|Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
| Recipient site angiography is done preoperatively to outline the condition of the recipient vessels and the deep inferior epigastric vessels if surgical trauma is suspected. The choice of recipient vessels may influence the decision of which rectus to use for pedicle orientation. A caudal tail of muscle can be carried and folded back during the anastomosing of the vessels then laid over the anastomosis. The rectus is ideal for anterior defects when the patient can be placed in the supine position, allowing two teams to work simultaneously. A template of the defect is useful for determining size and orientation of the muscle and/or the skin paddle.
Surface markings include the midline, the lateral muscle extent, and the iliofemoral axis. The level of the deep inferior epigastric artery is marked, originating approximately 1 cm above the inguinal ligament and entering the deep lateral side of the muscle midway between the umbilicus and the pelvic crest.
The choice of the skin incision for a pure muscle flap depends on the amount of muscle required and the wishes of the patient regarding scar placement. A vertical paramedian incision is quick and efficient but leaves a noticeable scar. A transverse suprapubic incision with abdominal wall undermining gives good access to the lower muscle and the pedicle. An abdominoplasty can be combined with the muscle harvest as an added bonus to the patient.
If a skin island is planned, an ellipse is drawn in a vertical, transverse, or oblique orientation depending on the donor scar, previous abdominal incisions, and the recipient requirements. Irrespective of design, care should be taken to include the large periumbilical perforators in the base of the flap. If length is a primary concern, the flap should be placed obliquely to orient along the normal axial vascular pattern of the abdominal wall (See Plate XX-1).
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