Novel Windmill Nonischemic Free Bilateral Deep Inferior Epigastric Perforator Flap for Extensive Defect Reconstruction

Reconstructing extensive lower extremity soft tissue defects can present significant challenges for plastic surgeons. Determining a donor site for a flap of adequate surface area to cover critical structures while minimizing donor-site morbidity is difficult. We describe a novel windmill nonischemic free bilateral deep inferior epigastric perforator (DIEP) flap as a suitable option for the reconstruction of extensive lower extremity defects. Our patient is a 59-year-old man with a body mass index of 36 kg/m² and a history of 23 kg weight loss after gastric sleeve placement. He presented to our service from the level 1 trauma center after sustaining a high-intensity crush injury to the right lower extremity and undergoing orthopedic reconstruction, which was complicated by wound dehiscence and hardware exposure. Following debridement, the defect measured 65 × 25 cm. A bilateral DIEP flap measuring 70 × 21 cm (among the largest by surface area described) was designed. The flap covered the defect fully, with perfusion obtained outside the zones of injury. A dual pedicle design was used to augment perfusion to the flap, with proximal and distal anastomoses in the lower extremity. Bilateral pedicles and 2 separate rotations across the recipient site allowed for reconstruction with no ischemia time. No complications occurred postoperatively or during the follow-up period (2.25 y). Combined or sequential flap transplantation is widely used in the reconstruction of extensive soft tissue defects. However, the windmill nonischemic free bilateral DIEP flap can cover a massive defect in a single stage with no ischemia time.