outcomes.

Increased long-term expression of pentraxin 3 in irradiated human arteries and veins compared to internal controls from free tissue transfers

BackgroundClinical studies have shown that radiotherapy increases the risk of cardiovascular disease at irradiated sites years after exposure. However, there is a lack of biological explanations in humans. We therefore examined human blood vessels exposed to radiotherapy and studied C-reactive protein (CRP) and pentraxin 3 (PTX3), a new marker for adverse cardiovascular outcome dependent on TNF- alpha (TNFα) or interleukin-1beta (IL-1β) expression.MethodsPairs of irradiated and non-irradiated human conduit arteries and veins were harvested from the same patient during autologous free tissue transfer for cancer-reconstruction at a median time of 48 weeks after radiotherapy. Differential gene expression was studied using qRT-PCR, confirmed by immunohistochemistry and cellular origins determined by immunofluorescence.ResultsGene expression in irradiated arteries compared to non-irradiated showed a consistent up-regulation of PTX3 in all patients and in a majority of veins (p < 0.001). Both TNFα and IL-1β were increased in irradiated compared to non-irradiated arteries (p < 0.01) and IL-1β correlated to the PTX3 expression (p = 0.017). Immunohistochemical and immunofluorescence staining confirmed an increased expression of PTX3 in endothelial cells, macrophages and smooth muscle cells.ConclusionsThe sustained expression of PTX3 in arteries and veins tie biological evidence in humans to clinical studies and encourage further exploration of innate immunity in the pathogenesis of a radiation-induced vasculopathy.

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.