|Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.|
| over the sartorius is then incised so that the junction of the superficial circumflex iliac vessels and the deeper vessel can be visualized. This deeper branch is tied, and the dissection is carried across the floor of the femoral triangle to the lateral edge of the femoral sheath. Throughout this elevation from lateral to medial, incisions are carried out along the superior and inferior margins of the flap simultaneously. If just one margin is elevated, the flap tends to slide superiorly or inferiorly, so that the orientation of
the vascular axis is disturbed and a key branch may inadvertently be tied off.
E. In this view, the flap has been laid back in its bed and the superficial inferior epigastric vein can be visualized running along the base of its medial border. This vein often gives off a large branch that enters the flap and drains the superficial venous system. This vein is the principal structure that should be identified as one proceeds along the superior flap margin during elevation and dissection. The superficial inferior epigastric vein may also be accompanied by a small-to-medium-sized artery that also augments the base of the flap. The vein is dissected proximally to the femoral bulb, where it can be isolated and serve either as the primary or as supplementary venous drainage to the flap, augmenting that of the venae comitantes accompanying the arteries. This vein can also be mobilized up over the lower abdomen for several centimeters, to be used as a vein graft or an internal shunt to the deep venous system.
F. The entire flap has been mobilized on its vascular pedicles, with the superficial circumflex iliac artery and vein arising directly from the femoral artery and vein and the inferior epigastric vein draining more inferiorly into the saphenous bulb. One has, in effect, a single arterial input and a double venous outflow. Vascular anatomy in this area is highly variable. The superficial circumflex iliac artery may come off a common branch that also supplies the superficial inferior epigastric artery. Occasionally, these structures come off the profunda femoral artery or even off abnormal vessels that arise above the inguinal ligament. One should therefore anticipate anatomic variations.
This patient had a chronic drainage sinus in the center of the scar tissue over a nonunited fracture of the tibia and fibula.
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