Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 7:
Bilateral Inferior Epigastric Flap (BIEF)
  Bilateral Inferior Epigastric Flap (BIEF)


The bilateral inferior epigastric flap (BIEF) is similar to the transverse rectus abdominis myocutaneous (TRAM) flap but has no muscle component. It incorporates the skin area primarily supplied by the superficial inferior epigastric vessels. As a unilateral flap, it was described by Shaw many years ago as one of the first direct axial cutaneous flaps.1 He used this as a vertical low abdominal flap to provide vascular cover for complex hand injuries. As a unilateral microvascular free transplant, it was studied extensively during the groin flap era and was first described as a bilateral free flap by LeQuang of Paris 2 at the International Microsurgery Meeting in Brazil in 1979.

Holmstrom 3 successfully used the "abdominoplasty flap" for breast reconstruction during the same period. This flap differs from the groin flap in that it encompasses a skin territory above the inguinal ligament, whereas the groin flap straddles and parallels the inguinal ligament.4 The territory of the groin flap could actually be included with the inferior epigastric flap by performance of multiple microvascular repairs and internal shunts between the conjoined vascular pedicles of the BIEF and the groin flap. A flap this large, however, would require skin grafting for donor site closure, which would negate one of its strongest points - the "acceptable donor scar."


The BIEF, like the groin flap, is a pure skin flap. Because of this, it has most if not all of the same advantages and disadvantages as the groin flap. Since the displacement of cutaneous flaps by the pure muscle and myocutaneous flaps through their relative ease of dissection, reliability, size of vascular pedicles and infection FIGhting ability, the indications for use of skin flaps have become markedly tailored.

The BIEF is indicated when a large volume of tissue (skin cover) is needed and where minimal donor site deformity is of importance. It is in reality an abdominoplasty in which the excised tissue is used as a transplant rather than sent to pathology. One of its primary uses is in breast reconstruction. Here, unlike in the TRAM flap, the rectus muscle is spared and the lower abdominal fascia is not disturbed except for the lower anterior sheath of the rectus. The flap is also ideally suited for covering symmetric lesions lying on either side of the midline (as originally described by LeQuang), such as massive neck contractures in which the bilateral inferior pedicles can be matched easily into the recipient neck vessels. It can also cover long linear defects in the upper and lower extremities.

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