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Deep Inferior Epigastric Perforator (DIEP) Flap

The DIEP flap is a fasciocutaneous perforator flap based on the deep inferior epigastric artery (DIEA) and its musculocutaneous perforators through the rectus abdominis muscle, harvesting lower-abdominal skin and fat while completely sparing the rectus muscle and fascia. Originally developed as the workhorse of autologous breast reconstruction, the DIEP flap is increasingly applied as a pedicled flap for vulvar, perineal, and vaginal reconstruction — particularly after pelvic exenteration. The Höckel algorithm specifically names DIEP as an option for vulvovaginal reconstruction, and the Negosanti algorithm (2015) proposes that every type of vulvar defect can be repaired with just two flaps — the pedicled DIEP and the lotus petal flap.[1][2]

For the broader GU flap menu see Flaps for GU Reconstruction. For the parent muscle-flap page see VRAM; for the SEPA-based mons pubis variant see EPAP; for the broader perforator framework see SCIP / perforator flap.

Concept — DIEP vs TRAM / VRAM​

The DIEP flap is the perforator-based evolution of the TRAM / VRAM flap. While TRAM / VRAM sacrifice the rectus abdominis muscle (and often the anterior rectus sheath), DIEP dissects the perforating vessels through the muscle substance — preserving the muscle, motor innervation, and fascial integrity of the abdominal wall. Result: dramatically reduced donor-site morbidity — no abdominal-wall weakness, no hernia risk from muscle sacrifice, and no mesh required.[3][4]

ConfigurationUse
Free flapDominant breast-reconstruction application; pedicle divided and microsurgically anastomosed to chest recipient vessels
Pedicled flapPrimary vulvovaginal indication — flap remains attached to its DIEA pedicle and is rotated inferiorly through the abdominal wall into the pelvic / perineal defect

Vascular Anatomy — The Deep Inferior Epigastric Artery​

Origin and course (Myung 2018, n = 368 hemiabdomens)[5]​

  • DIEA arises from the external iliac artery in the medial direction.
  • Courses caudally then turns cephalad — average descending length before the turning point: 11.29 mm.
  • As the origin angle decreases (toward caudal), the initial-descent distance increases (r = 0.382, p < 0.05).

Branching pattern (Rozen 2010 CTA, n = 500 hemiabdomens)[6][7]​

TypeDescriptionPrevalence (in vivo)Prevalence (cadaveric)Perforator transverse distance
0Absent DIEARareNot previously described—
ISingle trunk (no bifurcation)Higher than cadaveric29%Intermediate
IIBifurcating trunk (medial + lateral branches)Most common57%Shortest (less muscle sacrifice)
IIITrifurcating trunkLower than cadaveric14%Greatest (more muscle sacrifice)
IVFour-trunk DIEARareNot previously described—
  • No overall concordance in branching patterns between contralateral sides of the same abdominal wall — except Type I (51% concordance, p = 0.04).[6]
  • Bifurcating (Type II) is most favorable — perforators have a shorter intramuscular course requiring less muscle dissection.[7]
  • Trifurcating (Type III) has the greatest transverse distances — correlates with greater rectus muscle sacrifice during dissection.[7]

Perforator anatomy​

StudyFinding
Ireton 2014 SR (60 articles)[8]Musculocutaneous perforators most common (33–100%); extramuscular perforators (0–67.6%) — paramedian or perpendicular course; extramuscular subtypes are the most desirable for dissection (minimal muscle disruption)
El-Mrakby 2002 (20 cadavers)[9]Average 5.4 large perforators / hemiabdomen; lateral division and lateral perforators more dominant (80%) than medial (20%); most perforators located laterally and below the umbilicus, mean 4 cm from umbilicus
Meyerov 2025 CTA (n = 180)[10]Average 2.9 ± 1.6 perforators / hemiabdomen; larger-caliber vessels closer to the umbilicus (p < 0.001)
Bailey 2010 single-dominant-medial-row (3D)[11]Dominant perforator within a 3 cm radius of the umbilicus, average size > 1.8 mm; medial row near the umbilicus contains the largest perforators in the entire DIEA system

Perforasome perfusion (Schaverien 2008)[12]​

  • Medial row perforators — central elliptical perfusion; consistently supply zones I and II, half of III and IV; large-diameter subdermal-plexus linking vessels between perforators.
  • Lateral row perforators — predominantly ipsilateral; perfuse medial-row territory by recurrent flow through the subdermal plexus.
  • Recommendation: discard half of zone III and all of zone IV to avoid partial flap loss / fat necrosis.[10]

Hartrampf perfusion zones​

ZoneTerritoryPerfusion
IIpsilateral periumbilicalBest
IIContralateral periumbilicalGood
IIIIpsilateral lateralModerate
IVContralateral lateralWorst

Vascular territory of the DIEA (Boyd / Taylor / Corlett 1984)[13]​

  • DIEA is more significant than the superior epigastric artery in supplying the anterior abdominal-wall skin.
  • Highest concentration of major perforators is in the paraumbilical area.
  • Perforators feed a subcutaneous network that radiates from the umbilicus like spokes of a wheel.
  • Choke connections: inferiorly with SIEA, inferolaterally with SCIA, superolaterally with lateral cutaneous intercostal branches.

Venous anatomy​

  • Two venae comitantes accompany the DIEA in 90% of cases.[9]
  • Superficial inferior epigastric vein (SIEV) — important secondary venous drainage; the flap can be reliably thinned in the plane inferior to the SIEV.[14]

Sensory innervation​

  • The DIEP flap is insensate — sensory nerves (T7–T12 intercostal) are usually dissected when the flap is raised with a skin island.[2]

Flap Designs and Variants​

VariantSkin orientationApplicationKey feature
Transverse DIEP (free)Transverse lower abdominalBreast reconstructionWorkhorse of autologous breast recon[3]
Vertical DIEP (pedicled)Vertical paramedianVaginal reconstruction after PEPreferred for circumferential neovagina; tubed vertically[15]
Transverse DIEP (pedicled)Transverse lower abdominalVulvar / perineal reconstructionLarge skin island for surface coverage[16]
Thinned DIEP (pedicled)Transverse or verticalPerineal reconstructionDebulked inferior to SIEV; better cosmesis[14]
Pre-expanded DIEPExpanded transverseLarge defects (perineum / vulva / buttock)Tissue expansion ↑ coverage area; staged[17]
Laparoscopic / robotic DIEPTransverseBreast reconstructionMinimally invasive pedicle dissection; reduced fascial incision[18][19]

The Pedicled DIEP Flap for Vulvar / Perineal / Vaginal Reconstruction​

Concept​

In the pedicled configuration, the DIEP flap remains attached to its DIEA pedicle. The flap is harvested from the lower abdominal wall, the pedicle is dissected retrograde from the perforator through the rectus muscle to the DIEA origin at the external iliac artery, and the flap is then rotated inferiorly through the abdominal wall (retropubic tunnel or laparotomy incision) into the pelvic / perineal defect.[15][20]

Indications across vulvar algorithms​

AlgorithmPosition
Höckel 2008[2]Named option for vulvovaginal reconstruction; abdominal-wall skin on DIEA perforators; insensate; rectus parent flap (VRAM/TRAM) replaced by its muscle-sparing perforator evolution
Negosanti 2015 (n = 22)[1]Two-flap algorithm: every vulvar defect can be repaired with DIEP + lotus petal. Type IA → monolateral LPF; Type IB → bilateral LPF; Type II (vulvar + vaginal + pelvic dead space) → pedicled DIEP. DIEP preferred because it fills pelvic dead space
Caretto 2023 secondary recon (n = 66)[21]DIEP among the most frequently employed flaps for secondary reconstruction
Toulouse 2025[22]Perforator flaps first-line; DIEP for large defects requiring pelvic dead-space obliteration

Surgical Technique — Pedicled DIEP​

Preoperative planning​

  • CTA of the abdominal wall is essential — sensitivity and specificity of 100% for perforators > 0.5 mm.[14]
  • CTA defines perforator location, number, caliber, intramuscular course, and DIEA branching pattern.
  • Perforator selection: medial-row perforators near the umbilicus — largest perforators (> 1.8 mm) with most reliable perfusion.[11]
  • Handheld Doppler can supplement CTA intraoperatively.

Pedicled vertical DIEP for vaginal reconstruction — Ferron 2015 Toulouse technique[15]​

  1. Position — supine lithotomy.
  2. Midline laparotomy for pelvic exenteration — DIEP harvest uses the same abdominal incision.
  3. Perforator identification — one or two medial perforators on the anterior rectus sheath, based on preoperative CTA.
  4. Flap design — vertical skin island on the lower abdominal wall, centered on the selected perforators; vertical orientation allows tubing for circumferential neovagina.
  5. Suprafascial dissection — elevate lateral to medial in a suprafascial plane until perforators are identified entering the anterior rectus sheath.
  6. Fascial incision — incise the anterior rectus sheath around the perforators; keep the incision as small as possible (mean 6.6 cm with short-fasciotomy vs 11.1 cm conventional).[23]
  7. Intramuscular dissection — spread rectus muscle fibers in the direction of their orientation; ligate / divide muscle branches; preserve muscle fibers intact.
  8. Pedicle dissection — retrograde to the DIEA origin at the external iliac artery. Mean pedicle length 12.6 cm.[23]
  9. Flap mobilization on its DIEA pedicle.
  10. Flap transfer — rotated inferiorly through the laparotomy or through a retropubic / paravesical tunnel into the pelvic cavity.
  11. Neovagina formation — vertical skin island tubed (skin inward); brought to the prerectal pocket and anastomosed to the vaginal introitus.[24]
  12. Donor closure — anterior rectus sheath closed primarily; abdominal skin closed as part of the laparotomy. No mesh required.

Median DIEP harvest time: 60 minutes (Ferron).[15]

Pedicled DIEP for vulvar surface reconstruction — Muneuchi 2005[16]​

  • In a 71-year-old with large vulvar cancer, the DIEP flap was harvested through the abdominal incision — no additional scar.
  • Less invasive, simple procedure; morphologically / functionally satisfactory; no dysuria, no abdominal hernia.
  • Authors consider DIEP the first choice for vulvar reconstruction following radical vulvectomy.

Thinned pedicled DIEP — Fang 2011 (n = 12)[14]​

  • Thinned in the plane inferior to the SIEV based on preoperative CTA.
  • 3 vulval / vaginal tumor, 5 congenital vaginal agenesis, 4 perineal Paget's.
  • 10/12 flaps transplanted without complications; 1 partial necrosis (large 24 × 8.5 cm transverse flap); 1 dehiscence (re-sutured).
  • DIEP can be reliably debulked inferior to the SIEV with minimal necrosis risk.

Pre-expanded DIEP — Monsivais 2017[17]​

  • Pre-expansion → delay phenomenon improving vascularity; decreases donor morbidity; increases coverage area.
  • Requires staged procedures with risk of extrusion / infection.
  • Useful for very large defects of perineum / vulva / buttock.

Clinical Outcomes — Pedicled DIEP for Pelvic / Perineal Reconstruction​

StudynIndicationDesignFlap survivalDonor complicationsRecipient complicationsHeadline
Ferron 2015[15]10 DIEP (+ 3 VRAM)Vaginal recon after PEVertical pedicled100% (no necrosis)0% (DIEP)1 vaginal stenosis (DIEP); 1 incisional hernia (VRAM)DIEP preferred for circumferential vaginal recon; 60 min harvest
Pividori 2023[25]34Pelvic / perineal recon after PE / APRPedicled91% (2 total + 1 partial loss)3% major (CD ≥ III)32% ≥ 1 major complicationLow abdominal morbidity; 85% prior RT; 0% hernia
Qiu 2013[4]7 DIEP vs 21 TRAMVaginal recon after PEPedicled100% (DIEP) vs 62% (TRAM)0% (DIEP) vs 19% (TRAM)—DIEP superior: faster harvest (63 vs 105 min); no abdominal-wall complications
Fang 2011[14]12Perineal recon (vulvar tumor, vaginal agenesis, Paget's)Pedicled thinned83% (10/12 no complications)—1 partial necrosis, 1 dehiscenceThinning inferior to SIEV is safe
Wang 2007[20]5Vaginal recon (4 agenesis, 1 tumor)Pedicled100%—1 hematomaReliable neovagina; 2/5 sexually active
Ang 2009[24]6Vaginal recon (5 agenesis, 1 vaginectomy)Vertical pedicled100%—1 wound infectionVaginal depth stable; no orifice constriction
Muneuchi 2005[16]1Vulvar recon after radical vulvectomyPedicled100%0%0%First-choice claim for vulvar recon; uses abdominal incision
Negosanti 2015[1]22 (DIEP + LPF)Vulvar recon (all types)Pedicled100% (no major complications)——DIEP + LPF can repair all vulvar defects

DIEP vs TRAM / VRAM — Head-to-Head​

Qiu 2013 — TRAM vs DIEP for vaginal reconstruction after PE (n = 28)[4]​

OutcomeDIEP (n = 7)TRAM (n = 21)
Flap survival100%62% (3 total necrosis, 5 partial)
Mean harvest time63 min105 min
Abdominal-wall complications0%19% (despite mesh in all)
External-genitalia appearanceNormalNormal

DIEP superior in flap survival, harvest time, and donor morbidity — authors concluded DIEP could replace TRAM for vaginal reconstruction after PE.

VRAM donor-site morbidity (Radwan SR 2021, n = 1,827)[26]​

OutcomePooled
Perineal flap morbidity27%
Complete flap loss1.8%
Donor-site morbidity15%
Abdominal dehiscence5.5%
Incisional hernia3.3%
Perineal hernia0.2%

VRAM vs gracilis (Eseme meta-analysis)[27]​

VRAM donor-site complications 57.6% vs gracilis 16.0%; partial / total flap necrosis similar. Pividori's pedicled DIEP achieved only 3% major donor complications and 0% hernia — confirming DIEP addresses the primary VRAM limitation.[25]

Operative Efficiency​

Haddock & Teotia 2020 process analysis (n = 147 DIEP flaps, breast)[28]​

Eight critical maneuvers: skin → perforator identification → perforator decision-making → perforator dissection → pedicle dissection → flap harvest → preparation for microsurgery → venous anastomosis → arterial anastomosis.

Surgeon configurationMean flap-harvest time
Faculty surgeons54.8 min
Faculty + senior resident / fellow98.3 min
Supervised chief resident178.8 min (p < 0.001)

Single-perforator antegrade technique — Feingold 2009[29]​

  • Flap-harvest time on the order of one hour with antegrade technique.
  • Significantly less stress; minimized fascial incisions.
  • Strategy based on single-perforator harvest and discontinuous fascial incisions.

Short-fasciotomy technique — Kim 2023 (n = 304)[23]​

  • Mean fascial incision: 6.6 cm (short-fasciotomy) vs 11.1 cm (conventional).
  • Mean pedicle length 12.6 cm.
  • No flap loss in either group.
  • Rate of abdominal bulge / hernia significantly lower with short-fasciotomy.

Minimally invasive harvest​

ApproachSeriesKey result
Laparoscopic (Hivelin 2018)[18]Anatomic + clinicalMean anterior rectus sheath incision 12 cm → 3 cm (anatomic) / 5 cm (clinical); average laparoscopic harvest 50 min
Laparoscopic (Shakir 2020)[30]ClinicalMean fascial incision 2.0 cm; 60% of patients recovered without narcotics; mean LOS 2.5 d
Robotic (Wittesaele 2022)[19]n = 10Mean robot-assisted operating time 86 min; mean total operative time 479 min; no flap losses

Position in Reconstructive Algorithms​

AlgorithmDIEP positionSpecific indication
Höckel 2008[2]Named option for vulvovaginal reconDIEA-perforator-based abdominal-wall skin; insensate
Negosanti 2015[1]One of two flaps (with LPF)Type II defects (vulvar + vaginal resection with pelvic dead space)
Caretto 2023[21]Frequently employed for secondary vulvar reconSecondary recon when other flaps unavailable
Toulouse 2025[22]Perforator flaps first-line; DIEP for large defectsLarge defects requiring pelvic dead-space obliteration
Mericli 2016[31]DIEP as muscle-sparing alternative to VRAMVRAM still preferred for vagina / perineal-raphe subunit volume

Advantages​

AdvantageDetail
Complete muscle and fascia preservationRectus abdominis muscle, motor innervation, and anterior rectus sheath preserved intact[3][4]
Dramatically reduced donor-site morbidity3% major (Pividori) vs 15% mean for VRAM; 0% incisional hernia vs 3.3% for VRAM[25][26]
Superior flap survival vs TRAM100% (DIEP) vs 62% (TRAM) — Qiu head-to-head[4]
Faster harvest60–63 min (pedicled DIEP) vs 105 min (TRAM)[4][15]
Large skin islandUp to 24 × 8.5 cm or larger — covers extensive vulvar / perineal / vaginal defects[14]
Versatile designVertical (tubed neovagina) or transverse (surface coverage); thinnable[14][15][24]
Utilizes existing abdominal incisionIn PE via midline laparotomy — same incision, no additional scar[16]
Reliable vascular anatomyDIEA present in virtually all patients; mean 2.9 perforators / hemiabdomen; largest perforators within 3 cm of the umbilicus[10][11]
Fills pelvic dead spaceSufficient tissue volume to obliterate dead space after PE — reduces pelvic abscess[1][32]
No mesh requiredMuscle and fascia preserved[4]
Compatible with prior radiation85% of Pividori patients had prior RT — good outcomes[25]
Pre-expansion possibleTissue expansion ↑ coverage for very large defects[17]
No perineal hernia0% in Pividori[25]

Limitations​

LimitationDetail
Technically demandingPerforator dissection through the rectus muscle requires microsurgical expertise and a steep learning curve; failure to localize perforators led to conversion to VRAM in 2/13 (15%) in Ferron[15]
InsensateT7–T12 sensory nerves dissected during harvest — reconstructed vulva / vagina has no protective sensation[2]
Branching variabilityTrifurcating DIEA (Type III, 14%) has greatest transverse perforator distance and requires more muscle dissection[7]
Prior abdominal surgeryPrior TRAM / DIEP / vascular interventions may compromise the DIEA pedicle
Total / partial flap lossPividori: 2 total + 1 partial loss across 34 flaps (91% survival)[25]
Smoking / obesityIncreased fat necrosis and perfusion-related complications
Insensate vaginaTubed neovagina has no sensation — affects sexual function
Hair-bearingLower abdominal donor may be hair-bearing — relevant for tubed neovagina (intra-vaginal hair)

See Also​

References​

1. Negosanti L, Sgarzani R, Fabbri E, et al. Vulvar reconstruction by perforator flaps: algorithm for flap choice based on the topography of the defect. Int J Gynecol Cancer. 2015;25(7):1322–1327. doi:10.1097/IGC.0000000000000481

2. Höckel M, Dornhöfer N. Vulvovaginal reconstruction for neoplastic disease. Lancet Oncol. 2008;9(6):559–568. doi:10.1016/S1470-2045(08)70147-5

3. Granzow JW, Levine JL, Chiu ES, Allen RJ. Breast reconstruction using perforator flaps. J Surg Oncol. 2006;94(6):441–454. doi:10.1002/jso.20481

4. Qiu SS, Jurado M, Hontanilla B. Comparison of TRAM versus DIEP flap in total vaginal reconstruction after pelvic exenteration. Plast Reconstr Surg. 2013;132(6):1020e–1027e. doi:10.1097/PRS.0b013e3182a97ea2

5. Myung Y, Choi B, Yim SJ, et al. The originating pattern of deep inferior epigastric artery: anatomical study and surgical considerations. Surg Radiol Anat. 2018;40(8):873–879. doi:10.1007/s00276-018-2055-8

6. Rozen WM, Ashton MW, Grinsell D. The branching pattern of the deep inferior epigastric artery revisited in-vivo: a new classification based on CT angiography. Clin Anat. 2010;23(1):87–92. doi:10.1002/ca.20898

7. Rozen WM, Palmer KP, Suami H, et al. The DIEA branching pattern and its relationship to perforators: the importance of preoperative computed tomographic angiography for DIEA perforator flaps. Plast Reconstr Surg. 2008;121(2):367–373. doi:10.1097/01.prs.0000298313.28983.f4

8. Ireton JE, Lakhiani C, Saint-Cyr M. Vascular anatomy of the deep inferior epigastric artery perforator flap: a systematic review. Plast Reconstr Surg. 2014;134(5):810e–821e. doi:10.1097/PRS.0000000000000625

9. El-Mrakby HH, Milner RH. The vascular anatomy of the lower anterior abdominal wall: a microdissection study on the deep inferior epigastric vessels and the perforator branches. Plast Reconstr Surg. 2002;109(2):539–543. doi:10.1097/00006534-200202000-00020

10. Meyerov J, Ram R, Grinsell D. Refining the abdominal wall perforasome with clinical application. J Plast Reconstr Aesthet Surg. 2025;105:283–291. doi:10.1016/j.bjps.2025.04.024

11. Bailey SH, Saint-Cyr M, Wong C, et al. The single dominant medial row perforator DIEP flap in breast reconstruction: three-dimensional perforasome and clinical results. Plast Reconstr Surg. 2010;126(3):739–751. doi:10.1097/PRS.0b013e3181e5f844

12. Schaverien M, Saint-Cyr M, Arbique G, Brown SA. Arterial and venous anatomies of the deep inferior epigastric perforator and superficial inferior epigastric artery flaps. Plast Reconstr Surg. 2008;121(6):1909–1919. doi:10.1097/PRS.0b013e31817151f8

13. Boyd JB, Taylor GI, Corlett R. The vascular territories of the superior epigastric and the deep inferior epigastric systems. Plast Reconstr Surg. 1984;73(1):1–16. doi:10.1097/00006534-198401000-00001

14. Fang BR, Ameet H, Li XF, et al. Pedicled thinned deep inferior epigastric artery perforator flap for perineal reconstruction: a preliminary report. J Plast Reconstr Aesthet Surg. 2011;64(12):1627–1634. doi:10.1016/j.bjps.2011.04.013

15. Ferron G, Gangloff D, Querleu D, et al. Vaginal reconstruction with pedicled vertical deep inferior epigastric perforator flap (DIEP) after pelvic exenteration. A consecutive case series. Gynecol Oncol. 2015;138(3):603–608. doi:10.1016/j.ygyno.2015.06.031

16. Muneuchi G, Ohno M, Shiota A, Hata T, Igawa HH. Deep inferior epigastric perforator (DIEP) flap for vulvar reconstruction after radical vulvectomy: a less invasive and simple procedure utilizing an abdominal incision wound. Ann Plast Surg. 2005;55(4):427–429. doi:10.1097/01.sap.0000171425.83415.fa

17. Monsivais SE, Webster ND, Wong S, Saint-Cyr MH. Pre-expanded deep inferior epigastric perforator flap. Clin Plast Surg. 2017;44(1):109–115. doi:10.1016/j.cps.2016.09.002

18. Hivelin M, Soprani A, Schaffer N, Hans S, Lantieri L. Minimally invasive laparoscopically dissected deep inferior epigastric artery perforator flap: an anatomical feasibility study and a first clinical case. Plast Reconstr Surg. 2018;141(1):33–39. doi:10.1097/PRS.0000000000003989

19. Wittesaele W, Vandevoort M. Implementing the robotic deep inferior epigastric perforator flap in daily practice: a series of 10 cases. J Plast Reconstr Aesthet Surg. 2022;75(8):2577–2583. doi:10.1016/j.bjps.2022.02.054

20. Wang X, Qiao Q, Burd A, et al. A new technique of vaginal reconstruction with the deep inferior epigastric perforator flap: a preliminary report. Plast Reconstr Surg. 2007;119(6):1785–1790. doi:10.1097/01.prs.0000259076.16918.fa

21. Caretto AA, Servillo M, Tagliaferri L, et al. Secondary post-oncologic vulvar reconstruction — a simplified algorithm. Front Oncol. 2023;13:1195580. doi:10.3389/fonc.2023.1195580

22. Ricotta G, Russo SA, Ferron G, Meresse T, Martinez A. The Toulouse algorithm: vulvar cancer location-based reconstruction. Int J Gynecol Cancer. 2025;35(4):100065. doi:10.1016/j.ijgc.2024.100065

23. Kim J, Lee KT, Mun GH. Short fasciotomy-deep inferior epigastric perforator flap harvest for breast reconstruction. Plast Reconstr Surg. 2023;152(6):972e–984e. doi:10.1097/PRS.0000000000010382

24. Ang Z, Qun Q, Peirong Y, et al. Refined DIEP flap technique for vaginal reconstruction. Urology. 2009;74(1):197–201. doi:10.1016/j.urology.2008.11.054

25. Pividori M, Gangloff D, Ferron G, et al. Outcomes of DIEP flap reconstruction after pelvic cancer surgery: a retrospective multicenter case series. J Plast Reconstr Aesthet Surg. 2023;85:242–251. doi:10.1016/j.bjps.2023.07.005

26. Radwan RW, Tang AM, Harries RL, et al. Vertical rectus abdominis flap (VRAM) for perineal reconstruction following pelvic surgery: a systematic review. J Plast Reconstr Aesthet Surg. 2021;74(3):523–529. doi:10.1016/j.bjps.2020.10.100

27. Eseme EA, Scampa M, Viscardi JA, et al. Surgical outcomes of VRAM vs gracilis flaps in vulvo-perineal reconstruction following oncologic resection: a proportional meta-analysis. Cancers. 2022;14(17):4300. doi:10.3390/cancers14174300

28. Haddock NT, Teotia SS. Deconstructing the reconstruction: evaluation of process and efficiency in deep inferior epigastric perforator flaps. Plast Reconstr Surg. 2020;145(4):717e–724e. doi:10.1097/PRS.0000000000006630

29. Feingold RS. Improving surgeon confidence in the DIEP flap: a strategy for reducing operative time with minimally invasive donor site. Ann Plast Surg. 2009;62(5):533–537. doi:10.1097/SAP.0b013e31819fafdd

30. Shakir S, Spencer AB, Kozak GM, et al. Laparoscopically assisted DIEP flap harvest minimizes fascial incision in autologous breast reconstruction. Plast Reconstr Surg. 2020;146(3):265e–275e. doi:10.1097/PRS.0000000000007048

31. Mericli AF, Martin JP, Campbell CA. An algorithmic anatomical subunit approach to pelvic wound reconstruction. Plast Reconstr Surg. 2016;137(3):1004–1017. doi:10.1097/01.prs.0000479973.45051.b6

32. Jurado M, Bazán A, Elejabeitia J, et al. Primary vaginal and pelvic floor reconstruction at the time of pelvic exenteration: a study of morbidity. Gynecol Oncol. 2000;77(2):293–297. doi:10.1006/gyno.2000.5764