Name: An Experimental Human DIEP Flap Model to Investigate Preservation Strategies for Vascularized Composite Allografts and Free Flaps (Video) | JoVE Journal
Uploaded: 2025-12-05T13:15:00.000+00:00
Duration: 7 min 57 s
Description: Learn the surgical technique for harvesting human DIEP perforator flaps to improve preservation of vascularized composite allografts. This method advances experimental surgery research.

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<ol><li>Lupon, E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((vascularized+composite+allografts+in+france%3A+An+update%5BTitle%5D)+AND+%22Ann+Chir+Plast+Esthet%22%5BJournal%5D)">vascularized composite allografts in france: An update.</a> Ann Chir Plast Esthet. , (2024).</li>
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<li>Lupon, E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Microsurgery+in+low-+and+middle-income+countries%3A+Results+of+20+years+of+experience+in+cambodia%5BTitle%5D)+AND+%22J+Plast+Reconstr+Aesthet+Surg%22%5BJournal%5D)">Microsurgery in low- and middle-income countries: Results of 20 years of experience in cambodia.</a> J Plast Reconstr Aesthet Surg. 98, 161-169 (2024).</li>
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</ol>

The authors have nothing to disclose.

Human models help bridge findings from animal studies to clinical practice, improving the relevance and predictivity of preclinical research16,17,18. They must be carefully designed to ensure safety and ethical compliance, often limiting the scope and invasiveness of experiments17. Across the four harvested flaps, no additional dissection was necessary, and there was no significant prolongation of operati...

Vascularized composite allotransplantation (VCA) represents a promising reconstructive solution for patients with complex tissue defect, particularly in the face and upper limbs1. However, VCA is highly susceptible to ischemia-reperfusion injury, which can compromise graft viability and long-term outcomes2. In this context, preservation approaches such as cytoprotective agents injection, ex vivo machine perfusion, and supercooling have emerged as strategies to extend preservation time, optimize graft quality, and enable viability assessment prior to transplantation3,4,5,6,7. While normothermic ex vivo perfusion of solid organs has been successfully translated from an experimental laboratory technique into clinical practice over the past decade8, with promising results, it remains largely confined to the research setting in the field of VCA9.
To date, most studies investigating VCA perfusion protocols have relied on animal models, particularly swine or rodent composites10. While these models offer valuable insights, they inherently limit reproducibility and translational relevance due to anatomical, immunological, and physiological differences11,12. Human tissue models provide more relevant insights, but fresh tissues from brain-dead donors are extremely difficult to access for research purposes, requiring complex logistics, strict regulatory approval, and raising ethical concerns13,14. An ideal alternative would be a non-cadaveric, ethically acceptable, human-based flap model that does not carry the complexity or risk of a full VCA procedure and is entirely safe for the patient. Importantly, it should also be easily accessible to facilitate reproducible, scalable research.
Herein, a human deep inferior epigastric perforator (DIEP) flap model for VCA preservation research is described, using discarded tissue from abdominoplasty procedures without any additional risk to the patient.

<table><tbody><tr><td>1 mL and 5 mL Luer-Lok syringe</td><td>Becton Dickinson</td><td>https://www.bd.com/en-us/products-and-solutions/products/product-page.309646</td><td></td></tr><tr><td>11.5&amp;rdquo; Medium and Small Premium Surgiclip II Auto Suture vessel clip applier</td><td>Covidien</td><td>N/A</td><td></td></tr><tr><td>22&amp;ndash;24 G vessel cannula blunt tip</td><td>Medtronic Inc</td><td>N/A</td><td></td></tr><tr><td>5-0 silk suture&amp;nbsp;</td><td></td><td>N/A</td><td>Any compatible suture</td></tr><tr><td>A single-use, battery-powered disposable cautery pen&amp;nbsp;</td><td>Helpmedical, Europe</td><td>N/A</td><td>1200 &amp;deg;C, large-tip</td></tr><tr><td>Adson Forceps</td><td>MPM</td><td>106-2112A</td><td></td></tr><tr><td>Bipolar Coagulation Forceps</td><td>Olsen</td><td>20-1320I</td><td></td></tr><tr><td>Disposable Scalpel #15 &amp;amp; #21</td><td>Sklar</td><td>N/A</td><td></td></tr><tr><td>Eosin&amp;nbsp;</td><td>Microm Microtech</td><td>U/C0363</td><td></td></tr><tr><td>Faraboeuf retractors</td><td>Medicta Instruments</td><td>N/A</td><td></td></tr><tr><td>Fine needle cautery</td><td>Cormedica</td><td>N/A</td><td></td></tr><tr><td>OEC MiniView Max</td><td>GE Healthcare</td><td>N/A</td><td>Fluoroscopy system</td></tr><tr><td>Forceps Dilators</td><td>WPI</td><td>15910</td><td></td></tr><tr><td>Hematoxylin&amp;nbsp;</td><td>Microm Microtech</td><td>U/C0303</td><td></td></tr><tr><td>Iohexol 300 mg I/mL</td><td>GE Healthcare Canada Inc.</td><td>N/A</td><td></td></tr><tr><td>Micro scissors</td><td>WPI</td><td>504492</td><td></td></tr><tr><td>Valleylab Monopolar Diathermy</td><td>Medtronic Inc</td><td></td><td></td></tr><tr><td>Non-ionic iodinated contrast medium, Omnipaque 300 mg I/mL</td><td>GE Healthcare</td><td>N/A</td><td></td></tr><tr><td>Portable acoustic Doppler, 8 MHz</td><td>Parks Medical Electronics</td><td>https://www.parksmed.com/</td><td></td></tr><tr><td>Saline solution 0.9%</td><td>GenDepot</td><td>S0600-101</td><td></td></tr><tr><td>Standard plastic surgery instrument set</td><td>Aesculap</td><td>N/A</td><td>including scalpel handle No. 3, Metzenbaum and Mayo scissors, Adson and Gillies forceps, dissecting scissors, hemostats, and needle holders.</td></tr><tr><td>Strabismus scissors</td><td>Surtex</td><td>102-4109</td><td></td></tr><tr><td>Surgical marking pen</td><td>Cardinal health</td><td>212PR</td><td></td></tr><tr><td>Sutures Ethilon 4.0 and 3.0</td><td>Ethicon</td><td>1667G</td><td></td></tr><tr><td>Tissue Forceps</td><td>MPM</td><td>106-0511</td><td></td></tr></tbody></table>

an experimental human diep flap model to investigate preservation strategies for vascularized composite allografts and free flaps

An Experimental Human DIEP Flap Model to Investigate Preservation Strategies for Vascularized Composite Allografts and Free Flaps

Recently, preservation approaches such as cytoprotective agents injection, ex vivo machine perfusion, and supercooling have emerged as strategies to enhance long-term preservation of both standard and marginal organs by mitigating ischemic and hypoxic injury. Although encouraging, its application in the field of vascularized composite allotransplantation (VCA) remains largely confined to preclinical research. To date, most studies investigating VCA perfusion strategies have relied on animal models, particularly swine or rodent composites. While these models provide valuable mechanistic insights, their anatomical, immunological, and physiological differences limit reproducibility and translational relevance to human applications.
In this protocol, each surgical step required for the procurement of a human deep inferior epigastric perforator (DIEP) flap for preservation studies is described in detail. The perforator is transected above the fascia without any subfascial dissection, yielding a short yet sufficient pedicle for catheterization. This model takes advantage of discarded tissue from standard abdominoplasty procedures, posing no additional risk to the patient. Critical steps are outlined to ensure a functional flap is harvested without prolonging operative time or compromising patient safety. Functional imaging is subsequently performed to confirm flap viability prior to experimental use, and sequential biopsies may be performed to follow tissue integrity. This model is particularly suited for research involving muscle-sparing VCA procedures -- such as partial facial transplantation -- and may also have relevance for the study of autologous free flap preservation.

Eleven flaps were harvested from six female patients included in this study. Two senior plastic surgeons, experienced in flap surgery and abdominoplasty, performed the dissections. In one patient, the flap was harvested unilaterally due to a dissection issue. The harvested flaps had a mean weight of 198.6 ± 24.4 g (n = 11) and an average size of 10 cm × 6 cm, which corresponded to the sample requirements for the preservation study in which these flaps were used. The pedicle length, measured under gentle tension, averaged...

This protocol describes the surgical technique for harvesting a human perforator flap model based on the deep inferior epigastric artery pedicle, intended for experimental research.

Recently, preservation approaches such as cytoprotective agents injection, ex vivo machine perfusion, and supercooling have emerged as strategies to ...

Our study aims to improve preservation and survival of vascularized composite allografts, and free flaps using human experimental flaps models. Current research mainly relies on animal VCA and free flap models, often using rodent or large animal hand/limb osteomyocutaneous flaps. To begin, perform the preoperative dermal lipectomy marking with the patient and identify the midline from the pubic synthesis to the xiphoid process.Draw a transverse line approximately seven centimeters above the vulvar commissure. Extend this line laterally about seven centimeters on each side, gently curving it upward to join just below the anterior superior iliac spines. Identify the perforators around the umbilicus using a handheld acoustic doppler probe with eight to 10 megahertz while the patient is in the supine position.Using a dermographic pen, outline a skin paddle in an elliptical shape of the desired dimensions, including the perforator along its medial border, and extending on both sides of the umbilicus. Prepare and drape the surgical field from the xiphoid process to the upper third of the thighs, including the pubic region, using sterile surgical drapes as routinely performed in standard abdominal surgery. Make a low transverse skin incision along the preoperative marking approximately seven centimeters above the vulva commissure, gently curving toward the anterior superior iliac spines on each side using a number 15 or number 21 scalpel blade.Detach the umbilicus from the abdominal wall through a circumferential incision down to the hypodermis using a number 15 scalpel blade. Dissect the umbilicus vertically using mayo scissors from the superficial to the deep plane until it is completely freed while preserving its umbilical pedicle. Place a long, loose, non-absorbable suture on either side of the umbilical margin.Raise the superior abdominoplasty flap in the subcutaneous plane starting from the lower incision and progressing cranially toward the umbilicus. Use a fine tip monopolar electrocautery set to approximately 50 to 70 degrees Celsius and 80 watts in coagulation mode to separate the anterior rectus fascia from the overlying subcutaneous tissue and skin, while maintaining meticulous hemostasis throughout the dissection. As as the dissection approaches the previously isolated umbilical pedicle, continue with fine dissection using Metzenbaum scissors to avoid pedicle injury.Identify and carefully isolate the two dominant paraumbilical perforators arising from the deep inferior epigastric system. Dissect each perforator circumferentially under direct vision using Stevens or small Metzenbaum scissors, preserving their vascular pedicles. Divide the adipocutaneous panniculus longitudinally along the midline from the center of the lower pubic incision up to the umbilicus using a number 15 blade, followed by monopolar electrocautery set at approximately 50 to 70 degrees Celsius.Continue the dissection cranially up to the xiphoid region and along the lateral costal margins, keeping the flat pedicles intact and undivided. Ligate the deep inferior epigastric artery perforator pedicle using resorbable 3.0 sutures or automatic clips, and transect the perforator above the fascia with no subfascial dissection. Advance the supra umbilical skin and subcutaneous fat downward and secure the undermined abdominal flap to the inferior incision margin at the midline using a non-absorbable suture, leaving one end of the knot long.Use the long end of the midline non-absorbable suture, connecting the supra umbilical and pubic areas as a guide to draw the resection line on the excess adipocutaneous panniculus. The DIEP flaps are located below this marked resection line. Completely detach the perforator flap from the surrounding discarded tissue.Excise the redundant dermo adipose tissue corresponding to the excess skin and fat removed during the abdominoplasty. Then dissect the vascular pedicle under magnification using microsurgical instruments and identify both the artery and the vein. Gently open the arterial lumen with a microvascular dilator.Catheterize the artery using an 18 to 24 gauge cannula and secure it in the lumen with 5.0 silk suture ligation. Finally, inject contrast agent intra arterially through the catheter into the perforator artery and evaluate the flap under fluoroscopy. The harvested flaps had an average weight of around 198.6 grams, a mean size of 10 centimeters by six centimeters, a pedicle length of around 3.85 centimeters, and an external vessel diameter of 1.2 millimeters.Arteriography confirmed that all flaps had homogeneous and complete vascular filling, demonstrating good perfusion. There was no significant difference in operative time between six patients undergoing standard abdominoplasty with flap harvest and six retrospective cases without flap harvest. No postoperative abdominal wall deficits or infections were observed in any of the six patients during follow-up.After catheterization, the flaps were preserved at four degrees Celsius in vacuum-sealed bags and divided into treated and control groups based on perfusion with a cytoprotective agent or University of Wisconsin solution. Histological sections from punch biopsies at different time points showed progressive ischemic changes from zero to 48 hours after storage. We like human anatomical data for realistic VCA and free flap studies.Current models rely on animals and poorly reflect clinical surgery. Our human perfusion model reduces animal sacrifice and offers anatomical and surgical realism that animal models cannot replace for free flap studies. Our model enables preoperative testing of cytoprotective agents in human skin flaps to evaluate their protective effect against ischemic injury.

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Research

JoVE Journal

Medicine

Free tissue transfer is widely employed in reconstructive surgery to restore form and function following oncological resection and trauma. Preconditioning this tissue prior to surgery may improve outcome. This article describes an in situ transverse rectus abdominis myocutaneous flap (TRAM) in rats as a means for testing preconditioning strategies.

In situ Transverse Rectus Abdominis Myocutaneous Flap: A Rat Model of Myocutaneous Ischemia Reperfusion Injury

Vascularized Composite Allotransplantations (VCA) have become a clinical reality. However, broad clinical application of VCA is limited by chronic multi-drug immunosuppression. The authors present a reliable and reproducible large animal model to translate novel immunomodulatory strategies that can minimize or potentially eliminate the need of immunosuppression in VCA.

A Modified Heterotopic Swine Hind Limb Transplant Model for Translational Vascularized Composite Allotransplantation (VCA) Research

The window of the murine dorsal skinfold chamber presented visualizes a zone of acute persistent ischemia of a musculocutaneous flap. Intravital epi-fluorescence microscopy permits for direct and repetitive assessment of the microvasculature and quantification of hemodynamics. Morphologic and hemodynamic results can further be correlated with histological and molecular analyses.

Ischemic Tissue Injury in the Dorsal Skinfold Chamber of the Mouse: A Skin Flap Model to Investigate Acute Persistent Ischemia

To date, thick tissue defects are typically reconstructed by applying autologous tissue flaps or engineered tissues. In this protocol, we present a new method for engineering vascularized tissue flap bearing an autologous pedicle, to serve as a substitute to autologous flaps.

Engineered Vascularized Muscle Flap

This paper describes the steps required to raise a fasciocutaneous epigastric free flap and transfer it to the neck in the rat.

A Model of Free Tissue Transfer: The Rat Epigastric Free Flap

Vascularized composite allograft offers life-altering benefits to transplant recipients, but the biological causes of graft rejection and vasculopathy remain poorly understood. The rodent surgical model presented here offers a reproducible, clinically relevant model of transplantation, allowing researchers to evaluate rejection events and potential therapeutic strategies to prevent their occurrence.

Modified Heterotopic Hindlimb Osteomyocutaneous Flap Model in the Rat for Translational Vascularized Composite Allotransplantation Research

Here, we describe a pre-clinical animal model for studying the pathophysiology of ischemia-reperfusion injury in reconstructive microsurgery. This free skin flap model based on the superficial caudal epigastric vessels in the rat may also allow for the evaluation of different therapies and compounds to counteract ischemia-reperfusion injury-related damage.

A Pre-clinical Rat Model for the Study of Ischemia-reperfusion Injury in Reconstructive Microsurgery

The present protocol describes the porcine fascio-cutaneous flap model and its potential use in vascularized composite tissue research.

A Reliable Porcine Fascio-Cutaneous Flap Model for Vascularized Composite Allografts Bioengineering Studies

The protocol describes the surgical procurement and subsequent decellularization of vascularized porcine flaps by the perfusion of sodium dodecyl sulfate detergent through the flap vasculature in a customized perfusion bioreactor.

Procurement and Perfusion-Decellularization of Porcine Vascularized Flaps in a Customized Perfusion Bioreactor

This protocol describes harvesting, suturing, and monitoring fasciocutaneous flaps in rats that allow for good visualization and manipulation of blood flow through the superficial inferior epigastric vessels by means of clamping and ligating the femoral vessels. This is critical for studies involving ischemic preconditioning.

The Superficial Inferior Epigastric Artery Axial Flap to Study Ischemic Preconditioning Effects in a Rat Model

This protocol details the surgical technique used to harvest and prepare a full-face allograft for transplantation in patients with severe facial disfigurements, focusing primarily on soft tissue procurement with limited bony harvest restricted to the nasal framework.

Surgical Approach to Full Soft Tissue Face Allograft Procurement for Vascularized Composite Allotransplantation

Learn the surgical technique for harvesting human DIEP perforator flaps to improve preservation of vascularized composite allografts. This method advances experimental surgery research.

An Experimental Human DIEP Flap Model to Investigate Preservation Strategies for Vascularized Composite Allografts and Free Flaps (Video) | JoVE Journal

An Experimental Human DIEP Flap Model to Investigate Preservation Strategies for Vascularized Composite Allografts and Free Flaps

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