|Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.|
| tangentially. In thin individuals with a good superficial inferior epigastric Doppler signal, the flap can be raised rapidly in a superior-to-inferior direction, transilluminating the vessels as one proceeds. In people with a fair amount of subcutaneous tissue, in whom the inferior epigastric system cannot be well documented, the dissection can
begin with the inferior incision over the medial end of the inguinal ligament. The large inferior epigastric veins come into view in the subcutaneous tissue and can be followed back to their saphenous bulb termination. This dissection usually identifies the other branches the key venous branch with the accompanying epigastric artery, which should be dissected down to and through the femoral triangles onto the femoral arterial sheath. Often the inferior epigastric artery comes off with the superficial pudendal or circumflex iliac vessels and a larger end vessel can then be obtained for anastomosis. Actually, if a conjoined trunk is discovered, the pudendal vessels or circumflex iliac vessels should
be dissected for several centimeters, so that these can be used for internal shunts with the vessels from the opposite side if needed.
If the superficial inferior epigastric vessels are small and are not considered able to sustain the flap, the deep inferior epigastric vessels, as pointed out, can be used as an additional vascular system. Myocutaneous perforators can be easily identified in mobilizing the flap from the superior-to-inferior direction because they come through the rectus sheath in the upper central area of the flap. Usually, one large perforator can be traced through the rectus fascia and muscle to the deep inferior epigastric pedicle on the deep lateral surface of the muscle, where it can be traced to its external iliac origin, preserving the
| rectus muscle, its nerve supply, and the rectus sheath. Large vena comitantes accompany the deep inferior epigastric artery and a pedicle of 6 to 8 cm can often be developed. There are also branches from the deep inferior epigastric vessel that go out through the rectus sheath laterally with the intercostal communicators and accompanying intercostal nerve supply to the rectus muscle. One or two of these branches can be left, along with the deep inferior vascular pedicle, to be used for internal shunts with the superficial system of the same side or similar vessels from the opposite side.
When the flap is mobilized from superiorly to inferiorly, large musculocutaneous perforators from the deep circumflex iliac vessels may be found just above the inguinal ligaments and along the iliac crest coming through the external oblique muscle and fascia. These may be larger than the rectus perforators and can be preferentially dissected down through the external-internal oblique aponeurosis to develop a vascular pedicle of great length incorporating the entire deep circumflex iliac pedicle back to its external iliac or femoral origin.
In summary, one has the choice of three arterial inputs from both sides and the major superficial venous system drainage. The simplest and quickest way to mobilize the flap
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