|Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
| The fascial connections of the abdomen are somewhat complex and must be considered in closing the defect. Structural relationships extend from the three abdominal wall muscles to the rectus sheath. The aponeurosis of the external oblique remains anterior to the rectus muscle throughout its length. The transversalis fascia remains posterior to the rectus muscle through its length. The other relationships shift as one moves caudal along the rectus sheath. Above the arcuate line (about halfway between the umbilicus and the pubis), the internal oblique aponeurosis splits and fuses anteriorly with the external oblique aponeurosis. At the arcuate line, however, all three aponeuroses pass anterior to the rectus muscle. The free border of the fused inferior part of the internal oblique and the transversalis form the arcuate line. This leaves only the transversalis fascia to reinforce the posterior sheath, an obvious point of weakness in the absence of muscle and anterior sheath. When the muscle is taken alone, the rectus anterior sheath can be closed over the defect without much risk of herniation. With removal of the anterior sheath with the musculocutaneous flap, the risk of herniation is greater. If a small cuff of anterior sheath is left behind on either side, the defect can usually be closed primarily with safety. If direct closure is not possible, the addition of synthetic mesh can reinforce the defect.
PLATE XX-1. Anatomy
A. This broad, flat, paired anterior abdominal wall muscle arises by two heads from the symphysis pubis and pubic crest. The two paired muscles run together cranially to insert onto lower thoracic cartilages 5, 6, and 7. Embryologically, it forms from the fusion of the anterior mesodermal somites. The result of this appears as three complete tendinous inscriptions above the umbilicus and one incomplete inscription below the umbilicus.
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